Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 3 Advanced Wound Care Skills

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Ways of Describing Wounds Open wounds: breaks in the skin and possibly the underlying tissue Closed wounds: a result of damage to tissues underneath intact skin Intentional wounds: planned surgical or medical interventions

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Ways of Describing Wounds (cont.) Unintentional wounds: the result of accidents Acute wounds: expected to heal completely within a few days or weeks Chronic wounds: delayed in healing or may never heal completely

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Intentional and Unintentional Wounds

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Three Common Pressure Ulcers Late-stage pressure ulcers Venous (stasis) ulcers Arterial ulcers

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins To Help Prevent a Pressure Ulcer From Forming Avoid allowing a person to remain in one position for a long period of time. Use your observation skills (look for red, hot, or painful areas over pressure points or previously reddened areas that have turned white, pale, or shiny). Provide good skin care. Anticipate toileting needs and provide good perineal care.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins To Help Prevent a Pressure Ulcer From Forming (cont) Encourage exercise. Use lift devices and lift sheets when moving or repositioning people to minimize skin injury caused by friction or shearing. Encourage good nutrition and hydration. Use pressure-relieving devices.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question A gunshot wound is a(n): A.Intentional Wound B.Closed Wound C.Chronic Wound D.Unintentional Wound

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer D.Unintentional Wound Unintentional wounds are the result of an accident. Examples of unintentional wounds are those resulting from falls, motor vehicle crashes, and gun and knife violence.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Phases of Wound Healing Inflammatory phase: Begins immediately; during this phase the area is hot, red, swollen and painful. Proliferative phase: Begins 2 – 3 days after injury and can last 2 – 3 weeks; scar tissue replaces the tissue that is normally found in this area. Remodeling phase: This is the final stage of healing, in which more collagen is secreted and the wound is strengthened; this phase can last as long as 6 months.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Three Types of Wound Healing First-intention wound healing: an open wound is closed surgically with sutures or staples as soon as possible Second-intention wound healing: a wound is kept clean but otherwise left alone to let the tissue repair itself, allowing the wound to close on its own Third-intention wound healing: the wound is left open for a period of time to make sure no infection will occur, then closed surgically with sutures or staples

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Factors That Affect Wound Healing 1. Nutrition and hydration 2. Overall health status 3. Age 4. Wound condition

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Wound healing increases the body’s need for ___________ and _____________. A. fat and carbohydrates B. minerals and water C. calories and protein D. vitamins and supplements

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C.calories and protein The body requires more protein and calories to assist with cell repair and healing.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Complications of Wound Healing 1.Infection 2.Hemorrhage 3.Hematoma 4.Dehiscence and evisceration

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Infection

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins The First Sign of Hemorrhage

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Dehiscence and Evisceration

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Blood collected under the skin is known as: A. Pus B. Evisceration C. Hematoma D. Hemorrhage

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C.Hematoma Hematoma is better known as a bruise. Blood collects under the tissue and can interfere with healing.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Interventions to Support Wound Healing 1. Sutures and staples 2. Dressings and bandages 3. Drains (open and closed)

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Sutures and Staples Subcuticular sutures: placed underneath the dermis Retention sutures: threaded through a rubber tube over a plastic bridge

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Dressings Keep the wound clean Help prevent infection Maintain a moist environment that assists with wound healing Absorb wound drainage Treat infection Apply pressure to the wound (to prevent or control hemorrhage, bruising, or swelling) Remove necrotic (dead) tissue Protect the wound from further injury Protect the patient from becoming upset at the sight of the wound

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Dressings and Bandages Layers of dressings Contact layer Secondary layer Bandages Abdominal binder Montgomery straps/ties

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Transparent Dressing

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Tell whether the following statement is true or false. When applying a dressing, the contact layer is applied directly to the wound. A.True B.False

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. True The contact layer is against the wound and generally made of non-stick material or gel.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Abdominal Binder

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Drains Penrose drain Closed drainage systems –Jackson-Pratt drain –Hemovac drain

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Penrose Drain

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Closed Drainage Systems

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Wound Care Proper cleansing of a wound Removal of sutures and staples Débridement: the removal of necrotic tissue

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Cleaning an Incision Site Report it to the nurse immediately if: Edges of the wound are gaping open between the sutures or staples Sutures or staples have ripped out or broken Excessive swelling along the incision line is seen Excessive redness along the incision line is seen Incision line is hot to the touch

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Cleaning an Incision Site (cont) Purulent drainage or pus is seen along the incision line Wound drainage has a foul odor Patient complains of increased pain at wound site 2 to 3 days after the injury or surgery took place Fever occurs 24 hours or more after the injury or surgery took place Increased amount of bloody drainage is seen on the wound dressing or in the wound drainage system

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Different Types of Wound Drainage Serous: clear and watery-looking Sanguineous: bloody-looking Serosanguineous: pink and watery-looking Purulent: thick and ranging in color from dark yellow or green to creamy white

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Removing Sutures and Staples

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Pin Care

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Débridement Sharp (surgical) Mechanical Autolytic Enzymatic (chemical) Biological Vacuum-assisted closure (VAC) therapy

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Vacuum-assisted (VAC) therapy