Jeanne Lowe PhD, RN, CWCN
VA HSR&D Center of Excellence
Objectives:
•Describe skin function and structure
•Discuss normal phases of healing
•Identify factors that can interfere with normal healing
•Describe basics of wound assessment
•Discuss different categories of wound dressings
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Functions of the SkinProtectionThermoregulationSensationMetabolism Communication
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EpidermisDermis
Subcutaneous Fat
Muscle
Bone
Skin Structure
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Factors Contributing to Impaired Skin IntegrityCirculationNutritionCondition of the
EpidermisAllergiesInfections
Systemic DiseasesTraumaExcessive ExposureMechanical Forces
FrictionShearingPressure
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Phases of Wound HealingHemostasis and Inflammation
Platelets releasevasoactive substance
causing permeabilityenzymes that attract
leukocytesgrowth hormones that
influence fibroblastsWound develops
erythema and edema
Phases of Wound HealingWound “clean up”
Neutrophils arrivePhagocytosis
Macrophages appear within 3-4 daysPhagocytosisRelease of enzymes
that trigger fibroblast response
Stimulate angiogenesis
Wound RepairRegeneration of injured cells by cells of same type
(i.e. Epidermis, bone)
Replacement by fibrous tissue (fibroplasia, scar formation)
Fibroplasia (Proliferation)Occurs within the granulation tissue
framework (new blood vessels and loose collagen)
Proliferation of fibroblasts at site of injuryGrowth factorsCytokines
Surgical WoundIntentional injury that disrupts blood vessels and
causes clotting and cascade of events that leads to wound closure within 2 to 4 weeks
History of Surgery 18th Century surgeons were
apprentices of barbers and
butchers
Primary Closure
Patient Risk Factors for Post-Surgical Wound Complications
ObesityDiabetesImmunosuppressionCardiovascular diseaseSmokingCancerPrevious surgeryMalnutrition
Surgical Wounds: Complications
HemorrhageHematomasInfectionDehiscenceEviscerationFistula
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Incision Healing TimeEpithelial resurfacing complete at 2-3 days
No tensile strength, but impenetrable to bacteria
“Healing ridge” 5-9 daysLack of ridge = interventions to reduce incisional strain
Most dehiscences occur 5-8 days post-op, and about half are associated with infection
Incision Care Cover with dry sterile dressing 24 to 48
hours, then open to airGently wash between sutures/staples to
remove crustsReport persistent pain, bleeding,
erythema, wound edge separation or cloudy drainage
Wound Closure Aids
Steri-stripMontgomery strapsMedical StaplesSutures
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Steri-Strips
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Montgomery Straps
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Medical Staples
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Suture/Staple RemovalUsually removed 7-10 days post-opIncisions over areas with tension up to two
weeksIf concerned about incision dehiscence:
Remove every other oneSteri-strip
Wound DehiscenceFascial or Cutaneous
disruptionHeavy bacterial loadLong time-lapse since
woundingCrushed or ischemic
tissue – severe contused avulsion injury
Sustained high-level steroid therapy
Secondary Intention(includes chronic wounds)
Large tissue defectMore inflammationMore granulation tissueWound contraction - myofibroblasts
Factors Inhibiting Wound HealingMedication
Cortisone, and epinephrineMalnutrition
Protein & caloriesVitamin & mineral deficits
Zinc, Vitamin A, Vitamin C, Vitamin EDehydrationEdemaPerfusionChronic illness & other conditions
i.e. diabetes, CHF, immobility
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Principles of Wound CareKeep wound moist
Manage drainage
Fill deep wounds
Control bacterial load
Protect wound from trauma
Assess healing
Keep Wounds Moist Select dressings that maintain moisture.
Minimize time that wounds are open to air.
Add moisture to wound bed?
Maceration makes skin more fragile.
Excessive drainage requires nursing time.
Manage Drainage
Fill Dead SpaceFill wound with
dressing
Be careful not to over-fill (no rocks)
Control Bacterial LoadTake time to wash or
irrigate wounds to decrease bacterial load.
No need to scrub!
Protect From TraumaBe gentle to skin
Use non-stick dressings
Minimize tape
But . . .
Remember to protect yourself from splash
AssessKnow what is under
the dressing
Know typical healing pattern
Size matters
Document
Document findingsLocation
Size (length / width / depth)
Wound base
Drainage
Surrounding skin
Systemic infection
What we’re doing
Wound Documentation:Wound Base Descriptors
Granulation tissueRed, cobblestone/beefy.Only in full thickness
wounds
Epithelial tissueRegrowth of epidermisPink or pearly Smooth, shiny
Wound Documentation:Wound Base Descriptors
SloughNecrotic/avascular tissue.Moist.Can be white, yellow, tan, or
green.
EscharNecrotic/avascular.Black or brownHard or soft.Often leathery adherent tissue.
Wound Healing BasicsWounds do best in moist environment
not too wet, not too dryLoosely pack when needed
tight packing → injury to wound bed.Protect peri-wound skin
No Sting BarrierCleanse/irrigate before assessmentPre-medicate for pain prior to dressing changesIf culture is needed
cleanse wound thoroughly prior to swabbing swab in area of granulation/viable tissue if present. Never culture dressing!
