Wounds2 categories: - surgical - traumatic

Wound examples

•Closed surgical•Open surgical•Closed traumatic•Open traumatic

InfectionAny incision or wound increases the risk of infection!!

Wound Healing•First Intention•Second Intention•Third Intention

First Intention Healing

•Wounds with minimal tissue loss

•edges approximated•most surgical wounds•dec. infection/scar risk

Second Intention Healing

•Occurs with tissue loss•edges not approximate•left open to heal•opening fills with granulation tissue

Granulation tissue

•Soft, pink•capillary projections•once begins, usually stop packing wound

Second Intention (cont.)

•Later, epithelial cells grow over granulation tissue

•inc. risk for scarring and infection

Third Intention Healing

•Wound intentionally kept open for time

•Closed surgically later•Scarring common

Wound Healing Process

•Increased wbc’s during inflammation

Neutrophils (wbc type) - engulf bacteria - release enzyme

Wound Healing (cont.)

Monocytes (wbc type)- engulf bacteria, debris- live longer Fibroblast (cell type)- produce collagen

Wound problems

Dehiscence:•wound edges separateEvisceration:•separation of wound with contents expelled

Factors affecting healing:

•Extent of injury•Blood supply to area•Type of injured area - epithelial tissue heal fastest

Factors affecting healing (cont.)

•Presence of infection•Presence of debris•Health of patient

How should primary intention look?

•Color•Edges•Sutures•Bleeding / Drainage•Vital signs

Nursing assessment

•Anatomic location•Duration of wound•Size of wound in cm. - width, length, depth•Color of wound bed

Nursing Assessment (cont.)

•Presence of tunneling•Presence of exudate•Warm, cold, hard?•C/O pain?•Any foreign bodies?

Nursing Assessment (cont.)

•May draw diagram in notes if irregular

•Other objective assessments

- body temp, Bl. tests

Care of closed wounds

•Follow hospital policy and MD orders

•Change dsg and do not disturb suture line

Care of open wounds

•Check MD order•Must be kept moist•Cleanse at each dsg change with ordered solution or sterile NSS

Wet-to-Dry Dsg.

•Debride wound•Cleanse inside > out•Surgical asepsis•Volume of force impt.•Damp - don’t saturate

Packing the wound

•Must be used for deep wound

•Dead space is deadly•NSS on gauze OK•Tissue up gauze

Pressure Sores•Decubitis ulcers•Bedsores•Pressure ulcers

Causes:•Prolonged pressure•Shear•Friction•Stripping•Urine or stool

More causes!!•Perspiration•Arterial insufficiency•Wrinkles or debris in bedding

Nursing responsibility

Early prevention and recognition is the key!!

Early appearance

•Pallor over pressure area

•Reddened skin•Cellular death and skin breakdown

Stages of pressure sores

Stage 1 - inflamm and erythema - no blanching - lasts for 30 min after pressure relieved

Stage 2•Loss of epidermis•Damage to dermis•Shallow crater or blister

•Swollen and painful

Stage 3

•Subcutaneous involved•Not painful•May have foul drainage

Stage 4•Extensive damage to underlying structures

•Tendons, muscle, bone

Prevention•ID individuals at risk•Use preventative measures

•Adequate blood supply•Nutrition

REMEMBER:•Check MD order•Check protocol•Closed wounds dry•Open wounds moist•Cleanse inside to out

More to remember!

•NSS appropriate•Irrigation is best for open wound cleansing

•Obliterate dead space•Draining wound care