After completing the chapter, you will be able to accomplish the following:

1. Provide interventions to prevent pressure injury.
2. Clean a wound and apply a dry, sterile dressing.
3. Perform wound irrigation.
4. Collect a wound culture.
5. Provide care to a Penrose drain.
6. Provide care to a Jackson-Pratt drain.
7. Provide care to a Hemovac drain.
8. Apply negative-pressure wound therapy.
9. Remove sutures.
10. Remove surgical staples.
11. Apply an external heating pad.
12. Apply a warm compress.
13. Assist with a sitz bath.
14. Apply cold therapy.

• Assessment
• Clinical Decision Making/Clinical Judgment
• Infection
• Safety
• Tissue integrity

• approximated
• dehiscence
• ecchymosis
• edema
• epibole
• epithelialization
• erythema
• eschar
• granulation tissue
• ischemia
• maceration
• pathogens
• pressure injury
• sinus tract
• surgical staples
• surgical sutures
• tunneling
• undermining
• vasoconstriction
• vasodilation

The skin is the body's first line of defense, protecting the underlying structures, tissues, and organs. Alteration in skin integrity, disruption in the normal integrity and function of the skin and underlying tissues, is a potentially dangerous and possibly life-threatening situation. Disruptions in skin and tissue integrity are called wounds. Patients with a wound and/or pressure injury are at risk for complications such as infection, hemorrhage, dehiscence, evisceration, and delayed wound healing.

The nurse plays a major role in maintaining the patient's skin integrity, identifying risk factors that predispose a patient to a break in integrity, intervening to prevent or reduce a patient's risk for impaired skin integrity, and providing specific wound care when breaks in integrity occur. Nursing responsibilities related to skin integrity and wound care involve assessment of the patient and the wound and staging of pressure injuries (Fundamentals Review 8-1, 8-2, and 8-3), followed by the development of a plan of care, including the identification of appropriate outcomes, nursing interventions, and evaluation of the nursing care. Depending upon the patient's individualized care plan, specific wound care skills may be needed. Refer to Chapter 3 for additional information related to assessment of the skin and integumentary system.

It is important to use appropriate aseptic technique when caring for wounds and pressure injuries to prevent introduction of microorganisms. Hand hygiene before and after dressing changes is imperative; follow Standard Precautions and, if needed, Transmission-Based Precautions when providing wound care. Pressure injuries and chronic wounds may be treated using clean technique (Baranoski & Ayello, 2020; EPUAP, NPIAP, & PPPIA, 2019a; WOCN, 2012). Fundamentals Review 8-4 identifies basic principles related to the use of clean technique and wound care. Refer to Chapter 1 for a discussion of infection control precautions and additional information related to sterile technique, medical asepsis, and clean technique.

Ongoing assessment for possible skin or wound complications is required. An ideal dressing/product is one that provides an environment that promotes wound healing maintains a moist environment to promote healing, manages wound exudate, provides thermal insulation, acts as a barrier to microorganisms, reduces or eliminates pain, and allows for pain-free removal (Baranoski & Ayello, 2020; McNichol et al., 2022; Ousey et al., 2016; WOCN, 2016). There are hundreds of products available for use, each with distinctive actions as well as indications, contraindications, advantages, and disadvantages (see Fundamentals Review 8-5). As a result, inclusion of skills related to the use of each type of product is not possible. It is extremely important for the nurse to be familiar with the indications for and correct application of each type of dressing and wound care product in use. Fundamentals Review 8-5 outlines the characteristics, purposes, and the use of some of these wound dressing products.

Nurses must also be skilled in assessing the patient for pain and employing strategies to minimize the patient's pain experience. Some patients may experience both physiologic and psychological pain related to dressing changes and wound care. Perform a pain assessment prior to and during wound procedures (EPUAP, NPIAP, & PPPIA, 2019a). Ask the patient about pain from the wound and determine if the pain is a one-time episode, occurs with dressing changes, at rest, or is constant pain (Baranoski & Ayello, 2020). If the patient experiences increased or constant pain from the wound, perform further assessments. Increasing pain, especially when accompanied by an increased or purulent flow of drainage, may indicate delayed healing or an infection (Baranoski & Ayello, 2020; EPUAP, NPIAP, & PPPIAa, 2019a). Surgical incisional pain is usually most severe for the first 2 to 3 days and then progressively diminishes. Refer to Chapter 10 for additional information related to patient comfort and pain management.

It is often appropriate and necessary to consult with a wound care specialist, often a wound certified nurse specialist, to plan and coordinate the most effective care for a patient.

This chapter covers general guidelines to assist the nurse in providing care related to skin integrity and wounds. The nurse must be familiar with the indications for and correct application of the prescribed dressing and/or wound care and refer to the policies and procedures for the individual facility.

1. This is a significant change in the patient's assessment. Perform a thorough wound assessment and obtain vital signs. Assess the patient for any new symptoms, such as increased pain, chills, or abnormal sensation (e.g., numbness, tingling). Report findings to the health care team; a change in wound care, additional assessments (e.g., diagnostic tests, laboratory tests), or change/addition of medication may be required.
2. Reassure the patient regarding her wound status. Explain what the drains are, how they work, and their intended purpose. Provide information regarding wound care, drain care, and recording of drainage amounts. Discuss anticipated care requirements at home and potential arrangements to ensure required care is performed, either by the patient or significant other.
3. Reassure the patient regarding his wound status. Explain the purpose of the staples, the process of wound healing, and the purpose of adhesive wound strips. Discuss the patient's responsibilities for wound care at this point in his healing.