By Helen Harkreader, RN, PhD WOUND CARE By Helen Harkreader, RN, PhD

Wound Healing Processes Types of Wound Closures Primary Intention Sutures, staples, skin bonds, etc. Secondary Intention Partial thickness Regenerate specific cells Epithelialize Full thickness Regranulate Remodel Tertiary Intention Processes Involved in Wound healing Acute phase Hemostasis Inflammation Proliferation Remodeling Chronic phase Stalls for 2 weeks Change Tx Reassess full body, meds, labs. If stalls from one dressing to next, change the treatment.

Wound Assessments Etiology - watch those with ischemia Size – consistent measure from nurse to nurse L x W x D in centimeters (head to toe, 9 to 3 o’clock) Locations of tunnels & undermining by the clock Drainage – type (color, amount, consistency, odor) Wound bed % of red, yellow, black tissues Granulation, Slough, Eschar or tan crust or blister Wound edges – rolled (epiboly), macerated Peripheral tissues – discoloration, stains, scars? Edema, induration, scaling (peeling), plaques? Contaminated or infected? Ischemic wounds need care to not apply pressure with wounds. Otherwise what caused the wound, may need specific treatment. Is the problem a systemic cause (e.d, ischemia, poor nutrition, poor oxygenation, CHF causing edema, DM) or localized cause (abcess or insect bite).

Wound Culturing Cleanse the wound with saline Irrigate till clear if it is a deep wound. Use culturette that has 2 swabs Wipe tissue in 1 cm2 area Infection causing Bacteria is in the tissue Do not get just a sample of the drainage Multiple bacteria from peripheral tissues can be in the drainage Submit to lab e.g. E.D. does I&D and packs with iodine, what would be your results? Also, try to express drainage from all peripheral areas after irrigation. Give 2 latest examples.

Nutrition for Wound Healing Assessment of Nutrition - labs Serum Albumin 18 to 20 days half-life Affected by hydration (> if dehydrated, < if overhydrated) Transferrin – 8 to 10 days half-life easily affected by other factors. Prealbumin – 2 days half-life – best predictor Nutrients needed for Wound healing Calories –enough to support healing and other present disease processes Protein Vitamins

Nutrients Protein – fibroplasia, neogenesis, collagen formation, remodeling Carbohydrates – energy and protein sparing Fat - cell walls Vitamins – A, B, C, D, E, K Copper, Iron, Magnesium, Zinc

Types of Wounds Open wounds Closed Wounds Incisions, dehisced or delayed closure Pressure ulcers Arterial ulcers Venous stasis ulcers Neuropathic ulcers Diabetic ulcers Abcesses Fistulas Ostomies Trauma, Burns Closed Wounds Incisions Stitched, Stapled, Steri- stripped or Skin bonded Pressure ulcers Hematomas Abcesses, nodules, various dermatologic types. http://www.medicaledu.com/pictures.htm

Pressure Ulcers Braden Scale – 16 points or below is considered a risk Sensory Perception 4pts Completely, very, slightly, not impaired Moisture (4pts) Constantly, very, occasionally, rarely moist Activity (4pts) – bedfast, chairfast, walks occ, freq. Mobility (4pts) Completely, very, slightly immobile, no limitation Nutrition (4pts) Very poor, probably Inadequate, adequate, excellent Friction & Shear (3pts) Problem, potential problem, no apparent problem

Pressure Ulcers Stages Never back stage. Prevention and treatment 1 intact, persistent redness 2 partial thickness loss or blister 3 full thickness loss to but not through fascia 4 full thickness loss to muscle, bone, etc. Unstageable –purple, yellow or black-must be removed before staging Never back stage. Prevention and treatment Turn every 2 hours when in bed Move every 15 minutes or at least every hour in wheel chair or chair Apply appropriate dressing to manage drainage Educate patient and family on reasons for treatment and causes of pressure ulcers. Monitor q shift Dialysis presents a major problem: discuss.

Stage 1 Reddened boggy heel

Stage 2 Partial thickness loss Or blister

Stage 3 Down to but not through the facia

Stage 4 To muscle, bone, tendons, etc.

Unstageable Pressure Ulcers Purple, yellow, black

Other Ulcers Arterial Venous

Other ulcers Neuropathic Diabetic

Stay open-minded Remain alert to all possibilities.