WOUND WOUND CARECARE

By: NORMAN – ANGELO G. By: NORMAN – ANGELO G. CALDERON, MD, RNCALDERON, MD, RN

WOUND AND HEALINGWOUND AND HEALING

A A woundwound is a break in the skin (the outer layer is a break in the skin (the outer layer of skin is called the epidermis). Wounds are of skin is called the epidermis). Wounds are usually caused by cuts or scrapes. Different usually caused by cuts or scrapes. Different kinds of wounds may be treated differently kinds of wounds may be treated differently from one another, depending upon how they from one another, depending upon how they happened and how serious they are. happened and how serious they are.

HealingHealing is a response to the injury that sets is a response to the injury that sets into motion a sequence of events. With the into motion a sequence of events. With the exception of bone, all tissues heal with some exception of bone, all tissues heal with some scarring. The object of proper care is to scarring. The object of proper care is to minimize the possibility of infection and minimize the possibility of infection and scarring.scarring.

Phases of Wound Phases of Wound HealingHealing

I. I. Inflammatory Phase Inflammatory Phase A) Immediate to 2-5 daysA) Immediate to 2-5 days B) Hemostasis B) Hemostasis Vasoconstriction Vasoconstriction Platelet aggregation Platelet aggregation Thromboplastin forms clot Thromboplastin forms clot C) InflammationC) Inflammation Vasodilation Vasodilation Phagocytosis Phagocytosis

II. II. Proliferative Phase Proliferative Phase A) 2 days to 3 weeksA) 2 days to 3 weeks B) Granulation B) Granulation Fibroblasts lay bed of collagen Fibroblasts lay bed of collagen Fills defect and produces new capillaries Fills defect and produces new capillaries C) Contraction C) Contraction Wound edges pull together to reduce defect Wound edges pull together to reduce defect D) Epithelialization D) Epithelialization Crosses moist surface Crosses moist surface Cell travel about 3 cm from point of origin in all Cell travel about 3 cm from point of origin in all

directionsdirections

III. III. Remodeling Phase Remodeling Phase A) 3 weeks to 2 years A) 3 weeks to 2 years B) New collagen forms which increases B) New collagen forms which increases

tensile strength to wounds tensile strength to wounds C) Scar tissue is only 80 percent as strong C) Scar tissue is only 80 percent as strong

as original tissue as original tissue

New TrendsNew Trends

Major trend is to use Major trend is to use moisture retentive moisture retentive dressing dressing rather than drying the wound. rather than drying the wound.

( this allows the tissue to granulate)( this allows the tissue to granulate) Moisture enhances cellular activityMoisture enhances cellular activity in in

all phases of wound repair, facilitates all phases of wound repair, facilitates autolytic wound debridement of necrotic autolytic wound debridement of necrotic tissues, enables epithelial cells to migrate tissues, enables epithelial cells to migrate into the wound bed, insulates and protects into the wound bed, insulates and protects nerve endingsnerve endings

Clinical notesClinical notes

Document how long client has had Document how long client has had woundwound

Determine previous treatment if any Determine previous treatment if any and treatment resultsand treatment results

Check for allergiesCheck for allergies

WOUND WOUND ASSESSMENTASSESSMENT

EQUIPMENTS NEEDEDEQUIPMENTS NEEDED

1.1. Pliable disposable measuring devicePliable disposable measuring device

2.2. Cotton-tip applicator stickCotton-tip applicator stick

3.3. Plastic disposable bagPlastic disposable bag

4.4. Clean glovesClean gloves

5.5. Sterile glovesSterile gloves

Wound AssessmentWound AssessmentAssessmentAssessment1.1. Assess wound for moisture, Assess wound for moisture,

debridement, infection and cleanlinessdebridement, infection and cleanliness Rationale: To assess wound appropiatelyRationale: To assess wound appropiately

2.2. Make sure drainage from wound site is Make sure drainage from wound site is contained and adjacent skin is protected contained and adjacent skin is protected Rationale: Rationale: To prevent microorganisms from To prevent microorganisms from entering woundsentering wounds

