These tips-seme eld, some new-will help you meet the chalienge of assessing and caring for your

patient's wound.

12 COIVUVIANDMENTS
WOUND CARE HAS CHANGED dramatically in the past 10 years in fact, it continually evolves. But you can count on one thing not changing: the critical need for you to assess how well the wound is healing and to choose the best treatment option for continuing that process. The 12 commandments of wound care presented here will help you do just that. They incorporate timetested care tips and some of the newest trends. swab against a centimeter measuring guide. This works only for a wound that's been debridedyou can't accurately measure depth in a wound covered by necrotic tissue, such as eschar (black, leathery, dried collagen) or slough (soft, yellow, gummy debris). One more thing about depth: Devices designed specifically to measure it are generally used in research only because they're too expensive for bedside care. If you used a new one each time you measured a wound, your hospital would spend hundreds of thousands of dollars a Assess the wound year on these deviees alone. Even thoroughly You'll go through sev- less-expensive devices aren't practical because they're difficult to use; eral steps. \kasure the wound. Choose the some aren't sterile either. most appropriate way to measure Monitoring the perimeter of a your patients particular wound and shallow wound will help you assess stick with it throughout the healing how well it's healing. Plastic meaprocess. For example, you'd want to suring guides with concentric circles know the exact depth of a deep are available. Some dressings even wound or the perimeter of a super- incorporate a sizing grid. ficial, contracting wound. But you ean also make your own To improve your assessment., guide with a plastic bag. Place the make sure the patient is in the same bag over the wound and trace the position each time you measure the outer margins with an indelible wound. And if possible., you should marker. Cut off and discard the side always be the one to do it. of the bag that touched the woundMeasure the wound in centime- it's contaminated. Then date and ters. Start with the length (head to identify the remaining piece of plastoe) and width (side to side) basic tic and put it in the patient's record. measurements that you should have You can measure undermining or for all wounds. tunneling (breakdown of tissue beIf the patient has a deep wound, neath intact skin, resulting in pockdetermine the depth by inserting a ets or air space) with a sterile cotton sterile cotton swab at the deepest swab. Slide the swab into the openpoint of the wound, then holding the ing in the skin surface and along the muscle or fascial plane until you meet resistance. Withdraw the swab, BY DIANE KRASNER, RN, CETN, MS measure the extent of the underNursing Consultont, Enterostomal Therapy mining or tunneling in centimeters. Baltimore, Maryland

earncEUs
ANA/AACNAPPROVED 34
NURSING92, D E C E M B E R

then relate the location to a clock or compass face. For example, you might find 3 cm of undermining at 9 o'clock. Make sure you sketch the wound in your notes so other health care providers will understand your point of reference. And you can use terms such as "proximal," "medial," and "lateral" to help with orientation. o Identify the wound type. Ask yourself these questions: Is the wound acute (an abrasion or skin tear) or chronic (a pressure ulcer, diabetic ulcer, or venous ulcer)? Can you determine its etiology? For example, was it eaused by pressure on the saerum from the patient lying on his back for too long? Have diabetic neuropathy and poorly fitting shoes caused a diabetic foot ulcer? Has venous stasis ulceration occurred because external compression stockitigs weren't used as a preventive measure? Also, is the wound complicated by more than one problem? For example, you could be dealing with a wound that has a draining fistula, a pressure ulcer with a secondary malignancy, or a vascular problem that's compromising tissue perfusion in the area. Identify and prioritize interventions to address each problem. Suppose the patient has a leg ulcer caused by vascular insufficiency. He may need bypass graft surgery to improve blood flow before that ulcer will heal. To provide holistic eare, you may also have to administer compression therapy, give medication to improve vascular tone, and apply topical wound treatments, o Determine the nursing diagnosis.
JOHN W. KARAPELOL'

