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

2. 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.

3. 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).

4. 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.

5. 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

6. 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

7. 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.

8. 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

9. 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.

10. Stage 1
Reddened boggy heel

11. Stage 2
Partial thickness loss
Or blister

12. Stage 3
Down to but not through the facia

13. Stage 4
To muscle, bone, tendons, etc.

14. Unstageable Pressure Ulcers
Purple, yellow, black

15. Other Ulcers
Arterial
Venous

16. Other ulcers
Neuropathic
Diabetic

17. Stay open-minded
Remain alert to all possibilities.