Wound Care

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Important Data:

A wound is a disruption of the normal structure and function of the skin and underlying tissues caused by trauma, surgery, or disease.
Wounds can be classified based on their depth, size, and appearance.
Factors that can affect wound healing include age, nutrition, chronic disease, medications, and infection.
The wound healing process involves four stages: hemostasis, inflammation, proliferation, and remodeling.
Wound care involves assessing and managing the wound and providing appropriate interventions to promote healing and prevent complications.
Soft tissue injuries such as sprains, strains, and bruises.

The NCLEXRN exam may test several concepts related to soft tissue injuries, such as:

Anatomy and physiology: The nurse should have a good understanding of the anatomy and physiology of the affected area, including the musculoskeletal system and the mechanism of injury.
Assessment: The nurse should be able to perform a thorough assessment of the injury, including inspection, palpation, and range of motion testing. It is also important to assess for signs of potential complications, such as compartment syndrome.
Treatment: The nurse should be familiar with the appropriate treatment modalities for soft tissue injuries, including RICE therapy, immobilization, and pain management.
Medications: The nurse should understand the use of medications for soft tissue injuries, including nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants.
Patient education: The nurse should be able to educate the patient on the proper care and management of their injury, including the importance of rest, elevation, and compression, as well as the potential risks of returning to activity too soon.

Master R.I.C.E. is an acronym used to describe the treatment of soft tissue injuries such as sprains, strains, and bruises. The acronym stands for:

Rest: The affected area should be rested to prevent further damage and promote healing.
Ice: Applying ice to the affected area can reduce pain and swelling. It is recommended to apply ice for 20 minutes at a time, with breaks in between to prevent frostbite.
Compression: Wrapping the affected area with an elastic bandage or compression sleeve can help reduce swelling and provide support.
Elevation: Keeping the affected area elevated above the heart can help reduce swelling by promoting proper blood flow.

Master R.I.C.E. is a common first-line treatment for soft tissue injuries and is frequently tested on the NCLEX for Nursing RN. It is important to note that while Master R.I.C.E. can provide relief and aid in the healing process, it is not a substitute for professional medical care.

Wound care is an important concept that is frequently tested on the NCLEX RN. It involves the assessment, management, and treatment of wounds to promote healing and prevent infection. Nurses must have a solid understanding of the phases of wound healing, wound assessment, wound dressings, and wound management to provide safe and effective care to patients with wounds.

The NCLEX RN may test your knowledge of wound classification, such as the difference between acute and chronic wounds, and the types of wounds, including pressure ulcers, surgical incisions, and traumatic wounds. You may also be asked about the various factors that can impact wound healing, such as nutrition, age, chronic diseases, and medications.

Additionally, the NCLEX RN may test your knowledge of wound assessment, including how to properly document and measure the size and depth of a wound, identify the presence of infection or inflammation, and determine the type of drainage or exudate. You may also be asked about the different types of wound dressings and their indications, including transparent film dressings, hydrocolloid dressings, and foam dressings.

Other important concepts related to wound care that may be tested on the NCLEX RN include wound debridement, wound irrigation, wound vacuums, and the use of topical and systemic antibiotics. It is important for nurses to have a comprehensive understanding of these concepts to provide safe and effective wound care to their patients.

More tested concepts in the NCLEX RN:

Nursing interventions for wound care include cleaning the wound, applying dressings, administering medications, and providing patient education.
Cleaning a wound involves removing debris and bacteria, irrigating the wound with sterile saline, and applying an appropriate antiseptic solution.
Dressings can be used to protect the wound, absorb exudate, and promote healing. The type of dressing used depends on the type and stage of the wound.
Medications used in wound care include antibiotics, analgesics, and topical agents such as antiseptics, corticosteroids, and growth factors.
Patient education is important in wound care and should include information on wound care techniques, signs and symptoms of infection, and when to seek medical attention.
Complications of wound care include infection, delayed healing, hemorrhage, dehiscence, and evisceration. Nurses should be knowledgeable about preventing and managing these complications.

