Defense and Immunity

The result of planned invasive therapy or treatment 

purposefully created for therapeutic purposes

wound edges are clean, bleeding is controlled

sterile environment = decreased risk of infection 

Examples 

• surgery
• Intravenous therapy
• lumbar puncture

Accidental, occur from unexpected trauma such as accidents, stabbing, gunshots, burn

occur in unsterile environment, contamination is likely. 

Wound edges are jagged, bleeding is uncontrolled 

Examples - abrasion, skin tear, dermatitis, contusion

Occurs from intentitonal and unintentional trauma.

Skin surface is broken. Possible - bleeding, tissue damage, increased risk of infection, delayed healing

Examples

• Incisions - cutting or sharp instrument
• Abrasions - rubbing or scraping of epidermal layers of skin. Friction

Occurs due to a blow, force or strain caused by trauma such as a fall, an assault or a motor vehicle crash. 

Skin is not broken but soft tissue is damaged. Internal injury and hemorrhage may occur. 

Examples 

• Ecchymosis - discoloration of the skin resulting from bleeding underneath (caused by bruising) 
•  
• Hematomas - a solid swelling of clotted blood within the tissues

Heal within days to weeks. 

Wound edges are meet to close skin surface.

Decreased risk of infection

Move through the healing process without difficulty  

Example - surgical incisions

The healing process is impeded

Wound edges do not close the skin surface

Risk of infection is increased

remain in the inflammatory phase of healing 

Include any wound that does not heal along the expected continuum  

Examples 

• wounds related to arterial or venous insufficiency 
• pressure ulcers

The process of tissue response to injury 

Wound repair occurs by: 

Primary Intention (no tissue loss) - well approximated (skin edges tightly together) - a surgical incision - dine to suture up  

Secondary intention (tissue loss)- not well approximated - large open wounds (burns or major trauma) - take longer to heal and form more scar tissue - heal from inside out

Tertiary intention (delayed secondary)- left open for several days to allow edema or infection to resolve or fluid to drain and then closed.

1st stage of healing

a process which causes bleeding to stop

Occurs immediately after the initial injury

Follows hemostasis. lasts 4-6 days. white blood cells move and clean the wound

• lasts several weeks
• new tissue (granulation tissue) is built to fill wound space

Final stage of healing. begins 3 weeks after injury.

Local factors - occur directly in the wound 

• Pressure 
• Desiccation (dehydration)
• Maceration (overhydration) 
• trauma, edema, infection, excessive bleeding, necrosis (death of tissue), the presence of Biofilm (a think group of microorganisms)

Occur throughout the body 

• age 
• circulation and oxygenation of tissues
• nutritional status 
• wound condition 
• health status immunosuppression
• medication use

Infection

• HAIs – Hospital Associated Infections
• Symptoms occur 2-7 days post-injury or surgery
• S/S of infection - purulent drainage, increased drainage, pain, redness, swelling, increased body temp. & WBC count

Hemorrhage

• Frequently occurs during first 48 hours after injury
• Signs – BP low, high HR, paleness, dizziness, bruising

Dehiscence and Evisceration

• Partial or total separation of a wound
• Protrusion of viscera (serious complication).

Fistula Formation

• An abnormal passage from an internal organ to the outside of the body or from organ to organ
• Infection – fluid build up
• Monitor vital signs, labs (WBC)

wound with a localized area of injury to the skin and or underlying tissue

External pressure

Friction and shearing forces

Immobility

Nutrition and Hydration

Moisture

Mental status

Age

Purple or maroon localized area of discolored intact skin or blood blister due to damage to underlying tissue from pressure or shear

Intact skin over bony prominence; nonblanchable redness

Partial thickness loss of dermis

Partial thickness skin loss involving epidermis, dermis, or both.

The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. 

Full thickness tissue loss

Full thickness tissue loss with exposed bone, tendon, or muscle; slough may be present

Base of ulcer is covered by slough and/or eschar. 

Eschar must be removed(unless on heel) before stage can be determined accurately. 

History and Physical, Labs, Diagnostic Tests,  Risk Assessment (Braden Scale p.977)

Skin assessment including hygiene practices 

Pain assessment (before, during, after)

Wound assessment (sight and smell)

Color: (RYB Classification) 

• Red - protect 
• Yellow - cleanse 
• Black - debride 

Appearance: location, size, wound edges, tunneling, undermining, odor

Drainage - serous, serosanguineous, sanguineous, purulent

Common Drains: Penrose, T-tube, Jackson-Pratt, Hemovac

Serous - Clear and watery 

Sanguineous - bloody 

• bight - fresh bleeding 
• darker - older bleeding

Serosanguineous - light pink to blood tinged

Purulent -  thick green, yellow or brown with musty or foul odor.

Penrose - provides sinus tract. after incision and drainages of abscess, in abdominal surgery. 

T-tube - for bile drainage. after gallballalder durgery 

Jackson-Pratt - decreases dead space by collecting drainage. after breast removal, abdominal surgery

Hemovac - decreases dead space by collecting drainage. after abdominal surgery, orthopedic surgery

• Impaired Skin integrity
• Risk for Impaired Skin Integrity
• Impaired Mobility
• Ineffective Tissue Perfusion
• Risk for Infection
• Imbalanced Nutrition
• Body Image Disturbance
• Hopelessness
• Pain
• Knowledge Deficit

The patient will remain afebrile with the absence of redness or purulent drainage at the surgical site for the duration their hospital stay.

The patient’s skin will remain intact for the duration of their hospital stay

• Maintain aseptic technique with dressing changes.
• Use proper handwashing technique.
• Monitor wound for signs and symptoms of infection(redness, purulent or increased drainage, etc.)
• Monitor temperature every 4 hours.
• Reposition patient every two hours.
• Use padded devices( heal protectors, pillows) at pressure points.
• Consult with the wound care specialist.