932 Unit 8 © Integral Components of Client Care The RYB Color Code ‘To guide wound care, the nurse can use the RYB color code of wounds. This concept is based on the color of an ‘open wound—red, yellow, or black (RYB)—rather than the depth or size of a wound. On this scheme, the goals ‘of wound care are to protect (cover) red, cleanse yellow, and debride black. Wounds that are red are usually in the late regenera- tion phase of tissue repair (i.e., developing granulation tissue). They need to be protected to avoid disturbance to regenerating tissue. The nurse protects red wounds by (a) gentle cleansing (i.e., use of a noncytotoxic wound cleanser applied without pressure); (b) pro- tecting periwound skin with alcohol-free barrier film; (filling dead space with hydrogel or alginate; (4) cov- ering with an appropriate dressing such as transparent film, hydrocolloid dressing, or a clear absorbent acrylic dressing; and (e) changing the dressing as infrequently as possible. Yellow wounds are characterized primarily by liq- uid to semiliquid “slough” that is often accompanied by purulent drainage or previous infection. The nurse cleanses yellow wounds to remove nonviable tissue, Methods used may include applying damp-to-damp normal saline dressings, irrigating the wound, using absorbent dressing materials such as impregnated hydrogel or alginate dressings, and consulting with the primary care provider about the need for a topical anti- microbial to minimize bacterial growth. Black wounds are covered with thick necrotic tissue, or eschar. A stable black wound has a firm surface that should be left in place. Blood flow in the tissue under the stable eschar is poor and the wound is susceptible to infection. The eschar acts asa natural barrier to infection by keeping the bacteria from entering the wound. An unstable black wound has a loose, spongy, soft surface Pests) Cleaning Wounds * Follow stander precautions for personal protecton. Wear loves, gown, goggles, and mask as indicated + Use solutions such as isotonic saline or wound cleansers to Clean or iigate wounds. If antimicrobial solutions are used, rake sure thay ae wel dluted. + Microwave heating ofiquids to bo used on the wound 's ‘not recommendied. Wher possible, warm tne solution to body temperature before uso. Rationale: This prevants lowering the wound temperature, which slows the healing process. Microwave heating could cause the solution to become too hat. + fa woundis grossly contarrinated by forsion material, bacteria, slough, 0 neeratetissve, clean tha wound al avory dressing change. Rationale: Foreign bodies and devitalized tissue act {as a focus fer infection and can delay heaing. * a wound is cloan, has ite exudate, and rovoas haathy granu lation tssue, acid repeated cleaning, Rationale: Unnecessary that will need to be removed through debridement for the wound to heal. Debridement may be achieved in four different ways: sharp, mechanical, chemical, and auto- lytic, In sharp debridement, a scalpel or scissors are used to separate and remove dead tissue. In many settings, specially trained nurses (wound ostomy continence nurses [WOCNs)), physical therapists, and physician assistants are permitted to perform sharp debride- ment. Mechanical debridement is accomplished through scrubbing force or damp-to-damp dressings. Chemical debridement is more selective than sharp or mechanical techniques. Collagenase enzyme agents such as papain- urea are currently most recommended for this use. In autolytic debridement, dressings such as hydrocolloid and clear absorbent acrylic dressings trap the wound drainage against the eschar. The body’s own enzymes in the drainage break down the necrotic tissue. Although this method takes longer than the other three, it is the most selective and therefore causes the least damage to healthy surrounding and healing tissues. The use of fly larvae (maggots, Phaenicia sericata and other species) can be extremely effective in cleansing chronic wounds because the maggots secrete enzymes that break down necrotic tissue (while leaving healthy tissue untouched), eat bacteria, and decrease bacterial growth through the rise in surface pH that results from their presence (Wilson, Nigam, Knight, & Pritchard, 