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Learning objectives for lecture 4:
- 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.
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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
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What are some functions of skin?
- õ 1st line of defense
- õ Function:
- ô Protection
- ô Temperature regulation
- ô Sensation
- ô Psychosocial
- ô Immunological
- ô Absorption
- ô Elimination
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Factors affecting skin integrity:
- ô Resistance
- ô Nourished
- ô Hydrated
- ô Circulation
- ô Children (<2)
- ô Thinner skin
- ô Risk for infection
- ô Very thin or Very obese
- ô Fluid loss
- ô Elderly
- ô Fragile
- ô Circulation / oxygenation
- ô Nutrient absorption-elderly taste sweet last
- ô Collagen
- ô Risk for infection
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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?
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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
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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
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Differences between closed and open wounds:
- OPEN
- ô Skin broken
- ô Portal for entry
- ô Bleeding / tissue damage
- ô Delayed healing
- ô Abrasion / incision
- CLOSED
- · Blow / force / strain due to trauma
- o Internal injury-cardiac contusion
- o May have internal hemorrhage
- o May see ecchymosis or hematoma
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Differences between acute and chronic wounds:
- õ ACUTE
- ô Heals within days to weeks
- ô Edges meet
- ô Decreased risk for infection
- ô Chronic
- ô Edges not well approximated
- ô Healing process impeded
- ô Increased risk for infection
- ô Remains in inflammatory process
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Deepness of wounds:
- ô PARTIAL
- 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
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PRIMARY Healing:
- ô Little tissue loss
- ô Edges are approximated (close together)
- ô Heals rapidly
- ô Little scarring
- ô Small risk for infection
- ô Surgical incisions
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Secondary Healing:
- 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
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Tertiary healing:
- ô Widely separated tissue
- ô Deep wound
- ô Extensive drainage / debris
- ô High risk for infection
- õ Dehiscence - a splitting open.
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Phases in healing process:
- ô Hemostasis
- ô Inflammatory
- ô Proliferation
- ô Maturation
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What is hemostasis?
- 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
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What is the Inflammatory stage of in healing process?
- 4-6 days
- WBC’s arrive to ingest bacteria
- Macrophages ingest debris and release growth factorsThis attracts fibroblasts
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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
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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
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Factors affecting local wound healing:
- ô Pressure
- 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 Infection
- 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
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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
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Wound complications:
- ô Infection
- ô Hemorrhage
- ô Dehiscence-splitting open wound
- ô Evisceration
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Facts about infection:
- ô 2-7 days after surgery
- ô Purulent drainage
- ô Pain
- ô Swelling
- ô Redness
- ô Temp
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Hemorrhage:
- ô Watch dressing closely
- ô Pressure dressing
- ô Fluid replacement
- ô Hematoma: collection of blood under the skin
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Dehiscence and evisceration:
- õ Dehiscence
- o Partial/total separation of wound
- õ Evisceration
- ô Total separation of wound with Total separation of sound with viscera protruding STAY CALM Low Fowler’s position. Keep a POKER FACE!
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Pressure ulcers:
- 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 Immobility
- ô Malnutrition
- ô Fecal / urine incontinence-will break skin down if left to sit
- ô Altered LOC- altered level of consciousness
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Friction and Shearing with blood vessels:
- o Friction
- o 2 forces rub together.
- o Looks like an abrasion.
- o Seen on elbows / heels when patient tries to push themselves up in bed.
- ô Shearing
- 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
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Risk factors for pressure ulcers:
- ô Immobility
- ô Nutrition / Hydration
- ô Moisture
- ô Mental Status
- ô Age
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Stage 1 pressure ulcer:
- õ Signs:
- ô Non-blanchable erythema – red even with pressure
- ô Darker skin tones: blue / purple tones
- ô Epidermis layer only
- ô Reversible if pressure relieved
- õ Treatment:
- ô Frequent turning
- ô Pressure reduction surface
- ô Keep area clean and dry
- ô Keep well nourished
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Stage two pressure ulcers:
- õ Signs:
- 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
- õ Treatment:
- 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
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Stage three pressure ulcers:
- õ Signs:
- 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
- õ Treatment:
- ô Debride
- ó Surgery
- ó Proteolytic enzymes-Dakin solution
- ó Wet to dry-put saline soaked gauze in, collects bacteria and is pulled out with the dressing
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Stage four pressure ulcers:
- õ Signs:
- 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
- õ Treatment:
- ô Non-adherent dressing changes every 8-12 hours.
