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
- 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
- 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.
- 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
- 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
Remodeling (maturation) Phase
Final stage of healing. begins 3 weeks after injury.
Factors affecting wound healing
Local factors - occur directly in the wound
- Desiccation (dehydration)
- Maceration (overhydration)
- trauma, edema, infection, excessive bleeding, necrosis (death of tissue), the presence of Biofilm (a think group of microorganisms)
Factors affecting wound healing
Occur throughout the body
- circulation and oxygenation of tissues
- nutritional status
- wound condition
- health status immunosuppression
- medication use
- 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
- 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).
- 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
Factors and Risks for Pressure Ulcer Development
Friction and shearing forces
Nutrition and Hydration
Suspected Deep Tissue Injury
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.
Assessment of wounds & pressure ulcer
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
Common Nursing Diagnoses
- Impaired Skin integrity
- Risk for Impaired Skin Integrity
- Impaired Mobility
- Ineffective Tissue Perfusion
- Risk for Infection
- Imbalanced Nutrition
- Body Image Disturbance
- Knowledge Deficit
Planning - SMART Outcomes
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.