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Chapter 28 Wound Care.

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Presentation on theme: "Chapter 28 Wound Care."— Presentation transcript:

1 Chapter 28 Wound Care

2 Wounds Wound: damaged skin or soft tissue resulting from trauma
Open wounds: mucous membrane is no longer intact Closed wounds: no open mucous membrane

3 Wound Repair Inflammation: physiologic defense occurring immediately after tissue injury, lasting 2 to 5 days Purpose: limit local damage, remove injured cells/debris, prepare wound for healing Signs and symptoms of inflammation: swelling, redness, warmth, pain, and decreased function

4 Wound Repair (cont’d) Proliferation: period during which new cells fill and seal a wound; it occurs 2 days to weeks after inflammatory phase The integrity of skin and damaged tissue is restored by resolution, regeneration, and scar formation

5 Wound Repair (cont’d) Remodeling: period during which the wound undergoes changes and maturation Lasts 6 months to 2 years During remodeling, the wound contracts and the scar shrinks

6 The Inflammatory Response

7 Wound Healing First-intention healing: reparative process in which wound edges are directly next to each other Second-intention healing: wound edges are widely separated; time-consuming, complex reparative process Third-intention healing: deep wound edges brought together with some type of closure material, resulting in a broad, deep scar

8 Wound Healing Factors Type of wound injury Expanse or depth of wound
Circulation quality Amount of wound debris Presence of infection Client’s health status

9 Wound Repair

10 Wound Healing Complications
Wound healing key: adequate blood flow to the injured tissue Interfering factors may include: Compromised circulation Infection Purulent, bloody, or serous fluid accumulation preventing skin and tissue approximation

11 Wound Healing Complications (cont’d)
Potential surgical wound complications Dehiscence: separation of wound edges Evisceration: wound separation with protrusion of organs

12 Dressings Dressing purposes: Keeping wound clean Absorbing drainage
Controlling bleeding Protecting wound from further injury Holding medication in place Maintaining a moist environment

13 Dressings (cont’d) Types of dressings:
Gauze dressings: ideal for covering fresh wounds that are likely to bleed, or wounds that exude drainage Transparent dressings: used to cover peripheral and central IV insertion sites

14 Dressings (cont’d) Types of dressings (cont’d)
Hydrocolloid dressings: keep wounds moist; moist wounds heal more quickly; new cells grow more rapidly in a wet environment Dressing changes: when a wound requires assessment or care

15 Wound Management Drains Open drains Closed drains Sutures and staples

16 Wound Management (cont’d)
Bandages and binders Purpose: hold dressings in place, especially if tape cannot be used or dressing is very large Support area around the wound or injury to reduce pain Limit movement in wound area to promote healing

17 Wound Management (cont’d)
Roller bandage application Binder application – Different types of binders Single T-binder Double T-binder

18 Wound Management (cont’d)
Debridement: removal of dead tissue Sharp debridement: using sterile scissors, forceps, etc. Enzymatic debridement: using chemical substances Autolytic debridement: natural physiologic process

19 Wound Management (cont’d)
Debridement (cont’d): Mechanical debridement: physical removal of debris from a wound using wet-to-dry dressings, hydrotherapy, irrigation Commonly irrigated structures include: Wounds, eyes, ears, vagina

20 Wound Management (cont’d)
Heat and cold applications Ice bag and ice collar Chemical packs Compresses Aquathermia pad Soaks and moist packs Therapeutic baths

21 Pressure Ulcers Also known as decubitus ulcers
Appear over bony prominences of the sacrum, hips, heals, and places where pressure is unrelieved Risk factors include: Inactivity, immobility, malnutrition, emaciation Diaphoresis, incontinence, sedation Vascular disease, localized edema, dehydration

22 Pressure Ulcers (cont’d)
Stages of pressure ulcers Stage I: intact but reddened skin Stage II: reddened skin accompanied by blistering or a skin tear Stage III: shallow skin crater that extends to the subcutaneous tissue Stage IV: deeply ulcerated, extending to muscle and bone; life threatening

23 Pressure Ulcers (cont’d)
Prevention of pressure ulcers Change client’s position frequently Avoid using plastic-covered pillows Use the lateral position for side-lying Massage bony prominences Use pressure-relieving devices Provide a balanced diet and adequate fluid intake

24 Nursing Implications Potential nursing diagnoses: Acute pain
Impaired skin and tissue integrity Ineffective tissue perfusion Risk for infection


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