Providing Wound Care and Treating Pressure Ulcers

Providing Wound Care and Treating Pressure Ulcers
Chapter 38 Providing Wound Care and Treating Pressure Ulcers Copyright © 2014 by Elsevier Inc. All rights reserved.

Learning Objectives Theory Describe the physiologic processes by which wounds heal. Discuss factors that affect wound healing. Describe four signs and symptoms of wound infection. Discuss actions to be taken if wound dehiscence or evisceration occurs. Copyright © 2014 by Elsevier Inc. All rights reserved.

Wounds Occur in a variety of ways: Trauma Surgery Pressure Burns May be open or closed All bring the risk of infection or permanent damage Why is basic skin care such an important aspect of wound care and preventing pressure ulcers? (prevents tissue breakdown) How can these wounds occur? (motor vehicle accident, skateboard accident, appendicitis, house catches on fire) What is the difference between an open and closed wound? (open wound occurs through the skin; closed wound occurs without a break in the skin) Copyright © 2014 by Elsevier Inc. All rights reserved.

Wound Types Closed Contusion (bruise) Hematoma Sprain Open Incision Laceration Abrasion Puncture Penetrating Avulsion Ulceration What are the characteristics of the closed types? What are the characteristics of the open types? Copyright © 2014 by Elsevier Inc. All rights reserved.

Wound Types (cont’d) Partial-thickness wounds Superficial wounds Heal more quickly by producing new skin cells Fibrin clot forms framework for growing new cells Full-thickness wounds No dermal layer present except at margins of wounds All necrotic tissue must be removed Wound heals by contraction Wounds can be clean or dirty, depending on whether they host a large number of microorganisms. Does replacement tissue have the same functional characteristics as the tissue lost? (No, generally the fibrous connective tissue is not the same as original tissue.) Copyright © 2014 by Elsevier Inc. All rights reserved.

Phases of Wound Healing
Regardless of the cause, there are three distinct phases of wound healing Inflammatory phase Proliferation or reconstruction phase Maturation or remodeling phase How would a nurse explain these terms to a patient who has a limited education? Copyright © 2014 by Elsevier Inc. All rights reserved.

Inflammation Phase of Wound Healing
Begins immediately and lasts 1 to 4 days Swelling or edema of the injured part Erythema (redness) resulting from the increased blood supply Heat or increased temperature at the site Pain stemming from pressure on nerve receptors A possible loss of function resulting from all these changes How could a nurse explain this part of the inflammation phase to elementary-age students? (have visuals and pictures or posters showing the platelets, fibrin, and phagocytes) Copyright © 2014 by Elsevier Inc. All rights reserved.

Proliferation Stage of Wound Healing
Begins on third or fourth day; lasts 2 to 3 weeks Macrophages continue to clear the wound of debris, stimulating fibroblasts, which synthesize collagen New capillary networks formed to provide oxygen and nutrients to support the collagen and for further synthesis of granulation tissue Tissue is deep pink A full-thickness wound begins to close by contraction as new tissue is grown Scarring influenced by degree of stress on the wound What would be the importance of wound care during this phase? (Debris continues to be cleared; the collagen, which is the protein of all connective tissue, is forming; healthy tissue is formed by oxygen and nutrient support.) Copyright © 2014 by Elsevier Inc. All rights reserved.

Maturation Phase of Wound Healing
Final phase begins about 3 weeks after injury May take up to 2 years Collagen is lysed (broken down) and resynthesized by the macrophages, producing strong scar tissue Scar maturation, or remodeling Scar tissue slowly thins and becomes paler What would cause some wounds to take up to 2 years to heal, whereas others take a short time? (depends on the type of injury and whether the wound heals by first, second, or third intention) Copyright © 2014 by Elsevier Inc. All rights reserved.

Phases of Wound Healing: Surgical Incision
First intention A wound with little tissue loss Edges of the wound approximate, and only a slight chance of infection Second intention A wound with tissue loss Edges of wound do not approximate; wound is left open and fills with scar tissue Third intention Occurs when there is delayed suturing of a wound Wounds sutured after granulation tissue begins to form Discuss the concept of surgical incisions and traumatic wounds. Copyright © 2014 by Elsevier Inc. All rights reserved.

Factors Affecting Wound Healing
Age Children and adults heal more quickly than the elderly Peripheral vascular disease (PVD) Impaired blood flow Decreased immune system function Antibodies and monocytes necessary for wound healing Reduced liver function Impairs the synthesis of blood factors Which nursing interventions are used to assist a patient with PVD? (Keep patient’s legs in proper position for blood flow.) With decreased immune system? (Keep patient away from other sick people and practice good handwashing.) Copyright © 2014 by Elsevier Inc. All rights reserved.