For example "impaired skin integrity" is commonly used for partialthickness wounds (superficial wounds through the epidermis but not through the dermis) and Stage I and II pressure ulcers. For full-thick ness wounds (deep tissue destruction extending into subcutaneous tissue, musele, or bone) and Stage III and IV pressure ulcers, you might use "impaired tissue integrity.'* "Altered oral mucous membranes" might be appropriate for pressure ulcers in the mouth from endotraeheal tubes, poorly fitting dentures, or other mucosal wounds. (Remember, pressure ulcers aren't restricted to the classic areas; you may also see them on the back of the head, under the elbows, under airway tubes, and so on.) Patients at high risk for skin breakdown can be given the diagnosis "potential impaired skin integrity" Also, complete a risk-assessment tool to predict the likelihood of more tissue trauma. You might use the Norton or the Braden scale for assessing pressure ulcer risk. These scales evaluate such things as physical and mental condition, activity, mobility, and nutrition on a numeric scale. Other risk-assessment tools are used for different types of wounds. Check your policy and procedure manuals to determine which one is used at your hospital. * Assess the phase of the wound healing process. Wounds may be in the reaction (inflammation), regeneration (production of granulation tissues), or remodeling (matrix formation) phase. You may find that a chronic wound isn't healing because it's stalled in one phase. For example, a fungal infection could prevent a wound from moving out of the reaction phase (sometimes called the inflammatory phase). As ordered, you"d treat the infection with topical antifungal agents to help the wound progress toward healing, o Stage a pressure ulcer. Some nurses inappropriately stage all types of wounds. But only pressure ulcers should be staged. For guidance, check the the National Pressure Ulcer Advisory Panel's 1989 classification system (see Classifying Pressure Ulcers). This system has been adopted nationwide, and it's part of the new pressure ulcer guidelines published by the US. Department of Health and Human Services'
36 NURStNG92, DECEMBER

PREVENTING PRE5SURE ULCERS

The following points are excerpted from the Agency for Health Care Policy and Research's recent guidelines on predicting and preventing pressure ulcers. Risk assessment Consider all patients who are bedridden or chair-bound or who have difficulty repositioning themselves to be at risk for pressure ulcers. Select and use a risk-assessment method (such as the Norton or Braden scale), then systematically evaluate each patient's risk factors. Assess all at-risk patients when they're admitted to your institution and at regular intervals. Identify risk factors (such as decreased mental status, moisture, incontinence, and nutritional deficits) and restrictions on repositioning (such as a flail chest or unstable vertebral column) and take specific preventive steps. Modify tfie patient's care plan accarding to these risk factors. Skin care and early treatment Inspect tfie skin at least daily and document assessment results. Individualize the patient's bathing schedule. Use a mild cleaning agent; avoid hot water and excessive friction. Assess and treat incantinence. If it can't be controlled, clean the skin when it becomes soiled, use a topical moisture barrier, and select underpads or briefs that are absorbent and dry quickly. Use moisturizers for dry skin. Minimize environmental factors tfiat can lead to dry skin (low humidity and cold air, for example). Don't massage skin over bony prominences. Use proper positioning, transferring, and turning techniques to minimize skin injury from friction and shear forces. Use dry lubricants (cornstarch, for example) or protective coverings to reduce friction injury. Identify and correct factors compromising protein or calorie intake and consider nutritional supplements or support. Institute a rehabilitation program to maintain or improve the patient's mobility and activity. Monitor and document your interventions and their outcomes. Positioning and support Reposition bedridden patients at least every 2 hours; chair-bound patients, every hour. Prepare a written repositioning schedule. If a chair-bound patient can shift his weight, teach him to do so every 1 5 minutes. Place patients who are at risk for pressure ulcers on a pressurereducing mattress or chair cushion. Don't use doughnut-type cushion devices. Consider postural alignment, distribution of weight, balance and stability, and pressure relief when positioning a patient in a chair or wheelcfiair. Use lifting devices (such as a trapeze or bed linens) to move the patient; don't drag him during transfers or position changes. Use pillows or foam wedges to keep bony prominences (such as knees and ankles) from direct contact with each other, Use devices that totally relieve pressure on the heels. For example, place pillows under the calf to raise heels aff the bed. Avoid positioning the patient directly on the trochanter of the femur when he's in the side-lying position. Use tbe 30-degree lateral inclined position instead. Elevate the head of the bed as little as possible (maximum: 30 degrees) and for as short a time as possible.
Prepared by (he Nokmol Pressure Ulcor Advisor/ Panel (rom Pressure Ufcers in Adults: Prediction and Prevention, a ciinical practice guiddino published by the Agency fof Hoaltti Core Policy arxJ Research (AHCPR], Pubk Health Service, U.S. Deportrnent of Health and Human Services, May 1992 For a copy of the clinicd practice guideline, quick reference guide for clinicians, arxJ a pa. lient's guide, coH ths AHCPR Clearinghouse1 -800-358-9295. Or write to. AHCPR Publitalions Oearinghouse, P.O. Bon 8547, Silver Spring, MD 20907

