Chapter 28 Wound Care Copyright 2009 Wolters Kluwer

Wounds • Wound: damaged skin or soft tissue resulting from trauma – Open wounds:

Wound Repair • Inflammation: physiologic defense occurring immediately after tissue injury, lasting 2 to

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Wound Repair (cont’d) • Proliferation: period during which new cells fill and seal a

Wound Repair (cont’d) • Remodeling: period during which the wound undergoes changes and maturation

The Inflammatory Response Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Wound Healing • First-intention healing: reparative process in which wound edges are directly next

Wound Healing Factors • Type of wound injury • Expanse or depth of wound

Wound Repair Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Wound Healing Complications • Wound healing key: adequate blood flow to the injured tissue

Wound Healing Complications (cont’d) • Potential surgical wound complications – Dehiscence: separation of wound

Dressings • Dressing purposes: – Keeping wound clean – Absorbing drainage – Controlling bleeding

Dressings (cont’d) • Types of dressings: – Gauze dressings: ideal for covering fresh wounds

Dressings (cont’d) • Types of dressings (cont’d) – Hydrocolloid dressings: keep wounds moist; moist

Wound Management • Drains – Open drains – Closed drains • Sutures and staples

Wound Management (cont’d) • Bandages and binders – Purpose: hold dressings in place, especially

Wound Management (cont’d) • Roller bandage application • Binder application – Different types of

Wound Management (cont’d) • Debridement: removal of dead tissue – Sharp debridement: using sterile

Wound Management (cont’d) • Debridement (cont’d): – Mechanical debridement: physical removal of debris from

Wound Management (cont’d) • Heat and cold applications – Ice bag and ice collar

Pressure Ulcers • Also known as decubitus ulcers – Appear over bony prominences of

Pressure Ulcers (cont’d) • Stages of pressure ulcers – Stage I: intact but reddened

Pressure Ulcers (cont’d) • Prevention of pressure ulcers – Change client’s position frequently –

Nursing Implications • Potential nursing diagnoses: – Acute pain – Impaired skin and tissue

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Wounds • Wound: damaged skin or soft tissue resulting from trauma – Open wounds: mucous membrane is no longer intact – Closed wounds: no open mucous membrane Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Wound Healing Complications (cont’d) • Potential surgical wound complications – Dehiscence: separation of wound edges – Evisceration: wound separation with protrusion of organs Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Dressings • Dressing purposes: – Keeping wound clean – Absorbing drainage – Controlling bleeding – Protecting wound from further injury – Holding medication in place – Maintaining a moist environment Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Wound Management (cont’d) • Roller bandage application • Binder application – Different types of binders o Single T-binder o Double T-binder Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Wound Management (cont’d) • Heat and cold applications – Ice bag and ice collar – Chemical packs – Compresses – Aquathermia pad – Soaks and moist packs – Therapeutic baths Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Implications • Potential nursing diagnoses: – Acute pain – Impaired skin and tissue integrity – Ineffective tissue perfusion – Risk for infection Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins