Professional Documents
Culture Documents
CH 48 Wounds
CH 48 Wounds
PRESSURE ULCERS
- Stage 3: Full-Thickness skin loss
o Subcutaneous fat may be visible; but bone, tendon and muscle are NOT exposed
o Slough may be present but does not obscure depth of tissue loss
o MAY include undermining and tunneling
- Stage 4: Full-thickness tissue loss
o Exposed bone, tendon or muscle, subcutaneous fat may be visible
o Slough or eschar may be present
o Often includes undermining and tunneling
- Unstageable/Unclassified: Full-thickness skin or tissue loss- depth unknown
o Actual depth of an ulcer is completely obscured by slough and/or eschar in the
wound bed
o Until enough slough and/or eschar are removed to expose the base of a wound,
the true depth cannot be determined
- Suspected Deep-tissue injury- depth unknown
o Purple or maroon localized are of discolored intact skin or a blood-filled blister
caused by damage of underlying soft tissue from pressure and/or shear
o Area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or
cooler temperature as compared to adjacent tissue
- Measuring the length and width as well as depth = indicator for wound healing progress
WOUND CLASSIFICATIONS
- Wound: disruption of the integrity and function of tissues in the body
PROCESS OF WOUND HEALING
- Partial-thickness wounds: involve only epidermis and superficial dermal layers
o Shallow in depth, moist and painful
o Wound base generally appears red
o Heals by REGENERATION
- Full-thickness wounds: involve total loss of the skin layers (epidermis and dermis)
o Extends into subcutaneous layer
o Heals by FORMING NEW TISSUE (longer healing process)
- Primary intention
o Includes 3 phases: initial phase, granulation phase, maturation phase and scar
contraction
o Wound that is closed
o Caused by surgical incision; wound that is sutured or stapled
o Healing occurs by epitheliazation; heals quickly with minimal scar formation
- Secondary intention
o Wounds that occur from trauma, ulceration and infection have large amounts of
exudate and wide, irregular wound margins with extensive tissue loss
o Edges cannot be approximated
o Results in more debris, cells, and exudate = must be cleaned away
o Difference between secondary and primary is that there is greater defect in
secondary and gaping wound edges
o Wound is left open until it becomes filled by scar tissue
- Tertiary intention
o Wounds that are contaminated and require observation for signs of
inflammation
o Closure of wound is delayed until risk of infection is resolved
o Delayed primary intention due to delayed suturing of the wound
o Occurs whne a contaminated wound is left open and sutured closed after
infection is controlled
WOUND REPAIR
- Partial-thickness: heals by regeneration because epidermis regenerates
o Ex.) Scrape or abrasion
- Full-thickness: extend into dermis and heal by scar formation because deeper structures
do not regenerate
o Ex.) Pressure ulcers
- Partial-thickness wound repair
o Inflammatory response: beneficial. Collagen appears as early as the second day
and is the main component of scar tissue
Clean wound; inflammatory phase establishes a clean wound bed
This phase is prolonged if too little inflammation occurs (cancer or after
steroids) or too much inflammation (competition for available nutrients)
o Proliferative phase: Begins and lasts from 3 – 24 days
Main activities: filling of a wound with granulation tissue, wound
contraction and wound resurfacing by epitheliazation
Vascular bed is reestablished (granulation tissue), area is filled with
replacement tissue (collagen, contraction and granulation tissue), and the
surface is repaired (epitheliazation)
Impairment of healing during this stage usually results from systemic
factors = age, anemia, hypoproteinemia, zinc deficiency
o Maturation: final stage of healing
Sometimes takes place for more than a year
Collagen scar continues to reorganize and gain strength for several
months
Healed wound usually does not have the tensile strength of the tissue it
replaces
COMPLICATIONS OF WOUND HEALING
HEMORRHAGE
- Bleeding from a wound site
- Normal during and immediately after initial trauma
o Hemostasis occurs within several minutes unless large blood vessels are involved
or a patient has poor clotting function
o Surgical wounds = risk of hemorrhage is great during first 24-48 hours after
surgery or injury
INFECTION
- Erythema, increased amount of wound drainage, change in the appearance of the
wound drainage (thick, color change, presence of odor), periwound warmth/pain or
edema
- Pt may have a fever and increased WBC
- Bacterial infections inhibit wound healing
- Contaminated or traumatic wounds show signs of infection early, within 2-3 days
- Surgical wound infection usually does not develop until 4-5 day postop
- Edges of the wound will appear inflamed
- If drainage is present, it is odorous and purulent = yellow, green or brown color
o Types of wound drainage
Serous: clear, watery plasma
Purulent: thick, yellow, green, tan or brown
Serosanguineous: pale, pink, watery, mixture of clear and red fluid
Sanguineous: bright red, indicates active bleeding
DEHISCENCE
- When an incision fails to heal properly, the layers of skin and tissue separate
- This occurs most commonly before collagen formation (3-11 days after surgery)
- Partial or total separation of wound layers
- Patient who is at risk for poor wound healing (poor nutritional status, infection) is at risk
- Obese patients have a higher risk of wound dehiscence because of constant strain
placed on their wounds and the poor healing qualities of fat tissue
- Can happen in abdominal surgical wounds and occurs after a sudden strain such as
coughing, vomiting, sitting up in bed
- When there is an increase in serosanguineous drainage from a wound in the first few
days after surgery, be alert for potential for dehiscence
EVISCERATION
- Total separation of wound layers
- Protrusions of visceral organs through a wound opening
- Emergency!