Agency for Health Care Policy and Research. Other wounds may be described as partial-thickness, full-thickness, acute, or chronic, or by etiology {arterial ulcer, for example). Use first-, second-, or third-degree to describe burns. Other aspects to assess. Note the location of the wound, the color of the wound bed, the condition of the wound margins, and the integrity of the surrounding skin. Look for signs and symptoms of infection, such as redness, warmth, swelling, and pain. Do you sec exudate? If so. what color is it? And does it have an odor? Outline a care plan Each patient needs a wound care plan that's tailored to his needs. Standardized or standing wound care protocols are fine, as long as they can be individualized. Components of a comprehensive wound care protocol might include a riskassessment tool, a documentation flow sheet, standing treatment orders, and a surveillance plan (a means for identifying how many pa-

Measure the depth of the wound with o sterile cotton swab.

Use on acetate woutid guide wrth concentric circles printed on it to measure the wound's perimeter.

Use a sterile cotton swab to measure tunneling or undermining.

Qeon the wound with an angiocoth, syringe, and normal saline solution.

CLASSIFYING PRESSURE ULCERS

Stage I Nonbbnchable erythema of intact skin; the heralding lesion of skin ulceration Stage II Partial-thick ness skin loss involving epidermis or dermis. This ulcer is superficial ond appears as an abrasion, blister, or shallow croter. Stage III Full-thickness skin loss Involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer appeors as a deep crater with or without undermining of adjacent tissue. Stage IV Full-thick ness skin loss with extensive destruction, tissue necrosis, or domage to muscle, bone, or supporting structures (for example, tendon, joint capsules, and so on]
Adopted from tho Nolional Prassure Ulcer Adviiory Ponel Consensus Development Conference Slotoment. 1989.

Protect the wound margins with a dressinghere, a hydracolloid.

A dressing that retains moisture, such as the transparent dressing over this wound, promotes autolysis of eschor.

Vfe opted to conservatively manage these blackened, intoct, Stage IV pressure ulcers (see commondment 11).

COMPARING WOUND DRESSINGS

Category Cotton mesh gauze Products Advantages Moderately absorbent Disadvantages Bulky

Nonadherent dressing

Nonimpregnated: ETE Sterile Protective Dressing, EXU-DRY, Metalline, Release, Telfa Impregnated: Adaptic, Scorlet Red, \bseline Gauze, Xeroflo, Xeroform ACU-Derm, Biodusive, BllsterFilm, Ensure-It, Hi/moist, Omiderm, OpraFlex, OpSite, Polyderm Picture Frame Film, Fblyskin II, Tegaderm, Tegaderm Fbuch, Transite Exudate Transfer Film, UniFlex, \ t i r i / Moist, Visi Derm 11 Comfeel, DuoDERM, Hydrapad, Intact, intraSite, Johnson & Johnson Ucer Dressing, Restore, Sv/een-A-Peel, Tegasorb, ULTEC

Occlusive Nontraumatic

Minimally absorbent Some impregnated dressings contain antimicrobial agents that horm fibroblasts

Transparent film

Moisture retentive Semlpermeable \fery comfortable for patient Not bulky Allows for easy wound inspection Vfeter resistant Moisture retentive Occlusive or semipermeable \fery comfortable for patient Not bulky Excellent bacterial barriers, high tack Vfater resistant Moderately absorbent Moisture retentive Moderately absorbent Cooling, soothing effects Can be used an infected wounds VAiter resistant (if used with secondary transparent film) Allows for easy wound inspection Moisture retentive Highly absorbent

