1. State the different types of wound categories and identify the differences in each type.
2. Identify ways to prevent wounds and / or skin breakdown.
3. Define the different stages of wound healing.
4. State the goals of proper wound care.
5. Define aseptic conscience.
6. State the process of setting up and maintaining a sterile field.
7. Demonstrate donning sterile gloves.
8. State differences between aseptic and sterile technique.
9. Apply knowledge of wounds and wound care in documentation of procedure.
10. Identify different types of wound drains.
11. Compare different ways pressures ulcers can occur.
12. Compare different stages of pressure ulcers.
13. State factors that can affect pressure ulcer formation.
14. Identify ways to prevent pressure ulcer formation.
15. Define heat therapy and identify different treatment options.
16. Define cold therapy and identify different treatment options.
17. Calculate a patients Intake and Output.
Why such the emphasis on wound care / sterile technique?
õ Healthcare Associated Infections
õ 1.7 million infections
õ 99,000 deaths
õ $45 billion spent
õ Could save $31.5 billion
What are some functions of skin?
õ 1st line of defense
ô Temperature regulation
Factors affecting skin integrity:
ô Children (<2)
ô Thinner skin
ô Risk for infection
ô Very thin or Very obese
ô Fluid loss
ô Circulation / oxygenation
ô Nutrient absorption-elderly taste sweet last
ô Risk for infection
What is a wound and what are four things to consider?
ô Any break or disruption in the normal integrity of skin / tissues.
ô 4 things to take into consideration:
ô How was it acquired? Intentional or unintentional?
ô Is it open or closed?
ô How long have they had it?
ô How deep is it?
Description of intentional wound:
ô Planned / purposeful
ô Created for a specific purpose
ô Edges are clean
ô Bleeding is controlled
ô Decreased risk for infection risk for infection
Description of unintentional wounds:
ô Accidental/ unexpected
ô Occurs in unsterile environment
ô Contamination likely
ô Edges are jagged
ô Bleeding uncontrolled
ô High Risk infection risk
ô Longer healing time
ô Multiple injuries
Differences between closed and open wounds:
ô Skin broken
ô Portal for entry
ô Bleeding / tissue damage
ô Delayed healing
ô Abrasion / incision
· Blow / force / strain due to trauma
o Internal injury-cardiac contusion
o May have internal hemorrhage
o May see ecchymosis or hematoma
Differences between acute and chronic wounds:
ô Heals within days to weeks
ô Edges meet
ô Decreased risk for infection
ô Edges not well approximated
ô Healing process impeded
ô Increased risk for infection
ô Remains in inflammatory process
Deepness of wounds:
ô All or at least a portion of the dermis is intact
ô Full thickness
ô Entire dermis is affected including sweat glands, and hair follicles
ô Complex full thickness is when dermis and underlying subcutaneous fat tissue is damaged or destroyed
ô Little tissue loss
ô Edges are approximated (close together)
ô Heals rapidly
ô Little scarring
ô Small risk for infection
ô Surgical incisions
ô Loss of tissue
ô Wound edges are widely separated
ô Wound is pink to dark red
ô Granulation à large scar
ô Healing time is longer
ô Burns; pressure ulcers
ô Widely separated tissue
ô Deep wound
ô Extensive drainage / debris
ô High risk for infection
õ Dehiscence - a splitting open.
Phases in healing process:
What is hemostasis?
Immediately after injury
Vessels constrict, platelets arrive and begin clot formation
Vessels then dilate allowing blood and plasma to leak into area – exudates
Scab may form to protect site
What is the Inflammatory stage of in healing process?
WBC’s arrive to ingest bacteria
Macrophages ingest debris and release growth factorsThis attracts fibroblasts
What is proliferation in the healing process?
Fibroblasts build new tissue
New blood vessels form
O2 and nutrients brought in
New tissue is granulation tissue
Very vascular – bleeds easilyWound begins to close during this phase
What is Maturation in the healing process?
3 weeks after injury
Continues months to years after injury
Collagen that was deposited is now remodeled to look like adjacent tissue
Factors affecting local wound healing:
ô Desiccation-extreme dryness
ô Maceration-softening by soaking in a liquid, wet pants, pruny looking, skin can tear
ô Trauma-if sticks use light saline solution to loosen
ô Edema- mutrients blocked from swollen capillaries
ô Necrosis-premature death of skin cells, dead tissue, wounds need to be debreided. Slough-moist yellow stringy material, not quite dead, eschar- black dry leathery, debridement-surgical removal of crap, premedicate patient
Factors affecting systemic wound healing:
ô Age, elderly, infants, children
ô Circulation / Oxygenation-elderly
ô Nutritional status-sweet tastebuds are the last to go; diet consult can help
ô Wound condition
ô Medications / health status –steroid inhibit healing
ô Dehiscence-splitting open wound
Facts about infection:
ô 2-7 days after surgery
ô Purulent drainage
ô Watch dressing closely
ô Pressure dressing
ô Fluid replacement
ô Hematoma: collection of blood under the skin
Dehiscence and evisceration:
o Partial/total separation of wound
ô Total separation of wound with Total separation of sound with viscera protruding STAY CALM Low Fowler’s position. Keep a POKER FACE!
