Evidence Based Practice
According to Bales (2007), clinical guidelines help to make sure that evidenced-based
practice is being carried out. Guidelines for the management of wounds may be necessary in area
where care is inappropriate and costly. Wound care can sometimes be driven by ritualistic
practice instead of evidenced-based practice. Guidelines should be used sensibly and applied
with discretion. Local circumstances and patient’s needs should always be taken into
consideration. According to the Wound, Ostomy, and Continence Nurses Society (2005), the
recommendations for assessment of wounds in patient’s is that prior to treatment , the causative
and contributing factors and significant signs and symptoms should be assessed to differentiate
between the types of lower-extremity ulcers. The next step is to assess the patient’s history which
should address risk factors for lower-extremity venous disease, wound history, and pain history.
Certain labs should be assessed next such as hemoglobin, hematocrit, and prothrombin time. If
the patient is taking coagulation therapy then the erythrocyte sedimentation rate should also be
assessed. A thorough examination of the lower extremities should be done to assess for wounds.
First, perfusion status should be assessed by checking the patient’s skin temperature, venous
refill time, color changes, and presence of paresthesias. Second, the presence or absence of pedal
pulses should be determined by palpating both the dorsalis pedis and posterior tibial pulses.
Third, the skin of the leg should be observed for edema, hemosiderosis, venous dermatitis,
atrophie blanche, varicose veins, ankle flaring, scarring from previous scars,
lipodermatosclerosis, and tinea pedis. The next step of the assessment includes determining the
characteristics of the typical venous ulcer. Next, a Duplex image with or without color should be
used to diagnose anatomical and hemodynamic abnormalities with venous disease. The next step
is to assess for factors that may impede the healing of the wound. Next, the patient should be
monitored for the percentage of change in the ulcer area to assess for healing. The final step in
the assessment process is to consider further referral for patients with cellulits, deep vein
thrombosis, variceal bleeds, wounds that are atypical in appearance or location, dermatitis that is
unresponsive to topical steroids, and wounds that are unresponsive to two to four weeks of
appropriate therapies.
According to the Wound, Ostomy, and Continence Nurses Society (2005), the guidelines
for treatment of wounds include cleansing the wound with each dressing change and avoiding the
use of known skin irritants and allergens on the skin. There is not a particular method of
debridement that has been proven optimal. EMLA cream can be used as an effective pain
reliever during sharp debridement. It also decreases the median number of debridements required
to clean the ulcer. Hydrocolloid or foam dressings may be used to decrease the pain associated
with the ulcer. The hydrocolloid dressings under compression did not heal more venous leg
ulcers than simple, low-adherent dressings. A specific type of dressing or frequency of dressing
change when used under compression wraps has not been identified. There is also no evidence to
represent the duration, safety, and efficacy of a topical antibiotic. Cadexomer Iodine can be
useful in removing slough and decreasing bacterial bioburden and it has been proven to be more
effective than standard treatments. Oral zinc sulfate does not aid in the healing of leg ulcers in
patients who have a normal zinc level. Mesoglycan by intramuscular injection along with
standard treatment has resulted in faster ulcer healing. Flavenoids may also be used to improve
ulcer healing. Short stretch compression bandaging and horse chestnut seed extract can be used
to reduce pain levels. Compression therapy is more beneficial to the patient with leg ulcers and
high compression is more effective than low. Pentoxifylline appears to be an effective adjunct to
compression therapy. Repifermin has been shown to accelerate wound healing. Subendoscopic
perforator surgery procedure was comparable to the Linton procedure for patients with venous
leg ulcers. There is not enough evidence to prove that skin grafting improves healing. Some
evidence shows that ultrasound might be helpful as an adjunctive therapy. A home-based
exercise program including isotonic exercise can help to improve poor calf muscle and calf
muscle pump function.
P.B was assessed using many of the guidelines recommended for assessment of the
wound. The treatment of her wound was different because a wound vacuum assisted closure was
being used to treat her wound and she was receiving wound dressing changes and debridement
every Monday, Wednesday, and Friday. Her wound dressing changes and debridements were
taking place in an operating room using strict sterile technique.
curriculums to address this along with work institutions. Manufacturers of wound care products
should also be used as a resource in aiding how to effectively use a product. The study shows
that outdated practices of wound care are being used if favor of modern processes despite
evidence showing they are detrimental to the patient’s wound healing.
The research applies to P.B.’s condition because her wound had been being treated for
sixteen days. According to Benbow (2007), if the exudates are excessive, then wound drainage
devices should be used, such as negative pressure or vacuum assisted therapy, which is how
P.B.’s wound was being evaluated. Care of the surrounding tissue is important with any
treatment chosen. The wound was constantly being evaluated for effectiveness of the selected
interventions and treatment. The nursing staff was expected to complete care plans daily for her
care and wound care was a focus daily. The nursing staff played a key role in making sure that
wound interventions were maintained daily.
Role of the Nurse
P.B. has many nursing diagnoses that pertain to her health deviation. In order of
importance they are Ineffective Tissue Perfusion related to mechanical reduction of arterial and
venous blood flow related to right lateral labial necrotic tissue, Impaired Skin Integrity related to
internal factors secondary to right lateral labial necrotic tissue, Acute Pain related to skin trauma
and wound infection secondary to sepsis, Hyperthermia related to an increased metabolic state
secondary to sepsis, Fatigue related to disease state secondary to sepsis, and disturbed body
image related to altered appearance secondary to right labial abscess.
Ineffective tissue perfusion related to mechanical reduction of venous blood flow
secondary to right labial necrotic tissue is characterized by wound vacuum assisted closure,
contact precautions, cellulitis, increased neutrophil count, and a decreased lymphocyte count.
The short term goals for the patient is that she will have less inflammation and improved blood
flow throughout the shift, explain reasons for measures taken to prevent pooling of blood in the
lower extremities during the shift, and will not develop a thrombi throughout shift. The nursing
interventions for this patient included monitoring the patient’s vital signs every four hours,
observing for the development of pulmonary emboli, monitoring the clotting profile,
administering enoxaparin as ordered daily, apply intermittent pneumatic compression stockings
as ordered, instruct the patient to not cross her legs, administer docusate to prevent constipation
as ordered, and to educate the patient on the use of intermittent compression stockings and
anticoagulant therapy.
Impaired Skin Integrity related to internal factors secondary to right lateral labial necrotic
tissue is characterized by a wound vacuum assisted closure intact, contact precautions, cellulitis,
an increased neutrophil count, and a decreased leukocyte count. The short-term goals for P.B. are
that she will exhibit no signs of skin breakdown throughout the shift and she will exhibit
improved or healed lesions or wounds throughout the shift. Nursing interventions for P.B.
include inspecting P.B.’s skin every four hours and describe and document findings, monitor for
the intactness of the wound vacuum assisted closure, assist the patient with general hygiene and
comfort measures, administer hydrocodone/acetaminophen as needed for pain, and encouraging
the patient to express her feelings about her interruption in skin integrity.