WOUND HEALING

• OPEN
• involves disriuption or break in the skin
• CLOSED
• no break in skin (bruise)
• INTENTIONAL
• occurs during treatment (i.e. surgery, radiation burn, venipuncture, drawing blood)
• UNINTENTIONAL
• accidental (i.e. fracture caused by a fall, stabwound)

• INCISION
• caused by sharp instrument (surgical)
• CONTUSION
• blow from blunt force (bruise)
• ABRASION
• surface scrape (intentional or accidental)
• PUNCTURE
• penetration of skin & possibly underlying tissues from sharp instrument
• LACERATION
• open wound with jagged edges
• PENETRATING
• goes through skin, into body cavity or organ
• PRESSURE ULCER
• related to excessive pressure on body site

• CLEAN
• free of infectious organisms
• CONTAMINATED
• containing microorganisms and includes:
• -open, fresh accidental wound
• -surgical wound involving major break in sterile technique
• -surgical wound where there is spillage from GI tract
• DIRTY OR INFECTED
• -old, accidental wound containing dead tissue
• -wound with evidence of infection (i.e. purulent drainage)

• INFLAMMATORY PHASE
• time of injury - day 3 or 4
• PROLIFERATIVE OR RECONSTRUCTIVE PHASE
• day 4-21
• MATURATION OR REMODELING PHASE
• day 21-2 years

• first 3-4 days of injury
• -blood supply to wound increases, bringing nutrients and substances necessary for healing process
• -area appears red and edematous (signs of infection, but normal in this phase)
• PAIN is experienced

• HEMOSTASIS (clotting)
• -vasoconstriction for control of bleeding
• -platelet accumulation
• -deposition of fibrin and formation of blood clots to provide a fibrin matrix
• -scab formation on surface of wound aids hemostasis & inhibits wound contamination

• PHAGOCYTOSIS
• -leukocytes (neutrophils) move in
• -macrophages engulf, digest microorganisms to clean debris from wound bed
• -shedding of dead tissue occurs

• GRANULATION
• -new capillaries grow across wound, increasing blood supply
• -tissue becomes translucent red, fragile, bleeds easily
• EPITHELIALIZATION
• -when granulation tissue matures, epithelial cells migrate to it to fill wound bed.
• SCAR FORMATION
• -if wound has greater tissue loss, healing occurs from inside out.
• -fibroblasts migrate to wound & initiate collagen synthesis (protein substance that adds strength)
• -progressive accumulation of collagen forms basic structure of scar.

• -fibroblasts continue to synthesize collagen
• -maturation of scar occurs

**scar tissue never exceeds 80% of pre-injury strength**

• PRIMARY INTENTION
• -occurs when tissue surfaces are approximated (brought together or closed)
• -minimal or no tissue loss
• -heals with minimal granulation tissue and scarring (scar is thin, flat)
• --->examples: minor clean cut; surgical incision with surgical closure
• SECONDARY INTENTION
• -wound edges cannot be approximated due to tissue loss and type of wound
• -repair time is longer
• -epithelialization occurs from wound margins
• -scarring is greater
• -allowed to heal and close on own
• -greater susceptibility to infection (i.e. pressure ulcer; large, irregular, or infected wounds)
• TERTIARY INTENTION
• delayed closure
• -occurs in wounds which may be contaminated, infected, or draining excessive exudate
• -wound is intentionally left open to permit drainage of contaminated material
• -wound is surgically closed when infection has cleared & initial granulation has taken place
• i.e. contaminated abdominal wound

• HYGIENE
• NUTRITIONAL/FLUID STATUS
• AGE
• OXYGEN STATUS
• IMMUNE STATUS
• NEUROLOGICAL STATUS
• MEDICATIONS

• HYGIENE
• risks for wound infection
• -Poor personal hygiene
• -diaphoresis, incontinence
• NUTRITIONAL/FLUID STATUS
• -Protein, Zinc, Vitamins A & C necessary (vital) for tissue repair
• -Obesity--adipose tissue has poor blood supply (diabetes)
• -Emaciation (wasted condition of body; thin)--O2 transport is deficient
• -Metabolic demand--increases for wound healing
• -Hydration--promotes cellular function
• AGE
• -Degenerative changes in blood vessels, immune system and respiratory system slow healing time
• -Inflammatory response is delayed in elderly
• OXYGEN STATUS
• -impaired blood flow to wound or tissues delays wound healing
• -smoking constricts blood vessels, reduces tissue oxygenation; also impairs clotting (hemostasis)
• IMMUNE STATUS
• immunosuppressed patients have:
• ---slower inflammatory response,
• ---slower wound epithelialization,
• ---decrease in leukocytes
• NEUROLOGICAL STATUS
• -Impaired sensation or sensory awareness (LOC) increase risk for skin breakdown
• MEDICATIONS
• meds which inhibit inflammation can alter cell growth and inflammatory phase of healing
• i.e. steroids, NSAIDS, chemotherapy drugs

