wound care fundamentals of nursing care, 2 nd ed., ch 26 objectives 1. define various terms r/t...
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Wound Care
Fundamentals of Nursing Care, 2nd ed., Ch 26Objectives 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 1st, 2nd, 3rd, intention wound
closures.
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
Wound Conditions
• Edema: Swelling• Erythema: Redness• Necrotic: Dead tissue• Ischemia: Reduced blood
flow• Purulent: Containing pus
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
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
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
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
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
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
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
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
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.
Factors Affecting Wound Healing
• Age• Chronic illness• Diabetes
mellitus• Hypoxemia• Lifestyle
choices• Lymphedema
• Medications• Multiple wounds• Nutrition &
hydration• Radiation exposure• Wound tension
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
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
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
Signs of Wound Infection
• Redness or increased warmth• Swelling• Wound drainage• Unpleasant smell• Pain around wound• Fever above 100°F
Débridement
Process of removing necrotic tissue from a wound so that healing can occur.
Wound Treatments
• Débriding a wound• Sharp• Mechanical• Enzymatic• Autolysis
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
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
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
Wound Drainage
• Sanguineous• Serous• Purulent• Bilious• Serosanguineous• Seropurulent
Wound Assessment
• Site• Wound type• Wound closure• Condition of wound bed• Condition of skin surrounding
wound• Pain • Drainage
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
Types of Dressings
• Antimicrobial with silver or dacexomer
• Alginate• Gauze• Foam dressings• Honey-impregnated dressings• Hydrocolloid• Hydrogel• Negative pressure wound therapy• Transparent films
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
• 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
Securing Dressing & Tape Application
Dressing may be secured with•Stretch gauze (Conform, Kerlix, Kling)
•Mesh netting•Elastic bandage•Montgomery straps•Binders•Tape
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.
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
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
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
Nursing Care Plan for a Pressure Ulcer
Determine stage:• Stages I–IV: classified by tissue
involvement• Stages III & IV: involve tissue
necrosis
Nursing Interventions
• Prevention• Meticulous skin care• Adequate nutrition• Frequent repositioning• Therapeutic mattresses• Client/family teaching