Minimally absorbent Channeling (wrinkling) occurs

Mydrocolloid

Melt out occurs, resulting in residue in the wound bed and particles on the wound margins

Hydrogd

Biolex \ ^ u n d Gel, Carrington Dermal V^feund Gel, GearSite, Elasto-Gel, Geliperm Wet/ Granulate, Hydron VtourxJ Dressing, IntraSite Gel, Nu-Gel, Second Skin, Spand-Gel, Vigilon

Exudote absorber

Algosteril, Allevyn Cavity Vfciund Dressings, Bard Absorption Dressing, Debrisan, Envisan, Hydragon, Kaltostat, Mesalt, Sorbsan

Foam

Allevyn, EPIGARD, Epi-Lock, LYOfoam, Mitroflex

Moisture retentive \fery comfortable for patient Moderately absorbent Insulating

Note: The products included here are representativs of wtwt's avoilobb,- Ihe lists under each category oren't meant to be inclusive. From "Seleeling Wound Drwjinfls by Catogory." NAMD Journal.'^ 1991 Notional Association of Retail Druggists. Alexandria, Wi., May 1991. Adapted with permission of the pubNshef

NURSING92, DECEMBER

Nursing

considerations

Can be used dry to cover surgical wounds, wet-to-dry to nonselectively debride some wounds, and moist to pack undermining and tunneling Combine with normal saline solution for granulation or antibiotic solutions for infection Use transparent films or occlusive tope to retain moisture, p.m. Cover with nonwoven gauzes to increase absorption Nonodhesive Doesn't require secondary dressing Useful for skin tears and other friable wounds, wounds near body hair, donor sites, and skin grafts Adhesive Doesn't require secondary dressing Useful for autolytic debridement, as well as superficial wounds, donor sites, obrasions, and burns

tients in the institution have wounds or pressure ulcers and how many of these developed after admission). You don't have to write your protocols from scratch: Printed care plans and guidelines can serve as models for developing specific standards for your institution. For example, the International Association for Enterostomal Therapy sells its standards of care for pressure and leg ulcers. Or you could get a copy of the new pressure ulcer guidelines from the Agency for Health Care Policy and Research.

touch technique that saves supplies, nursing time, and money. Traditional gauze dressings, by comparison, are changed two or three times a day and must be applied using sterile technique. So they tend to be very expensive. Keep the wound bed clean and debrided The wound bed must be carefully cleaned before you apply the new dressing. This is critical: You can't just pull off the old dressing and apply a new one. To clean the wound, use a solution that's free of cytotoxic agents or dangerous chemicals; otherwise, macrophages, fibroblasts, and delicate granulation tissue could be harmed. For most wounds, normal saline solution is the agent of choice. Besides being gentle to healing tissue, it's also cost-effective special cleaners cost three to four times more than normal saline solution. But some woundssuch as traumatic wounds filled with gravel and road debrismust be cleaned with special nonionic surfactant cleaners (Shur-Clens and Saf-Ciens. for example). These break up the debris without damaging tissue; they're especially effective for removing dried blood, exudate, and foreign matter. This helps reduce infection rates in contaminated wounds. You may also have to irrigate a wound filled with a lot of debris or exudate. Use an 18- or 19-gauge angiocath and a 30- or 35-ml syringe. This combination produces 8 to 11 pounds per square inch of pressure at the wound surfacea safe amount. Anything higher could damage the wound or drive bacteria into the tissue. If the wound has copious exudate, try using an exudate-absorbing product to keep the wound clean. For example, you might select from among the calcium alginates. copolymer starches, foams, and hypertonic saline dressings. An incontinent patient with wounds in the sacral/coccyx area, buttocks, or thighs may need a collection device. A fecal collector, urinary pouch, or external catheter will help protect the area from contamination, maceration, and further tissue trauma. In extreme cases, the patient may need a coiostomy, ileNURS1NG92, DECEMBER 9t

