Wound Management & Healing

  1. Maturation
    • remodel-can take up to a year.
    • wound appears white (capillaries that formed during inflammatory stage are no longer needed)
  2. Proliferation
    • contracting of the wound edges
    • (edges approximate more, less likely to seperate during this stage)
  3. Inflammatory
    • inflamed-red, swollen, tender.
    • (platelets coem to stop bleeding & WBC's come to fight infection)
  4. Skin Integrity and Wound Healing
    Risk for injury R/T different factors
    Tissue Perfusion
    • How it affects wound healing:
    • provides circulation (blood & o2) neede for repair
    • Safety Concerns:
    • more prone to infection
  5. Skin Integrity and Wound Healing
    Risk for injury R/T different factors
    • How it affects wound healing:
    • increased metabolism, less nutrients avail for tissue repair, sweating can add to moisture level.
    • Safety Concerns:
  6. Skin Integrity and Wound Healing
    Risk for injury R/T different factors
    • How it affects wound healing:
    • can lead to maceration (skin wrinkling)
    • Safety Concerns:
    • skin breaks down when moist, good medium for bacteria
  7. Skin Integrity and Wound Healing
    Risk for injury R/T different factors
    Chronic diseases & or medications
    • How it affects wound healing:
    • additional stress on the body already trying to mend, meds can interfer with ability to mend or fight off infection
    • Safety Concerns:
    • body overloaded & not able to mend in timely manner
  8. Skin Integrity and Wound Healing
    Risk for injury R/T different factors
    • How it affects wound healing:
    • need protein for collagen and tissue formation
    • Safety Concerns:
    • Won't have the protein needed for repair
  9. Skin Integrity and Wound Healing
    Risk for injury R/T different factors
    Increased Age
    • How it affects wound healing:
    • skin frail, loss of turgor, decreased peripheral circulatiom & oxygenation, decreased collagen, altered immune system
    • Safety Concerns:
    • skin more prone to friction/shearing damage, slower to regenerate.
  10. Frank
    • Obvious
    • This is what it is
    • "Frank blood in stool"
  11. Tertiary Intention
    • wound left open for several days
    • then edges are approximated
    • deep with widely separated edges
    • delayed closure of wound edges, no sutureing for a period of time-will leave open suture at later date when risk for infection is past.
    • Ex: Eviscerated wound, wound that wouldn't stay closed and now visceral organs are protruding.
  12. Secondary Intention
    • wound left open and fills with scar tissue
    • Greater risk for infection and scarring
    • Tissue loss/wound edges widely separated
    • Heals from inner layer to surface-longer healing time
    • Ex: Pressure Ulcer
  13. Primary intention
    • approximated edges
    • closed wound
    • quick healing
    • minimal scaring
    • Little to no tissue loss
    • low risk for infection
    • Ex: paper cut
  14. Prevention of Pressure Ulcers con't
    • provide frequent skin care
    • small easily digestable meals and fluids (protein, vit A & C)
    • measure size-depth
    • note color, consistency & odor of drainage from ulcers if present
    • debride wound with agents like Accuzyme
  15. Prevention of Pressure Ulcers
    • comprehensive skin assessment upon admission
    • document or red/non blanchable areas (measure and doc)
    • encourage activity, ROM
    • turn every 2 hrs with positioning devices (pillows, padding)
    • position: less upright the better (to upright=more pressure on pressure points)
  16. Braden Scale
    • used to ID those at risk for pressure ulcers, or impaired skin integ.
    • Numeric Value (6 risk factors) less than or equal to 18=risk, completed within 48-72 hrs of admission.
    • sensory perception(1-4), moisture(1-4), activity(1-4), mobility(1-4), nutrition(1-4) friction and shear(1-3)
    • Lower number =higher risk
    • greater than 18 risk lessens.
  17. Pressure Ulcers
    Focused Skin Assessment:
    • head to toe
    • pressure points, boney prominences
    • check for blanching, occurs when normal red tones of light skinned client are absent. If it doesn't blanch deep tissue injury is suspected. (circulation focus)
    • Assess color, temperature, turgor
    • Check hidden areas under tape, dressings, casts, splints
    • Check areas that were injured before-old pressure ulcer wound.
  18. Risk Factors for Pressure Ulcers
    • Intrinsic Factors: immobility, impaired sensation, malnourishment, aging, fever
    • Extrinsic Factors: friction-rubbing surface of one object against another, Shearing- gravity and resistance (pulling someone up in bed, shear off skin),exposure to moisture
  19. Nursing Diagnosis
    • Impaired skin integrity
    • Impaired tissue integrity
  20. *Supporting/ immobilizing a wound
    *Applying heat and cold-old treatment
    • Binders/Bandages
    • montgomery straps
  21. Dressing a wound
    • Gause/transparent film (tegaderm)
    • Hydrocolloids/hydrogels (mold don't change often)
  22. First Priority interventions R/T wound care
    • Cleansing/irrigating: saline, dakins soln (ordered), not H202!
