Time heals all wounds, but not at the same rate
Care improves through education
Teaching wound care might be about as much fun as cleaning off crusty dead tissue from a bedsore.
But this inservice could go a long way toward improving your patients’ wound-healing time and reducing the number of nursing visits.
Nurses with agencies in Ohio and Kentucky have developed wound care inservices, assessments, and protocols that have helped to reduce patients’ infection rates and improve care.
University MEDNET Home Care of Eastlake, OH, spent a year developing a wound care protocol, which was taught in a mandatory inservice that provided continuing education credits. (See Virginia agency’s wound care inservice, p. 39.)
"We had some chronic wounds that were taking a very long time to heal and required maybe two-to-three visits a day," recalls Donna Schott, RN, BSN, continuous quality improvement and staff development supervisor with University MEDNET Home Care.
Since the nonprofit agency, which serves three counties in northeastern Ohio, implemented its new process in the spring of 1996, the wound infection rate has decreased from 9% to about 3%, Schott says.
"We don’t have enough data right now to show a trend of the number of days it takes to heal a wound, but that’s what we’re checking for right now, and we expect that to decrease," she adds.
University MEDNET Home Care formed a task force that developed a wound assessment form. The assessment was used as a guideline during the inservice, says Connie Kless, RN, BSN, CETN, leader of the skin care task force.
"We went through each aspect of the form and taught them what to look for in a wound, how to assess a wound," Kless says.
A need for standardized assessments
Family Home Health Care of Somerset, KY, also was looking for faster healing results when the agency’s quality improvement coordinator focused on wound outcomes as a performance improvement area.
The full-service agency, which serves south-central and northeastern Kentucky, held a two-hour wound care inservice for nurses that included teaching them about how to do a thorough wound assessment, says Dinah Burton, RN, BSN, CNA, quality improvement coordinator.
So far, it seems to be working.
"We’re still in the initial phases," Burton says. "But we can already tell the wounds are healing much more quickly."
Burton and the agency’s quality improvement specialists started the program by researching literature related to current standards of practice and trends in wound treatment and assessments. Then they compared the findings with their own assessment and treatments.
"Wound assessment is one of the things we found needed improving because staff didn’t always assess the wounds in the same way or in a way that would help determine appropriate treatment," Burton explains.
Based upon the research findings and analysis of the data collected within the agency, a more specific, standardized assessment was developed.
The assessment covered the physical assessment of the wound, a nutritional assessment, infection control issues, identification of risk factors, and the type of treatment and care that is appropriate.
Burton says a chief purpose of the initial phase of the program was to make nurses familiar with measuring wound outcomes: "What do we need to assess on patients with wounds to be consistent and to be able to identify the most appropriate treatment in order to improve outcomes?"
Schott, Burton, and Kless offer the following advice on how to teach nurses a wound assessment and treatment program as well as tips to promote faster healing:
1. Cover the basic types of wounds and their healing times within the agency.
Family Home Health Care has divided the different types of wounds into three basic types for the purposes of data collection and analysis, Burton says.
"Those different types of wounds generally have different healing times, and we wanted our data to be as precise as possible," she explains.
• Stage 1 are pressure ulcers, in which the skin hasn’t broken yet, and skin tears are grouped together as the easiest to treat because they generally heal more quickly than complicated wounds.
• Stage 2-4 pressure ulcers are the wounds Family Home Health Care has made its primary focus. These types of ulcers have the following characteristics: In stage 2 the first layer of skin is affected; in stage 3 it goes through the skin but not to the muscle or bone; in stage 4 it can affect the muscle and bone; therefore, this type will usually take the longest to heal.
• Venous stasis ulcers are the result of poor circulation in the lower extremities. This causes the skin to break down, sometimes giving it a purplish-red coloring on the lower half of the leg. These types of wounds leave the skin dry with small little sores all over. "They take a long time to heal because of the circulatory problems," Burton says. "If something isn’t done to improve the circulation, those wounds may never heal."
2. Give tips on how to properly clean a wound and change its dressing.
"Whenever you clean a wound, you need to use enough force to get all the debris out without hurting or traumatizing the new tissue that’s starting to develop," Kless advises. "New tissue is very fragile, but if you just clean without pressure, you won’t get out all the debris. So a good cleansing is very important."
Kless recommends that nurses use a 19 gauge angiocath and 35 cc syringe to obtain adequate pressure for cleaning the wound. Normal saline is what she uses as a cleaning fluid in the syringe because there’s no toxicity in it.
During a wound inservice, Kless shows nurses slides of healthy and dead tissue to help them to identify the difference. She also explains the correct process for changing wound dressings. The first step is to use wet-to-dry dressings that will help with the removal of necrotic or dead tissue from the wound, she says.
Wounds need a moist environment for healing, so typically nurses place a wet dressing on the site and allow it to dry before they remove it. When it dries, the dead tissue sticks to it and is removed with the dressing.
"Once all the dead issue is removed, you have to stop using the wet-to-dry dressing because if you continue, you will take off healthy tissue, and this will prolong the healing time," Kless explains.
3. Explain what the latest trends and standards are in wound care, and make sure nurses know which products are used by the agency.
"For the most part, they’ve all done wound care at one time or another, and if the nurses come from a nursing home, then obviously they’ve done a lot of wound care," Burton says. "But people have gotten out of the habit of keeping up with the current trends and standards in wound care."
Burton also has found that some physicians were still using one or two protocols for treating wounds that are considered outdated according to current research.
Nurses also need to be taught how to use the appropriate product for each wound. Burton uses the 4 x 4 gauze as an example of a product that has been around a long time and still is used frequently, although it may not be the most appropriate product, depending on how it is used.
Depending on the wound’s amount of drainage, nurses might want to use a hydrocolloid dressing that will keep the wound bed moist and allow it to heal faster. Other types of dressings include films, hydrogels, and calcium alginates.
Burton and Schott say they spent a lot of time doing research to learn the newest treatment for wound care.
"We did a manual literature search at the library," Schott recalls. "Then we developed the protocol." The protocol included a list of steps to follow with different treatment tracts depending on what happens with the wound.
4. Develop a protocol or standard for assessing patients’ wounds.
Education managers can make sure nurses are consistently assessing wounds the same way by putting this process in writing, the experts suggest.
Burton spent a lot of time during the wound care inservice on discussing a standard way to assess wounds. The wound type and classification could be assessed. Also, nurses might identify the wound’s chief characteristics, such as its location, size, drainage, odor, condition of surrounding skin, presence of eschar, and signs of infection.
She taught them "how to consistently measure the size and the amount of drainage and eschar and how to determine what’s small, moderate, and large."
Other characteristics, she adds, include checking the wound for eschar or slough, which is either a yellow material or hard black area. "The wound can’t heal unless this is removed, and we discussed the best way to get that removed," Burton relates.
Observations in the field
Specific treatments, such as nutritional, cleansing, and dressings also were discussed as part of the inservice. Burton brought the various types of dressings into the inservice and passed them around for the nurses to examine.
An important part of Family Home Health Care’s education on wound assessment and treatment was conducted in the field during the data collection phase before the inservice. A specialist conducted patient visits with the nurses to observe how they treated patients’ wounds.
"When we went out, we found that some were using the most appropriate treatment, and a few were not," Burton says, adding that the specialist provided one-on-one recommendations and consultation with the nurses at that time.
"What we’re going to be looking for in the next phase is that a more consistent assessment and the most appropriate treatment has been used since the inservice, and that will hopefully have contributed to decreasing wound healing times in our patients."
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