õ Can be acute or chronic
õ Cause: pressure, insurance will not cover until stage 1 or 2
õ Elderly are the typical patient:
ô Chronic illness
ô Fecal / urine incontinence-will break skin down if left to sit
ô Altered LOC- altered level of consciousness
Friction and Shearing with blood vessels:
o 2 forces rub together.
o Looks like an abrasion.
o Seen on elbows / heels when patient tries to push themselves up in bed.
o Layer of skin slides over another layer separating the underlying tissue.
o Occurs when you pull instead of lift or when patient slides in bed / chair.
o Properly move is to lift not drag a person
Risk factors for pressure ulcers:
ô Nutrition / Hydration
ô Mental Status
Stage 1 pressure ulcer:
ô Non-blanchable erythema – red even with pressure
ô Darker skin tones: blue / purple tones
ô Epidermis layer only
ô Reversible if pressure relieved
ô Frequent turning
ô Pressure reduction surface
ô Keep area clean and dry
ô Keep well nourished
Stage two pressure ulcers:
ô Partial thickness (epidermis / dermis)
ô Presents as abrasion, blister, shallow crater
ô Swollen, painful
ô Several weeks to heal as long as pressure relieved
ô Moist healing environment
ô Saline or occlusive dressing to promote healing but prevent scar
ô Will not be tested on dressing in notes on last 3 pages
Stage three pressure ulcers:
ô Full thickness – subcutaneous tissue down to fascia
ô Deep crater with / without undermining or tunneling
ô Infection = foul smelling drainage
ô Months to heal
ô Seen on coccyx
ó Proteolytic enzymes-Dakin solution
ó Wet to dry-put saline soaked gauze in, collects bacteria and is pulled out with the dressing
Stage four pressure ulcers:
ô Extensive damage – tendons, muscle, bone
ô May look small but tunneled underneath
ô Foul smelling discharge
ô Infection à Sepsis
ô Months à Years to heal
ô Non-adherent dressing changes every 8-12 hours.
ô Skin grafts
Prevention of pressure ulcers:
ô Avoid hard surfaces
ô Keep area clean & dry
ô Avoid massaging over boney prominences
ô Smooth, wrinkle free linen
ô Reposition every 2 hours
ô Shift weight every 15 minutes
Supporting the healing process of pressure wounds:
ô Adequate fluid intake
ô Adequate nutrition
ô Prevent infection
ô Position to relieve pressure
Assessment of wound care:
ó What does it look like?
ó What does it smell like?
ó Any drainage?
ó Any odor?
ô Palpate area around site for pain / tenderness
ó Acute care – upon admission and each shift and transferred to unit
ó Long term care – upon admission and weekly
ó Home Health – upon admission then each visit
Appearance of wound:
ó Relate to the nearest anatomic landmark
ó Mm or cm
ó Length x width x depth;
ó sterile -Qtip and measuring tape
ô Approximation of wound edges
ô Color of wound and surrounding edges- when you are documenting you are painting a verbal picture
ô Presence of drains, tubes, staples, sutures
Color of open wounds:
ô Red = protect / cover
ó Cleanse gently
ó Topical antimicrobials
ó Transparent film
ó Change as little as possible
ô Yellow= cleanse
ó Wet – to – dry dressing
ó Wound irrigation
ó Absorbent dressing
ô Black (BAD)= debride
ó Debride for healing to occur
ó Sharp debridement:
õ Scalpel or scissors
ó Mechanical debridement:
õ Scrubbing or wet-to-dry dressing
ó Chemical debridement:
õ Enzymes to remove dead tissue
Drainage of a wound:
õ Forms during inflammatory process
õ Fluid / cells that leak from blood vessels
õ Clear and watery
ó Looks like blood
ó Bright red – fresh
ó Dark red – old
ó Serum and blood cells
ó Light pink to blood tinged
ó WBC’s, liquefied dead tissue debris, bacteria
ó Foul odor
ó Different colors-yellow green most common colors
Documentation of wound (COCA)
ô C: color of wound, bed, drainage
ô O: odor if any
ô C: consistency of drainage
ô A: amount (scant, moderate, large)
Goals of proper wound care:
ô Promote healing
ô Provide comfort
ô Prevent / eliminate / control infection
ô Absorb drainage
ô Maintain a moist environment
ô Protect surround skin
ô Protect wound from further injury
ô Freedom from disease producing organisms
ô #1 way to prevent spread of organisms: HANDWASHING
ô Medical: areas contaminated if they bear or are suspected of bearing pathogens
ô Surgical: areas contaminated if they are touched by anything non-sterile
ô Sterile: ALL pathogens have been destroyed
ô Aseptic Conscience: You broke sterile technique
ô Open packages awayfrom body.
ô Surface below must be sterile if handling fluid.
ô Keep all items above waist level
ô Don’ t cough, sneeze, talk, or reach over field.
ô Don’t walk away or turn your back.
ô 1 inch around edge is not sterile.
ô Items must be sterile if entering skin / cavity.
ô ANY DOUBT = CONTAMINATED!!!
ô All contents inside are sterile, all contents outside are contaminated.
ô Date and initial label when opened.
ô If date 24 >hours toss it!
ô Hold label into hand when pouring.
ô LIP when previously opened. – pour a bit out
ô Skin to inside only.
ô Dominate hand 1st.
ô Outer part handled by gloves only.
Cleansing the wound:
õ Clean from top to bottom
õ Move from incision outward
õ Replace gauze / sponge with each swipe
õ New gauze / swab with each circle
õ Begin in center and move outward
õ Clean 1 inch beyond dressing
Types of Drains:
ô Penrose – drainage empties into gauze.
o Drainage moves from area of greater pressure to lesser pressure.
o Safety pin on end to keep from losing tube.
ô Jackson-Pratt (JP) – applies low suction to area being drained.
o Must be emptied, measured, and suction reapplied.
Other wound therapies:
õ Fibrin Sealants
õ Inject into tissue to seal off.
õ Angioseal – see after heart catheterizations.
õ Vacuum-assisted Closure (VAC)
õ Applies constant negative pressure to pull drainage out of the wound.
õ Promotes blood flow, growth of new vessels, and pulls edges together.
Other wound therapies:
õ Transport sound waves through gel to bone. When it hits the bone it breaks apart and creates thermal energy.