Adhesive Doesn't require secondary dressing Useful for autolytic debridement, as well as for covering a variety of acute and chronic wounds Available in powder, wafer, and paste form Adhesive or nonadhesive May or may not require secondary dressing Useful for autolytic debridement, as well O for covering a variety of S acute and chronic wounds Available in sheet or gel forms Sheets don't leave a residue; get easily rinsed off Nonadhesive Requires secondary dressing Useful for autolytic debridement and for heavily exudating wounds Available as starches, pastes, beads, hypertonic saline gauzes, and calcium alginote dressings Nonadherent May or may not require secondary dressing Useful for friable wounds or wourwds near body hair

A plan that looks great on paper may not stand up to the reality test. In other words, be prepared to modify and revise your plan as necessary. Be prepared to reconsider your choice of dressing as the wound's status changes. Wet-to-dry dressings, for example, are no longer used throughout the healing process. But you could still start with one to nonselectively debride a wound that's full of slough. Once the wound is clean, though, you'd switch to a dressing that would allow granulation, such as a hydrocolloid or hydrogel. At that point, a wet-to-dry dressing could debride healing tissue and put you back at square one. Later, you'd move to a dressing that would promote reepithelialization, such as a composite or transparent film dressing. The bottom line is this; Treatment must evolve as the wound heals.

Modify the plan, p.r.n.

A landmark study published 30 years ago demonstrated that wounds heal faster with less scarring in a moist environment than in a dry one. A moist environment promotes faster granulation and reepithelialization and reduces pain. So stay away from antacids, heat lamps, and other topical treatments that dry out the wound bed. Moisture-retentive dressings are easy to use and cost-effective because they're changed less frequently than other dressingssome dressings can remain in place for up to 5 days. Many moisture-retentive dressings can be applied using a no-

Keep the wound bed moist

ostomy, or urostomy to permanently divert stool or urine and allow the wound to heal and stay healed. If the wound contains eschar or slough, it must be debrided. You can use wet-to-dry gauze if the wound is filled with necrotic debris. But discontinue this method as soon as the wound is clean. Whirlpool is another form of nonselective debridement that may be useful for some wounds, such as diabetic or venous ulcers. Enzymatic debridement, a chemical process, is a selective debridement methodit doesn't damage healthy tissue. Carefully read the package inserts of the products you re using. Different types of enzymes behave differently and require specific secondary dressings and changing schedules. Watch for adverse reactions such as inflammation or pain. Enzymatic debridement is contraindicated in patients with clotting disorders. As with any type of debridement, it should be used cautiously in patients with infection, cellulitis. cavity wounds, wounds with exposed nerves, or neoplasms. A doctor can perform surgical debridement, another selective method, at the bedside or in the operating room, depending on the extent of the wound. Surgical debridement is fast and can be extremely effective when performed skillfully. It's contraindicated for patients with clotting disorders. In some cases, nurses who have special preparation (usually nurse practitioners, clinical nurse specialists, and enterostomal therapy nurses) can perform this procedure on clearly identified necrotic tissue. Check your nurse practice act and your hospital's policy and procedure manuals to find out what's allowed in your state and at your institution. Autolytic debridement is the newest method of selective debridement. It's versatile and easy to performall you do is cover the wound with an occlusive or semiocclusive dressing to provide a moist environment. The body's own defense mechanisms clean the wound of necrotic debris. This process isn't as fast as surgical debridement, but it's more selective and usually painless for the patient. Transparent film dressings, hydrocolloids and hydrogels are
40
NURSING92, DECEMBER

good choices to promote autolysis. But use caution with immunosuppressed patients or patients with infected wounds. Protect healthy tissue Good skin surrounding a wound is vulnerable to maceration, erosion, and insults from wound exudate, repeated dressing changes, or other trauma. If the skin is still intact, you can protect it with skin sealants or moisture-barrier ointments. But if the skin is broken, you'll need to apply a dressing that retains moisture (such as a transparent film dressing or a hydrocolloid) to protect the wound margins. Use a pressure-relieving device for example, pillows, chair cushions, mattress overlays, or specialty beds to protect skin and tissue from ischemia. But don't use doughnut cushion devices because they create larger areas of ischemia.

