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Introduction   

Home health nurses provide services outside an acute environment such as a hospital. A benefit of home health care is the opportunity for patients to manage their wounds effectively in the comfort of their homes. Home health nurses play a vital role in this process. Not only do they manage wounds, but they also serve as an educational source in wound care for their patients. 

Home health nurses should know the various wound types and any treatment needed. Depending on the wound type, wound care can be simple or more complex. Different types of wound cleansers, ointments, creams, and dressings exist. Knowledge and ability to perform the most appropriate wound care is critical to proper wound healing. Lastly, there are many barriers to wound healing, especially in elderly patients. Nurses should assess whether these barriers might be present in patients with wounds.  

Types of Wounds 

Home health patients present with varying types of wounds. They can be acute or chronic and, therefore, require different types of treatment and education. An acute wound occurs suddenly instead of over time. It usually heals with no issues and as expected. Acute wounds include surgical wounds, traumatic wounds, abrasions, and burns (3). 

On the contrary, many home health patients have chronic or long-lasting wounds. A wound is considered chronic if it does not heal as expected and in a predictable amount of time (1). Wounds lasting longer than four weeks are considered chronic. Chronic wounds have been known to last months or even years. This type of wound does not move through the healing phases and may remain inflammatory. Chronic wounds differ from acute wounds because they do not follow the typical healing process. They may heal very slowly or not at all. Home health nurses may encounter the following types of chronic wounds: diabetic, vascular, and pressure. Nurses should have a thorough understanding of chronic wounds to perform effective treatment. Some conditions that may contribute to chronic wounds are diabetes, heart failure, obesity, and hypertension. 

Diabetic Wounds 

Diabetic wounds, or ulcers, are a complication of diabetes. It is estimated that 1 in 10 adults worldwide have diabetes. They result from high blood glucose levels, damage to blood vessels and nerves, and can lead to peripheral neuropathy and vascular disease (4). They are found in the feet and can be challenging for the patient to detect. Left untreated, this can lead to lower limb amputation. Home health nurses must teach patients to do frequent foot checks, ambulate with shoes, and keep their feet clean and dry. A critical goal in diabetic wound management is the prevention of infection. 

Venous Ulcers 

Venous ulcers are the most common chronic wounds in the lower extremities. They result from venous hypertension due to venous reflux. Risk factors for venous ulcers include but are not limited to, higher BMI, chronic venous insufficiency, a history of pulmonary embolism, and deep vein thrombosis (5). Venous ulcers can affect a patient’s quality of life, and early intervention is needed for a better outcome.  

Venous ulcers typically present with irregular shapes and well-defined borders. Patients might complain of pain, itching, and worsening edema that is relieved with elevation. Treatment should focus on healing and prevention. These ulcers have a high recurrence rate and may require many different interventions. 

Pressure Wounds 

There are many different terms used to describe pressure wounds. Pressure ulcers, bedsores, decubitus ulcers, and pressure injuries are the most commonly used terms. These wounds result from unrelieved pressure and shear forces over boy prominences (6). This constant pressure prevents adequate blood flow and can lead to cell death. Prolonged contact with commonly used objects in a patient’s environment can also lead to pressure wounds. Environmental factors may include items such as beds and chairs. Pressure wounds can occur anywhere where prolonged pressure exists. The most common areas are the sacrum, coccyx, and ischial tuberosity. They can also be found on heels, ears, elbows, lateral malleolus, and the scalp. Pressure wounds are preventable, and patients and caregivers should be educated on wound prevention. Risk factors include decreased sensation, cognition, incontinence, paralysis, mobility issues, and advanced age. 

There are four stages in pressure ulcer classification (6). 

Stage 1: Intact skin with non-blanchable erythema. 

Stage 2: Partial thickness skin loss involving the epidermis and dermis. 

Stage 3: Full-thickness skin loss extending to subcutaneous tissue but not beneath it. Slough or eschar may be present. 

Stage 4: Full-thickness skin loss extending through the fascia with tissue loss. Muscles, bones, or tendons may be visible.  

Unstageable: Depth cannot be determined as slough or eschar covers the wound bed. 

Another pressure-related wound is the deep tissue injury (DTI). These wounds usually have a deep purple discoloration and are intact. They are commonly found on heels. 