- Requires surgical repair
- Place sterile gauze soaked in sterile saline over extruding tissues to reduce chances of
bacterial invasion and drying of the tissues
- Immediately place damp sterile gauze over the site, contact surgical team, do not allow
patient anything by mouth, observe for s/s of shock, prepare patient for emergency
surgery
IMPLEMENTATION
- 3 major areas of nursing interventions for prevention of pressure ulcers
o Skin care and management of incontinence
Avoid soap and hot water
Use cleansers with nonionic surfactants that are gentle to the skin
Make sure skin is completely dry
Apply moisturizer to keep epidermis well lubricated but not
oversaturated
Incontinent episode = gently clean area, dry, apply thick layer of moisture
barrier to exposed areas
Bowel incontinence = proper diet and meds
Urinary = behavioral techniques, medication and surgery = timed voiding
Use absorbent apds and garments
o Mechanical loading and support devices, which includes proper positioning and
the use of therapeutic surfaces
Elevating HOB to 30 degrees or less
30 degree lateral position
Shift weight every 15 minutes while sitting
Sit on foam/gel/air cushion
Rigid and donut shaped = reduce blood supply
Never massage reddened areas
o Education
ACUTE CARE
- Management of pressure ulcers
o Acute wounds = assess every 8 hours
o Evaluate the wound with every dressing change, usually not more than 1 time
per day
- Wound management
o Clean pressure ulcers only with noncytotoxic wound cleaners like normal saline
or commercial wound cleaners
o Irrigation: common method of delivering a wound-cleansing solution to wound.
Debrides cecrotic tissue with pressure that can remove debris from wound bed
without damaging healthy tissue
Use 19 gauge angiocatheter and 35 ml syringe that delivers saline to a
pressure ulcer at 8 psi
o Debridement: removal of nonviable, necrotic tissue
Removal of necrotic tissue is necessary to rid the wound of a source of
infection, enable visualization of the wound bed and provide a clean base
necessary for healing
During debridement, some normal wound observations include:
Increase in wound exudate, odor and size
Administer an ordered analgesic 30 minutes before debridement
Methods
Mechanical
o Wound irrigation and whirlpool treatments
Autolytic
o Removal of dead tissue via lysis of necrotic tissue by the
WBCs and nautral enzymes of body. Use dressings that
support moisture at the wound surface. If wound base is
dry, use a dressing that adds moisture. If there is excessive
exudate, use a dressing that absorbs the excessive
moisture while maintaining moisture at the wound bed =
transparent film and hydrocolloid dressings
Chemical
o Use of topical enzyme preparation, Dakin’s solution or
sterile maggots. Dakin’s solution breaks down and loosens
dead tissue in a wound. Apply solution to gauze and apply
to wound. Sterile maggots ingest dead tissue
o Requires HCP order
Sharp/surgical
o Removal of devitalized tissue with scalpel, scissors or other
sharp instrument. Usually performed by physicians.
Quickest method of debridement. Usually indicated when
patient has signs of sepsis or cellulitis
Moist environment supports the movement of epithelial cells and
facilitates wound closure
Excessive exudate/drainage = supports bacterial growth, macerates the
periwound skin and slows healing process
- Protecting a wound from further injury
o Place a folded thin blanket or pillow over abdominal wound
o Light but firm pressure over wound when coughin
o Wear an abdominal binder
- Education
- Nutritional status
o If patient’s oral intake is inadequate, enteral nutrition is likely choice
o 30-35 calories/kg
o Increased caloric intake helps replace subcutaneous tissue
o Vitamin C = collagen synthesis, capillary wall integrity, fibroblast function and
immunological function
o Pt can lose as much as 50 g of protein per day from an open, high exudative
pressure ulcer
o Recommended intake of protein = 0.8 g/kg/day
Need 1.8 g/kg/day for ehaling
o Maintain Hb 12g/100 mL
FIRST AID FOR WOUNDS
- Dressings
o Mechanically debride the wound using a saline moist-to-dry dressing
When wounds such as a necrotic wound require debriding, a moist to dry
dressing technique can be considered
You place the moist dressing (contact) over wound bed, cover with a
clean gauze and allow the contact layer to dry
Contact dressing is allowed to dry so it stick sto underlying tissue and
debrides the wound during removal
Nonselective
Recommended for debridement in a necrotic wound
- Minimize periwound skin breakdown by keeping skin clean and dry and reduing the use
of tape
- Moist wound base facilitates the movement of epitheliazation
TYPES OF DRESSINGS
- To avoid causing damage to the periwound skin, it is important that the dressing
technique that yo use to treat pressure ulcers and other wounds is not excessively moist
- Gauze sponges: absorbent and especially useful in wounds to wick away wound exudate
o 4x4 size most common
o Can be saturated with solutions and used to clean and pack a wound
o Unfolding dressing allows easy wicking action