3.3. Make sure skin sealant is used Make sure skin sealant is used appropriatelyappropriately Rationale: To maintain Rationale: To maintain sterility during dressing changessterility during dressing changes

Wound AssessmentWound Assessment

4.4. Check that dressing is dry on air-Check that dressing is dry on air-exposed site Rationale:exposed site Rationale: To prevent To prevent bacterial proliferationtionbacterial proliferationtion

5.5. Make sure drainage system is Make sure drainage system is operatingoperating

Rationale:Rationale:To maintain drainage if a To maintain drainage if a drainage system is useddrainage system is used

WOUND ASSESSMENT WOUND ASSESSMENT PROCEDUREPROCEDURE

1.1. Wear sterile Wear sterile glovesgloves

2.2. Examine wound. Examine wound. Note appearance Note appearance of wound bedof wound bed

Check for Check for exudate, drainage, exudate, drainage, necrotic tissue or necrotic tissue or sign of infectionsign of infection

3.Assess 3.Assess surrounding area surrounding area for problems in for problems in skin nutritionskin nutrition

Atrophy, loss of hair, Atrophy, loss of hair, thickening of nailsthickening of nails

Edema of skin or scaly Edema of skin or scaly skinskin

Skin hydrationSkin hydration Skin integrity or Skin integrity or

macerationmaceration Skin color (red Skin color (red

[inflammation], white [inflammation], white [arterial [arterial insufficiency],black insufficiency],black [necrosis], brown[venous [necrosis], brown[venous insufficiency])insufficiency])

Skin temperature (cool, Skin temperature (cool, cold,warm,normal)cold,warm,normal)

4.Assess extent of 4.Assess extent of woundwound

Measure length and Measure length and width of wound using width of wound using disposable measuring disposable measuring devicedevice

Measure depth of wound Measure depth of wound by using by using cotton-tipped cotton-tipped applicator stickapplicator stick

Check for tunneling or Check for tunneling or sinus tract by placing sinus tract by placing cotton-tipped cotton-tipped applicator stickapplicator stick into into suspected area suspected area advancing until advancing until resistance is metresistance is met

55. . Observe color of Observe color of wound wound ::

A. A. blackblack (necrotic (necrotic tissue), tissue),

B.B. yellow yellow (pus,fibrin,debris), (pus,fibrin,debris),

C. C. redred (wound (wound ready to heal)ready to heal)

6. 6. Assess for wound Assess for wound drainagedrainage: :

A. Type (dry or moist), A. Type (dry or moist),

B. Amount ( minimum, B. Amount ( minimum, moderate, maximum),moderate, maximum),

C. Color of drainage C. Color of drainage

-clear[-clear[serousserous],],

-brown, brown-yellow -brown, brown-yellow [[sloughslough], ],

-yellow,yellow-green-yellow,yellow-green[pus [pus from strep or staphfrom strep or staph], ], blue-green blue-green [[pseudomonaspseudomonas])])

7. 7. Assess for level Assess for level of moisture in of moisture in wound. wound. A moist A moist environment allows environment allows wound to heal wound to heal without forming a without forming a scabscab

88. . Assess odor Assess odor of woundof wound: :

A.A. foul foul (infected[necrotic (infected[necrotic tissue has an odor tissue has an odor even if not even if not infected]) B. infected]) B. sweet sweet (pseudomonas (pseudomonas infection)infection)

LABORATORY LABORATORY ASSESSMENTASSESSMENT

Laboratory values need to be assessed Laboratory values need to be assessed routinely while the wound is healing:routinely while the wound is healing:

1.1. Increased WBC count indicates Increased WBC count indicates infectioninfection

2.2. Low hemoglobin and hematocrit Low hemoglobin and hematocrit indicate anemia, which can decrease indicate anemia, which can decrease oxygen transport to the woundoxygen transport to the wound

