Fundamentals - Practice & Skills, part 14: Wound Care and Diabetic Foot Care
by Meris Shuwarger BSN, RN, CEN, TCRN August 06, 2021 Updated: December 07, 2022 7 min read 2 Comments
This article covers wound care and diabetic foot care. You can follow along with our Fundamentals of Nursing flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
Wound care is an important aspect of nursing fundamentals. It’s also a speciality, with many established professional organizations set up in support of nurses who have earned their CWCN (and affiliated) certifications. If you've followed along with these videos, you might recall that Cathy Parkes is a certified wound care nurse. Check out our Wound Care Flashcards for Nurses for a deeper dive.
In the previous article in our series about skin integrity, we discussed various aspects of wound healing, including the phases of healing, intention, complications, barriers to healing, drainage, and appearance. There’s some overlap as we continue with a discussion of how to care for a wound, which deals more with the hands-on treatment of the patient.
When obtaining a culture of a wound, take the sample before beginning antibiotic treatment. The reason to obtain the culture before administering antibiotics is to avoid getting a false reading ― it is important to know how the healing process is progressing before administering antibiotics.
Make sure to irrigate the wound with normal saline. Do not use wound cleanser.
When swabbing, swab a 1 cm area of viable tissue in the wound bed for approximately 5 seconds, and use enough force to produce exudate (fluid that’s a byproduct of the white blood cells having killed bacteria, also known as pus).
Make sure to swab the wound for viable tissue; do not swab the eschar or slough (necrotic or avascular tissue — avascular tissue is tissue that does not contain blood vessels).
Also make sure not to swab the skin surface around the wound. This could taint the sample being obtained for the culture.
When irrigating a wound, wear a gown, gloves, and eye protection. This protects you should any liquid from an open wound splash back toward you.
Irrigate the wound with normal saline or a prescribed solution.
Use a 35-mL piston syringe and a 19-gauge catheter or needle to irrigate the wound, and use an irrigation force of approximately 8 – 15 psi (pounds per square inch); this administers enough solution without harming the patient. Irrigation is a cleaning process, with the goal of removing any sort of debris from out of the wound.
Sterile dressing change
Changing a sterile dressing is a skill that is part of any nursing fundamentals class. Follow these steps when changing a sterile dressing:
- When removing the existing dressing, use clean gloves to remove the soiled dressing, i.e., gloves off of the wall. Sterile gloves may not be required, depending on the type of wound.
- Note the appearance and drainage of the wound.
- Prepare a sterile field: perform hand hygiene, set up the sterile field, and don sterile gloves.
- Clean the wound with a gauze moistened with sterile saline or wound cleanser. Gently clean from top to bottom and/or from the center of the wound moving outward. Never clean toward the wound. The goal is to clean away from the wound to avoid introducing new bacteria. Use a new piece of gauze for each stroke.
- Consider the wound as a sterile environment (even though it is not) that requires protection — there is already bacteria in the wound, and the goal is to protect the wound from getting other, new bacteria dragged toward it.
- Once the wound is cleaned, remove the gloves, perform hand hygiene, and don new sterile gloves.
- Apply any prescribed topical medications and place a dry/sterile dressing over the wound. Secure the dressing with tape or a gauze wrap.
- Label the dressing with the date, time, and nurse’s initials.
Clean gloves versus sterile gloves
Clean gloves may be more appropriate for cleaning chronic or old wounds or pressure injuries. It is important to defer to the facility’s policy and guidelines regarding when it is okay to use clean gloves and not sterile gloves.
Removing sutures and staples
The following steps apply to the removal of sutures and staples:
- Before removing sutures or staples, make sure to have a provider order.
- Clean the incision before and after removal.
- As the staples and sutures are removed, count and chart the number that are removed.
- Remove alternate sutures and staples (that is, every other one). This is to assess for wound dehiscence (partial or total separation of previously approximated wound edges). If there is any dehiscence, leaving every other suture or staple in place will keep the wound in an easily closable state while the provider is contacted.
To remove sutures, use a sterile suture removal kit (to avoid introducing new bacteria to the wound).
