Wounds.txt

A break or disruption in the normal integrity of the skin & tissues.

• Intentional vs Unintentional
• Open vs Closed
• Acute vs Chronic

• Inflammatory phase - begins at time of injury - 3 days
• Proliferation phase - 3 days - 24 days
• Maturation phase - end, can last months

• Vasoconstriction
• Vasodilation
• Cells drawn to area
• Mitosis
• Clot dissolves

• Granulation tissue forms
• Fibroblasts
• Epithelialization

• Withstand stress
• Fibroblasts leave
• Collagen organized & tighter
• Strength approx 35%-59%
• Scars - avascular collagen

First Intention - Dry dressing

• Second Intention -
• 1. Largest scar
• 2. Risk for infection
• 3. Longest healing time

• Third Intention - Wet to Dry Dressings
• Debridement
• Dressing - absorb

• Primary, secondary, tertiary intentions
• Type of injury
• Patient health

• No tissue loss
• Sutured closed
• Edges approximated
• Epithelialization
• Minimal scarring

• Tissue loss
• Edges separated
• Heal by granulation & contraction
• Wound pink/red
• Large scar
• Chance of infection

• Open wound then approximated
• Closure delayed until risk for infection is gone
• Minimal scar

• Partial thickness - damage to epidermis & dermis
• Full thickness - damage beyond subcutaneous tissue/fascia/muscle/bone

• #2 health care associated
• 100,000 bacteria count
• Appear 2-7 days post
• Purulent drainage, pain, redness, edema, fever, chills, increased WBC count
• Danger: sepsis & osteomyelitis

• External:
• -Saturated dressing
• -Blood pools under patient
• -Check frequently

• Internal:
• -Hematoma
• -Swelling
• -Vital sign changes
• -Hypovolemic shock

Dehiscence - partial or total separation of wound

Evisceration - protrustion of visceral organs incision

• Risk Factors:
• Obesity, malnourished, smokers, infected wounds

• Warning Signs:
• 3-11 days post op
• Increase in drainage from wound

• Cover wound with sterile towels soaked in NS (normal saline)
• Supine wiht knees bent
• Notify MD immediately
• Stay calm & remain with pt

• Location
• Size
• Depth, W & L
• Approximation of edges
• Drainage
• Color of wound
• Surrounding skin
• Odor
• Drains, tubes
• Sutures, staples
• Pain

• Pain
• Redness
• Swelling
• Heat

(Priscilla rides several horses)

• Redness
• Ecchymosis
• Edema
• Drainage
• Approximation

• Serous: clear, slightly yellow, thin
• Sanguineous: RBC's, bright red vs dark red
• Serosanguineous: mix of RBC & serum, pink to red
• Purulent: WBC, dead tissue debris, bacteria, green, yellow, odorous

• Remove blood & drainage from a wound
• Open drain - Penrose & T-tube
• Closed drain - Hemovac & Jackson-Pratt
• Assess amount & color of drainage

• Prevent infection
• Cleanse wound
• Remove nonviable tissue
• Manage exudate
• Maintain a moist wound bed
• Protect the wound

Reduces infection & removes nonviable tissue

• Cleansing a closed incision site
• Irrigation of a wound
• Debridement - removal of nonviable necrotic tissue

• Apply noncytoxic solution
• Normal saline

• Removes exudates, use sterile technique with 35 mL syringe & 19 gauge needle
• Normal saline

Consult health care facility policy

Portable units that exert a safe, constant, low pressure vacuum to remove & collect drainage

• Clean wound first with NS
• Use a sterile swab from a culturette tube
• Rotate swab in clean tissue, put pressure to obtain fluid

• Use sterile technique
• Aseptic technique
• Protection of wound
• Monitoring of patient's glucose, nutrition, albumin levels & hemoglobin

• Mechanical:
• -Wet to dry saline gause dressing
• -Whirlpool treatments
• -Never use in clean granulated wound

• Autolytic:
• -Synthetic dressings over a wound to allow the eschar to be self digested by body's own enzymes

Chemical:

• Surgical:
• -Removal of thick, adherent wound crust using a scapel or scissors
• -Surgical procedure

• Protects wound
• Hemostasis
• Promotes healing
• Supports wound site
• Provides moist environment

• Advantages:
• -Readily available
• -Packing wounds
• -Can be combined with other products

• Disadvantages:
• -Fiber shreds
• -Change frequently
• -May stick to wound bed
• -May delay healing

• Advantages:
• -Waterproof
• -Promotes autolytic
• -Change q 5-7 days or when it starts to leak
• -Transparent

• Disadvantages:
• -Doesn't absorb moisture
• -May stick to wounds
• -Not for draining wounds

• Advantages:
• -Many sizes
• -Easy to apply
• -Easy to remove

• Disadvantages:
• Needs a topper
• Not for dry wounds
• Not for infected wounds

• Advantages:
• -Adhesive border
• -Used for autolytic debridment

• Disadvantages:
• -May not keep wound moist

• Advantages:
• -On for 3-5 days
• -Reduce pain
• -Self adhesive
• -Absorbent

• Disadvantages:
• -Have odor
• -Loss of shape on wound
• -Expensive
• -Not for heavy drainage

• Advantages:
• -Rehydrate
• -Reduce pain
• -Changed daily
• -Autolytic debridement

• Disadvantages:
• -Need a secondary dressing
• -May cause maceration

• Advantages:
• -Absorbent
• -Can be used as packing for deep wounds
• -Can be used in infected wounds

• Disadvantages:
• -Needs topper
• -Distinct odor & gelling may be confused with infection

• Advantages:
• -Inhibits pathogen growth
• -Cost effective antimicrobial action for 7 days

• Disadvantages:
• -Needs topper
• -Needs to be removed prior to MRI
• -May turn skin black

• Changing:
• -Know type of dressing, placement of drains, & equipment needed

• Securing:
• -Tape, ties, or binders

• Comfort measures:
• -Carefully remove tape - towards wound
• -Gently cleanse wound
• -Administer analgesics before dressing change

• Sterile to Sterile - don't cross over field
• Only sterile objects on sterile field
• A sterile object or field out of range of vision or an object below the waist is contaminated
• A sterile field becomes contaminated by prolonged exposure to air
• Sterile to wet = contaminated
• The edges of field are considered contaminated

• Drainage
• Wound site
• Granulation
• Skin condition
• Type of irrigation fluid used
• Method of wound irrigation
• Observations of wound
• Type of dressing applied