There are several types of injuries related to wound care that are commonly tested in NCLEXRN, including:

Pressure injuries: also known as pressure ulcers or bedsores, which are caused by prolonged pressure on the skin.
Diabetic ulcers: occur in patients with diabetes, often as a result of poor circulation or neuropathy.
Venous stasis ulcers: occur in patients with venous insufficiency, where the veins are unable to properly circulate blood back to the heart.
Arterial ulcers: occur in patients with arterial insufficiency, where there is poor blood flow to the affected area.
Surgical wounds: can occur after surgical procedures and require careful monitoring to prevent infection and promote healing.
Traumatic wounds: can result from a variety of injuries, such as cuts, abrasions, and burns.
Pressure injuries related to medical devices: such as those caused by oxygen masks, feeding tubes, or urinary catheters.

Common wound locations include:

Pressure injuries on bony prominences, such as the sacrum, heels, and elbows.
Surgical incisions, which may be located in various areas depending on the type of surgery.
Diabetic foot ulcers, typically located on the bottom of the foot.
Venous stasis ulcers, which are typically found on the lower legs, around the ankles and inner part of the leg.
Arterial ulcers, usually located on the feet and toes.
Trauma wounds, which can occur anywhere on the body depending on the nature of the injury.

The National Pressure Injury Staging System (NPISS) is used to classify pressure injuries, and it consists of four stages:

Stage 1: Non-blanchable erythema of intact skin
Stage 2: Partial-thickness skin loss with exposed dermis
Stage 3: Full-thickness skin loss
Stage 4: Full-thickness skin and tissue loss, extending to muscle, bone, or supporting structures

It’s important to note that suspected deep tissue injury (SDTI) is also a category in the NPISS, which refers to an area of intact skin that is purple or maroon or a blood-filled blister. SDTI may indicate tissue damage beneath the skin that has not yet become visible.

The Braden Scale is a tool used to assess a patient’s risk for developing pressure injuries. The scale is comprised of six factors, each with a score ranging from 1 to 4, with a lower score indicating a higher risk for pressure injury development. These factors include:

Sensory perception: the ability to respond meaningfully to pressure-related discomfort
Moisture: the degree to which the skin is exposed to moisture
Activity: the degree of physical activity
Mobility: ability to change and control body position
Nutrition: usual food intake pattern
Friction and shear: the effect of skin resistance to skin-to-surface forces

The scores from each factor are totaled, with a final score ranging from 6 to 23. A score of 18 or lower indicates that the patient is at risk for pressure injury development and requires preventative measures. The Braden Scale is an important tool for nurses to use in assessing patient risk and developing appropriate care plans to prevent pressure injuries.

Here are some factors that can affect wound healing, as recognized by NCLEX RN:

Age
Nutrition and hydration status
Chronic diseases (e.g. diabetes, kidney disease, hypertension)
Medications (e.g. steroids, immunosuppressants, chemotherapy)
Infection
Smoking
Obesity
Immobility
Poor circulation
Excessive tension on wound edges
Psychological stress
Poor tissue perfusion
Impaired oxygenation
Excessive wound moisture or dryness
Foreign bodies in the wound
Radiation therapy

Appropriate Interventions

Appropriate interventions to promote healing and prevent complications in wound care are crucial to ensure positive patient outcomes. Some interventions that are commonly tested on the NCLEX RN include:

Pressure redistribution: Turning and repositioning the patient regularly can help to prevent pressure injuries from developing or worsening. The use of special support surfaces such as mattresses and cushions can also redistribute pressure and reduce the risk of injury.
Wound care dressings: The choice of wound care dressing will depend on the type of wound and its characteristics. Dressings can help to promote healing, manage exudate, prevent infection, and protect the wound from further damage.
Debridement: Removal of necrotic tissue and foreign material from the wound bed can help to promote healing and prevent infection. Debridement can be done through a variety of methods such as sharp debridement, enzymatic debridement, and autolytic debridement.
Infection prevention and control: Preventing and managing infection is a key aspect of wound care. This may involve measures such as hand hygiene, sterile technique, antimicrobial therapy, and regular assessment for signs of infection.
Nutritional support: Adequate nutrition is essential for wound healing. Patients who are at risk for malnutrition or have poor oral intake may require enteral or parenteral nutrition support.
Pain management: Effective pain management is important for patient comfort and compliance with wound care interventions. Pain management may involve the use of pharmacologic and non-pharmacologic interventions.
Patient education: Patient education is critical for successful wound healing and prevention of complications. Patients should be educated on proper wound care techniques, signs and symptoms of infection, and strategies for prevention of further injury.

