Wound Care: Cleaning and Dressing Wounds

Skin integrity is the body's first defense, and when it breaks, your job is to clean, dress, and protect the wound so it heals and does not get infected. This covers the skin, what threatens it, and how to clean and dress wounds, including negative pressure therapy.

Structure of the Skin

The skin is the body's largest organ: a barrier, a thermostat, and a sensory surface. The epidermis is the outer barrier; the dermis below holds blood vessels, nerves, and hair follicles; and the hypodermis beneath that is fat and connective tissue for insulation and cushioning.

Functions of the Skin

• Protection: a physical barrier against pathogens and chemicals, with melanin absorbing UV radiation to limit DNA damage.
• Regulation: temperature control through sweating, vasodilation, and vasoconstriction, and water balance via transepidermal water loss (TEWL).
• Sensation: receptors for touch, pressure, pain (nociceptors), and temperature (thermoreceptors).
• Metabolic: vitamin D synthesis in sunlight, and fat storage in the hypodermis.
• Immune defense: Langerhans cells present antigens to the immune system, and antimicrobial peptides limit pathogen growth.
• Excretion: sweat removes waste like urea, salts, and ammonia.

Skin Integrity

Skin integrity is skin that is whole and intact. It is the first line of defense, so a breach opens the door to infection and other complications.

Factors that affect it: age (thinner, less elastic skin), nutrition, hydration, mobility (immobility risks pressure ulcers), and hygiene.

Threats: pressure ulcers (bedsores) from prolonged pressure; maceration from prolonged moisture; excoriation from scratching or mechanical damage; and skin tears from shear, friction, or blunt force.

Maintaining it: regular assessment of high-risk areas, moisturization, pressure relief through repositioning, good nutrition and hydration, and infection control.

Wound Care Basics

A wound is any break in the skin or underlying tissue. Acute wounds heal through the normal stages; chronic wounds stall because of conditions like diabetes or vascular disease. Debridement removes dead or infected tissue to give a healthy wound bed.

Exudate (wound fluid) is normal but must be managed to prevent infection and maceration. Granulation tissue (red, bumpy) signals progress, and epithelialization (new tissue forming over the wound) is the final stage. Dressings protect the wound, manage exudate, and keep the bed at the right moisture: hydrocolloids, hydrogels, foams, and alginates, each for specific wound conditions. Sterile technique and appropriate cleansers prevent infection.

Types of Wounds

Intentional wounds come from procedures (surgery, venipuncture); unintentional from accidents. A wound is closed if tissue is traumatized without breaking the skin, open if the skin or mucous membrane is broken.

By contamination:

• Clean. Uninfected, minimal inflammation, no entry into respiratory, GI, genital, or urinary tracts. Usually closed.
• Clean-contaminated. Surgical entry into one of those tracts, with no evidence of infection.
• Contaminated. Open fresh accidental wounds, or a major break in sterile technique or GI spillage, with inflammation.
• Dirty or infected. Dead tissue or clinical infection (purulent drainage).

Wound Assessment

1. Size (length, width) as a baseline to track healing.
2. Depth and underlying tissue involvement.
3. Wound bed appearance (color, granulation tissue).
4. Exudate (amount, color, consistency).
5. Periwound skin (integrity, color, temperature).
6. Edges (regularity, undermining, tunneling).
7. Pain (location, intensity).
8. Odor (infection or necrotic tissue).
9. Foreign bodies.
10. Overall condition (vital signs, systemic symptoms like fever).
11. Previous interventions and their effectiveness.
12. Patient understanding and compliance.

Cleaning and Dressing a Wound

1. Gather supplies: gloves, sterile gauze, wound cleanser, dressings, prescribed medications.
2. Wash your hands before and after.
3. Explain the procedure, get consent, and position the patient with the wound accessible.
4. Glove up, with a gown or mask if needed.
5. Remove the old dressing, noting drainage type and amount, and discard it in a biohazard bag.
6. Assess the wound: size, depth, color, odor, signs of infection.
7. Irrigate gently with sterile cleanser or saline, cleaning from the least contaminated area (the wound) to the most contaminated (surrounding skin).
8. Pat the wound and surrounding skin dry with sterile gauze to prevent maceration.
9. Apply prescribed topical medication.
10. Apply a new sterile dressing that fully covers and adheres.
11. Secure with tape or bandages without restricting circulation.
12. Dispose of supplies and PPE.
13. Wash your hands.
14. Document the assessment, dressing applied, and observations.
15. Teach the patient and caregivers wound care, signs of complications, and followup.

Negative Pressure Wound Therapy (NPWT)

NPWT applies negative pressure to the wound bed to promote healing.

1. Assess the wound (size, depth, exudate, condition) to confirm NPWT fits and set a baseline.
2. Gather equipment: the vacuum-assisted closure (VAC) device, sterile foam or gauze dressing, transparent film, tubing, dressings.
3. Explain the procedure and get consent.
4. Debride necrotic tissue, debris, and excess exudate.
5. Place sterile foam or gauze into the wound bed, seal with transparent film, and connect to the NPWT device for an airtight seal.
6. Set the prescribed negative pressure based on the wound and the provider's order.
7. Check the system for suction and seal integrity, and watch for discomfort, bleeding, or other complications.
8. Teach the patient and caregivers device operation, dressing changes, complication signs, and followup.
9. Document the assessment, parameters, measurements, and response.