Grasp the knot of the suture with a pair of forceps and gently lift it. Then make a cut on one side of the suture below the knot, close to the skin, and pull the suture through the skin. This technique avoids pulling any dirty suture through the tissue that has already closed.
To remove staples, use a sterile staple remover.
Place the lower jaw of the staple remover under the center of the staple and squeeze the handles together. This has the effect of butterflying the staple, allowing it to come out easily.
A drain is when tubing is inserted into a wound or cavity to remove blood and fluid. This promotes healing and reduces the risk of infection.
A drain may be one of two types: open or closed.
When the wound is draining freely, an open drain may be used, which utilizes tubing without a collection device. The fluid is deposited onto the surface of the skin or the dressing. A Penrose drain is an example of an open drain.
Closed drains are external tubing that ends in a container that uses negative pressure (i.e., suction) to collect fluid. Closed drains include the Jackson-Pratt (or JP) drain (a closed-suction medical device), hemovac drain (a device placed under the skin during surgery to remove any blood or other fluids), or anything that’s set to suction.
Care of a closed drain
When caring for closed drains, remember that they function using negative pressure, so it is important to secure the device to clothing to prevent pulling at the insertion site.
Empty a closed drain before it fills halfway. For a JP drain, which looks a little like a hand grenade, there is a little cap at the top, which can be popped open. Turn the container upside down and squeeze it to empty all of the contents into a graduated cylinder (to accurately measure the output). Before closing it, compress the container so that all of the air is squeezed out, and then replace the cap. That creates negative suction — the drain will attempt to reopen, constantly applying suction to the area where the drain has been placed in the body.
With the hemovac drain, compress it as if it were a hamburger and then close it. It, too, will try to open back up, creating the necessary negative pressure to work the drain.
Make sure to change the dressing daily. Clean the site around the drain using a new cotton swab for each swipe. And assess for signs or symptoms of infection (redness, purulent or odorous discharge, swelling).
Diabetic foot care
Diabetes is a chronic health condition that affects how the body turns food into energy. Diabetes causes chronic hyperglycemia (increased blood sugar levels) due to either insufficient insulin production by the pancreas or insulin resistance of the cells in the body.
Diabetes is one of the most common diseases in America, with one in ten Americans living with the condition, so you are likely to encounter many patients with some type of diabetes during your nursing career.
Learn more about diabetes, the endocrine system, and more with our Medical-Surgical Nursing Flashcards which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
Foot care is very important for patients with diabetes because the feet of a diabetic patient can be injured easily. This means teaching the patient how to care for their feet to avoid injuries that could lead to serious complications, including amputation.
Diabetic foot care checklist
A patient with diabetes needs to see a podiatrist regularly and wear professionally fitted shoes. A professionally fitted shoe is crafted so the patient is not putting any undue pressure on their feet in a way that could cause blisters or injury.
Patients need to be taught to inspect their feet every day, using a mirror to help them. This can be done by placing a mirror on the floor, holding a foot over it, and looking at the foot. Then, pick the foot up and look in between the toes using the mirror. This is to catch any sort of skin breakdown as soon as possible. Also, patients should check the insides of their shoes for objects before putting them on.
Patients should apply moisturizer to their feet, but not in between their toes (where it will stay moist, which may cause skin breakdown).
Patients should wear cotton socks (no synthetic fabrics). They should not go barefoot or wear open-toe shoes.
When cutting their toenails, patients should cut straight across, and not round the edges. Use a nail file if necessary to file away any sharp corners.
Do not use any over-the-counter products to treat corns or calluses, which might lead to skin breakdown.
Patients should not use heating pads on their feet. This is because a diabetic patient may have neuropathy of their lower extremities and not feel the heat from the pad, even excessive heat, and this could lead to them burning their feet without their realizing it.
Finally, patients should not soak their feet. Prolonged moisture is not good for a diabetic’s feet. And when entering a tub or shower, the patient should check the water temperature with their elbow or wrist, not their feet — again, this is because if they cannot fully feel their feet, they may burn themselves on water that is too hot.
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 leveluprn.com, 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.
January 05, 2022
I was following all this discussion..thank you for taking sometime to make this topic easier to understand and to remember..👍
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November 28, 2022
Diabetics should not use a heating pad because they can not feel it if it gets too hot, and can cause burns.