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Nurse Teachings on Wound Care

Reference: https://www.homehealthpatienteducation.com

Home Health Patient Education offers more than 7200 nurse teachings and OASIS assessment templates for Start of Care, Resumption of Care, Recertification, Discharge, Wound Care and 60 Day Summary. These nurse teachings and OASIS assessment tools are very useful for home health nurses to save time on skilled nursing documentation.

We are presenting here some sample nurse teachings on wound care offered by Home Health Patient Education.

Nurse Teachings on Wound Care: Signs and Symptoms of Wound Infection

Patient/caregiver were instructed upon signs and symptoms of wound infection as follows:

  1. Chills & Fever: Individuals with infected wounds could present with chills and elevated body temperature. During infection, human body tends to display a natural immune response of elevated temperature, as infecting microorganisms multiply poorly at higher body temperature. Once the new higher temperature set point is decided, individuals start shivering and chilling, which leads to extensive muscle contractions and relaxation. This muscle contraction and relaxation generates the needed heat to raise the body temperature from where it is to the new higher set point, resulting in fever.
  2. Increasing pain: Wound that is healing well presents with progressively subsiding pain levels. The microorganisms in an infected wound increasingly trigger the nerve cells at the wound site causing increased pain. Progressively increasing pain in a wound site can be a clear sign for infection and need to be investigated further.
  3. Increasing erythema: Wounds usually have some associated inflammation and consequently, present with some redness or erythema around the wound. The erythema should progressively reduce in a wound that is healing on schedule, without any complications. An infected wound can present with furthering/worsening of the inflammatory process, resulting in deepening and expanding of redness around the wound site. Keeping track of the erythema at a wound site, by taking picture of the wound every time the dressing is changed, can help an easy comparison.
  4. Increasing swelling: Wounds usually have some associated inflammation and consequently, present with some swelling of the wound site. The swelling should progressively reduce in a wound that is healing on schedule, without any complications. An infected wound can present with furthering/worsening of the inflammatory process, resulting in persistent and increasing swelling of the wound site. Keeping track of the swelling at a wound site, by measuring the swelling of the involved body part using a tape, every time the dressing is changed, can help an easy comparison.
  5. Unduly warm skin around the wound site: Wounds usually have some associated inflammation and consequently, present with some warmth of skin around the wound site. The warmth should progressively reduce in a wound that is healing on schedule, without any complications. An infected wound can present with furthering/worsening of the warmth, resulting in persistent and increasing warmth of the wound site.
  6. Increasing drainage from the wound site: Wounds can present with serous (drainage that is thin and clear), serosanguineous (thin and clear drainage mixed with some blood, pink in color), or sanguineous (frank red blood) drainage. The drainage should progressively reduce and contain in a wound that is consistent with healing. An infected wound can present with furthering/worsening of the drainage, resulting in persistent and increasing drainage from the wound site.
  7. Changes in the nature of drainage from the wound site: Change in the nature of drainage from serous to other forms (serosanguineous or sanguineous or purulent (yellow or brown colored thick fluid, often with foul odor) can be a sign of worsening wound condition & infection and requires appropriate medical attention.
  8. Foul odor or worsening of odor from the wound site: A clean wound should usually not emit any unpleasant odor. If a wound continues to emit unpleasant odor, despite regular cleansing and irrigation, it could be a sign of infection and requires further investigation.
  9. Increasing size or depth of the wound: The size of a wound should progressively reduce in a wound that is healing on schedule, without any complications. An infected wound can present with worsening of the local wound conditions, resulting in extension of wound borders, increase in the wound size, and further deepening of the wound. Keeping track of the wound measurements, by measuring the wound site on every dressing change, can help an easy comparison.
  10. Change in color of the wound bed and surrounding wound environment: A normally healing wound should display a healthy pinkish – bright red color to the wound bed and surrounding environment inside the wound. This color is due to the growth of healthy granulation tissue, which is the tissue helping for wound healing. Any appearance of yellow brown color to the wound bed and surrounding wound environment in the wound could be a sign of infection. Keep close watch with appearance of wound bed and surrounding wound environment during every dressing change.

Nurse Teachings on Wound Care: When to observe hand hygiene protocol

Patient/caregiver were instructed upon when to observe hand hygiene protocol as follows:

  1. Perform hand hygiene before donning the gloves and starting to gather wound care supplies in the patient environment. The supplies are considered a clean environment and accessing the supplies without proper hand hygiene can potentially contaminate them. Read through the wound care orders carefully and gather all the supplies needed. Make sure you have all the supplies needed in place, before starting to perform the wound care.
  2. While performing wound care on a patient, doff the gloves and perform hand hygiene every time you go from dirty/contaminated surface to clean surface, such as, accessing the supplies. Trying to access the supplies in patient environment in the midst of the wound care process can potentially contaminate the supplies and patient environment. If you were to access the supplies while performing the wound care, doff the gloves and perform hand hygiene before accessing the supplies.
  3. While performing wound care on a patient, doff the gloves and perform hand hygiene every time you go from dirty/contaminated/soiled body part to a clean body part on the same patient. Trying to access the clean body part in the midst of the wound care process with soiled gloved hands, without observing hand hygiene, can potentially contaminate the clean body part. If you were to access the clean body part after accessing the patient’s wound, doff the gloves, perform hand hygiene, and don clean gloves again before accessing the clean body part.
  4. In a situation when you are caring for more than one wound on the same patient, doff the gloves and perform hand hygiene every time you change the wound caring for. Individual wounds can have different environments and bacteria thriving. Trying to access different wounds during the wound care process with soiled gloved hands, without observing hand hygiene, can potentially lead to transmission of infections between the wounds. During the wound care process, always remember to doff the gloves, perform hand hygiene, and don clean gloves again before accessing a different wound site.
  5. Always perform hand hygiene after coming into direct contact with wound drainage, body secretions, blood & body fluids, and excreta. Performing wound care without observing hand hygiene, after coming into contact with body fluids & secretions can potentially lead to wound contamination.
  6. Always perform hand hygiene after completing the wound care process, immediately after doffing the gloves. This can help prevent transmission of infection, if any, to other patients you are caring for the day. This can also help prevent contaminating other clean surfaces in the work environment.

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