Eliminate dead space Exudate or wound fluid can accumulate in undermined or tunneled areas or in sinus tracts. These areas are known as "dead space." Dead space becomes a breeding ground for bacteria and other organisms. To prevent problems, eliminate the dead space by lightly packing it with gauze strips or rolls or by filling the space with an exudateabsorbing product, such as calcium alginates, copolymer starches, absorption dressings, foams, hydrocolloid paste, or hypertonic saline gauze..

Evaluate and reevaluate the wound Some wounds are simply baffling. If you aren't sure what you're seeing, consult your enterostomal therapy nurse, clinical nurse specialist, wound care specialist, a dermatologist, or a plastic surgeon immediately. Select dressings thoughtfully Similarly, you'd consult a specialThe proper dressing ist if the wound hadn't responded to will help the wound 1 or 2 weeks of treatment. Cancer heal. That's why you need to care- can develop in chronic wounds, defully consider the dressings avail- laying healing. Serial biopsies of susable and choose the one that will picious lesions in the wound will best suit your patient's needs. Check rule this out. Other common causes the specific advantages and disad- of delayed wound healing include vantages of them in Comparing systemic factors (such as ischemia Wound Dressings. The broader the or poor nutrition and hydration starange of products in your arsenal, tus) and local factors (such as subthe better your chances of selecting clinical infections and unrelieved the right dressing for a wound. pressure). Sometimes you may need to comImpaired circulation will delay bine products from different cate- healing too. Without blood flow to gories to produce the best result- the area, the wound won't get the in fact, combining dressings Is the blood, oxygen, and nutrients needed wave of the future in wound care. for regeneration and repair. Toxic For example, you might use a hy- substances build up in the area, furdrogel to keep the wound bed moist, ther delaying healing. And some cover it with a foam to adsorb ex- bacteria thrive in an ischemic envicess exudate, and cover that with a ronment. If this is the cause of detransparent film to retain moisture layed healing, consult with a doctor and provide a secondary dressing. to determine how circulation can be You can't combine these dressings improved. haphazardly, thoughyou need to know which products complement Control costs each other so you don't harm the paTreating wounds is tient. Combining an occlusive dresscostly. So focusing on ing with an enzymatic debriding prevention and early agent, for example, could cause se- intervention rather than treatment vere cellulitis and seriously damage itself is a cost-saving philosophy the wound. Make sure you read the the old adage "an ounce of prevenguidelines on the package inserts tion is worth a pound of cure" is so for information on safely combining true in wound care. You can save a products. lot of money for your itistitution and

your patient by using wound care products judiciously. For example, suppose your patient is at high risk for a pressure ulcer and you apply a pressure-relieving device costing $50. That's money well spent if it prevents a pressure ulcer, which couJd cost as much as $30,000 to treat not to mention the pain and suffering the patient would have lo endure. A homebound patient can cut costs too. Why should he spend $6 for a bottle of normal saline solution to fiush a wound when he could simply add 2 teaspoons of salt to a liter of boiled water that's been cooled? The result is the same. Many studies have shown that the costliest component of dressing changes is the nurse's time. Using dressings that need changing less frequently (for example, hydrocolloids, hydrogels, calcium alginates, exudate absorbers, and foams) saves thousands of nursing hours. Also, using a no-touch technique for selected wounds instead of strict sterile technique can save a singie facility hundreds of thousands of dollars a year on sterile gloves, drapes, and barriers. Know your limits and the limits of treatment Your state's nurse practice act sets the limits of your wound care. For example, RNs in all states can perform routine wound care and dressing changes. As I mentioned, only some states allow you to perform surgical debridement. Make sure you're familiar