3.3. Altered serum glucose levelAltered serum glucose level

WOUND WOUND CLEANINGCLEANING

Wound CleaningWound Cleaning

EquipmentEquipment1.1. Sterile normal saline or any non-cytotoxic Sterile normal saline or any non-cytotoxic

wound cleanserwound cleanser2.2. Sterile dressingSterile dressing3.3. TapeTape4.4. Sterile round bowlSterile round bowl5.5. Sterile emesis basinSterile emesis basin6.6. Sterile glovesSterile gloves7.7. Absorbent padsAbsorbent pads8.8. Disposable bagsDisposable bags9.9. GooglesGoogles

Clinical noteClinical note

If a wound is clean and has If a wound is clean and has granulation tissue present, granulation tissue present, cleaning is contraindicatedcleaning is contraindicated

Rationale: Wound healing can be Rationale: Wound healing can be delayed by destroying newly delayed by destroying newly produced tissue. It can also remove produced tissue. It can also remove exudate that may have bactericidal exudate that may have bactericidal properties.properties.

WOUND CLEANING WOUND CLEANING PROCEDUREPROCEDURE

1. Check physician’s 1. Check physician’s order for wound order for wound cleaning solution. cleaning solution. Sterile saline or Sterile saline or noncytotoxic solution noncytotoxic solution should be used. should be used.

Rationale:other products Rationale:other products such as hydrogen such as hydrogen peroxide should be peroxide should be avoided as they are avoided as they are toxic to cellstoxic to cells

2. 2. Pour cleaning Pour cleaning solution over gauze solution over gauze pads. Do not use pads. Do not use products that shed products that shed cotton fibers.(this cotton fibers.(this can lead to foreign can lead to foreign body reaction, thus body reaction, thus delaying the healing delaying the healing process prolonging process prolonging the inflammatory the inflammatory phasephase

If antimicrobial If antimicrobial solutions are used, solutions are used, be sure to be sure to dilutedilute it it

Warm solutionWarm solution to to body body temperature( this temperature( this prevents lowering of prevents lowering of wound temperature wound temperature delaying the healing delaying the healing process)process)

33. . Wear sterile glovesWear sterile gloves Pick up several gauze Pick up several gauze

pads, pulling edges pads, pulling edges together to form a together to form a ball ball ( prevents glove from ( prevents glove from touching the wound)touching the wound)

Sterile cleansing Sterile cleansing solutions can be poured solutions can be poured directly directly over wound over wound before gauze pads are before gauze pads are use for cleaning. Place use for cleaning. Place emesis basin on side of emesis basin on side of patient to catch excess patient to catch excess cleansing solution.cleansing solution.

Clean wound from Clean wound from cleanest to dirtiestcleanest to dirtiest

Clean from Clean from top to top to bottom bottom using new using new gauze with each strokegauze with each stroke

WOUND WOUND IRRIGATIONIRRIGATION

Wound IrrigationWound Irrigation

Equipment:Equipment:1.1. Same as in wound cleaningSame as in wound cleaning

2.2. Warm irrigation solutionWarm irrigation solution

3.3. Syringe: 30 to 60 ml syringe Syringe: 30 to 60 ml syringe

4.4. Clean and sterile gloves (2 pairs)Clean and sterile gloves (2 pairs)

WOUND IRIGATION WOUND IRIGATION PROCEDUREPROCEDURE

1.1. Check orders for type and amount Check orders for type and amount of irrigating solution to be used.of irrigating solution to be used.

2.2. Don sterile gloves and remove Don sterile gloves and remove dressing. discard dressing and dressing. discard dressing and gloves in disposable baggloves in disposable bag

3.3. Open sterile supplies, pour warmed Open sterile supplies, pour warmed irrigating solution into sterile basinirrigating solution into sterile basin

4. Don sterile gloves. Draw up solution 4. Don sterile gloves. Draw up solution into syringeinto syringe

5. Instill solution into wound5. Instill solution into wound6. Place sterile emesis basin next to 6. Place sterile emesis basin next to

wound to catch irrigation solution wound to catch irrigation solution as it drains from woundas it drains from wound

7. Repeat irrigation process until 7. Repeat irrigation process until returns are clear and free from returns are clear and free from debrisdebris

8. Cleanse around wound with moist 8. Cleanse around wound with moist gauze pads; dry thoroughly with dry gauze pads; dry thoroughly with dry gauze padsgauze pads