2019). Cleaning Wounds Wound cleaning involves the removal of debris, such as foreign materials, excess slough, necrotic tissue, bacteria, and other microorganisms. The choices of cleaning agent and method depend largely on agency protocol and the primary care provider's preference. Recommended guide- lines for cleaning wounds are shown in the accompanying Practice Guidelines. cleaning can delay wound heaing by traumatizing newly pro- ‘duced, deca tissues, reducing the surface temperature ofthe wound, and removing exudate, which self may have bactericil properties. “Uso gauze squares or nonwoven swabs that do not shod ‘bers. Avoid using cotton balls and other products that shed foors onto the wound suriaco, Rationale: The fers become ‘embedded in granulation tissue and can act a foc for Infection. They may also stimulate “foreign body" reactions, prolonging the infammatory phase of heaing and delaying the heaing process. “+ Avoid drying a wound after cleaning it. Ratlonale: This helps retain wound mosture, ‘+ Hold clearing sponges with forcops or with gloved hand, + Consider not clearing the wound at all iit appears to be clean,Cleaning Surgical Wounds Not all dressings on surgical wounds require changing, Sometimes surgeons in the operating room apply a dress- ing that remains in place until the sutures are removed, and no further dressings are required. In many situations, however, surgical dressings are changed regularly to pre- vent the growth of microorganisms. Surgical drains are inserted to permit the drainage of excessive serosanguinous fluid and purulent mate- rial and to promote healing of underlying tissues. These drains may be inserted and sutured through the inci- sion line, but they are most commonly inserted through stab wounds a few centimeters away from the incision line so that the incision itself may be kept dry. Without a drain, some wounds would heal on the surface and trap the discharge inside, and an abscess might form, ‘These devices (e-g., the Penrose drain) have an open end that drains onto a dressing, The main surgical incision is considered cleaner than the surgical stab wound made for the drain insertion. The main incision is therefore cleaned first, and under no circumstances are materi- als that were used to clean the stab wound used subse- quently to clean the main incision. In this way, the main incision is kept free of the microorganisms around the stab wound. Figure 36.10 I “wo Jackson Prat dovices comoressed to facitte colecton of exudates, Chapter 36 © Skin Integrity and Wound Care 933 Wound Drainage Systems A closed wound drainage system consists of a drain con- nected to either an electric suction or a portable drainage suction, such asa Hemovac (Figure 36.91) or Jackson-Pratt (Figure 36.10 m). The closed system reduces the poten- tial entry of microorganisms into the wound through the drain. The drainage tubes are sutured in place and connected to a reservoir. For example, the Jackson-Pratt drainage tube is connected to a reservoir that maintains constant low suction. These portable wound suctions also provide for accurate measurement of the drainage. The surgeon inserts the wound drainage tube during, surgery. Generally the suction is discontinued 3 to 5 days postoperatively or when the drainage is minimal. When ‘emptying the container, the nurse should wear gloves and avoid touching the drainage port (Figure 36.11 M). To rees- tablish suction, the nurse places the container on a solid, flat surface with the port open, and cleanses the opening and plug with an alcohol swab. The palm of one hand then presses the top and bottom together while the other hand replaces the drainage plug before releasing hand pressure to reestablish the vacuum necessary for the closed drain- age system to work (Figure 36.12 M. Skill 36.1 describes cleaning and dressing a surgical ‘wound and drain, Figure 36.12 I Witn one hanc, press the top and bottom togethes With the otfer hand, repiace the plug beter rooasing hand.Cea 934 Unit 8 © Integral Components of Client Care PURPOSES + Topromote wound healing by primary intention + Toprevent infection ‘+ Toassess the heaing process + Toprotect the wound trom mechanical trauma ‘ASSESSMENT Assess ‘+ Cient allergies to wound cleaning agents + The appearance and 828 ofthe wound ‘+The amount and character of exudates + Gient complaints of discomfort ‘+ The time ofthe last pain medication ‘+ Signs of systemic infection (86, sevated body temperature, laphoresis, malaise, leukocytosis) PLANNING. Bofore changing a dressing, dotorine any specific odes about the wound or crossing, Assignment Cleaning a wound, especialy ono with a drain, equites application of knowledge, problem-solving, and aseptc technique. AS a resul, this procecure is not assigned to assistive personne! AP, The nurse can ask the AP to report soled cressings that nead to be changed or fa cressing has become loose and needs to be renforced. The nurse s responsible fr the assassmont and evaluation ofthe wound Equipment Bath blanket (f necessary) Mosture-proot bag Mask (optional ‘Acetone or another soluton{f necessary to loosen achesive) Ciean gloves: Sterie gloves Storie dressing set * Drape or towel Gauze squares Gontainer for cleaning solution Gieaning solution (2.9, normal sane) “Two pars of forceps Gauze crossings and surgipads ‘+ Additonal supplies required forthe particular dressing (0.9, extra gauze dressings and oriment, f ordered) + Tape tie tapes, or binder IMPLEMENTATION Preparation Prepare the cient and assemble the equipment, * Obtain assistance for changing a dressing ona restless or con- fusod clent. Rationale: The clont might move and contaminato the sterile flor the wound. + Assist tne clont to a comfortable poston in whieh the wound ‘can be ready exposed. Expose only the wound area, using a bath blanket fo cover the ciant, If necessary. Rationale: Undue exposure is physicaly and psychologicaly distressing to most inaiauial, + Mace @ cut on the moisture-proot bag for disposal ofthe soiled dressings, and place the bag within reach. Rationale: Making 2 Cuff eps keep the outside ofthe bag free from contamination »by the soled aressings and prevents subsequent contamination ofthe nurse's hans or of sterile instrument tips when discard ing dressings or sponges. Placement of tho bag within reach prevents the nurse rom reaching across the ster fet and the wound and potentaly contaminating these areas. + Apply a face mask, if requzed, Rationale: Some agencies require that a mask be worn for surgical dressing changes to prevent contamination of the wound by droplet spray fram the ‘nurse's respiratory tract. Performance 1. Proto performing the procedure, introduce sland verily the cf- nt’ ident using aganey protocdl. Expian to the ciort what you are going to do, why tis necessary and how to paricpate, Dscuss| how the resus wilbe used planning further car or treatments. 2. Perform hand hygiene and observe other appropri prevertion control procedures, 3. Provide for cent privacy 4, Remove and aspose of soiled cressings appropriatoy. + Apply clean goves and remove the outer abdominal dressing or surgioad, + adhesive tape was used, move by holing down the skin and puling the tape gantly but fly toward the wound. Rationale: Pressing down on the skin provides countertrac- fon against the pulng motion. Tape s puled toward the inci ‘80 f6 prevent strain onthe sutures or wound. ‘+ Lift the outer dressing so thatthe underside is away trom the cfent’s fac. Rationale: The appearance and odor of the dranage may be upsetting o the clent. *+ Pace the soiled dressing in the mosture-proof bag with- ‘out touching the outside of tho bag. Rationale: Coram! ration ofthe outside of the bag is avoided to prevent the ‘Spread of microorganisms fo the nurse and subsequent to others. ‘+ omove the undordessings, taking caro not to cisiodge ‘any drains the gauze sticks to the drain, suppor the drain vith one hand and remove the gauze with the other. *+ Assess the location, type (ool, consistency, and odor of ‘wound drainage, and the number of gauzas saturated or the diameter of drainage colected on tha dressings. ‘+ Discara the soled dressings in tho bag as before. ‘+ Remove and discard gloves inthe molsture-proo! bag. + Porform hand hygiene. 5. Set up the stare suopies. ‘Open the stele dressing set, using aseotic technique. + Pace the sterile drape beside the wound, ‘+ Opon the stele cleaning solution and pour it over the gauze sponges in the plastic container, + Aopiy sterie doves. 