Maceration - White wrinkled skin from excessive moisture
Induration - Increased firmness of tissue
Erythema - Redness of skin due to inflammation, injury
Hyperkeratosis -Thickening of skin- callous formation
Hemosiderin Staining - Discoloration due to release of iron containing pigment from disintegration of red blood cells- indicator of venous disease
Lipodermato- sclerosis - Thickening of tissues under the skin of the leg resulting in hard, woody texture
Surgical asepsis(sterile technique)
Used to eliminate all micro-organisms from an object or area.
When working with a sterile field or with sterile equipment, any break in technique results in contamination.
Principles of Medical Asepsis
Use practices of personal grooming
Wash hands frequently
Keep soiled items and equipment from touching clothing
Do not place soiled linen or other items on the floor
Clean least soiled areas first (clean to dirty)
Dispose of soiled or used items in appropriate containers
Avoid leaning against equipment or touching eyes, nose, mouth after immediate use
Principles of Surgical Asepsis
All objects used in or over a sterile field must be sterile
Sterile items out of vision or below the waist level are considered unsterile
Sterile objects become unsterile by prolonged airborne exposure
Sterile objects become contaminated when touched by unsterile objects
Types of Wound Care Products: Wound Hydration
Hydrogels (intrasite, duoderm gel)
Types of Wound Care Products: Moisture Retention
Types of Wound Care Products: Exudate Management
Calcium alginates (kaltostat, Seasorb/Ag)
Hydro fibers (Aquacel plain/Ag)
Foams (mepilex with/without border)
Types of Wound Care Products: Odour Management
antifungal powders (Tinactin, Flagyl)
Types of Wound Care Products: Antimicrobials
Silvers (acticoat, actisorb, silver nitrate)
Cadexomer iodine (iodosorb)
Types of Wound Care Products: Non Adherent Layers
Vaseline gauze (bactigras, adaptic)
Types of Wound Care Products: Non-Adherent Layers
Restore/Ag, vaseline gauze, telfa
Types of Wound Care Products: Other Specialty Products
Compression (coban, comprilan, tubigrip)
growth factors (promogran, prisma)
Negative Pressure Wound Therapy (VAC)
Impact Of Chronic Wounds
Quality of life - Often lengthy healing time!
Restricts normal activity
Altered body image
Increased cost:mean hospital costs and length of stay increase when an ulcer
Estimated $9000/month to treat in the community (RNAO)
Surface Area= Length x Width
Length = the longest axis of the wound
Width = 90 ° to the length at the next
Depth: Use Q-tip to measure deepest area of wound to skin surface
Cleaning The Wound: IRRIGATION
Wound irrigation = using wound cleansing solution with a small amount of pressure (4-15 psi, FYI only) to decrease the amount of bacteria and to remove debris (dead tissue, dressing fibers, metabolic waste, etc.) from the wound bed.
Allows visualization of the wound bed, to assess depth and structures involved.Five types of debridement:1.Surgical debridement
When the non-viable tissue is cut away by using a scalpel, scissors, or other sharp instrumentQuickest method of debridement
Indicated when large amount of non-viable tissue are present and client is septic
Risks: Causes bleeding, has potential to cause injury to nervous or other viable tissue
Subcutaneous debridement is a controlled act that must be carried out by a physician or delegate.
Physical force to remove dead tissue.
wet-to-dry dressings, high pressure irrigation, and whirlpool treatments.In wet-to-dry dressings, the nurse places a saline moistened gauze in the wound bed and allowed to dry thoroughly. When the dry dressing is removed, necrotic tissue is removed but so is viable tissue. It should never be used in a clean, granulating wound. It is also a very painful procedure.(medicate!)
All types of mechanical debridement are slow, painful, and non-selective in type of tissue removed.
Uses the body's own enzymes and moisture to re-hydrate, soften and finally liquefy hard eschar and slough.
Very selective – only necrotic tissue is liquified.
The process is safe
Effective,versatile and easy to perform
Little to no pain for the patient
Wound must be monitored closely for signs of infection.
May promote anaerobic growth if an occlusive hydrocolloid is used
Addition of chemical enzymes to the wound bed that breaks down tissue. Some enzymatic debriders are selective (i.e. removes only dead tissue), while some are not (i.e. removes dead and healthy tissue).
Useful on wounds with a large amount of necrotic debris that is not appropriate for
Selective: Minimal or no damage to healthy tissue with proper application only to necrotic tissue.
