Best Practices in Wound Care :Best Practices in Wound Care Based on evidence-based practice guidelines Results of a Wound Care Survey from Nursing2004, September By Elizabeth A. Ayello, RN, APRN,BC, CWOCN, PhD, FAAN, FAPWCA, Sharon Baranoski, RN, APN, CWCOCN, MSN, FAAN, DAPWCA, and David S. Salati, RN, NREMT-P, CCRN, CEN, BSN Contact hours: 4 Expiration date: 6/30/2007 Source: Nursing2005, June Online: http://www.nursing2005.com © 2005, Lippincott Williams & Wilkins


Best practices in wound care :Best practices in wound care What’s the best tool to identify patients at risk for developing pressure ulcers? Use the Braden risk assessment tool, which assesses for sensory perception, moisture, activity, mobility, nutrition, and friction/shear How can you more easily identify a Stage 1 pressure ulcer in patients with darkly pigmented skin? Look for darkened areas that are purple, brown, or black over bony prominences; change in texture of skin over bony prominences, boggy or hard skin; or a change in skin temperature


Best practices in wound care :Best practices in wound care Should you keep a wound bed wet or dry? Use moist therapy because it accelerates healing Whose assessment of patients’ pain is most reliable—theirs or yours? Patients’ self-report of pain is the most reliable assessment of their pain; remember, dressing changes can be a painful experience


Best practices in wound care :Best practices in wound care How should you assess wounds? Regularly assess wounds for location, stage, sinus tracks, undermining, tunneling, exudates, necrotic tissue and signs of healing What patients are at risk for developing wounds (and for impaired healing)? Those with poor nutrition, chronic disease, immobility, and limited ability to communicate


Best practices in wound care :Best practices in wound care How do you select which dressing to use? It’s based on the wound bed characteristics--amount of exudate, pain, necrotic vs. viable tissue, infection What’s best, wet-to-moist or wet-to-dry dressings? Wet-to-moist dressings are preferred because they support healing. In contrast, wet-to-dry dressings, which you can use to mechanically debride necrotic wounds, can pull off healthy granulating tissue What methods are used to remove necrotic tissue? Enzymes, surgical, autolytic, mechanical, maggots


Best practices in wound care :Best practices in wound care What are the signs and symptoms of chronic wound infection? Signs and symptoms of infection may not be present in chronic wounds, so look for increasing pain in the ulcer area, erythema, edema, heat, purulent exudate, delayed ulcer healing, discoloration of friable granulation tissue, pocketing at the base of the wound, foul odor, or wound breakdown (Note: Watch for these in immuno-suppressed patients as well)


Best practices in wound care :Best practices in wound care What criteria are used to determine whether a wound is considered infected? If bacteria exceeds 105 microorganisms/ml, the wound is considered infected Is bacteria in a wound ever helpful? Yes, low-level Staphlococcus aureus can stimulate the inflammatory response


Best practices in wound care :Best practices in wound care How do you obtain a wound culture specimen? Tissue biopsy (the gold standard) or needle aspiration Before taking a wound culture, what should you use to clean the wound? Use non-cytotoxic cleaners (not providone-iodine) When changing a dressing on a chronic wound, do you need to don sterile gloves? No--nonsterile gloves are acceptable


Selected references :Selected references Ayello EA, Cuddigan JE. Conquer chronic wounds with wound bed preparation. The Nurse Practitioner. 29(3):8-25, March 2004. Ayello EA, Cuddigan JE. Debridement: Controlling the necrotic/cellular burden. Advances in Skin and Wound Care. 17(2): 66-78, March 2004. Ayello EA, Meaney G. Replicating a survey of pressure ulcer content in nursing textbooks. Journal of Wound, Ostomy and Continence Nursing. 30(5):266-271, September 2003. Braden B, Bergstrom N. Clinical utility of the Braden Scale for predicting pressure sore risk. Decubitus. 2(3):44-46, 50-51, August 1989. Ehrenberg A, et al. Can decision support improve nurses' use of knowledge? Journal of Wound, Ostomy and Continence Nursing. 31(5):256-258, September/October 2004. Gardner SE, et al. A tool to assess clinical signs and symptoms of localized chronic wound infection: Development and reliability. Ostomy/Wound Management. 47(1):40-47, January 2001. Gardner SE, et al. The validity of the clinical signs and symptoms used to identify localized chronic wound infection. Wound Repair and Regeneration. 9(3):178-186, May-June 2001. Gardner SE, Frantz RA. Wound bioburden. In Baronoski S, Ayello EA (eds), Wound Care Essentials: Practice Principles. Springhouse, Pa., Lippincott Williams & Wilkins, 2004. Gunningberg L, Ehrenberg A. Accuracy and quality in the nursing documentation of pressure ulcers: A comparison of record content and patient examination. Journal of Wound, Ostomy and Continence Nursing. 31(6):328-335, November/December 2004. Henderson CT, et al. Draft definition of stage I pressure ulcers: Inclusion of persons with darkly pigmented skin. NPUAP Task Force on stage I definition and darkly pigmented skin. Advances in Wound Care. 10(5):16-19, 1997.


Selected Web sites :Selected Web sites American Academy of Wound Management Braden Risk Scale The European Wound Management Association National Pressure Ulcer Advisory Panel Wound Ostomy and Continence Nurses Society Wound Ostomy and Continence Nurses Certification Board Agency for Healthcare Research and Quality 1994 pressure ulcer guidelines (Click on Clinical information: Clinical practice guideline)


Slide 11:This outline was prepared by Mary Bailey, RN, CEN, BSN, Clinical Educator, Albert Einstein Medical Center, Philadelphia, Pa., based on the article “Wound Care Survey Report,” published in Nursing2005’s June issue. Access the complete article FREE online at http://www.nursing2005.com