Fundamentals - Practice & Skills, part 14: Wound Care and Diabetic Foot Care

by Meris Shuwarger August 06, 2021

Full Transcript

Hi. I'm Meris, and in this video, we're going to be talking about wound care and diabetic foot care. I'm going to be following along using our Fundamentals of Nursing flashcards. You can snag these on our website, and a bunch of other amazing flashcards. If you already have a set and you're following along with me, I'm starting on card number 85. Let's get started.

Okay. So starting up, we're talking about wound culture and wound irrigation. Big things to know. When you're culturing a wound, you need to do it before starting antibiotic treatment. If we start antibiotics first, we're going to get a false reading, so we need to know what's really going on before antibiotics. Another thing I really want to call your attention to here is that you need to swab viable tissue, so you don't want to swab the eschar or slough. You want to swab the actual wound itself that has good viable tissue.

Okay. Irrigation, you're going to want to wear gown, gloves, and eye protection. Anytime we're doing irrigation, there is the chance that you could have splashing of that back towards you. And because it is an open wound, we want to protect our eyes, so make sure you have eye protection and a gown and gloves. Be sure to use a 35-mL piston syringe and a 19-gauge catheter or needle to irrigate. So just be sure you understand that we are not trying to blast this patient's skin off. We're trying to remove any sort of debris, anything that needs to be cleaned out of there.

Okay. So moving on, we're talking about doing a sterile dressing change. Now, this might be a skill that you have to do for your Fundamentals class. And if it is, you already know you've got to be really careful about what you do. I'm not going to go super in-depth in the steps here in this video, but what I want to call your attention to is that we use clean gloves, meaning gloves off of the wall, when we are removing an existing dressing. So I'm not putting on sterile gloves to take off the old dressing, just regular clean gloves. And then, when I'm ready, I'm going to set up my sterile field, put on my sterile gloves, and start cleaning the wound. Remember that we think of the wound itself as being sterile. It's not actually sterile, but what that means is that the bacteria it has is already in that wound. So we want to protect that wound from getting other bacteria dragged towards it. So when you clean, when you use moistened gauze to clean it, you are either going to start from the top and go down and then move out to the sides in that way with new gauze every time, or you're going to start from the center and move outwards. It's just going to depend on what your school or your facility asks for you to do. But the point being, we never clean towards the wound. We are cleaning from the wound and then away so that we can avoid introducing new bacteria. Make sure, too, you'll see a key point icon here. Sometimes, sterile gloves are not really indicated, especially if it's a very chronic, old wound, but you're going to want to defer to, of course, your facility policy and guidelines on that.

Moving on to removing sutures and staples. One of the things that I want to point out here right away is the key point icon here with bold red text. That means it's very important. We've called it out in two different ways, right? So first thing is you have to have a provider order for this. We don't just go removing sutures or staples at our own discretion. And when you're removing them, you want to do every other, meaning alternate which ones you're removing. If I remove all of them and then I start to see that the wound is separating or dehiscing, well, I've already removed a whole bunch of them. If I remove every other, I can start to see that it's separating, but still there are some sutures or staples in place. That allows me to then stop and contact the provider, so make sure you're doing every other.

When you remove sutures, you're going to want to use a sterile suture removal kit. Very important that it's sterile, of course. Avoid introducing new bacteria. We're going to grasp the knot of the suture with the forceps and gently lift it. Then make a cut on the suture below the knot, close to the skin, and pull. That way, we can avoid pulling some dirty suture through the tissue that we have already closed. And then when it comes to removing staples, you're going to use a staple remover. You're going to place the device in the center of the staple and push down. And I really like doing staple removal because then it just kind of butterflies that staple, and it comes right out.

Now let's talk about caring for drains. Some patients may have a wound that requires some kind of a drain. It can be open or closed. So open would be something like a Penrose drain where it's just draining freely. It's going to deposit that fluid onto the surface of the skin or a dressing if we have some-- if we think to put something there. But then we also have closed drains, and these are going to be things like a Jackson-Pratt drain - you'll hear that called a JP drain - a Hemovac, and anything that's set to suction, that's going to be a closed drain. Now, when we're caring for closed drains, they function through negative pressure. So either that's with suction, like something is actually directly connected to suction, and it is removing the wound drainage that way, or through negative pressure created through the closed system. What does that mean? It means that my JP drain looks kind of like a hand grenade, and it has a little thing at the top. I can pop it open, turn it upside down, squeeze it to empty all of the contents into a graduated cylinder so I can accurately measure the output, but then I don't just close it back up. I need to squeeze it, compress it, so that all of the air that I can get out is out and then close it. Now, that creates negative suction where that drain wants to reopen, so it is constantly applying suction to the area where the drain is in the body. That's going to bring more fluid out. Same thing with the Hemovac there. You're going to compress it kind of like a hamburger and then close it, and it's going to try and open back up. That is how those work. So just make sure that you are changing that dressing daily, and we are assessing the site around the drain to make sure it looks healthy and it doesn't show any signs of infection.

Okay. Now this last card is a big one. You've got to know it for nursing school. Got to know it for all of these exams and for in clinical practice. It's diabetic foot care. And as you can see, we have a nice bulleted list here for you with a lot of bold red terms because this is really important stuff to know. So one of the things is that your patients need to wear professionally fitted shoes. If I go to Target and buy some shoes, that's great, but they're not professionally fitted. They need to be done in that way so that I'm not putting any undue pressure on my feet in a way that could cause blisters or injury. The other thing is that your patients need to be taught to inspect their feet daily in a mirror. So get a mirror, put it on the floor, put your feet over it, look at them. Pick your feet up, look in between your toes using a mirror every single day. No other timing is appropriate because we need to catch any sort of skin breakdown as soon as possible, so educate your patients about that. Your patients should be applying moisturizer to their feet but not in between their toes. We don't want to put lotion in between the toes because it will stay moist, and that will cause skin breakdown. We also want our patients wearing cotton but not synthetic socks. We want our patients to cut their toenails straight across, don't round the edges, and use a nail file if necessary to file away those sharp corners. We won't want them to use any over-the-counter products to treat corns or calluses. And we want to make sure that our patients know not to use heating pads on their feet. Tell me why in the comments. Why should we not use heating pads for the foot of a diabetic? I want to hear your answers below. And then the other thing is we don't want our patients to soak their feet. That's not going to be good. We don't want that prolonged moisture. But when they get into the shower, we want them to check the temperature of the water using their wrist or their elbow so that they can fully feel that and make sure that it's not going to burn the surfaces of their feet.

Okay. So that is it for reviewing wound care, care of drains, diabetic foot care. I hope that was a good review. If it was, it would mean the world to me if you would like this video. Be sure to subscribe because you don't want to miss what's coming next. It's everybody's favorite, fluid and electrolytes. We're going to be talking about osmolarity. We're going to talk about fluid volume excess, fluid volume deficit, all of those kinds of really important things. You want to be the first to know, so make sure you subscribe. Thanks so much, and happy studying.

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