EXCELLENCE IN
WOUND CARE
EXCEEDING THE INDUSTRY STANDARDS OF WOUND CARE IN A
SKILLED FACILITY SETTING
WHERE DO WE START?
All nurses receive basic instruction in incision management and
wound care in school, but is basic enough?
How have your experiences driven your practices as a nurse?
Is it time to update your knowledge base?
Are you meeting or exceeding BEST practice as a nurse?
IT’S MORE
THAN JUST A
DRESSING
CHANGE…
• “If you always do what you’ve always
done, you’ll always get what you’ve always
got.”
•
― Henry Ford
EXPECTATIONS
• Admit skin assessment and new wounds should be verified by two nurses
• Notify admin of any wounds present ON ADMISSION via wound qliq
• Report any NEW wounds (any type) ASAP upon discovery via wound qliq
• Document the site, measurement, and wound characteristics thoroughly in
PCC, be as descriptive as possible
• Report any s/s infection or complications to MD’s involved
• Monitor wound treatment for effectiveness and document client response
WOUND CARE 101:
REVIEWING YOUR KNOWLEDGE
WHEN DO YOU PERFORM HAND HYGIENE FOR
WOUND CARE?
Before you gather or touch clean supplies
Before donning gloves
After removing gloves
When hands are soiled or contaminated
When/if gloves are torn
After finishing the procedure and discarding trash
THE WOUND CARE
PROCESS
Cleansing agent
(or orders NOT to
clean!)
Drying agent (or
allow to air dry)
WHAT DOES
YOUR ORDER
SAY???!
EVERY wound
order must have
the following
components:
A primary dressing
A secondary
dressing
A securement
(unless a border
dressing is used,
more on that later!)
A NOTE ABOUT ORDERS….
• As nurses, we MUST FOLLOW THE ORDER, we cannot deviate unless ordered by the
physician.
• Is the order still appropriate for the wound you are treating? If not, CALL! Get new
orders! Do not just “try something” without notifying your provider. This is not within
the nursing scope of practice!
• Is the wound closed? DON’T FORGET TO COMPLETE THE ORDERS IN PCC!
WHAT IS THAT??!!!!
STAGING! IT’S A THING!
Two nurses must verify
skin assessment on
admission, and both
nurses’ names should
be documented in PCC
on admit assessment.
When in doubt, ASK!
Use your resources
when it comes to
staging. Call Monette
for questions!
NOT
BLANCHABLE!
May be pink or
red, skin intact
No change in
epidermal
layer of skin
(no dryness,
peeling, or
blisters)
Most often can
be resolved
with offloading
and skin
protection
STAGE 1
PRESSURE
WOUNDS
NOT BLANCHABLE, and
PAINFUL!
STAGE 2
PRESSURE
WOUNDS
Absolutely NO presence of
slough, eschar, or dead
tissue
May appear as dry peeling
skin, a blister, or shallow
“moon crater”, with or
without drainage
Involves full thickness dermal layers, muscle, or fascia
Slough, eschar, or non-viable tissue MAY be present
May have moderate to copious amounts of drainage
May exhibit tunneling or undermining
STAGE III PRESSURE WOUNDS
Will involve muscle/fascia, will also involve
BONE, LIGAMENTS, OR TENDONS
STAGE 4
WOUNDS
MAY exhibit dead tissue in the wound bed in
the form of slough, eschar, or nonviable tissue
May be malodorous, and will have moderate
to copious amounts of drainage.
These wounds can take months or years to
heal, and may require surgical intervention
SUSPECTED DEEP TISSUE INJURIES
SUSPECTED deep tissue injuries are also sometimes called
DTI’s.
These areas are closed but may be mushy, boggy, or softer
in comparison with the other areas of skin
May be purple, red, or dusky in appearance
No presence of eschar or slough, skin intact
May heal over time with offloading and care, but may also
worsen and result in Stage 3 or Stage 4 wounds.
UNSTAGEABLE WOUNDS
• More than 50% slough or eschar covers the wound bed surface
• Unable to view the tissue underneath and may drain or be very dry
• Will eventually be staged a 3 or 4 after the nonviable tissue is resolved
• May require sharp or enzymatic debridement