Unit 9 Wound Care and Sterile Technique Metro Community College Nursing Program Nancy Pares, RN, MSN

Factors that influence wound healing Age Elders: less elastic, drier, circulation impairment longer regeneration Mobility Increased pressure leads to breakdown Nutrition Poor nutrition, less regeneration, dehydration leads to poor turgor, increase risk of infection

Factors affecting skin integrity con’t Sensation level Increased risk for pressure and breakdown Impaired circulation Decreased O2 supply impacts healing ability, vessel disease, smoking Medications Side effects: itching, rashes Diabetes Impairs inflammatory response from hypoglycemia; must maintain control of BS

Factors cont Moisture Obesity Fever Infection Lifestyle Leads to maceration Obesity Less blood supply in adipose tissue Fever Affects moisture and metabolic rate Infection Impedes healing Lifestyle Tanning, bathing, piercings

Classification of wounds Based on length of time wound existed and the condition of the wound Open/closed No breaks in skin vs. true break in skin Acute/chronic Short vs. prolonged healing Clean/contaminated/infected Uninfected vs. open traumatic vs. evidence of infection

Classification cont Superficial Partial Full Penetrating Epidermis: friction, shearing, burns Partial Extend into dermis Full Extend into subcutaneous tissue Penetrating Involves internal organs

Wound drainage Serous: clear-straw colored, watery Sanguinous: bloody Clean wounds Sanguinous: bloody Deep wounds Serosanguinous: pale pink (mixed) New wounds Purulent: yellow or green tinged pus Purosanguinous: red tinged pus

Wound healing process Regeneration Primary intention Same process regardless of injury or tissues When wound involves only epidermis No scar Primary intention Minimal scarring Clean, surgical incision; edges well approximated

Wound healing Secondary intention Tertiary intention (delayed closure) Extensive tissue loss Wound not well approximated; heals from inner surface to outer; epithelial tissue may look like sign of infection Tertiary intention (delayed closure) Granulating tissue is brought together; initially wound heals by secondary intention then is sutured; moderate scarring

Wound healing stages Inflammatory: cleansing stage lasts 1-5 days Hemostasis; vasoconstriction, platelets arrive at site, clotting occurs Inflammation: vasodilatation, phagocytosis, scab formation Proliferative: granulation stage lasts 5-21 days Fibroblasts form a bed of collagen Fills defects and produces new capillaries Maturation: epitheliazation, begins 2nd or 3rd wk Contraction of wound edges; scar tissue formation; scar tissue is 80% strong as original tissue.

Complications of wound healing Hemorrhage Infection 2-3 days in contaminated wound; 4-5 days post op Hematoma Dehiscence: likely during inflammatory phase Evisceration Place sterile saline soaked 4x4 over area Call MD or notify charge/ surgical emergency Fistula: abnormal passageway often from infection

Nursing Assessment Location Size Appearance Skin around the wound Anatomic terms Size Length and width Appearance Type, color (Red, yellow black), condition, Skin around the wound Drainage Patient pain

Nursing interventions related to wound care Cleansing and irrigation Use saline, dilute antimicrobial or commercially prepared cleansers—no hydrogen peroxide, alcohol or iodine; gentle is best; hydrotherapy=debridement Caring for drainage devices : Vol 2

Debridement Sharp Mechanical Enzymatic Autolysis MD or PT at bedside or OR Mechanical Wet to dry dressing-used less Hydrotherapy Enzymatic Topical agent Autolysis Uses body out mechanisms

Applying wound dressings Gauze Transparent Clear, semi permeable, non absorbent, often used for IV sites Hydrocolloids/hydrogels Water loving particles that form a gel with exudate Absorption See page 840 table

Supporting and immobilizing Securing dressings Tape, Montgomery straps Binders See 34-6,7 Vol 2 Important Nursing interventions Inspect skin, assess and change dressings as ordered Always ACE wrap distal to proximal Assess for circulatory impairment

Heat and Cold Therapy Clients at risk Moist heat Dry heat Very old or very young Sensory impairment Body areas: highly vascular—fingers, hands, face Moist heat Moisture amplifies the treatment; vasodilates, reduces muscle tension Dry heat Use with great caution

Cold therapy Vasoconstriction Decreases edema and inflammation Acts as a local anesthetic Slows bacterial growth Used in the first 24 hrs following injury R-est I-ce C-ompress E-levate

Sterile Technique Surgical asepsis Absence of all microorganisms Slightest break in technique=contamination Sterile object is only sterile when touched by another sterile object When in doubt….throw it out…. Place only sterile objects on a sterile field Sterile object or field that is out of visual range is contaminated

Sterile technique con’t If exposed to air for a prolonged time=contaminated Sterile border =field plus 1 inch Do not reach over a sterile field Keep hands in front and above waist in field of vision Procedures which require sterile technique Injection preparation , catherizations