1. Stressors that Affect Skin Integrity Wound Care
NUR101 Fall 2010
LECTURE # 8
K. Burger MSEd, MSN, RN, CNE
PPP By: Sharon Niggemeier RN MSN Revised kburger906,907

2. Factors that Impair Wound Healing
Age
Malnutrition
Obesity/Emaciation
Poor circulation and oxygenation
Immunosuppression
Smoking
Incontinence
Medications ( Steroids )
Co-morbidities ( Diabetes)
Wound Stress
Radiation

3. Wounds - Classification
Intentional – results from planned treatment
Unintentional wounds- results from unexpected trauma…accident/ burns/ shooting
Open -skin broken, portal of entry
Closed – trauma from force, skin intact, soft tissue damage, internal injury, possible bleeding
Acute – goes through normal/timely healing process
Chronic – fails to go through normal stages of healing; no timely progress in healing

4. Wounds –Classification
Superficial
Penetrating
Perforating
Laceration
Puncture
Abrasion
Contusion
Clean
Contaminated
Infected
Colonized
Pressure Ulcers Stage I Stage II Stage III Stage IV

5. Wound Assessment
Appearance: granulation tissue, eschar, slough, edema, tunneling, undermining, sinus tracts, color
Drainage: serous, serosanguineous, sanguineous, purulent and amount
Pain
Size & location on body
Presence of sutures/staples
Presence of drains/tubes
Wound edges

6. ??Other Factors to Assess??
ODOR
LAB VALUES
WHAT CAUSED THE WOUND?
NEED FOR TETANUS?
WHEN DID WOUND OCCUR?
WHAT (IF ANY) TREATMENTS HAVE BEEN TRIED?

7. Wound - Healing
Healthy body has the ability to restore itself, it depends on the amount of damage and state of health of the individual.
Referred to as regeneration (renewal) of tissue.
There are (3) phases of regeneration

8. Phase I Wound Healing
Inflammatory phase- begins immediately after injury.
Includes Hemostasis (cessation of bleeding) due to vasoconstriction and platelet aggregation
Release of histamine, increasing capillary permeability (plasma leaking) and vasodilation
Also phagocytosis ( process when macrophages engulf microbes and secrete growth factors that promote angiogenesis) stimulates epithelial buds at the end of injured tissue resulting in increased circulation which sustains the healing process

9. Phase ICONTINUED Wound Healing
Inflammatory Response
4 Cardinal S/S
Pain
Redness
Heat
Edema

10. Phase I Inflammatory Response SYSTEMIC RESPONSE
Elevated temperature
Elevated WBC ( norms )
Malaise

11. Phase II Wound Healing
Proliferation (Fibroplasia) Phase - second phase , fibroblasts synthesize collagens which add strength to the wound. Begins 2-3 days after injury.
Thin layer of epithelial cells forms, blood flow is reinstituted. Tissue forms - known as granulation tissue. Translucent red color/fragile/bleeds easily.

12. Phase III Wound Healing
Maturation (Remodeling) Phase- final phase begins about 3 weeks after the injury.
Collagen originally in haphazard order remodels and reorganizes into a a more orderly structure.
Scar (cicatrix) forms - avascular tissue , doesn’t sweat, grow hair, or tan.
Keloid- abnormal amount of collagen laid down, hypertrophic scar. ( common in dark skin).

13. Types of Wound Healing
Primary Intention: clean, straight line, edges well approximated with sutures, rapid healing
Secondary Intention: larger wounds with tissue loss, edges not approximated, heals from the inside out, granulation tissue fills in the wound, longer healing time, larger scars
Tertiary Intention: delay 3-5 days before injury is sutured, greater access for pathogens to invade, greater inflammation, more granulation, larger scars .

14. Wound Complications
Infection- S/S purulent drainage, pain, redness around wound, edema, increased temp, elevated WBC
Hemorrhage – S/S large amts sanquineous drainage + other symptoms of hypovolemic shock. Check UNDER clients
Dehiscence- S/S wound edges pulling away; not well-approximated. Early sign = increasing serosanquineous drainage
Evisceration- S/S wound opens revealing internal organs. Emergency rx = sterile NS gauze to cover; prepare for OR
Psychosocial impact – Encourage verbalization of feelings; encourage self-care as tolerated by client

15. Promotion of Wound Healing
Dressings: keep wound covered & clean
Wound bed moist / Surrounding skin dry
Debridement when necessary
Remove exudate: Drains, Wound VAC, Irrigation
Pack wounds loosely
Nutritional interventions

16. Debridement Methods Surgical Mechanical
Enzymatic ( proteolytic enzymes)
Autolytic
Maggots

17. Wound Dressing Principles
If exudate is present - Select one that absorbs exudate.
Keep wound bed moist but surrounding skin dry
Pack wounds loosely to avoid pressure on new granulation tissue
Fasten securely using tape, binders etc… OR self-adhesive type dressing materials.

18. Dressings for DRY wounds
Transparent: gas exchanged between wound & environment but bacteria prevented from entering. Creates moist healing environment Example: Tegaderm
Hydrogels: High water content enhances epithelialization and autolytic debridment. Needs cover dressing and wound edge barrier Example: Carrasyn
Wet – to- Moist Gauze dressings: keeps wound bed moist. Minimizes trauma to granulation tissues

19. Dressings for MOIST wounds
Hydrocolloid: hydrophilic particles mix with water to from a gel... wound stays moist. DO NOT use in infected wounds. Example: Duoderm
Absorption Materials: beads, powders, rope or sheets that absorb large amount of exudate Example: Calcium Alginate
Foam: Made of hydrophilic material. Highly absorbent. Example: Allevyn
Dry Gauze: Can absorb wound drainage. Can be impregnated with agents to promote healing

20. Irrigations Cleanses a wound using pressure
Sterile Normal Saline = usually prescribed
Avoid caustic agents ie: peroxide, iodine etc.
Pressure between 4-15 pounds per square inch (psi) i.e. 60ml syringe with catheter tip

21. Other Therapies
Wound V.A.C. – negative pressure vacuum assisted closure system. Removes drainage and helps wounds close.
Hydrotherapy – Pulse lavage, Whirlpool Aids in debridement and cleansing, warm water vasodilation.
Hyperbaric Oxygen
Electrical Stimulation

22. Bandages & Binders Secures dressings in place Determine size needed
Outer covering must cover entire wound
Tape to secure (initial,date time)

23. Heat & Cold Therapy
Heat- reduces pain & promotes healing through vasodilation
Increases oxygen and nutrients to aid in inflammatory response
Reduces edema by promoting removal of excessive interstitial fluid
Promotes muscle relaxation

24. Heat & Cold Therapy Cold- decreases pain by vasoconstriction
Decreased blood flow to the area decreases inflammation and edema
Raises the threshold of pain receptors thereby decreasing pain
Decreases muscle tension

25. Safety Precautions Heat & Cold Therapy
Very young and very old
Peripheral vascular disease
Decreased LOC
Spinal cord injury
Presence of edema and/or scar tissue
NO LONGER than 20-30minutes at a time. Rebound phenomena