with the scope of practice in your area. Also, recognize which wounds should be left alone. I once cared for a bedridden woman with blackened, intact. Stage IV pressure ulcers on her heels. Because she had poor circulation in her legs, we didn't debride these pressure ulcers. Doing so would have created deep, open wounds that wouldn't have healed but could have become routes for systemic infection. So we elevated her legs with pillows to relieve pressure on the heels and monitored the eschar to make sure it didn't worsen. Similarly conservative treatment might be appropriate for a terminally ill patient subjecting him to potentially painful treatment may be counterproductive In his last weeks of life. Certain wounds are beyond the scope of topical treatment and will require surgical intervention. Refer severely undermined or tunneling wounds, wounds over difficult areas (joints, elbows, or the greater trochanter), wounds involving bone, and deep wounds in immunocompromised patients to a surgeon or plastic surgeon for evaluation. The patient may need a myocutaneous flap repair to cover a wound that isn't healing. IVeat the whole patient, not just the wound A wound disrupts the patient's entire life, so provide holistic care. Nutritional support may be as important as local wound care. Without enough proteins, vitamins.

minerals, and calories, the patient can't form the collagen and granulation tissue needed to regenerate and repair the wound. Monitor serum albumin levels and request a nutritional consultation if the results are borderline or low. Also watch the patient's hydration. If it's inadequate or if he's showing signs of dehydration (decreased skin turgor and sunken eyeballs, for example), carefully monitor his intake and output and give fluid replacement as needed. And don't forget the medical or nursing problem that brought the patient to the hospital in the first plaeepatients are rarely admitted solely because they have a wound that hasn't healed. Draw on the skills of a multidisciplinary team of health care professionals including nurses, doctors, physical therapists nutritionists, pharmacists, and social workers to deliver the comprehensive care your patient needs. B
SELECTED REFERENCES Colburn, L.: "Preveniing Pressure Utcers: How to Recognize and Care for Puticnis at Risk." Nursin^,90. 20(12):6()-6.'i. December tWO. Krasner, D.: "Resotvingttic Dressing Ditemma; Selecting Wound Dressings by Category," OslomylWaund Mana^menl. 35:62. 64-70, July/ August 1991. Krasner. D. ^ d ) : Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. King of Prussia, Pa.. Health Management Publications. 1990. Maklebust, J., and Sieggreen. tW.: Pressure Ulcers: Guidelines for Prevention and Nursing Management. West Dundee, lit.. S-N Pubticalions. Inc.. 1991. National Pressure Utcer Advisory Panel: "Pressure UtcersPrevalence. Cost and Risk Assessment: Consensus Development Conference Statement." Decuhitiis. 2(2):24-:a, May 1989. Panet for the Prediction and Prevention of Pressure Utcers in Adutts: Pressure Ukerx in Adults: Prediction and Prevention. Rockvitte. Md., Agency for Health Care Policy and Research, May 1992.

Take the test on the next pageand earn CEUs. Here's what to do:
1 . Write your answer in the corresponding box or blank on the answer form WITH A PENCIL. 2 * Fill in your name, address, state(s) of licensure, license number(s), and Social Security number in the spaces provided on the answer form. 3 . Cut out the answer form only (keep the test) and mail it to: The Nursing Institute, 2710 Yorktowne Blvd., Brick, NJ 08723. A $12.95 processing fee is required. Send a check, payable to The Nursing Institute. In 4 to 6 weeks, you'll be notified of your test results by The Nursing Institute, an affiliate of Springhouse Corporation, publisher of Nursing92. If you pass the test, a certificate for 3 contact hours (0.3 CEU) will be awarded by the Institute, which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditation.* You'll also receive an answer booklet containing the rationale for each correct answer. If you fail the test, an answer booklet will not be sent so that you'll have the option of taking the test again (at no additional cost).
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NURSING92, D E C E M B E R

41

'TTTTrrTTTTTTTTTTTTTTTTTTTTTTTTTTTl

THE 12 COMMANDMENTS OF WOUND CARE

CEU OBJECTIVES After reoding the preceding orticle and toking this test, you shoukJ be able to: 1 . ktentify data to assess a wound. 2 . Identify a wound care pbn. 3. Identify solutions artd dressings to be used specific to wound core pnablems. 4 . ktentify cbssification stages of pressure ukers arxJ nursing octions to prevent pressure ulcers from developing.

