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

2. 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

3. 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

4. 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

5. 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

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

7. 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

8. 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

9. 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

10. 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 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.

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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