May cause temporary increase in exudate from wound
Requires a prescription. (Expensive)
Inflammation or discomfort may occur
Maggot Debridement Therapy (MDT) is the medical use of live maggots (only greenbottle fly larvae) for treating non-healing wounds.
Disinfected fly larvae are applied to the wound for 2 or 3 days within special dressings to keep them from migrating.
Actions on the wound:
1.They clean the wounds by eating dead and infected tissue ("debridement");
2.They disinfect the wound (kill bacteria);
3.Thus,they speed the rate of healing.
Sterile technique is used with a culturette tube to obtain pathogens in an infected wound
Requires a doctor’s order –wound C&S
Never collect from old drainage!
Cleanse wound first with normal saline
Obtain specimen from the healthiest looking tissue.
Tubes: aerobic for surface wounds and anaerobic if within body cavities
Definition – filling a wound with a dressing material to promote granulation tissue by secondary intention through the elimination of “dead space”.
Many materials, such as alginates, foams, hydrocolloids, anti-microbials or gauze, can be used to pack wounds. (P&P,Table 47-9)
When dead space (eg/tunnelling) is NOT filled with packing material, it allows debris to accumulate, which can lead to further abscess development
Packing Wounds Procedure
Packing a wound is a sterile procedure!
Initially,same procedure as for dry dressing. Upon removal of old packing, assess for amount and type of exudate, assess wound and periwound.
Perform hand hygiene, apply sterile gloves, cleanse or irrigate per order.
If packing with alginate, hydrocolloid or foam dressings:
Cover wound base and fill tunnel with dry dressing. Add additional layers for deep wound if necessary. (Follow pkg directions)
Wound exodate moistens dressing to maintain moist wound bed.
Will need additional moisture if wound bed dry (eg/ hydrogel)
If packing with gauze:Lightly moistened gauze packing with prescribed solution, wring out excess (moist like your eyeball)
Unfold and place on wound bed and inside tunnels one layer at a time (“fluffed”) until all surfaces are covered.
Material is held above the wound and not
allowed to come into contact with skin surface prior to insertion into the wound bed.
Gently pack! Packing should not extend higher than wound surface. If pressure is too firm, it will prohibit formation of new granulation tissue
Do NOT cover periwound. (causes maceration)
Packing material is secured with dry gauze, abd pads if drainage is moderate. Some special dressing materials require special outer covering, read directions.
Tape or ties, adhesive soft covering (mefix, hypofix) can be used depending on the size and location of wound.
Type of dressing and packing material selected will depend on stage of ulcer, wound bed, and goal of therapy. Also, it will change as wound bed changes (heals or worsens).
Types of Drains
Penrose drain - Passive drain with a pin or clip placed through the drain to prevent it from slipping into the wound
Jackson Pratt & Hemovac - Active drains that create self suction when suction device (bladder or bag) is fully compressed
Drain Assessment & Care
Type of drain, number of drains and drain placement
Security of the drain and condition of the collecting apparatus
Type and amount of drainage
Empty daily and document output
Daily drain cleansing with dry dressing (drain sponges)
Sutures are threads used to sew body tissues together.
They can be made of silk, steel, cotton, linen, wire, nylon and Dacron.
Intermittent suturing - is done when each individual suture is tied.
Continuous suturing and blanket
suturing - are a series of sutures with only two knots, one at the beginning and one at the end.
Steel staples - are commonly used as they cause less trauma and provide extra strength.
Wound repair: Partial thickness
Are shallow wounds involving loss of the epidermis and possible partial loss of the dermis
healing process: inflammatory response, epithelial proliferation(reproduction), migration and establishment of epidermal layer.
Inflammatory response - cause redness and swelling and moderate amount of serous membrane. Limited to first 24 hours after wounding
Epithelial proliferation(reproduction) and migration - starts at both the wound edges and the epithelial cell lining which allow quick surfacing
Wound left open to air can resurface = 6 to 7 days
Wound that is kept moist can resurface = 4 days
Wound repair: Full- thickness
Healing process: Inflammatory, proliferation and remodeling phases are involve in the
Inflammatory - body's reaction to wound.
Beginning within minutes of injury and lasting approximately 3 days
Damages tissue and mast cells secrete:
Histamine - Result in vasodilation of surrounding capillaries and exudation of serum and white blood cells into damage tissue