• EXUDATE
• SEROUS DRAINAGE
• SANGUINOUS (HEMORRHAGIC) DRAINAGE
• SEROSANGUINOUS
• PURULENT DRAINAGE
• SLOUGH
• ESCHAR

• A CHALLENGE TO NURSING CARE
• AREA of LOCALIZED ISCHEMIA
• -deficiency of blood to tissues results in deprivation of oxygen and nutrients (ischemia)
• -tissue death (necrosis) may occur
• TYPICALLY LOCATED OVER BONY PROMINENCE
• -caused by constant pressure and moisture
• SHEARING AND FRICTION OFTEN ACT IN CONJUNCTION WITH PRESSURE TO PRODUCE AN ULCER
• -can put powder on bedpan rim to prevent rubbing

• STAGE I
• localized, non-blanchable redness of intact skin
• in dark-skinned persons--area may be warm, cool, discolored or bluish
• STAGE II
• partial-thickness skin loss of dermis and epidermis (involves first 2 layers of skin)
• appears as shallow, open ulcer with red pink wound bed
• does not have slough or bruising
• may also present as an intact or open/ruptured serum-filled blister
• STAGE III
• full thickness tissue loss
• subcutaneous fat may be visible (3 layers of skin)
• slough may be present, but does not obscure the depth of tissue loss
• may include undermining or tunneling
• STAGE IV
• full thickness tissue loss with exposed bone, tendon, or muscle (4 layers of skin)
• slough or eschar may be present on some parts of the wound bed
• often includes undermining, tunneling, or sinus tracts may form
• UNSTAGEABLE
• full thickness tissue loss
• base of ulcer is covered by slough (yellow, tan, gray, green, brown) and/or eschar (tan brown, black) in the wound bed
• SUSPECTED DEEP TISSUE INJURY
• -purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying tissue from pressure and/or shear
• -may be preceded by tissue which is painful, mushy, boggy, warmer, or cooler in comparison to adjacent tissue.

• NORTON SCALE
• 5 categories of risk:
• -general physical condition
• --mental state
• ---activity
• ----mobility
• -----incontinence
• maximum score = 20
• score 5 of 12 or < indicates R/F development of ulcer
• BRADEN SCALE
• consists of 6 subscales
• maximum score = 23
• score of 16 or < indicates risk

• Perform risk assessment on admission and daily
• --lift folds of skin: breasts, wrinkles, fat excess skin...
• Provide adequate nutrition
• Maintain skin hygiene: use mild cleansing agents; minimize friction and force when cleaning; don't use same washcloth for opposite folds; pat dry
• Do not massage over bony prominences
• Reduce friction by use of cornstarch or powder
• Pad bony prominences esp. heels and elbows
• Provide smooth, firm, wrinkle-free foundation
• Provide special mattress/specialty bed per risk assessment score and facility protocol
• Reposition, turn q 2 hours or more; consider use of trapeze bar.

• THE CHRONIC WOUND
• non-healing/slow-healing
• does not progress from Inflammatory Phase
• causes: repetitive chemical and/or mechanical trauma
• Signs/Symptoms:
• --Delayed healing despite intervention
• --change in color of wound bed
• --friable (dry, crumbly) granulation tissue
• --new or increased pain, drainage, or odor
• INFECTION
• wound may be infected at time of injury, during surgery, or post-op
• signs/symptoms (post-op on day 2-7)
• --fever, elevated WBC's
• --Purulent drainage
• --swelling, tenderness
• --erythema at wound edges
• --general malaise
• HEMORRHAGE
• possible causes:
• dislodged clot
• slipped ligature during surgery
• erosion or cut of blood vessel
• internal hemorrhage
• --may occur without evidence of external bleeding
• --Signs/Symptoms:
• swelling in wound area
• change in general condition of pt
• --Hematoma = localized collection of blood inside tissues; forms in early post-op period
• External Hemorrhage
• greatest risk = first 48 hours
• ID'd by bloody drainage at site or on surgical dressing
• --mark with date, time, initials and check back with patient to view progression of strikethrough.
• FISTULA FORMATION
• fistula = abnormal passage between 2 internal organs or between an organ and the external skin surface.
• May result from:
• Abscess or infection
• Injury, inflammation
• Disease such as cancer
• DEHISCENCE
• partial or total rupture of wound
• may occur post-op day 4-5
• factors include:
• --obesity
• --poor nutrition; dehydration
• --excessive coughing; vomiting
• --suture failure; multiple trauma
• Evisceration = dehiscence with protrusion of internal viscera
• Interventions:
• --support wound with large sterile dressing soaked in sterile normal saline
• --notify M.D. STAT!

