Wound Management & Healing

• remodel-can take up to a year.
• wound appears white (capillaries that formed during inflammatory stage are no longer needed)

• contracting of the wound edges
• (edges approximate more, less likely to seperate during this stage)

• inflamed-red, swollen, tender.
• (platelets coem to stop bleeding & WBC's come to fight infection)

• How it affects wound healing:
• provides circulation (blood & o2) neede for repair
• Safety Concerns:
• more prone to infection

• How it affects wound healing:
• increased metabolism, less nutrients avail for tissue repair, sweating can add to moisture level.
• Safety Concerns:

• How it affects wound healing:
• can lead to maceration (skin wrinkling)
• Safety Concerns:
• skin breaks down when moist, good medium for bacteria

• 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

• How it affects wound healing:
• need protein for collagen and tissue formation
• Safety Concerns:
• Won't have the protein needed for repair

• 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.

• Obvious
• This is what it is
• "Frank blood in stool"

• 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.

• 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

• approximated edges
• closed wound
• quick healing
• minimal scaring
• Little to no tissue loss
• low risk for infection
• Ex: paper cut

• 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

• 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)

• 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.

• 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.

• 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

• Impaired skin integrity
• Impaired tissue integrity

• Binders/Bandages
• montgomery straps

• Gause/transparent film (tegaderm)
• Hydrocolloids/hydrogels (mold don't change often)

• 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.

• 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

• 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.

protrusion of visceral organs through a wound opening

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.

Circle that can be compressed to suction blood or fluids out of a wound.

extension of the wound bed into adjacent tissue

• 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.

• Area of wound bed that extends under the skin creating a pocket around the ulcers edge.
• deeper-level damage under boggy superficial layers.

abnormal connection between 2 body cavities GI &GU

appears 2-5days postoperatively (purulent drainage, odor, swollen, warm to touch, red)

• persistent bleeding. may be internal swelling or distention, chg in amount draining from drain,
• symptoms of shock, or external (obvious).

• Steri-strips
• sutures
• staples
• surgical glue
• VAC-vacuum assisted wound closure

negative pressure pump pulls drainage out. Foam attached by a tube to the pump to keep infection out. VAC

absorbed over time

removed as ordered

usually left in 7-10days* but depends

usually just fall off

• Never good
• yellow, contains pus
• WBCs, tissue debris, bacteria
• may smell

mix of blood and serum

• thick bloody drainage
• bright to dark red
• Ex: found in post op wound.

• staw-colored, watery and clear
• Ex: in blisters

• 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.

• 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

if it involves internal organs

• full-thickness:depth seen with burns
• superficial: surface only
• partial: into dermis

• 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.

• length of time for healing
• acute-short
• chronic-long term

tissue integrity, is the tissue still there (closed) or is it gone or (open)