9. Remove gloves and place in 9. Remove gloves and place in disposable bagdisposable bag

10. Don sterile gloves and apply 10. Don sterile gloves and apply dressingdressing

11. Remove gloves and place in 11. Remove gloves and place in disposable bagdisposable bag

DressingsDressings

A. Wet to Damp DressingA. Wet to Damp Dressing

EquipmentEquipment1.1. 4x4 gauze 4x4 gauze

2.2. ABD padsABD pads

3.3. Sterile solutionsSterile solutions

4.4. Sterile glovesSterile gloves

5.5. Clean glovesClean gloves

6.6. TapeTape

7.7. Disposable bagDisposable bag

Wet to Damp DressingWet to Damp DressingProcedure:Procedure:

1. Identify type and 1. Identify type and number of number of dressings and type dressings and type of solution needed.of solution needed.

2.Clean over-bed 2.Clean over-bed table; open sterile table; open sterile packages and place packages and place on over-bed table. on over-bed table. Arrange packages Arrange packages making sure you do making sure you do not cross sterile not cross sterile field.field.

Cut tape strips and Cut tape strips and place on over-bed place on over-bed table. table.

3.Ensure that two 3.Ensure that two packages of 4 x 4 packages of 4 x 4 gauze pads are open gauze pads are open for use in outer for use in outer dressing.dressing.

Fanfold top linen to Fanfold top linen to foot of bed. Provide foot of bed. Provide patient’s privacypatient’s privacy

Place bag for soiled Place bag for soiled dressing near the dressing near the tabletable

4. Pour sterile 4. Pour sterile solution into 4 x 4 solution into 4 x 4 gauze dressing gauze dressing containercontainer

5. Wear clean gloves 5. Wear clean gloves and remove and remove dressing. Place in dressing. Place in disposable bagdisposable bag

6.Obtain wound 6.Obtain wound specimen for specimen for culture if ordered.culture if ordered.

Remove clean Remove clean gloves and dispose gloves and dispose in appropriate in appropriate containercontainer

Collecting Wound Collecting Wound SpecimenSpecimen

Rinse wound with sterile NSSRinse wound with sterile NSS Use non-cotton tipped swabUse non-cotton tipped swab Rotate swab while obtaining specimenRotate swab while obtaining specimen Swab wound edges starting from top; Swab wound edges starting from top;

crisscross wound to bottomcrisscross wound to bottom Do not take specimen from exudateDo not take specimen from exudate Remove gloves and place in disposable bagRemove gloves and place in disposable bag Wash your handsWash your hands

7. Don sterile gloves 7. Don sterile gloves and have materials and have materials needed for needed for dressing change dressing change availableavailable

8. Wring out several 8. Wring out several gauze pads until gauze pads until slightly moist.( if slightly moist.( if dressing is too moist dressing is too moist risk of infection and risk of infection and maceration of maceration of surrounding skin is surrounding skin is increased.increased.

Fluff moistened Fluff moistened dressing and lightly dressing and lightly packed them in all packed them in all crevices and crevices and depressions in depressions in wound.Necrotic tissues wound.Necrotic tissues are usually in deep are usually in deep crevices(tightly packed crevices(tightly packed wound dressing inhibit wound dressing inhibit wound edges from wound edges from contracting and may contracting and may compress capillaries)compress capillaries)

Irrigate wound if Irrigate wound if grossly contaminated.grossly contaminated.

9.Apply dry sterile 9.Apply dry sterile gauze over moist gauze over moist dressingdressing

Rationale:Rationale:

This will absorb This will absorb excess exudatesexcess exudates

10.Place sterile ABD 10.Place sterile ABD pads over wound pads over wound site.site.

Rationale:Rationale:

Pads protects wound Pads protects wound from trauma and from trauma and external external contaminationcontamination

11.Tape wound 11.Tape wound securely.securely.

