Wound Care

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 Question

•Is the following statement true or false?

Macrophages are types of white blood cells.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

 Answer

True.

Macrophages are types of white blood cells.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

 Wounds

• Wound: damaged skin or soft tissue

resulting from trauma

– Open wounds: mucous membrane is

no longer intact

– Closed wounds: no open mucous

membrane

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 Wound Repair
• Inflammation: physiologic defense occurring
immediately after tissue injury, lasting 2 to 5
days
– Purpose: limit local damage, remove
injured cells/debris, prepare wound for
healing
– Signs and symptoms of inflammation:
swelling, redness, warmth, pain, and
decreased function
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 Wound Repair (cont’d)

• Proliferation: period during which new cells

fill and seal a wound; it occurs 2 days to 3
weeks after inflammatory phase

– The integrity of skin and damaged tissue

is restored by resolution, regeneration,
and scar formation

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 Wound Repair (cont’d)

• Remodeling: period during which the wound

undergoes changes and maturation

– Lasts 6 months to 2 years

– During remodeling, the wound contracts

and the scar shrinks

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The Inflammatory Response

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 Wound Healing
• First-intention healing: reparative process in
which wound edges are directly next to each
other
• Second-intention healing: wound edges are
widely separated; time-consuming, complex
reparative process
• Third-intention healing: deep wound edges
brought together with some type of closure
material, resulting in a broad, deep scar
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 Wound Healing Factors
• Type of wound injury
• Expanse or depth of wound
• Circulation quality
• Amount of wound debris
• Presence of infection
• Client’s health status

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 Wound Repair

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 Wound Healing Complications
• Wound healing key: adequate blood flow to
the injured tissue
• Interfering factors may include:
– Compromised circulation
– Infection
– Purulent, bloody, or serous fluid
accumulation preventing skin and tissue
approximation
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 Wound Healing Complications
(cont’d)

• Potential surgical wound complications

– Dehiscence: separation of wound edges

– Evisceration: wound separation with

protrusion of organs

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 Dressings
• Dressing purposes:
– Keeping wound clean
– Absorbing drainage
– Controlling bleeding
– Protecting wound from further injury
– Holding medication in place
– Maintaining a moist environment
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 Dressings (cont’d)
• Types of dressings:

– Gauze dressings: ideal for covering fresh

wounds that are likely to bleed, or wounds
that exude drainage

– Transparent dressings: used to cover

peripheral and central IV insertion sites

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 Dressings (cont’d)

• Types of dressings (cont’d)

– Hydrocolloid dressings: keep wounds

moist; moist wounds heal more quickly;
new cells grow more rapidly in a wet
environment

– Dressing changes: when a wound

requires assessment or care
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 Question

•Which dressing is ideal for covering

fresh wounds that are likely to bleed?
a. Gauze
b. Transparent
c. Hydrocolloid
d. Dressing

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 Answer
a. Gauze

Gauze dressing is used for covering fresh

wounds. Transparent dressings are used to
cover IV insertion sites. Hydrocolloid
dressings keep wounds moist. Dressing
changes are done when a wound requires
assessment, care, or is saturated with
drainage.
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 Wound Management

• Drains

– Open drains

– Closed drains

• Sutures; Staples

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 Question

•Is the following statement true or false?

Steri-Strips can be used to close superficial

lacerations instead of sutures or staples.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

 Answer

True.

Steri-Strips are also used to close superficial

lacerations instead of sutures or staples.

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 Wound Management (cont’d)
• Bandages and binders
– Purpose: hold dressings in place,
especially if tape cannot be used or
dressing is very large
– Support area around the wound or injury
to reduce pain
– Limit movement in wound area to
promote healing
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Wound Management (cont’d)

• Roller bandage application

• Binder application

– Different types of binders

o Single T-binder

o Double T-binder

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 Wound Management (cont’d)

• Debridement: removal of dead tissue

– Sharp debridement: using sterile scissors,
forceps, etc.
– Enzymatic debridement: using chemical
substances
– Autolytic debridement: natural physiologic
process

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 Wound Management (cont’d)
• Debridement (cont’d):
– Mechanical debridement: physical removal
of debris from a wound using wet-to-dry
dressings, hydrotherapy, irrigation
o Commonly irrigated structures include:
 Wounds, eyes, ears, vagina

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 Question

•Which type of debridement breaks

down and liquefies wound debris?
a. Autolytic
b. Sharp
c. Mechanical
d. Enzymatic

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 Answer
d. Enzymatic
Enzymatic debridement involves the use of
topically applied chemical substances. Autolytic
debridement allows the body’s enzymes to
soften, liquefy, and release devitalized tissue.
Sharp debridement is the removal of necrotic
tissue with sterile scissors, forceps, or other
instruments. Mechanical debridement involves
physical removal of debris.

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 Wound Management (cont’d)
• Heat and cold applications
– Ice bag and ice collar
– Chemical packs
– Compresses
– Aquathermia pad
– Soaks and moist packs
– Therapeutic baths

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 Pressure Ulcers
•Also known as decubitus ulcers
– Appear over bony prominences of
the sacrum, hips, heals, and places
where pressure is unrelieved
•Risk factors include:
− Inactivity, immobility, malnutrition,
emaciation
− Diaphoresis, incontinence, sedation
− Vascular disease, localized edema,
dehydration
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 Pressure Ulcers (cont’d)
• Stages of pressure ulcers
– Stage I: intact but reddened skin
– Stage II: reddened skin accompanied by
blistering or a skin tear
– Stage III: shallow skin crater that
extends to the subcutaneous tissue
– Stage IV: deeply ulcerated, extending to
muscle and bone; life threatening
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 Pressure Ulcers (cont’d)
• Prevention of pressure ulcers
– Change client’s position frequently
– Avoid using plastic-covered pillows
– Use the lateral position for side-lying
– Massage bony prominences
– Use pressure-relieving devices
– Provide a balanced diet and adequate
fluid intake
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 Nursing Implications

•Potential nursing diagnoses:

– Acute pain
– Impaired skin and tissue integrity
– Ineffective tissue perfusion
– Risk for infection

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General Gerontologic Considerations
• Wound healing is delayed in older adults;
regeneration of healthy skin takes twice as
long for an 80-year-old as it does for a 30-
year-old
• Age-related changes affecting wound healing
include thinning dermal layer of skin;
decreased subcutaneous tissue
• Signs of inflammation may be more subtle in
older adults
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General Gerontologic Considerations
(cont’d)
• Diminished immune response from reduced T-
lymphocyte cells predisposes older adults to
wound infections
• Conditions that interfere with circulation
increase the older adult’s susceptibility to
delayed wound healing and wound infections
• Diminished mobility requires aggressive skin
care to prevent pressure ulcers
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General Gerontologic Considerations
(cont’d)
• Due to decreased blood supply to the skin,
older adults may need position changes every
60 to 90 minutes, instead of every 20 minutes
• Use special care when moving older adults;
avoid friction on the skin
• Depression, poor appetite, cognitive
impairments, and physical/economic barriers
interfering with adequate nutrition may impair
wound healing
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