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UNIT 4 Supporting Physiological Function
Wound and Tissue Pain Routinely ask your patients about pain or discomfort related to the wound or wound care. You will need to develop a pain man- agement plan if the patient is uncomfortable. Key Point: Always take the patient’s complaint of pain seriously, especially if there is a sudden increase. Pain is often an early symptom of infection—in the immunocom- promised patient, pain may be the only symptom of infection. Nutritional Status Screen and assess the nutri- tional status of each patient admitted with a pressure injury and whenever there is a change in the patient’s condition. A referral to the dietitian for early assess- ment and intervention may be necessary if nutritional problems are present. Sufficient calories are needed for wound healing. This plan may involve adding oral supplemental meals or even enteral or parenteral nutrition. Assessing Untreated Wounds For an untreated wound, make the same assessments as for a treated wound. Make additional assessments that allow you to determine the immediate treatment needed. For example, assess for bleeding. If bleeding is profuse, apply direct pressure to the site. If bleeding continues after you apply pressure for 5 minutes or if blood is spurting from the wound, call the provider immediately. Severe pain, numbness, or loss of move- ment below the wound also requires immediate, com- prehensive evaluation. For a description of focused assessment for an untreated wound,
studies, and wound cultures. To learn more about these tests and see the normal ranges, See Chapter 32, Diagnostic Testing, Tests for Assessing Wounds , in Volume 2. Wound cultures may be ordered to determine the types of bacteria present. Local or systemic signs of infection, suddenly elevated glucose levels, pain in a neuropathic extremity, or lack of healing after 2 weeks in a clean wound may indicate the need for a wound culture. Cultures may be obtained by swab, aspiration, or tissue biopsy. Swabbing The most common and most noninva- sive method to obtain a culture is with a swab. Swab specimens have been shown to be acceptably accurate in representing bacteria counts biopsied from a wound (Haalboom et al., 2018). The use of swab cultures is a reasonable alternative to biopsy in the clinical setting, except when antibiotic-resistant bacteria are suspected
(Copeland-Halperin et al., 2016). To see the complete procedure,
Go to Chapter 32, Procedure 32-1: Obtaining a Wound Culture by Swab, in Volume 2.
Needle Aspiration Specifically trained providers (e.g., physicians, advanced practice nurses) may per- form needle aspiration of a wound. This procedure involves the insertion of a needle into the tissue to aspi- rate tissue fluid. Organisms present in the tissue fluid can then be detected. Needle aspiration is an invasive procedure with the risk of inadvertent needle damage to tissue and underlying structures. Tissue Biopsy The most accurate method for cul- turing a chronic wound is tissue biopsy. It has long been considered the “gold standard.” A specially trained pro- vider removes tissue from the wound edge and sends it to a pathology laboratory or other specialized diag- nostic center. This invasive procedure creates a risk of sepsis, causes pain, and disrupts the wound bed, some- times causing delayed healing. Knowledge Check 32-7 ■ What should be included in a wound assessment? ■ What is the preferred method of wound culture that may be performed by a registered nurse (RN)? ■ Identify three types of laboratory data that may be associated with a delay in wound healing. What Assessments Can I Delegate? Initial assessment of a wound, as well as ongoing evalu- ation of a wound that requires treatment, must be done by the RN. You may delegate the following to unlicensed assistive personnel (UAP): ■ Inspection of the skin for evidence of skin break- down. Instruct the UAP to notify you of redness,
See the Chapter 32, Focused Assessment, Physical Examination: Wound Assessment, in Volume 2.
Tetanus Immunization Determine whether the patient needs a tetanus immunization. Tetanus-prone wounds include compound fractures, gunshot wounds, crush injuries, burns, punctures, foreign object injuries, wounds contaminated with soil, and wounds neglected for more than 24 hours. An immunization should be given if: ■ The last immunization was 10 or more years ago (Cen- ters for Disease Control and Prevention [CDC], 2020; Havers et al., 2020). ■ The wound is contaminated with dirt or debris or is a burn, and the most recent tetanus immunization was given more than 5 years ago. ■ It is uncertain when the patient last received an immunization. Laboratory Data You should integrate laboratory data with your history and physical assessment findings. The most common laboratory assessments related to skin integrity are pro- tein levels, complete blood count, erythrocyte sedimen- tation rate, glucose, thyroid and iron levels, coagulation
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