Defense and Immunity

  1. Wound classification

    Intentional wounds
    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 


    • surgery
    • Intravenous therapy
    • lumbar puncture
  2. Wound classification

    Unintentional wounds
    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
  3. Open wound
    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
  4. Closed Wounds
    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
  5. Acute Wounds
    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
  6. Chronic Wounds
    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
  7. Wound Healing
    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.
  8. Hemostasis
    1st stage of healing

    a process which causes bleeding to stop

    Occurs immediately after the initial injury
  9. Inflammatory Phase
    Follows hemostasis. lasts 4-6 days. white blood cells move and clean the wound
  10. Proliferation Phase
    • lasts several weeks
    • new tissue (granulation tissue) is built to fill wound space
  11. Remodeling (maturation) Phase
    Final stage of healing. begins 3 weeks after injury.
  12. Factors affecting wound healing

    Local factors
    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)
  13. Factors affecting wound healing
    Systemic Factors
    Occur throughout the body 

    • age 
    • circulation and oxygenation of tissues
    • nutritional status 
    • wound condition 
    • health status immunosuppression
    • medication use
  14. Wound Complications

    • 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).

    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)
  15. Pressure Ulcer
    wound with a localized area of injury to the skin and or underlying tissue
  16. Factors and Risks for Pressure Ulcer Development
    External pressure

    Friction and shearing forces


    Nutrition and Hydration


    Mental status

  17. 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
  18. Stage I
    Intact skin over bony prominence; nonblanchable redness
  19. Stage II
    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. 
  20. Stage III
    Full thickness tissue loss
  21. Stage IV
    Full thickness tissue loss with exposed bone, tendon, or muscle; slough may be present
  22. Unstageable
    Base of ulcer is covered by slough and/or eschar. 

    Eschar must be removed(unless on 
    heel) before stage can be determined accurately. 
  23. 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

  24. Drainage
    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.
  25. Common Drains
    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
  26. Common Nursing Diagnoses
    • 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
  27. 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
  28. Nursing interventions
    • 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.
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Defense and Immunity
Defense and Immunity