6. Clean the wound, indicate. ‘Clean the wound, using your gloved hands or forceps and ‘gauze swabs moistened with cleaning solution. + fusing foreops, koop the forcops tips lower than tho handles at al times. Rationale: This prevents theirCleaning a Sutured Wound and Dres: Chapter 36 © Skin Integrity and Wound Gare 935 g a Wound with a Drain—continued sa124 a @ Methods of cleaning surgical wounds: A, clearing the wound rom top to bot, starting al he center; B, cleaning a wound outward rom the Ineson; C, cleaning around a Penrose dra sto, For all methods, a clan stevie swab Is used foreach are, ‘Aca pckriy LW. OS. ‘contamination by fd travoing up tothe handle and nurse's wrist and back to the tps. ‘+ Uso the caring mathodsilustratod and doscrivod in @ or ‘one recommencied by agency protocdl. + Uso a soparate swao for each stroke and discard each swab alter use. Rationale: This prevents the introduction of ‘microorganisms fo other wound aroas. + ra drain is present, clan it next, taking care to avoid reach ing across the coanod incision. Ciean tho sn around tho igure 36.18 I Dressings ever roving paris must remain s2cure| despite the clont's movement. Paco tho tape over ait ata ght angle tothe drecton the jort moves.Figure 36.16 Bl Mortoamery straps, ots tapes, ar used to secure large cessings that requre Frequent changing. Chapter 36 © Skin Integrity and Wound Gare 944 ‘These straps prevent skin irritation and discomfort caused by removing the adhesive each time the dressing is changed, Medical tape can cause injuries if used incorrectly. Blisters will form if ton much tension is applied while placing the tape, when edema has collected alter the tape ‘was placed, and when aleohol or benzoic-based prep solu- tions are used under the tape. Medical tape manufacturers issue safety guidelines for specific tape products. Before using medical tapes read the safety guidelines for indica- tions of use and safe application and removal Skill 36.3 provides guidelines to obtain a specimen of ‘wound drainage. ESTEE eR LSE CURL a Sy PURPOSES * To identify the microorganisms potently causing an infection land te antibiotics to Which they ae sensitive + To evaluate tho etectvenoss of antotic therapy ‘ASSESSMENT Assess ‘Appearance of the wound and surounding tissue, Check the character and amount of wound drainage ‘+ Glent complaints of pan or discomfort at the wound ste ‘+ Sans of nection such as fever, chils, or elevated white blood ‘col WBC) count PLANNING Before obtaining a specimen of wound drainage, deterrine (a) whether the wound should be cleaned prior to obtahing the specimen and {bj whether the ste rom whion to fake the specimen has been specfes, Assignment Obtaining a wound cultures an invasive procedure that requies the application of sterie technique, knowledge of wound healing, and potental problem-solving to ensure clint safety; therefore, the nurse heeds to portorm ths sal and doos not assign t to AP. Equipment Personal protective equipment, goggle, and gown if approprate Giean gloves Storie aloves if needed for aseotic technique Mosture-proot bag Storie drossing sot NNorral saine and irgating sings CCuture tube with swab and transport medium fzerobic and anaerobic lubes are avalabl) or stele syringe with need for anaorotic culture ‘+ Completed labels for each container “Completes reauistion to accompany the specmmens to the laboratory IMPLEMENTATION Proparation (Check the medical orders to determine I the specimen isto be: lected for an aerebie (growing ony in the presence of oxygen) or anaeroble (grving only n the absonce of oxygan) culture. Aorobic ‘organisms are gereraly found on the surface of he wound, whereas, anaerobic organisms Would be found in deep wounds, tunnels, and Cavities. Administer an analgesic 30 minutes before the procedure it the clients complaining of pan atthe wound ste Performance 1. Prior to performing the procedure, introduce sel and verity the cSent's identity using agency protocol, Explain tothe cient hal you are going fo do, wy tis necessary, and how fo par tiepate, Discuss how the suits wa be used in planning further ‘cao or toatments, 2, Perform hand hygiene and observe other appropriate infection prevention procedures. Provide