1. Alterations in Physical Integrity

2. Types of Wounds
Wound: disruption of normal anatomical structure and FX that results from pathological processes beginning internally or externally to the involved organ(s). (p. 1551)

3. Classification of Wounds
Intentional vs. Unintentional
Intentional:
Usually the result of therapy. Occur under aseptic conditions.
Wound edges: usually smooth/clean
Unintentional:
Occurs unexpectedly. Occurs under unsterile conditions.
Wound edges: sometimes jagged.

4. Open vs. Closed
Open:
Involves a break in the skin or mucous membranes.
Wound edges are not closed.
If drainage system in place, it is an open system.
Closed
Involves no break in skin integrity.
Wound edges are closed.
If drainage system is in place, it is a closed system.

5. Acquisition 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.

6. Contamination
Clean wounds: Closed surgical wound not entering GI, respiratory, genital, uninfected urinary tract, or oropharyngeal cavity.
Contaminated wounds
Open, 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.

7. Acute: 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.

8. Stages 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 tissue
the closing of the top of the wound by epitheliazation.

10. Maturative 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.

11. Classification of Wound Healing
Primary Intention
Wounds 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.

12. Classification of Wound Healing
Secondary Intention
Wound edges do not approximate.
Wound is left open until it becomes filled by scar tissue.
Chance of infection is greater.Inflammatory phase is often chronic
Wound filled with granulation tissue (a form of connective tissue that has a more abundant blood supply than collagen.
Scarring is greater.

13. Classification of Wound Healing
Tertiary Intention
There 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.

15. Wound 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.

16. Factors affecting Wound Healing
Compromised host
Stress
Nutrition
Patient teaching
Obesity
Hospital in-patient “time”
Medications (immunosuppressants)
Blood sugar

17. Factors Inhibiting Wound Healing: Elderly
Diminished epidermal cell activity
After 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 layers
Both 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.

18. Factors Inhibiting Wound Healing: Elderly
Impaired immune function of skin cells
Increases the risk of infection
Hypodermics 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 collagen
Decreased skin turgor Greater risk for shearing and tearing injuries.

19. Complications of Wound Healing
Hemorrhage
Dehiscence
Evisceration
Infection
Fistulas

20. Nursing Process for Wound Management
Untreated Wounds – basic first aide
Treated Wounds – prescribed per M.D. or wound care nurse.
Wound Care Protocol

21. Wound Assessment Appearance Drainage (penrose, J-P drain, Hemovac)
Swelling & Induration
Pain
Temperature

22. Sequential signs of primary wound healing:
Absence of bleeding
Inflammation
Granulation tissue
Scar formation
Reduction in scar size

23. Lab Data
WBC
Hgb, Hct
BUN, Albumin
Wound cultures

24. MD promotes wound healing
RN provides:
Ongoing wound assessment
Aseptic wound care according to MD specifications
Documentation of wound status
Keeps MD apprised of wound status as appro.

25. To promote healing/prevent complications…
Adequate nutrition
Prevent wound stress/trauma
vomiting
coughing
abdominal distention
Prevent wound infection

26. Factors Affecting Wound Care
Type of wound
Size
Drainage/exudate
Open vs. closed
Wound location
MD orders
Presence of complications

27. Drain management Open vs. closed Monitor drainage
Universal precautions, aseptic technique

28. Penrose Drain
Open Drainage System

29. Jackson Pratt Drain
Close Drainage system

30. Hemovacs
Drainage Collection Bag (T-tubes)
Close Drainage System

31. Sutures….
Staples….
Hot/cold applications

32. Pressure ulcer Pressure sore, Decubitus Ulcer
Epidermis:
Stratum corneum
stratum basale
Dermis

34. Tissue 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.

35. Normal 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.

36. Characteristics of Intact Dark Skin that might alert nurses to the potential for pressure ulcers (p. 1546)
Color
Temperature
Touch
Appearance

37. Risk Factors for Skin Breakdown
Impaired Sensory input
Impaired motor fx
Alteration in LOC
Orthopedic devices
Any equipment

38. Contributing Factors Shearing Force Friction Edema Anemia Cachexia
Obesity
Infection
Impaired peripheral circulation
Age (elderly)
Nutrition

39. Evaluation Tools

40. Classification of Pressure Ulcers
Nonblanchable erythema of the intact skin. II
Partial-thickness skin loss involving epidermis and /or dermis.
III
Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia. IV
Full-thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structures.

41. Stage I
(no skin loss)

42. Stage I
(no skin loss)

43. (Shallow crater – involves epidermis and/or dermis)
Stage II
(Shallow crater – involves epidermis and/or dermis)

44. Shallow crater – involves epidermis and/or dermis)
Stage II
Shallow crater – involves epidermis and/or dermis)

45. Stage III
(Full thickness involving damage/necrosis of subc. Tissue. Does not extend down through underlying fascia)

46. Stage III or IV

47. Four Stages of Ulcers