Tape wound dressing Tape wound dressing lengthwise , top lengthwise , top and bottom of and bottom of dressingdressing

B. Dry Dressing for Open B. Dry Dressing for Open Wound DrainageWound Drainage

Equipments:Equipments:1.1. Dressings (4 x 4 gauze, ABD pads)Dressings (4 x 4 gauze, ABD pads)2.2. Precut sterile 4 x 4 gauze pads (2)Precut sterile 4 x 4 gauze pads (2)3.3. Forceps and cotton ballsForceps and cotton balls4.4. Sterile cleansing solution and sterile containerSterile cleansing solution and sterile container5.5. Sterile safety pinSterile safety pin6.6. Sterile scissorsSterile scissors7.7. Sterile glovesSterile gloves8.8. Clean glovesClean gloves9.9. Disposable bagDisposable bag

Dry DressingDry DressingProcedure:Procedure:

1. Wear clean gloves1. Wear clean gloves2. Remove soiled 2. Remove soiled

dressing and place in dressing and place in disposable bagdisposable bag

Remove clean glovesRemove clean gloves Open sterile Open sterile

packages;place on packages;place on over-bed tableover-bed table

Pour sterile cleansing Pour sterile cleansing solution into containersolution into container

Observe wound Observe wound closely for sign of closely for sign of infection or healing.infection or healing.

3.Don sterile gloves 3.Don sterile gloves and closely and closely observe pin in observe pin in Penrose drain. If Penrose drain. If pin is crusted pin is crusted replace with new replace with new sterile pin. Be sterile pin. Be careful not to careful not to dislodge pindislodge pin

Penrose CleaningPenrose Cleaning

To advance Penrose drain, complete the To advance Penrose drain, complete the following steps:following steps:

1.1. Using sterile forceps, pull drain out of Using sterile forceps, pull drain out of wound number of centimeters orderedwound number of centimeters ordered

2.2. Reposition safety pin so it is at level of Reposition safety pin so it is at level of skin. Pin prevents drain from slipping skin. Pin prevents drain from slipping back into wound.back into wound.

3.3. Cut off excess tubing with sterile Cut off excess tubing with sterile scissors.Leave at least 2 inches of tubing scissors.Leave at least 2 inches of tubing on outside. This prevents drain from on outside. This prevents drain from being drawn back into wound opening.being drawn back into wound opening.

4. Clean drain site with 4. Clean drain site with sterile solution. Use sterile solution. Use forceps with cotton forceps with cotton balls soaked in balls soaked in cleansing solution. cleansing solution. Start cleansing at Start cleansing at drain site, moving in drain site, moving in circular motion circular motion towards towards periphery.Rationale: periphery.Rationale: this prevents infection this prevents infection of the drain site.of the drain site.

Discard cottons balls Discard cottons balls in disposable bagin disposable bag

Advance drain if Advance drain if orderedordered

5.Place precut 4 x 4 5.Place precut 4 x 4 gauze under gauze under Penrose drainPenrose drain

Place several 4 x 4 Place several 4 x 4 gauze pads under gauze pads under drain sitedrain site

Apply 4 x 4 gauze Apply 4 x 4 gauze pads over drain pads over drain (Pads absorbs (Pads absorbs drainage and drainage and prevents drainage prevents drainage from accumulating from accumulating into skin.)into skin.)

6. Place ABD pads 6. Place ABD pads over sterile gauze over sterile gauze pads. Remove pads. Remove gloves and place in gloves and place in disposable bag.disposable bag.

7. Tape ABD pads 7. Tape ABD pads securely to skin. securely to skin. Montgomery tie Montgomery tie tape should be use tape should be use if frequent dressing if frequent dressing changes are changes are recquired or client recquired or client have sensitive skin.have sensitive skin.