• LOCATION
• document anatomical size
• SIZE
• measure in cm: length, width, depth
• COLOR
• of wound bed (red, yellow, black)
• SURROUNDING SKIN
• color of wound edges
• erythema of wound edge
• DRAINAGE
• amount, color, consistency, odor
• degree of saturation of dressing (i.e. how many gauzes)
• SWELLING
• use gloves; palpate for tenseness around wound
• minimal to moderate swelling normal in early stages of healing process
• TEMPERATURE
• palpate wound and surrounding tissues
• cold = hypoxia, possible tissue necrosis (not enough O² to tissues
• increased warmth = infection
• PAIN
• expect severe-moderate pain for 3-5 days post-op
• suddens onset of severe pain = possible hemorrhage or infection
• WOUND CLOSURE
• describe type of closure (staples, suture...)
• note if intact
• well-approximated?
• DRAINS
• type of drain used
• inspect placement
• note/measure amount, character of drainage (purulent, sanguinous, serosanguinous...)
• DIAGNOSTICS/LAB TESTS USED IN ASSESSMENT

• WBC^S
• increase = infection
• decrease = delayed wound healing
• Hgb
• low = impaired O2 transport to tissues
• Erythrocyte Sed. Rate (ESR)
• high = general indication of inflammation/infection
• ALBUMIN
• overall nutritional status; indicates body's reserves for rebuilding cells
• low = hemodilution (increase in plasma volume = reduced RBC concentration) (i.e. with blood loss)
• Wound Culture
• r/o (rule out) or confirm presence of infectious organism
• Diagnostic Imaging
• to rule out or diagnose infection of bone
• --X-Ray
• --Bone Scan

Impaired Skin Integrity

Risk For Impaired Skin Integrity

Risk for Infection

Acute Pain

Body Image Disturbance

Imbalanced Nutrition

Impaired Mobility

Anxiety, Hopelessness

Fear

Can a serious, infected, chronic wound heal completely by client’s discharge from acute care?

• IN ORDER TO EFFECTIVELY TREAT A WOUND, THE NURSE MUST TREAT
• “THE WHOLE PERSON.”

Referral to wound care specialist is necessary for all complicated or chronic wounds, including Stage 3-4 pressure ulcers.

Medications:

• o Treat systemic or local infection:
• antibiotics, topical antiinfectives

• o Treat pain:
• analgesics, topical local anesthetics

o Nutritional supplements

Dietary Interventions

o Provide adequate Nutrition/Calories

Vitamin C (citrus, green vegs.)

Vitamin A (green/yellow fruits & vegs. dairy, fish-liver oil, egg yolk)

Protein (meat, fish, eggs, dairy, legumes)

Zinc (dairy, eggs, legumes, liver, whole grains)

Hygiene

o Keep skin clean and dry

Clean the Wound With Cleaning Agents

o Removes bacteria, slough and necrotic tissue

• DEBRIS IN A WOUND PREVENTS THE WOUND FROM HEALING
• Wound Debridement
• – Removal of dirt, foreign matter or necrotic tissue (e.g. eschar) from a wound that cannot be removed via normal cleaning.
• Allows thorough examination of the extent of wound

• o Types of Debridement
• Sharp – use of a scalpel, scissors, or laser
• Mechanical – use of mechanical force, (e.g. whirlpool, scrubbing, or wet-to-moist dressing)
• Enzymatic – chemical breakdown of necrosis
• Autolytic – moisture-retentive dressing with occlusive seal allows body’s own macrophages and neutrophils to destroy necrotic tissue

Purposes of Dressings

Protect wound from mechanical injury

Protect wound from microbial contamination

• Provide high humidity
• a moist wound bed promotes re-epithelialization of the wound

Absorb drainage and/or debride a wound

Prevent hemorrhage (when applied as a pressure dressing)

• Permit drainage of excessive fluid from surgical
• incisions

Drain purulent material from infected wounds

Promote healing

Assist in wound closure/approximation

Hyperbaric therapy

Light therapy

Ultrasound, Electrotherapy

• Self-care includes
• maintaining hygiene (handwashing)
• understanding correct wound care supplies and techniques
• signs of infection
• Family teaching includes:
• positioning
• protective devices
• hygiene and nutrition

Does wound show signs of healing?

Does wound remain free from signs of infection?

Does skin of Stage 1 pressure ulcer remain intact?

Is client verbalizing adaptation to changes in body image?