for elent privacy. . Remove ary outer dressings that cover the wound. + Apply clean gloves. ‘+ Remove the outer cressing, and observe ary drainage on the dressing. Hold the dressing 60 that the client doos not 20 the drainage, Rationale: The appearance of the drain age could upset the client. + Determine the amount, color, consistency, and odor of the ‘ranage, for example, “ane 44 gauzo saluratod with pala yellow, thick, malodorous drainage.” *+ Discard the dressing in tho moisture: proof bag. Handi it ‘caetuly so thatthe dressing does not touch the outside ff the bag. Rationale: Touching the outside ofthe bag wil contaminate it ‘+ Ramavo ana discard gloves. + Perform hand hygene. ‘Continued on page 942 PreyLe 942 Unit 8 © Integral Components of Giient Care Ce ina ke eee une ced 5. Open the stele dressing set (s00 Skil 31.9) 16. Assoss the wound, + Assos tho appoarance of tho tissuos in and around the ‘wound and the drainage. Infection can cause reddened tissues witha thick discharge, which may be foul smeting, \hiish, or cotored, leanse the wound using aseptic technique. + Apply gloves * fa topleal antimicrobial olntmont or cream is boing sed fo treat the wound, wipe or irigate (see Skil 36.2) tovemeve it, Rationale: Resioual antiseptic must be removed prior to cute + Caan the wound with normal saline unl al exudate has ‘been removed. + Aitor cleansing, appy a storie gauzo pad o the wound. Rationale: This absorbs excess cleansing soliion. + Rlomove and ciscard gloves. + Perform hand hygiene {8 Obtain the aerebic cut. ‘Apply clean gloves, * Opon a spocimon tubo and place the cap upside down on ‘afr, dry surface so thatthe inside wll not become con- taminated, ori the swab is attached tothe id, twist the cap toloosen the swab. Hold the tube in one hand and take out the swab inthe ther. + Rotate the swab back and foth over clean areas of granulation ‘sup tom tha Sdes or base of the wound. Rationale: cro: ‘organisms most likey to be responsible for @ wound infection resco in viable tssu0. @ * Do not use pus or pooled exudates to culture, Rational ‘These sacrations contain a mixture of contaminants that are not the same as those causing the infection. * Avoid touching the swab to intact skin atthe wound edges. Rationale: This prevents the introduction of supercial skn ‘organisms into the cuture ‘Return the swab to the culture tube, taking care not to touch the top othe outside ofthe tube. Secure the swab ‘orld iriy, Rationale: The outside o the container must remain tres of pathogenic mecroorganisme fo prevent thar spread to others. @ + Crush the barter othe inner compartment contaning the transport mecium atthe bottom othe tube, Rationale: This ensures that the swab wit the specimen is surrounded bby medium, wich prevents the specimen from drying out or any meroorganisms from continuing to muti. @ ia spoci- ‘men is requited from another site, repeat the steps, Soscty the exact ste (@.9., inferior drain ste or lower aspect of {© Cetaining a cuture specimen trom the base ofthe wound @ Fem the sya othe cuturtte tube. {© Break the ampule containing the transport medkum, incision onthe label of each container. Be sure to put each ‘swab inthe appropriately labeled tube. 9. Dress the wound, ‘Apply any ordorad mocication to tho wound, + Cover the wound with a sterle wound dressing. See “Table 26.4 (oage 889) for selecting a wound desing, ‘+ Remove and discard gloves, + Perform hand hygiane. 410. Arrange fo the specimen to be transported tothe laboratory Immesiatay, Bo sure to include the comptod raquiston. 11. Document all relevant information, ‘+ cord on the efen's chart the taking ofthe specimen and ‘Include the date and tme; the appearance of the wound: the color, consistency, amount, and odor of any drainage: tho type ofcuture colected: and any csscomfort expor- ‘enced by the cls SAMPLE DOCUMENTATION 15/27/2020 1000 Specimen trom ® hip to lab for anaerobic culture Wound 2x3 om, é-mm deep, minimal amount thick yetow drainage. 