Dressing types are an important aspect of wound care management, and nurses should have a good understanding of the types of dressings available and their indications. Some of the dressing types that are frequently tested on the NCLEX RN include:

Gauze Dressings: These are woven or non-woven dressings that are commonly used for wounds with moderate to heavy drainage. They can be impregnated with antimicrobial agents or other substances to promote healing.
Hydrocolloid Dressings: These dressings are used for wounds with light to moderate drainage and promote moist wound healing. They are made of gel-forming agents that absorb wound exudate and form a gel that keeps the wound moist and facilitates healing.
Transparent Film Dressings: These dressings are used for superficial wounds with minimal drainage and are effective in protecting the wound from external contamination while allowing for visualization of the wound site.
Alginate Dressings: These dressings are highly absorbent and are used for wounds with heavy drainage. They are made from seaweed and are effective in promoting wound healing by providing a moist environment.
Foam Dressings: These dressings are highly absorbent and are used for wounds with moderate to heavy drainage. They are effective in providing cushioning and protection for the wound.
Hydrogel Dressings: These dressings are used for wounds with light to moderate drainage and promote moist wound healing. They are made of water or glycerin-based gels that help to hydrate the wound bed and promote healing.
Negative Pressure Wound Therapy (NPWT): This is a specialized dressing system that applies negative pressure to the wound bed, which promotes healing and reduces the risk of infection. It is typically used for wounds with heavy drainage or that are difficult to heal.

Burns

Burn Assessment:

Determine the extent of the burn injury by estimating the percentage of body surface area (BSA) affected.
Assess the depth of the burn (1st, 2nd, or 3rd degree) by examining the appearance and texture of the burned tissue.
Evaluate the presence of other injuries or conditions that may impact burn recovery, such as smoke inhalation or preexisting medical conditions.

Assess for the burn location.

The area of a burn injury usually directs treatment. Burns on the face, hands, feet, and genitalia, as well as large burns in other areas of the body and those associated with inhalation injury, are often referred to burn centers for specialized expertise.

The size of the burn is expressed through percentage according to the total body surface area (TBSA), Rule of Nines.

Small Burns (<25%). Response of the body is localized.
Large Burns (>25%). Response of the body is systemic.

Types of Burns:

Thermal burns (caused by contact with flames, hot surfaces, liquids, or steam)
Chemical burns (caused by exposure to caustic or corrosive chemicals)
Electrical burns (caused by contact with electric current)
Radiation burns (caused by exposure to ionizing radiation)

Rule of 9’s Burns:

A method for estimating the percentage of total body surface area (TBSA) affected by a burn.
Divides the body into areas that represent 9% or multiples of 9% of the TBSA.
Used for quick assessment and triage of burn patients.

Parkland Formula: (4ml x TBSA (%) x body weight in kg)

A calculation used to determine the fluid replacement needs of a patient with a burn injury.
The formula is based on the patient’s weight and the percentage of TBSA affected by the burn.
The goal is to maintain adequate tissue perfusion and prevent complications associated with fluid loss.

First half of the solution is given in the first 8 hours (3,200 mL)
One quarter of the solution is given in the second 8 hours (1,600 mL)
Another quarter of the solution is given in the third 8 hours (1,600 mL)
Avoid colloid-containing solution for the first 24 hours because it may aggravate edema due to an increase in capillary permeability.
The amount of fluid in the second 24 hours will depend on the patient’s urine output and hemodynamic studies (Hct, CVP, and BUN/Crea)
Colloid-containing solutions may be given with D5W with glucose.
Monitor urine output. A urine output of 0.5 to 1 mL/kg/h is used as an indication of appropriate resuscitation in thermal and chemical injuries. In electrical injuries, a urine output of 75 to 100 mL/h is the goal.

Burn Intervention:

Stages of Burn Care

Management of burn care is organized into three stages: emergent, acute, and rehabilitative. The major concerns during the stages of burn care include fluid replacement, wound healing, and psychosocial support. After removing the patient from the source of the burn, the healthcare team evaluates the patient’s ABCs and proceeds to implement the steps of burn care management.

Pain Management

Pain due to burns can range from mild to severe to excruciating. Pain management, which includes pharmacologic and nonpharmacologic approaches, is a central component of the complex issues involved in treating patients with burns.