Wound Wound DrainageDrainage

Drainage Bag for WoundsDrainage Bag for WoundsPurpose:Purpose:

Collecting drainage specially if it is Collecting drainage specially if it is excessiveexcessive

Measuring drainageMeasuring drainage Protecting skin from drainageProtecting skin from drainage Containing drainageContaining drainage Containing microorganisms to decrease Containing microorganisms to decrease

their spread to other areastheir spread to other areas Decreasing frequency of dressing Decreasing frequency of dressing

changeschanges

Care for the Client with Care for the Client with Drainage Bags:Drainage Bags:

PROCEDURE:PROCEDURE:1.1. Don clean glovesDon clean gloves2.2. Remove dressing Remove dressing

and place in and place in disposable bagdisposable bag

3.3. Measure Measure drainage from drainage from pouches, as pouches, as orderedordered

4.4. Remove clean gloves and wear Remove clean gloves and wear sterile glovessterile gloves

5.5. Clean drain site with sterile cleansing Clean drain site with sterile cleansing solution and forceps and cotton balls. solution and forceps and cotton balls. New cotton balls for each siteNew cotton balls for each site

6.6. Apply sterile dressing as ordered, Apply sterile dressing as ordered, drainage pouches may be left open drainage pouches may be left open for assessmentfor assessment

Closed Wound Drainage Closed Wound Drainage SystemSystem

Equipments:Equipments:1.1. Specimen cup for measuring Specimen cup for measuring

drainagedrainage

2.2. Input & Output bedside recordInput & Output bedside record

3.3. Absorbent padAbsorbent pad

4.4. Clean glovesClean gloves

Closed Wound Drainage Closed Wound Drainage Procedure:Procedure:

1.1. Wear clean gloves. Wear clean gloves. Expose catheter Expose catheter insertion site while insertion site while keeping client drapedkeeping client draped

Place drainage Place drainage system on absorbent system on absorbent pad or towel(to pad or towel(to protect bed from protect bed from being soiled)being soiled)

Examine Jackson Pratt Examine Jackson Pratt or hemovac catheter or hemovac catheter for patency, seal and for patency, seal and stability. If occluded stability. If occluded notify physiciannotify physician

2.Empty hemovac 2.Empty hemovac drainage system drainage system by removing by removing Hemovac plus from Hemovac plus from pouring spout. Pour pouring spout. Pour drainage into drainage into specimen bottle.specimen bottle.

Safety alert:Safety alert:

To maintain patency, To maintain patency, compress Jackson Pratt or compress Jackson Pratt or

Hemovac container every 4 Hemovac container every 4 hrshrs

3.Compress hemovac 3.Compress hemovac by pressing top by pressing top and bottom and bottom together with your together with your hands. Keep pump hands. Keep pump tightly compressed tightly compressed while you reinsert while you reinsert plug plug

4.Disconnect tubing 4.Disconnect tubing from Jackson Pratt from Jackson Pratt system. Pour system. Pour drainage into drainage into specimen container specimen container

5.Compress bulb on 5.Compress bulb on Jackson-Pratt Jackson-Pratt system.system.

Hold bulb tightly Hold bulb tightly compressed and compressed and connect to tubingconnect to tubing

6. Place drainage 6. Place drainage system on bed. (this system on bed. (this facilitates facilitates observation and observation and drainage of wound)drainage of wound)

Measure and record Measure and record amount of drainageamount of drainage

Observe color, Observe color, consistency and consistency and odorodor

Decubitus Decubitus UlcerUlcer

Pressure Ulcer StagingPressure Ulcer Staging

Stage IStage I- - Non-blanching erythema Non-blanching erythema of intact skin, the heralding of intact skin, the heralding lesion of skin ulcerationlesion of skin ulceration

Stage IIStage II- - Partial thickness skin Partial thickness skin loss loss involving epidermis and involving epidermis and dermis. The ulcer is superficial dermis. The ulcer is superficial and presents clinically as an and presents clinically as an abrasion, blister or shallow abrasion, blister or shallow cratercrater

Stage IIIStage III- - Full-thickness skin lossFull-thickness skin loss involving damage or necrosis of involving damage or necrosis of subcutaneous tissue subcutaneous tissue that may that may extend down to, but not through extend down to, but not through the underlying fascia. Presents as the underlying fascia. Presents as deep crater with or without the deep crater with or without the undermining of he adjacent tissueundermining of he adjacent tissue

Stage IV- Stage IV- Full-thickness skin loss Full-thickness skin loss with extensive destructionwith extensive destruction, , necrosis, damage to bone, muscle necrosis, damage to bone, muscle and surrounding structuresand surrounding structures

Treatment protocolTreatment protocol

The EndThe End