'No odor. Skin around wound erythematous. Pain 0 on 0-10 scale, IN. Jamaghani, RNChapter 36 © Skin Integrity and Wound Care 943 Cn ina Ok een ced Variation: Obtaining a Specimen or Anaerobic Cute + Label ne tube or singe appro + hop clean doves 1 Remove an erent ges * Insert a sterile 10-mL syringe (without needle) into the wound, ‘Perform hand hygiene. o and aspirate 1 to § mL of drainage into the syringe. '* Send the tube or syringe of drainage to the laboratory immedi- Ef '* Attach the needle to the syringe, and expel all air from the: ately, Do not rettigerate the specimen. c Syringo and ned. a + medline ihe raage hohe snarbic tre be a andcap the ibe to S + Gowan aortic cute sna syst winch svao 8 ‘redial poss nto she sad than ony oe ges or gpl entonent EVALUATION + Comes ngs of wound asassent a carage 0 ev + Condit sopropriafolowup such as arinseingantioos cum sass deterne any changes er mesiveg wourd vont as Gos + Report te cute est oho rary eae pride J INFANTS “The sin of infants is more ragle than that of older chidken and ads, and more suscapline 0 faction, shearing tom ficton, and burns CHILDREN ‘+ Staphylococcus and fungus aro two malor infectious agonts afectng te skin of chidren. Abrasions or sal lacerations, commonly experienced by ciloron, provide an entry inthe skin for these organisms, Minor wounds shou be clearsed with ‘warm, soapy water and covered with a stele bandage, Children should be instructed not to touen the wound ‘+ With more serious skin injuries, remind the child not to touch the wound, drains, or dressing. Cover with an appropriate bandage that wil romain intact curing the childs usual actives. Cover a transparent dressing with opaque matral i ening tha sito i cstrssing to the cid. Restrain only wnen all atorna tives have been tried and when absolutely necessary + For youngor chien, demonstrate wound caro on a dol. Roas 8128 thatthe wound wil ot be permanent and that nothing will {all out of the boy, hse eeaeuen ey Pressure Injury and Wound Care ‘OLDER ADULTS: 4 wrinkled skin taut during application ofa transparent dressing. Obtan assistance f needed. SSknis more fragile and can easly tea” with removal of tape (especially adhesive tape). Use paper, clea, or foam tape and ‘ape remover as indicated, keeping tape use to the minimum required. Use extreme caution during tape removal. possibe, se conforming gauze bandage (2g. Flastoml, Fiexcon Keil Lite, or King) or elastic sel-acherent prockicts (0.9, Coban of Cote 1 hold a dressing in pe (Older aduts who ae in long-term care facts often have the folowing conditions: mmobily, manutton, and incont- rnenco—al of which increase the sk for devolopment of skin ‘breakdown ‘Skin breaktown can occur as quicky as witrin 2 hours, so ‘assessments should be done with each repositioning of the cl. ‘Athorough assossmant ofa clan's heels should be done every Shit. Tha skin can break down quickly from freon of mows ‘mont in bed CE) Cation: Centered care: Provicing Wound Care at Home Almost all wounds will be healing while the client is at home, Whether the nurse is performing wound care for the client or supporting the client and family in perform- ing wound care themselves, certain principles apply. + Perform appropriate client teaching for promoting wound healing and maintenance of healthy skin + Instruct family about hygiene and medical asepsis; hhand cleansing before and after dressing changes; and using a clean area for storage of dressing supplies. + Instruct the client and family on where to obtain needed supplies. Be sensitive to the cost of dressings (eg, transparent barriers are costly) and suggest less expensive alternatives if necessary. Be creative in the use of household items for padding pressure areas Instruct the client and family in proper disposal of con- taminated dressings. All contaminated items should be sealed in moisture-proof containers. Verify how the client may bathe with the wound (ie., does the wound need to be covered with a waterproof barrier or should it be cleansed in the shower?) Tap water may be used to cleanse wounds instead of normal saline (Cornish & Douglas, 2016; Edwards- Jones, Atkin, & Guttormsen, 2018). Provide pain medication approximately 30 minutes before the procedure if the wound care causes pain or discomfort Keep pets out of the area when setting up for and performing procedures. Instruct the client and family to report any increasing wound drainage, pain, or redness; increasing swelling; or opening or gaping of wound edges.