NO intramuscular or subcutaneous administration because the patient is hypovolemic.
Intravenous analgesics: Morphine, Demerol
Oral administration is NOT considered due to GI dysfunction.
Minor burns: per orem
Nonpharmacological: Deep breathing exercises, guided imagery

PHASE / STAGE 1

Resuscitative/Emergent Phase

The emergent (resuscitative) phase of burn management begins at the time of burn injury. The focus of this phase is to address the immediate and potentially fatal problems caused by the burn injury. Assessing the patient’s burns will determine the plan of treatment. The main concerns include hypovolemic shock and edema formation.

Injury to Return of Capillary Permeability

As quickly as 20 minutes after the burn occurs, injury to the capillaries can cause major fluid and electrolyte shifts from the vasculature into the interstitial tissues. The primary concern is hypovolemic shock, as the vascular fluids move into interstitial spaces (second-spacing) and areas that normally have no fluid (third-spacing), leading to vascular volume loss. Examples of third-spacing include blisters and edema. Capillary permeability is restored by adequate fluid replacement. As interstitial fluid gradually returns to the vascular space, edema disappears and diuresis begins.

48-72 hours

The emergent phase usually lasts 48-72 hours from the time the burn occurred. The beginning of diuresis marks the end of the emergent phase.

IV Fluid Replacement

Patients with 15% TBSA or more will need at least two large bore IV access sites for infusing large volumes of fluid. After calculating the patient’s fluid needs using the Parkland (Braxton) formula, crystalloid solutions (Lactated Ringer’s) or colloidal solutions (albumin) are infused as scheduled. Colloidal solutions are recommended after the first 12-24 hours postburn when capillary permeability returns to normal and the fluid stays in the vasculature for circulation. The rate of fluid administration is titrated hourly based on patient response such as urine output or vital signs.

PHASE / STAGE 2

Acute Phase

During the acute phase of burn management, wound care is the primary focus. This phase, which may last for weeks or months, starts with diuresis and ends with wound healing or skin grafting. Bowel sounds return and the patient may need psychosocial support as reality sets in. The patient’s laboratory values, especially sodium, potassium, and glucose, should be closely monitored as capillary permeability restores to normal. As the burn wounds begin to heal, encourage the patient to stretch and move as much as possible to prevent painful contractures.

Watch out for signs of infection. Erythema, warmth, malodorous exudates, and tenderness.
Initiate universal precaution. Use of gowns, gloves, and eye protection. Including frequent hand hygiene.
Wound culture and antimicrobial therapy. Culture and sensitivity is usually ordered on admission for patients with burns to test for presence of MRSA.
Wound care. Early excision and closure of the burn wound helps in preventing infection.
Control of hyperglycemia. Insulin is indicated (even without diabetes) for severely burned patients to improve protein synthesis, attenuate lean body mass loss, decrease hypermetabolism, and accelerate donor healing time.

Diuresis to Near Wound Closure

Fluid mobilization results in diuresis and the patient becomes less edematous. Necrotic tissue surrounding the wound sloughs off as fibroblasts begin the process of forming granulation tissue. Partial-thickness burn wounds will heal within 10-21 days as long as kept moist and free of infection. However, full-thickness burn wounds require the surgical excision of burn eschar and application of skin grafts for healing.

PHASE / STAGE 3

Wound Closure to Return of Optimal Level

During the final stage of burn care management, wounds have healed and the patient begins to engage in self-care. The patient works toward rehabilitation and reintegration into society. Teaching and psychosocial support will help the patient manage changes in body image. Since newly-healed areas of skin may be hypersensitive to sun, teach the patient to avoid direct sunlight for the next 3 months to prevent hyperpigmentation and sunburns. Teach the patient how to complete dressing changes and wound care. If necessary, refer the patient to home care nursing services for follow-up care after discharge.

In conclusion, wound care is a critical concept that is frequently tested in the NCLEX RN exam. Understanding the assessment, management, and prevention of various types of wounds, as well as appropriate interventions to promote healing and prevent complications, is essential for nurses in providing safe and effective care to their patients. Being familiar with the different types of wound dressings and devices, as well as the stages of burn care, is also important for nurses to effectively manage their patients’ wounds. By reviewing and mastering these concepts, nurses can be better prepared to excel in their nursing practice and in passing the NCLEX RN exam.