RNs Need to Treat Both Physical and Emotional Impact of Wounds

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June 7th, 2012

By , BSN, RN

Yesterday, as part of my continuing focus on wounds and wound care I wrote, “The sight and smell of an infected or untreated wound can be very hard to cope with even for seasoned medical professionals.” This may be one of the brashest understatements I have ever written. However, it also got me thinking—remembering really.

I am passionate about wound care. It is not a field I actively pursue any longer, but at one time I had the good fortune to work and be acquainted with a group of healthcare professionals who make wound care their mission. I learned more about nursing, teamwork, my patients, and myself during those couple of years than I ever could have imagined.

Patients suffering from severe wounds, whether chronic or acute, do actually suffer. Wounds hurt, even more when they become infected. They are ugly, they have potential to be disfiguring for a lifetime, and they often smell worse than anything you can imagine. And these are the people who need skilled nurses, experienced nurses, compassionate nurses the most.

Why Do Wounds Smell and Weep?

Wounds usually smell because of infection. Bacteria that colonize in wounds can release compounds that cause unpleasant odors. I had a professor in nursing school who used to say, “If you ever smell Pseudomonas you will never forget it.” Man, she wasn’t kidding. Pseudomonas has a characteristic sweet smell that completely supports the theory that smell is our strongest memory sense. Klebsiella also has a distinct odor. Anaerobes are frequently the culprit of foul odors, and any wound that suddenly becomes foul smelling has likely become colonized with anaerobes.

Wounds weep either blood or pus. This is sort of a simplistic statement. Wound drainage or “exudate” is material, such as fluid and cells, that escape from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces. There are three types of exudate:

  • Serous Exudate – Consists chiefly of serum (the clear portion of blood). It is watery in appearance and has few cells. It is the fluid inside a burn blister.
  • Purulent Exudate – This is a thicker excretion because of the presence of pus. It consists of white blood cells, liquefied dead tissue debris, and dead and living bacteria. Purulent exudates vary in color and frequently smell.
  • Sanguineous (hemorrhagic) Exudate – Red blood cells are the key component here, which indicates damage to capillaries severe enough to allow the escape of red blood cells from plasma. Nurses often need to distinguish whether the sanguineous exudate is dark or bright. A bright red indicates fresh bleeding while a darker shade denotes older bleeding.

Mixed types of exudate are often seen (i.e. serosanguineous or purosanguineous) and can indicate a need for the wound’s further examination.

So, What Does This Have To Do With Nursing?

Well, we are likely the healthcare providers who will first notice the problem. It will be during a dressing change, or just when you enter the patient’s room—you know. The scientific side of nursing will to clean the wound, inspect it, chart it, and if it is bad enough, inform the wound care team or physician. But remember, I said you are likely the first healthcare provider to notice. Trust me, the patient already knows.

This is where the nurturing side, the compassionate side of nursing is brought into play. And, it’s not for the weak of stomach or, particularly, the weak of heart. Bad smells carry a social stigma along with the health hazards inherent in the wound itself. Wet, sticky, bandages are a sign for all to see that there is a problem. People with wounds in this state often suffer inhibited work, social, and sex lives and frequently have feelings of shame and depression.

In the language of nursing their “impaired skin integrity” is contributing to a “disturbed body image.” These are both NANDA-I approved nursing diagnoses and areas we must address. One of the hardest things to do can be not having a physical reaction to the way the client’s wound looks or smells.

Back to my past. One physician, in particular, is my “gold standard” on this topic. He was seemingly oblivious to anything peculiar when dealing with his patients. I adopted many of his characteristics over the years of working with him. He would enter the room (exam, pre-op, operating), always smile, always sit or crouch down to the patient's eye level, and always put out a hand. To tell the truth, he didn’t always remember the patient’s name (in pre-op or the OR that was my job). He, oddly, usually remembered their wound. What seemed to come naturally was putting them at ease, even while examining and discussing their health condition.

It was that ease that was most difficult for me to incorporate naturally and it was what made our patients, even the most debilitated physically and emotionally, respond to him and the rest of the care team. I frequently thought many of them got better because they didn’t want to disappoint him.

You learn little tricks to help you not react (breath through your mouth, use a minty lip balm).  Keeping the patient engaged is the key. Many of them won’t look at their wounds, won’t acknowledge there is a problem, or want to discuss it. You can teach them how to clean and dress their wounds, give them pamphlets and supplies, and help them plan future appointments but it is the emotional part of nursing that will often make the biggest impact on their healing and wellness. There have been a number of studies testing the use of therapeutic touch in wound healing; some have shown significant positive effect and the research continues.

Like I said when I started writing this, the look and smell of wound can be difficult for even the most seasoned healthcare professional. Understatement. I know nurses and doctors who can only barely get through examining an infected wound. They do other things well. However, if you are interested in not just the physical care of a patient but the emotional well being of patients with these health issues (and you have the stomach for it), wound care is an excellent professional choice.

It also can be perfect for someone who likes instant gratification. If wound care and/or a healthy patient are your passion there is nothing more gratifying than cleaning up a nasty wound, making it pink and healthy and scent-free. Everyone feels better almost immediately.

I take great pride in what I learned about wound care from the aforementioned physician and his nursing staff. In my years as a traveling RN it was those lessons I frequently put into play. I even taught other nurses and doctors a few things I learned under his tutelage. No matter what area of direct patient care you work in you are likely to come across a client who is the victim of bad wound luck. Understanding the mental as well as the physical ramifications of the problem will make you a better nurse. Thanks, Dr. A.

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