o Purpose = provide moisture to wound yet allow wound drainage to be wicked
into dry cover gauze pad
- Self-adhesive transparent film
o Traps moisture over a wound, providing a moist environment
o Transparent film dressing ideal for small superficial wounds such as stage 1
pressure ulcer or partial-thickness wound
o Use film dressing as a secondary dressing and for autolytic debridement of small
wounds
o Advantages
Adheres to undamaged skin
Serves as a barrier to external fluids and bacteria but till allows the
wound surface to breathe because oxygen passes through transparent
dressing
Promotes a moist environment that speeds epithelial cell growth
Can be removed without damaging underlying tissues
Permits viewing a wound
Does not require a secondary dressing
- Hydrocolloid dressings
o Dressings with complex formulations of colloids and adhesive components
o Adhesive and occlusive
o Wound contact layer of this dressing forms a gel as wound exudate is absorbed
and maintains a moist healing environemtn
o Support healing in clean granulating wounds and autolytically debride necrotic
wounds
o Functions
Absorbs drainage through the use of exudate absorbers in the dressing
Maintains wound moisture
Slowly liquefies necrotic debris
Impermeable to bacteria and other contaminants
Self-adhesive and molds well
Acts as preventive dressing for high-friction areas
May be left in place for 3-5 days, minimizing skin trauma and disruption
of healing
o Useful in shallow-to-moderately deep dermal ulcers
o Cannot absorb amount of drainage from heavily drainage wounds
o Contraindicated for use in full-thickness and infected wounds
o Most leave a residue in the wound bed that is easy to confuse with purulent
drainage
- Hydrogel dressings
o Gauze or sheet dressings impregnated with water or glycerin-based amorphous
gel
o Hydrates wounds and absorbs small amounts of exudate
o For partial-thickness and full-thickness, deep wounds with some exudate,
necrotic wounds, burns and radiation damaged skin
o They can be very useful in wounds because they are soothing and do not adhere
to wound bed
o Disadvantage = require secondary dressing and you must take care to prevent
periwound maceration
o Come in a sheet dressing or tube; squirt gel directly into wound base
o Advantages
Soothing and can reduce wound pain
Provides moist environment
Debrides necrotic tissue (by softening)
Does not adhere to the wound base and is easy to remove
- Foam dressings
o Large amounts of exudate and those that need packing
o Used around drainage tubes to absorb drainage
- Calcium alginate
o Manufactured from seaweed and come in sheet and rope form
o Aglinate forms a soft gel when in contact with wound fluid
o Highly absorbent
o For wounds with an excessive amount of drainage and don’t cause trauma when
removed
o DO NOT USE THESE IN DRY WOUNDS and they require a secondary dressing
PACKING A WOUND
- First step is to assess size, depth and shape
o Determines size and type of dressing used to pack wound
- Dressing needcs to be flexible and in contact with entrie wound surface
- Alginate used for packing
- Gauze = saturate with solution, wring, unfold and lightly pack
- Entire wound surface needs to be in ctonact with part of the moist gauze dressing
- Don’t pack a wound too tightly
o Overpacking = causes pressure on the wound bed tissue
o Pack wound only until packing material reaches the surface of the wound
o Should not extend higher than wound surface
o Packing that overlaps = maceration of skin surrounding wound
- Negative-pressure wound therapy/vacuum-assisted closure
o Subatmospheric (negative) pressure to wound through suction to facilitate
healing and collect wound healing
o Device that helps in wound closure by apply8ing localized negative pressure to
draw edges of a wound together
o Supports wound healing by edema reduction and fluid removal, macro
deformation and wound contraction, and micro deformation and mechanical
stretch perfusion
o Angiogenesis, granulation tissue formation and reduction in bacterial bioburden
o Treats acute and chronic wounds
o Wear time for dressing = 24 hours – 5 days
o As wound heals, granulation tissue lines its surface
o Enhances adherence of split thickness skin grafts
o Airtight seal mut be maintained
DRAINAGE EVACUATION
- Convenient portable units that connect to tubular drains lying within a wound bed and
exert a safe, constant, low pressure vacuum to remove and collect drainage
o Evacuator collects drainage
o Assess for volume and character every shift
HYPERBARIC OXYGEN
- Delivers 100% o2
- 30-40 treatments m-f
- About 2 hours
- Can be very successful
BANDAGES AND BINDERS
- Use tape, ties or secondary dressing to secure a dressing
- Strips of tape are used to secure dressings
o Nonallergenic paper and silincone tapes = minimize irritation
o Ensure it adheres to several inches of skin on both sides
o Press tape gently making sure to exert pressure away froun wound
o Remoce = loosen ends and gently pull the outer end parallel ith the skin surface
toward wound. Apply light traction to skin away from the wound as tape is
loosened and removed
- Montgomery ties = reusable