- ô Skin grafts
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Prevention of pressure ulcers:
- ô Proper
- 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
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Supporting the healing process of pressure wounds:
- ô Adequate fluid intake
- ô Adequate nutrition
- ô Prevent infection
- ô Position to relieve pressure
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Assessment of wound care:
- ô Inspect:
- 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
- ô Timeline:
- 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
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Appearance of wound:
- ô Location:
- ó Relate to the nearest anatomic landmark
- ô Size
- 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
- ô Odor
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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
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Drainage of a wound:
- ó Exudate
- õ Forms during inflammatory process
- õ Fluid / cells that leak from blood vessels
- ó Serous
- õ Clear and watery
- ô Sanguineous
- ó Looks like blood
- ó Bright red – fresh
- ó Dark red – old
- Serosanguineous:
- ó Serum and blood cells
- ó Light pink to blood tinged
- ô Purulent
- ó WBC’s, liquefied dead tissue debris, bacteria
- ó Thick
- ó Foul odor
- ó Different colors-yellow green most common colors
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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)
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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
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Asepsis:
- 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
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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!!!
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Sterile solution:
- 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
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Sterile gloves:
- ô Skin to inside only.
- ô Dominate hand 1st.
- ô Outer part handled by gloves only.
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Cleansing the wound:
- ô Linear
- õ Clean from top to bottom
- õ Move from incision outward
- õ Replace gauze / sponge with each swipe
- ô Circular
- õ New gauze / swab with each circle
- õ Begin in center and move outward
- õ Clean 1 inch beyond dressing
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Types of Drains:
- õ Open
- 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.
- õ Closed
- ô Jackson-Pratt (JP) – applies low suction to area being drained.
- o Must be emptied, measured, and suction reapplied.
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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.
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Other wound therapies:
- õ Ultrasound
- õ Transport sound waves through gel to bone. When it hits the bone it breaks apart and creates thermal energy.
- õ Increases blood supply.
- õ Stimulates inflammatory process.
- õ Acute wounds, hematomas, bruises.
- õ Pulsed Diathermy
- õ Electromagnetic energy.
- õ Increases vasodilation, hematoma absorption, fibroblast action. Decreases edema.
- õ Wounds covered by casts, surgical incisions, skin grafts, diabetic wounds.
- õ One more therapy…
- õ Hyperbaric Oxygen
- õ Chamber where patient breathes 100% oxygen in increased atmospheric pressure.
- õ Increases O2 perfusion to tissue.
- õ Acute burns, gas gangrene, skin grafts / flaps, carbon monoxide poisoning, radiation tissue damage.
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Heat therapy:
- õ Joint Stiffness / Low back pain.
- õ increases blood flow to area – promotes tissue healing.
- õ Muscle relaxation.
- õ Reduced joint stiffness.
- õ Excessive vasodilation à drop in BP à fainting.
- õ Do not use for >30 minutes at a time.
- Heat Therapy
- õ Hot water bag / bottle
- õ Aquathermia / K-pad
- õ Commercial hot packs
- õ Moist compress
- õ Heating pad
- õ Soak
- õ Sitz bath
- õ Bair Hugger
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Cold therapy:
- õ Vasoconstriction.
- õ Skin color decreases and becomes cool. Pale
- õ Can damage skin due to decreased O2 and nutrients.
- õ Blood being shunted to other areas à increased BP.
- õ If temp drops to <60, vasodilation will kick in to prevent tissue from freezing.
- Cold therapy
- õ Commercial ice packs / cold packs
- õ Cold compress
- õ Ice bag / glove / collar
- õ Soak
- õ Cooling sponge bath
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Precautions for heat and cold therapy:
- õ Neurosensory impairment
- õ Impaired mental status
- õ Impaired circulation
- õ immediately after surgery
- õ Open wounds
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Blood Glucose Monitoring:
- õ Wash hands (yours and patient) or clean the site with alcohol. Do not fan to dry!
- õ Warm = vasodilation = blood sample.
- õ Discard 1st drop.
- õ Hold pressure to site with gauze not alcohol pad.
- õ Check your result against patient’s signs / symptoms.
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Intake and output:
- õ Intake
- õ Any fluid or food that is fluid at room temperature.
- õ Ice cream / jello
- õ 1 oz = ___________ mL
- õ Output
- õ Anything that comes out of the body in liquid form.
- õ Vomitus
- õ Diarrhea
- õ Drainage from suction / devices.
- Intake should equal output. May take 2-3 days to balance out, but eventually should.Make family aware if patient on I/O so they can help you keep track and also inform you of anything extra brought in
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