Measure the depth of a wound by

1. inserting a gloved finger into the wound until you reach the bottom. 2. inspecting the wound and comparing it with a common object. 3. using a measuring guide with concentric circles. 4. inserting a sterile cotton swab, then holding it against a centimeter measuring guide. You can make your own guide for measuring the perimeter of a shallow wound by 1. piecing a plastic bag over the wound and tracing the outer morgins with an indelible marker. 2. drawing concentric circles 1 cm apart on a piece of rigid plastic or old X-ray film. 3. using the sterile side af o dressing wropper and an indelible marker. 4. comparing it with voriaus common objects as its size chor>ges. When measuring wound undermining or tunneling, you'd 1. use a plastic meosuring guide with concentric circles. 2. relate the location to a clock face. 3. use 0 centimeter measuring guide. 4. use gloved finger to explore its depth. If the patient has a fuil-thickness wound, your nursing diagnosis wouid be 1. potential impaired skin integrity. 2. impoired skin integrity. 3. impaired tissue integrity. 4. impaired mucous membranes. Wet-to-dry dressings are used to 1. nonselectively debride a wound. 2. promote gronulation tissue growth. 3. break up debris without damaging tissue. 4. promote macrophage formation.

6.

The agent of choice for cleaning most wounds is 1. povidone-iodine. 2. hydrogen peroxide. 3. sterile distilled woter. 4. normal soline solution. Calcium alginates and hypertonic saline dressings are used to 1. debride wounds. 2. absorb copious exudate. 3. treat local wound infections. 4. stimulate granubtion. Debride wounds that are 1. infected. 2. producing copious exudate. 3. healing slowly. 4. full of eschar or slough. Which of the following is true about wound care treatments? 1. Hydrogels promote autolysis. 2. An occlusive dressing can be combined with on enzymatic debriding agent. 3. Packing a wound with gauze strips helps the wound retain moisture. 4. A hydrogel con't be combined with a foam dressing.

12. Which dressing would you use to nonselectively debrkle some wounds? 1. Tegaderm 3. cotton mesh gauze 2. Svireen-A-Peel 4. Adaptic 13. One way to control the cost of wound treatment is to 1. use the least expensive product avaibbte. 2. use strict sterile technique to prevent secondory infection. 3. make your own normal saline solution in the unit kitchen. 4. use dressings that require less-frequent chonging. 14. A pressure ulcer that appears as a deep crater without undermining of adjacent tissue would be classified as 1. Stage I. 3. Stage III. 2. Stage II. 4, Stage IV. 15. Skin care and early treatment to prevent pressure ulcers should include 1. massaging skin over bony prominences at each repositioning. 2. daily skin inspection v/ith documented assessment, 3. applying a moisturizer to reduce friction injuries. 4. using indwelling catheters for urinary incontinence to prevent skin breokdown. 16. Positioning and support measures to prevent pressure ulcers include 1. repositioning chair-bound pottents every hour. 2. using pressure-reducing mattresses or chair cushions (or all patients. 3. using foam or synthetic sheepskin heel boots on patients who may be at risk for pressure ulcers. 4. turning patients side to side every 2 hours and using the full loterol position.

7.

B.

9.

10. To protect skin and tissue from ischemia, you'd use a 1. doughnut cushion device. 2. skin sealant or moisture-barrier ointment. 3. transparent film dressing. 4. pressure-relieving device. 1 1 . If a wound hasn't responded to treatment in G week or two, you'd 1. revise your entire plan. 2. culture the wound. 3. consult 0 specialist. 4. try a different dressing.

Carefully cut along dotted line.

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ANSWER FORM: WOUND CARE

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Social Siate(s) of Licensure and Nursing License No.fs]

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Before the expirotion dote of November 30, 1993, cut out tfiis form and mail it to; The Nursng Institute, 2710 Yorktowne Blvd., Brick, NJ 08723. Be sure to answer all the questions and enclose your check for $ 1 2 . 9 5 , payable to The Nursing Institute.

WM