2Types of WoundsWound: disruption of normal anatomical structure and FX that results from pathological processes beginning internally or externally to the involved organ(s). (p. 1551)
3Classification of Wounds Intentional vs. UnintentionalIntentional:Usually the result of therapy. Occur under aseptic conditions.Wound edges: usually smooth/cleanUnintentional:Occurs unexpectedly. Occurs under unsterile conditions.Wound edges: sometimes jagged.
4Open vs. ClosedOpen:Involves a break in the skin or mucous membranes.Wound edges are not closed.If drainage system in place, it is an open system.ClosedInvolves no break in skin integrity.Wound edges are closed.If drainage system is in place, it is a closed system.
5Acquisition Incision: Wound made with a sharp instrument. Puncture/Perforating:Penetrating wound in which a foreign object enters/exits an internal organ.Contusion:Closed wound caused by a blow to the body by blunt object.Laceration: Tearing apart of tissues. Wound has irregular edges.Abrasion:Superficial wound.Scraping, rubbing of skin’s surface.Penetrating:Wound involving a break in epidermal skin layer, as well as dermis and deeper tissues or organs.
6ContaminationClean wounds: Closed surgical wound not entering GI, respiratory, genital, uninfected urinary tract, or oropharyngeal cavity.Contaminated woundsOpen, traumatic, accidental wound.Surgical wound involving a break in aseptic technique.Clean-contaminated wounds:Surgical wound entering GI, respiratory, genital, uninfected urinary tract, or oropharyngeal cavity under controlled conditions.Dirty or infected wounds:Any wound that does not properly heal and grows organisms.Old traumatic wound, surgical incision into a area infected.
7Acute: Wound that proceeds through an orderly and timely reparative process. Chronic: Wound that fails to proceed through an orderly and timely reparative process.Superficial: Wound that involves only epidermal layer of skin.
8Stages of Wound Healing Regeneration: The process of tissue renewal Defensive stage (Inflammatory Phase/Reaction) (hemostasis, inflammation, cell migration & epithelialization)
9(Proliferative Phase/Regeneration) Reconstructive stage(Proliferative Phase/Regeneration)Filling in of the wound with new connective or granulation tissuethe closing of the top of the wound by epitheliazation.
10Maturative stage (Maturation Phase /Remodeling) May take more than a year.Collagen scar continues to reorganize and gain strength for several months.Usu. scar tissue has fewer pigmented cells and has a lighter color than normal skin.
11Classification of Wound Healing Primary IntentionWounds that heal with little tissue loss.The skin wedges are approximated.Risk of infection is low.Healing occurs quickly:drainage stops by day 3 of closure,wound is epitheliazed by day 4,inflammation is present up to day 5,healing edge is present by day 9.
12Classification of Wound Healing Secondary IntentionWound edges do not approximate.Wound is left open until it becomes filled by scar tissue.Chance of infection is greater.Inflammatory phase is often chronicWound filled with granulation tissue (a form of connective tissue that has a more abundant blood supply than collagen.Scarring is greater.
13Classification of Wound Healing Tertiary IntentionThere is a time delay between the time of the injury and the approximation of the wound edges.Attempt by surgeon to allow for effective drainage and cleansing of a clean-contaminated or contaminated wound.Not closed until all evidence of edema and wound debris has been removed.Dressing is used to protect.
15Wound Drainage Serous: Clear, watery Sanguineous: Hemorrhagic. Specify color.Serosanguinous: pink to light red in color. Thinner than sanguineous.Purulent: thick drainage that is often yellow-green in color.
17Factors Inhibiting Wound Healing: Elderly Diminished epidermal cell activityAfter age of 50 cell renewal time is increased by one third. Epithelial cell renewal takes 30 or more days for the elderly. SLOWS Healing…Atrophy and Thinning of both skin layersBoth layers are thinner and flatter. The thinning of the epidermis reduces the skin’s natural barriers.Weakening in the epidermis and dermis attachment.The epidermis can slide – precipitates skin tears.
18Factors Inhibiting Wound Healing: Elderly Impaired immune function of skin cellsIncreases the risk of infectionHypodermics is decreased (insulator of the skin)Little subcutaneous padding over bony prominences. More at risk for skin breakdown and heat stroke.Loss in the amt. of collagenDecreased skin turgor Greater risk for shearing and tearing injuries.
19Complications of Wound Healing HemorrhageDehiscenceEviscerationInfectionFistulas
20Nursing Process for Wound Management Untreated Wounds – basic first aideTreated Wounds – prescribed per M.D. or wound care nurse.Wound Care Protocol
34Tissue Ischemia: local absence of blood flow/major reduction in blood flow Blanching: Normal red tones of light-skinned client are absent. Does not occur in clients with darkly pigmented skin.Darkly pigmented skin: Skin that remains unchanged (does not blanch) when pressure is applied over a boney prominence – irrespective of the client’s race or ethnicity.
35Normal Reactive Hyperemia: Visible effect of localized vasodilatation, the body’s normal response to lack of blood flow to the underlying tissue. Area blanches with fingertip pressure. Lasts less than 1 hour.Abnormal reactive hyperemia: Excessive vasodilatation and induration in response to pressure. The skin appears bright pink to red. Lasts more than 1 hour to 2 weeks after the removal of the pressure. Does not blanch.
36Characteristics of Intact Dark Skin that might alert nurses to the potential for pressure ulcers (p. 1546)ColorTemperatureTouchAppearance
37Risk Factors for Skin Breakdown Impaired Sensory inputImpaired motor fxAlteration in LOCOrthopedic devicesAny equipment
40Classification of Pressure Ulcers Nonblanchable erythema of the intact skin.IIPartial-thickness skin loss involving epidermis and /or dermis.IIIFull-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia.IVFull-thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structures.