1. Wound Care Fundamentals of Nursing Care, 2 nd ed., Ch 26 Objectives 1. Define various terms r/t wound care. 2.Contrast contusion, abrasion, puncture, penetrating, & LAC wounds, & pressure ulcers. 3.Correctly stage pressure ulcers. 4. Compare 1 st, 2 nd, 3 rd, intention wound closures.

2. Terminology Related to Wound Healing Dehiscence: Partial or complete separation of outer wound layers Evisceration: The rupturing of a wound Eschar: Hard, dry, leathery dead tissue Granulation tissue: New tissue that grows & fills in a wound Sinus tract: Tunnel that develops between 2 cavities or between an infected cavity & the skin’s surface

3. Wound Conditions Edema: Swelling Erythema: Redness Necrotic: Dead tissue Ischemia: Reduced blood flow Purulent: Containing pus

4. Classifications of Wounds General Wounds Contusions Abrasions Puncture wounds Penetrating wounds Lacerations Other Wounds Commonly Found in Hospitalized Pts Stasis ulcers Sinus tracts Surgical incisions

5. Categories of Wound Contamination Clean: Not infected Clean-contaminated: Has direct contact with normal flora & potential for infection Contaminated: Grossly contaminated by breaking asepsis Infected: Infectious process established Colonized: High # of microorganisms present without signs of infection

6. Risk Factors for Pressure Ulcer Development Being elderly Being emaciated or malnourished Being incontinent of bowel or bladder Being immobile Having impaired circulation or chronic metabolic conditions

7. Stage of Pressure Ulcers Deep tissue injury: Area over a bony prominence that differs from surrounding tissue; may be blister-like or a discoloration Stage I: Erythema Stage II: Partial-thickness loss of dermis Stage III: Full-thickness loss; damage to epidermis, dermis, & subcutaneous tissue Stage IV: Full-thickness loss; damage to deep tissue, muscle, fascia, tendon, joint capsule, and/or bone Unstageable: Eschar covers the wound, making it impossible to tell the depth

8. Assessment Parameters: Pressure Ulcers Pallor: Related to impaired circulation Erythema: Increased capillary blood flow due to inflammation Jaundice: High serum level of bilirubin; skin is more susceptible to loss of integrity Bruising: Note any discolored areas that are found to determine if new breakdown occurs

9. Assessment Parameters: Pressure Ulcers Pallor: Related to impaired circulation Erythema: Increased capillary blood flow d/t inflammation Jaundice: High serum level of bilirubin; skin is more susceptible to loss of integrity Bruising: Note any discolored areas that are found to determine if new breakdown occurs

10. 3 Phases of Wound Healing Inflammatory –Occurs when the wound is fresh; includes both hemostasis & phagocytosis Reconstruction (proliferation) –Occurs when the wound begins to heal, about 21 days after injury Maturation (remodeling) –Occurs when the wound contracts & the scar strengthens

11. Types of Wound Closures for Healing First intention –Wound is clean with little tissue loss, edges are approximated, & wound is sutured closed Second intention –There is greater tissue loss, wound edges are irregular, & wound is left open Third intention –Wound is left open for some time to form granulation tissue & then sutured closed

12. Complications of wound healing Slough: thin, mucous-like substance, loose stringy necrotic tissue; yellow or brown/gray-green Necrotic: dead, a vascular tissue which is black. Eschar: Devitalized tissue which is black, thick & leathery.

13. Factors Affecting Wound Healing Age Chronic illness Diabetes mellitus Hypoxemia Lifestyle choices Lymphedema Medications Multiple wounds Nutrition & hydration Radiation exposure Wound tension

14. Complications of Wound Healing & Nursing Responses Infection: –Inspect & assess wounds every 8 hours; notify physician of findings of infection Hemorrhage: –Notify physician immediately; place in Fowler’s position with knees flexed; apply pressure to bleeding; administer oxygen

15. Complications of Wound Healing & Nursing Responses Cellulitis Inflammation of tissue surrounding wound characterized by redness & induration Fistula An abnormal passage btw. 2 organs or an internal organ & body surface Sinus A canal or passageway leading to an abscess

16. Complications of Wound Healing & Nursing Responses Dehiscence: spontaneous opening of incision sign of impending dehiscence: – ↑ flow of serosanguineous drainage Evisceration: protrusion of internal organ through incision Wound dehiscence & evisceration: –Place patient in supine position; notify physician; react to evisceration immediately

17. Signs of Wound Infection Redness or increased warmth Swelling Wound drainage Unpleasant smell Pain around wound Fever above 100°F

18. Débridement Process of removing necrotic tissue from a wound so that healing can occur. Wound Treatments Débriding a wound Sharp Mechanical Enzymatic Autolysis

19. Wound Treatments Wound cleansing— warmed isotonic saline Antibiotic solutions may be ordered for wound irrigation Surgical wounds & open wound dressing require sterile technique. May require hydrocolloid or wet-to- dry dressings

20. Wound Treatments –Sutures & staples for closure Large retention sutures Dermabond: a synthetic glue Nursing Care Assessment of sutures every 8 hours –Note loosening, gaps, and redness May be responsible for removing suture/staples when the wound is healed

21. Types of Drains Hemovac: Active drain uses suction Jackson-Pratt: Active drain uses suction T-tube: Passive drain uses gravity Penrose: Open drain; not commonly used because can provide pathway for pathogens

22. Wound Drainage Sanguineous Serous Purulent Bilious Serosanguineous Seropurulent

23. Wound Assessment Site Wound type Wound closure Condition of wound bed Condition of skin surrounding wound Pain Drainage

24. Purposes of Dressing Protect the incision Absorb drainage as the wound heals Protect the wound from further injury Provide moist environment for healing Fill the open space within the wound

25. Types of Dressings Antimicrobial with silver or dacexomer Alginate Gauze Foam dressings Honey-impregnated dressings Hydrocolloid Hydrogel Negative pressure wound therapy Transparent films

26. Types of Dressings Stage I: Thin film dressings used to protect ulcers from shear Stage II noninfected— hydrocolloid dressing Stage III draining ulcers— absorbent dressing

27. Infected ulcers—nonocclusive Negative pressure treatment may ↑ healing rate by 40%. –Uses a device known as vacuum-assisted closure –Removes fluid from wound, allows penetration of fresh blood –Keeps wound moist Types of Dressings

28. Securing Dressing & Tape Application Dressing may be secured with Stretch gauze (Conform, Kerlix, Kling) Mesh netting Elastic bandage Montgomery straps Binders Tape

29. Protein & Wound Healing Protein intake is required for wounds to heal. Patients who are tube fed may not get enough protein & calories which slows wound healing.

30. Wound Documentation Amount & color of drainage on old dressing Length, width, diameter, & depth of wound Sinus tracts & their length Color of wound Appearance of surrounding skin Type of dressing applied

31. Nursing Care Plan for a Pressure Ulcer Assess the wound Assess nutritional status of pt Assess pt risk factors Analyze data & make nursing diagnoses Plan appropriate interventions Implement & evaluate interventions

32. Nursing Care Plan for a Pressure Ulcer Focused skin assessment Braden scale Numeric value for 6 risk factors related to impaired skin integrity Total score <18 = risk

33. Nursing Care Plan for a Pressure Ulcer Determine stage: Stages I–IV: classified by tissue involvement Stages III & IV: involve tissue necrosis

34. Nursing Interventions Prevention Meticulous skin care Adequate nutrition Frequent repositioning Therapeutic mattresses Client/family teaching