Dressing Types 

Selecting the most appropriate wound dressing is imperative for proper wound healing. There are many options, and it can take time to differentiate between them. Different dressings work in various ways and have other characteristics; therefore, home health nurses must know the most appropriate dressing according to the wound type.  

Overall, dressings act as a second skin, protecting the wound from microorganisms and further injury. “The dressings are used to remove excess fluid from the wound and protect it from infection” (6). Dressings should be kept clean and dry. They should be changed when saturated or when the integrity has been compromised, as evidenced by leaking or decreased adherence. Failure to do so can lead to infection and worsening pain. 

Wound dressings have evolved. Most dressings aim to keep a moist wound environment to promote healing. Qualities of commonly used wound dressings include promoting new tissue growth, protection from organisms, autolytic debridement, sterility, non-toxicity, and easy removal when needed (7).  

Dressing Types and Description (7):  

• Gauze: Basic, cheap, drying, can be painful to remove. 

• • They absorb wound drainage and provide wound protection.  

• • They are suitable for superficial wounds, lacerations, pressure ulcers with scant drainage, and wound packing. 

• Foams: soft, comfortable, moderately absorbent. 

• • They are used for pressure ulcers, diabetic foot ulcers, traumatic wounds, skin tears, and fistulas. 

• Films retain moisture, are non-absorbent, and protect against infection. 

• • They are used for superficial wounds, IV sites, skin tears, and pressure ulcers. 

• Hydrogels: autolytic debridement, maintain moisture, are easy to remove, and are not used for wounds with a lot of drainage. 

• • Used for necrotic wounds, pressure ulcers, burn wounds, or to hydrate wounds. 

• Hydrocolloids are highly absorbent, can damage tissue by adhering to the wound, and can cause peri-wound maceration. 

• • They are used for skin tears, pressure ulcers, minor burns, and abrasions. 

• Alginates: not for dry wounds, maintain moisture, moderate to highly absorbent. 

• • They are used for surgical wounds, partial thickness burn wounds, and moderate to heavily exudating wounds. 

Wound dressings may also contain Silver (Ag +) due to its antimicrobial and anti-inflammatory properties.  

Wound Care Orders 

Wound care orders will include different elements. These include wound location, cleansing agent, topical medications, dressing type, and frequency of dressing change. Wound care nurses should evaluate wounds often and ensure the most optimal treatment is being used.  

Wound Order Examples: 

• Cleanse the left lower leg wound with normal saline; pat dry, apply a thin layer of triple antibiotic to the wound bed, and cover with a hydrocolloid dressing every three days and as needed if it is loose or soiled. 

•  Cleanse the Coccyx wound with a wound cleanser, pat dry, pack with alginate strips, and cover with a foam dressing every three days and as needed if it is loose or soiled. 

•  Cleanse the skin tear on the left forearm with normal saline; pat dry, apply a thin layer of medium-hone to the wound bed and cover it with a film dressing daily and as needed if it is loose or soiled. 

Aspects of Wound Care 

All wound care is performed after a provider’s order is received. Nurses should review the order carefully and note things like wound cleansers, needed supplies, topicals, and frequency. They should also provide the patient with written instructions.  

Infection Control 

One of the most important aspects of wound care is infection control. Chronic wounds can become infected, which complicates the recovery process. It is safe to assume that most chronic wounds are contaminated with bacteria. Reducing bacteria levels is crucial in preparing the wound bed and should always be a care goal.  

It is important to note that not all surface bacteria cause infection (8). Biofilms, for example, increase the wound bioburden. Fortunately, there are methods to reduce this bioburden. Keeping the wound clean and changing the dressing as ordered are the most basic ways to control infections. Debridement and antibiotic therapy are two examples used in infection control.  

Debriding is commonly used to aid in wound healing. It involves removing dead tissue, necrotic material, slough, and biofilm—the types of debridement range from simple to more complex (8). Simple debridement includes autolytic, enzymatic, and mechanical techniques. Complex debridement includes surgical techniques. 

Systemic antibiotics may be utilized for a severe infection. Topical antibiotics, which do not have the same capabilities as systemic antibiotics, are also used to treat minor ailments. 

Compression 

Compression is the recommended and most effective treatment for venous wounds. A compression bandage with two layers or stocking is most effective (9). This treatment should be initiated early to relieve venous insufficiency. Stockings are effective due to their uniform pressure on the skin and comfort. Venous wounds heal faster with compression than without it. 