Product SelectionFrequency of change
Ease of procedure
Caregiver ability
Availability of products
Cost/reimbursement factors
Dressing Purposes:To absorb drainageTo prevent contaminationTo prevent mechanical injury to the woundTo help maintain pressure to prevent
excessive bleedingTo provide a moist wound environmentTo provide comfort
Alginates/Fiber Gelling Dressings Antimicrobials Collagen Contact Layers Foams Gauze & Impregnated Gauze Hydrocolloid Hydrogels (Amorphous) Skin Sealants Topical Debriders Negative Pressure Therapy Compression Therapy
Topical Wound Care Products
Gauze Packing(Kerlix, Nu-gauze, 4 x 4s)
description - inexpensive, user dependent
indications - to fill deep defects to maintain moisture and absorb exudate, may be soaked with antibiotic solution
considerations - pack lightly, may cause surrounding wound maceration, may traumatize wound if allowed to dry
Contact Layer Dressings (Greasy gauzes, N-terface, Adaptic, Xeroform, Mepitel)
description - nonadherent, prevents trauma and permits exudate to “pass through” pores of dressing for absorption by a secondary dressing, inexpensive
indications - superficial wounds with minimal to moderate exudate
contraindications - if goal is to “clean up” wound
Hydrocolloids (Duoderm, Comfeel)
description - absorbs exudate, maintains moisture, insulates, protects from secondary infection, non-permeable
indications - or superficial wounds with minimal to moderate drainage
contraindications - infected woundsTypically changed every
3 - 5 days
Polyurethane Foam (Mepilex,Biatain, LyoFoam)
description - nonadherent foam, absorbs exudate, insulates, variable protection from environmental contaminants (outer layer water proof or water-repellent)
indications - superficial weeping wounds, cover for deep (packed) wounds
leave on for 3 - 5 days or change when cover-layer is at least
50% saturated
Hydrogels (solid gel sheets or amorphous gel)
description - nonadhesive, maintains moisture, protects wound and allows visualization, non-absorptive
indications - superficial wounds with minimal drainage; amorphous gel may be buttered on semi-dry red wound before applying moist dressing; good dressing for arterial ulcers
contraindications - heavily exudating wounds
Alginates / Fiber Gel (Kaltostat, Sorbsan, Medifil, Aquacel)
description - applied to wound dry but forms gel with absorption of exudate
indications - heavily exudating wounds to allow daily or QOD dressing changes
contraindications - minimally exudating wounds (it will stick to wound and dehydrate)
Moisture BarriersBarriers are products
that wick away moisture from skin
ContainZinc oxideDimethiconePetrolatumPolymer(i.e. SensiCare,
Proshield, Perineal wipes, No Sting)
Compression Therapy(Profore, SurePress, Jobst, Isotoner)
description – Single or multi-layer compression bandage or stocking usually applied over primary dressing
indications – management and treatment of venous leg ulcers. Can be left on for up to one week.
contraindications – do not use on patients with ABI <0.8 or on diabetic patients with advanced small vessel disease
Tapes and Adhesives
Consider gentleness to skin
Consider cost
Consider job to be done
Clinical InterventionsMonitor skin at every visitEvaluate type of skin care practicesAssess patient and/or caregiver abilityMinimize exposure of skin to moisture from
incontinence, perspiration, or drainageEvaluate need for specialty mattresses or
seating cushionsAssess nutritional status
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Nutritional DeficitsDetermine barriers to the patient eating sufficient quantities of quality food
Nutritionist consult? Diabetes education?
Moisture and incontinenceMinimize exposure to moisture and soilingUse briefs and underpads to wick away
moisture from skinTeach patients & caregivers to cleanse
skin at the time of soilingUrine & feces very caustic
Use barrier cream as necessary
Pressure Ulcer PreventionAssess for risk factors: immobility,
moisture & incontinence, inadequate nutrition, impaired sensation or perception, decreased activity, exposure to friction & shear
Incorporate risk assessment into plan of care
Monitor patient’s skin at each visit
Document Evaluation Is the skin intact? Is the wound healing? Did the interventions work or
not? If no progress at two-week assessment, time to
change interventions If yes, do you want to continue? If no, how do you want to revise? Does patient understand risk factors and wound care
plan?
89-year-old male with hx of COPD with chronic steroid use. Uses 2 L O2 at home and smokes 1/2 pack cigarettes a day. Hx. Includes DM, depression, and prostate cancer.
Presents to your clinic with right forearm wound after scraping arm against wheelchair.
Case Studies
49-year-old male with hx of IV heroin use. Smokes 2 packs cigarettes a day. Hx also includes Hep C, depression, and hypertension.
Presents to your clinic with fever, chills, and right lower limb wound that he has had for months.
Case Studies
46 year-old female admitted to hospital for elective surgery to remove renal growth. Morbidly obese, uses 2 L O2 at home, smokes 2 packs a day. Hx includes DM, depression, sleep apnea. Rarely gets out of bed at home (able to walk w/ assistance to bathroom).
Suspected deep tissue injury to sacrum present on admission. Wound surgically debrided.
Warning . . .
Case Studies
What do you see?
Make sure there are no hidden surprises