Chapter 28 Wound Care

Wounds Wound: damaged skin or soft tissue resulting from trauma Open wounds: mucous membrane is no longer intact Closed wounds: no open mucous membrane

Wound Repair Inflammation: physiologic defense occurring immediately after tissue injury, lasting 2 to 5 days Purpose: limit local damage, remove injured cells/debris, prepare wound for healing Signs and symptoms of inflammation: swelling, redness, warmth, pain, and decreased function

Wound Repair (cont’d) Proliferation: period during which new cells fill and seal a wound; it occurs 2 days to 3 weeks after inflammatory phase The integrity of skin and damaged tissue is restored by resolution, regeneration, and scar formation

Wound Repair (cont’d) Remodeling: period during which the wound undergoes changes and maturation Lasts 6 months to 2 years During remodeling, the wound contracts and the scar shrinks

The Inflammatory Response

Wound Healing First-intention healing: reparative process in which wound edges are directly next to each other Second-intention healing: wound edges are widely separated; time-consuming, complex reparative process Third-intention healing: deep wound edges brought together with some type of closure material, resulting in a broad, deep scar

Wound Healing Factors Type of wound injury Expanse or depth of wound Circulation quality Amount of wound debris Presence of infection Client’s health status

Wound Repair

Wound Healing Complications Wound healing key: adequate blood flow to the injured tissue Interfering factors may include: Compromised circulation Infection Purulent, bloody, or serous fluid accumulation preventing skin and tissue approximation

Wound Healing Complications (cont’d) Potential surgical wound complications Dehiscence: separation of wound edges Evisceration: wound separation with protrusion of organs

Dressings Dressing purposes: Keeping wound clean Absorbing drainage Controlling bleeding Protecting wound from further injury Holding medication in place Maintaining a moist environment

Dressings (cont’d) Types of dressings: Gauze dressings: ideal for covering fresh wounds that are likely to bleed, or wounds that exude drainage Transparent dressings: used to cover peripheral and central IV insertion sites

Dressings (cont’d) Types of dressings (cont’d) Hydrocolloid dressings: keep wounds moist; moist wounds heal more quickly; new cells grow more rapidly in a wet environment Dressing changes: when a wound requires assessment or care

Wound Management Drains Open drains Closed drains Sutures and staples

Wound Management (cont’d) Bandages and binders Purpose: hold dressings in place, especially if tape cannot be used or dressing is very large Support area around the wound or injury to reduce pain Limit movement in wound area to promote healing

Wound Management (cont’d) Roller bandage application Binder application – Different types of binders Single T-binder Double T-binder

Wound Management (cont’d) Debridement: removal of dead tissue Sharp debridement: using sterile scissors, forceps, etc. Enzymatic debridement: using chemical substances Autolytic debridement: natural physiologic process

Wound Management (cont’d) Debridement (cont’d): Mechanical debridement: physical removal of debris from a wound using wet-to-dry dressings, hydrotherapy, irrigation Commonly irrigated structures include: Wounds, eyes, ears, vagina

Wound Management (cont’d) Heat and cold applications Ice bag and ice collar Chemical packs Compresses Aquathermia pad Soaks and moist packs Therapeutic baths

Pressure Ulcers Also known as decubitus ulcers Appear over bony prominences of the sacrum, hips, heals, and places where pressure is unrelieved Risk factors include: Inactivity, immobility, malnutrition, emaciation Diaphoresis, incontinence, sedation Vascular disease, localized edema, dehydration

Pressure Ulcers (cont’d) Stages of pressure ulcers Stage I: intact but reddened skin Stage II: reddened skin accompanied by blistering or a skin tear Stage III: shallow skin crater that extends to the subcutaneous tissue Stage IV: deeply ulcerated, extending to muscle and bone; life threatening

Pressure Ulcers (cont’d) Prevention of pressure ulcers Change client’s position frequently Avoid using plastic-covered pillows Use the lateral position for side-lying Massage bony prominences Use pressure-relieving devices Provide a balanced diet and adequate fluid intake

Nursing Implications Potential nursing diagnoses: Acute pain Impaired skin and tissue integrity Ineffective tissue perfusion Risk for infection