Offloading 

If a wound is caused by pressure, the most critical first step is to identify and decrease or eliminate the pressure source. Without offloading the wound, healing is not possible. There are many devices available to aid in offloading. This includes specialized mattresses such as low air loss, cushions, and pillows (8). Often, patients have pressure injuries due to a mobility issue and require assistance to relieve pressure and reposition themselves. Repositioning is usually the key to pressure injury prevention. 

Negative Pressure Wound Therapy 

Negative pressure wound therapy (NPWT) is a system that utilizes controlled negative pressure. It decreases healing time by improving granulation tissue, improving profusion, and removing toxic drainage. This pressure is applied across the wound continuously or intermittently through cell foam or other dressings. NPWT can be used to remove exudate from a variety of wounds. NPWT is mostly contraindicated in infected, necrotic, and inadequately draining wounds. 

Wound Teaching 

Performing wound care can be a stressful experience for non-licensed caregivers due to fears of causing more harm or making a mistake (10). Home health patients and their caregivers should be provided with the tools and information needed to manage wounds at home. Nurses should use the teach-back method to ensure thorough understanding and should encourage questions.  

Patient education should be individualized and specific for the wound type, etc. A detailed explanation of routine wound healing and infection signs and symptoms should be provided. Patients should look for redness, increased pain, foul odor, warmth, and increased or abnormal exudate. Patients should be instructed to report any abnormalities or signs of infection as soon as possible. 

In general, nurses should provide the following information to their patients:  

• Wash hands before and after changing a dressing. 

• Ear gloves during the dressing change. 

• Put old dressing in a bag and dispose of it in the garbage. 

• Cleanse the wound thoroughly after removing the old dressing. 

• Assess the wound and peri-wound. 

• Apply to dress as ordered. 

Lastly, the nurse must teach at a literacy level appropriate for the patient. Medical jargon should also be avoided. Since patients have different language and learning needs, various techniques and tools should be utilized to achieve the best outcome. The patient will likely need repeated information and demonstrations before fully grasping the concept and feeling confident with wound care. 

Barriers To Wound Healing 

Wound healing can be a long process. Some wounds may never completely heal due to various factors. People who have chronic wounds, for example, are often chronically ill with many comorbidities that may delay wound healing. Inadequate nutrition can also prevent a wound from fully healing. ”  

Macronutrients such as carbohydrates, fats, proteins, fluids, and micronutrients that include amino acids, vitamins, and minerals are all vital for an unimpeded oud healing process (11). Minor wounds might require a high caloric intake, but more complex, more extensive wounds will require a higher nutritional and caloric intake. Vitamins C and A and Zinc are beneficial in wound healing.  

Nicotine and smoking negatively impact wound healing by promoting vasoconstriction. This leads to decreased microcirculation. Smokers tend to have reduced wound-healing capability. There is also evidence that alcohol consumption can increase certain types of wound infections and decrease wound healing. 

Medications can also negatively impact wound healing. This is seen with some commonly used drugs, such as nonsteroidal anti-inflammatories and steroids. This is something to remember when working with patients taking nonsteroidal anti-inflammatories for pain management (11). 

Aging can also impact wound healing. Overall, aging causes decreased organ function (12). Skin aging has both intrinsic and extrinsic factors. Aging negatively affects wound healing by causing a prolonged inflammatory response. For wounds to heal correctly, inflammation must be adequately controlled. Inflammation damages neighboring cells and delays wound healing. An expected condition of aging is impaired blood vessel growth. This leads to decreased perfusion to the wound site; therefore, less nutrients and oxygen can reach the wound to aid in healing. 

Conclusion

Home health wound care for acute and chronic wounds is a great resource for patients and caregivers seeking services within the comfort of their own homes. These patients look to their home health nurse for wound management and education on how to perform wound care. Nurses must be able to assess wound healing and carry out the most appropriate treatment.  

Knowledge of treatment options is critical to successful wound management. This includes knowing which dressings, medications, and devices are indicated for proper wound healing. There are both external and internal factors that can delay wound healing. Infection is also a common problem in chronic wounds and can be addressed with medication and specialized wound techniques. Education plays a huge role in wound healing and wound prevention. A variety of methods should be used to provide education to home health patients. Ideally, a return demonstration will be done to ensure proper understanding. 

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