    • Caring for a drainage device: JP, hemovac, wound vac, penrose drain, remove only if and when ordrered.
    • Debriding a wound: (not on test)
    • sharp (instrument or scissors)
    • mechanical
    • enzymatic topical agent
    • autolysis:occlusive moisture retaining dressing. Change dressing q72hrs, Takes longer, better tolerated.
  23. First Priority Interventions for complications
    • Hemorrhage: control and call surgeon
    • Dehiscence: can help prevent by splinting with pillow when coughting/sneezing etc. Keep patient calm, cover with bandage and call surgeon.
    • Evisceration:
    • stay with client & call for assistence
    • cover wound with sterile towels or dressing soaked in saline solution
    • position: supine w/hips knees bent-reduces pressue
    • observe for shock
  24. Dehiscence
    • partial or total seperation of wound layers. Suture re-opens.
    • May feel like a pop. increased seosang drainage 4-5 days post-op may be cause.
    • more likely with abdominal wounds, obese, those with poor nutrition, may follow a sneeze or cough.
  25. Evisceration
    protrusion of visceral organs through a wound opening
  26. Jackson Pratt (JP)
    Drainage collection device. Small circle with a long drainage tube with many holes. The tube is inserted into a wound and sewn inside to collect drainage. The nurse pulls the tube out with no anesthesia when it is time for it to come out. I don't know why...sound pretty painful to me.
  27. Hemovac
    Circle that can be compressed to suction blood or fluids out of a wound.
  28. Tunneling
    extension of the wound bed into adjacent tissue
  29. Sinus Tracts
    • blind tracts underneath the epidermis; tunnel
    • an abnormal channel leading from within bones or other structures to the skin surface; sometimes this type of passageway is termed a fistula.
    • a fistula is an abnormal pathway between two anatomic spaces or a pathway that leads from an internal cavity or organ to the surface of the body.
  30. Undermining
    • Area of wound bed that extends under the skin creating a pocket around the ulcers edge.
    • deeper-level damage under boggy superficial layers.
  31. Complications to wound healing
    Fistula formation:
    abnormal connection between 2 body cavities GI &GU
  32. Complications of wound healing
    appears 2-5days postoperatively (purulent drainage, odor, swollen, warm to touch, red)
  33. Complications of wound healing
    • persistent bleeding. may be internal swelling or distention, chg in amount draining from drain,
    • symptoms of shock, or external (obvious).
  34. Wound closure devices?
    • Steri-strips
    • sutures
    • staples
    • surgical glue
    • VAC-vacuum assisted wound closure
  35. Wound closure devices
    Vacuum-assisted wound closure:
    negative pressure pump pulls drainage out. Foam attached by a tube to the pump to keep infection out. VAC
  36. Wound closure devices
    Surgical glue:
    absorbed over time
  37. Wound closure devices
    removed as ordered
  38. Wound closure devices
    usually left in 7-10days* but depends
  39. Wound closure devices
    usually just fall off
  40. Wound drainage
    • Never good
    • yellow, contains pus
    • WBCs, tissue debris, bacteria
    • may smell
  41. Wound Drainage
    mix of blood and serum
  42. Wound Drainage
    • thick bloody drainage
    • bright to dark red
    • Ex: found in post op wound.
  43. Wound drainage
    Serous Exudate:
    • staw-colored, watery and clear
    • Ex: in blisters
  44. Assessment/Appearance of wounds
    • RED: healthy-tissue is regenerating
    • YELLOW: presence of purulent drainage & dead tissue (slough) Puss
    • BLACK: BAD, presence of thick necrotic (dead) tissue (eschar). must be removed for good tissue to grow.
  45. Assessment/Charting Info
    • Location: be specific, anatomical, forms often include drawings to help id site.
    • Size: lenght, width, depth (in cm). Measure with sterile cotton tip applicator inserted into wound.
    • Appearance: type, color, condition of skin around & wound itself, drainage, pain.
    • Drainage: amount, color, location, odor, consistancy
  46. Wound classification
    if it involves internal organs
  47. Wound classification
    Superficial/ Partial or full-thickness
    • full-thickness:depth seen with burns
    • superficial: surface only
    • partial: into dermis
  48. Wound classification
    • Clean- no debris, no germs
    • Contaminated- germs or debris in wound
    • Infected- inflammitory response has started, body trying to kill off germs or bacterial infection.
  49. Wound Classification
    • length of time for healing
    • acute-short
    • chronic-long term
  50. Wound Classification
    tissue integrity, is the tissue still there (closed) or is it gone or (open)
Card Set
Wound Management & Healing
Wound Management and Healing for Nursing Fundamentals