Factors Affecting Wound Healing (cont’d)
Decreased lung function Reduces oxygen needed to synthesize collagen and new epithelium Nutrition Proteins, carbohydrates, lipids, vitamins, and minerals needed for proper wound healing Lifestyle The person who does not smoke and who exercises regularly will heal more quickly How can the nurse encourage lung function? (Give patient incentive spirometer, and ambulate, if possible.) Encourage nutrition? (Provide the patient with good choices; sit with patient and talk during meal.) With lifestyle? (Encourage smoking cessation and provide other activities.) With medications such as steroids? (Monitor VS and labs carefully.) Copyright © 2014 by Elsevier Inc. All rights reserved.

Factors Affecting Wound Healing (cont’d)
Medications Steroids and other antiinflammatories, heparin, and antineoplastic agents interfere with the healing process Infection Wound infections slow the healing process Bacterial infections often cause wound drainage and should be assessed for color, consistency, and odor Chronic illnesses Diabetes, cardiovascular disease, or immune system disorders may slow wound healing How can a nurse monitor for infection? (monitor VS, check wound site, check labs) What part do chronic illnesses play in wound care? (Patient may not be aware of slower healing process; likely to need extra or longer care.) Copyright © 2014 by Elsevier Inc. All rights reserved.

Wound Complications Hemorrhage All patients with fresh surgical wounds should be monitored for signs of hemorrhage If hemorrhage is internal, hypovolemic shock may occur Signs and symptoms of hemorrhage Decreased BP; increased pulse rate; increased respirations; restlessness; diaphoresis; cold, clammy skin What types of surgical wounds would be more prone to hemorrhage? (pelvic fractures or breaks in long bones) Many patients are sent home after an accident or trauma only to continue bleeding at home and go into shock. Carefully monitor patients prone to hemorrhage. Copyright © 2014 by Elsevier Inc. All rights reserved.

Wound Complications (cont’d)
Infection Wound may be infected during surgery or postoperatively. Traumatic wounds are more likely to become infected Localized infection is an abscess, an accumulation of pus from debris as a result of phagocytosis Primary organisms responsible—S. aureus, E. coli, S. pyogenes, Proteus vulgaris, and P. aeruginosa What treatment is likely for a patient who has these types of microorganisms? (A culture may be taken and sent to lab; antibiotics may be administered; patient may have to have surgical site reopened for cleaning out wound.) Copyright © 2014 by Elsevier Inc. All rights reserved.

Figure 38-4: Take a specimen from the wound for a culture
Have students think about the equipment needed to do a wound culture. Copyright © 2014 by Elsevier Inc. All rights reserved.

Cellulitis Inflammation of tissue surrounding the wound, characterized by redness and induration Fistula An abnormal passage between two organs or an internal organ and the body surface Sinus A canal or passageway leading to an abscess What are the nursing interventions to carry out for these wound infections? (Use sterile equipment, wash hands, keep hair up, avoid talking while dressing wound.) Copyright © 2014 by Elsevier Inc. All rights reserved.

Dehiscence The spontaneous opening of an incision A sign of impending dehiscence may be an increased flow of serosanguineous drainage Evisceration Protrusion of an internal organ through an incision What are some possible causes of dehiscence or evisceration? (Patient may sneeze, cough, or move into a compromising position; sutures may not hold.) Copyright © 2014 by Elsevier Inc. All rights reserved.

Evisceration If evisceration occurs Place the patient in supine position Place large sterile dressings over the viscera Soak the dressings in sterile normal saline Notify the surgeon immediately Prepare the patient for return to surgery Keep NPO When is the patient most at risk for dehiscence or evisceration? (on fourth or fifth postoperative day) Copyright © 2014 by Elsevier Inc. All rights reserved.

Question 1 Which phase of healing begins on the third or fourth day after an injury and lasts 2 to 3 weeks? First Inflammatory Proliferation Maturation Answer: 3 Rationale: The proliferation phase begins on the third or fourth day after the injury and lasts 2 to 3 weeks. The first phase is known as the inflammatory stage. It begins immediately after the injury and lasts about 4 days. The final stage of healing is maturation. It begins about 3 weeks after the injury. Copyright © 2014 by Elsevier Inc. All rights reserved.

Question 2 Which of the following is not a factor in wound healing? Age Medications Lifestyle Type of wound Answer: 4 Rationale: The type of wound is not one of the factors in wound healing. The younger the person is, the faster a wound will heal. Certain medications such as steroids will slow the healing process. A lifestyle that includes exercise will increase blood flow to and healing of a wound. Copyright © 2014 by Elsevier Inc. All rights reserved.

Learning Objectives Theory Explain the major purpose of a wound drain. Identify the advantages of vacuum-assisted wound closure. Compare and contrast the therapeutic effects of heat and cold. Copyright © 2014 by Elsevier Inc. All rights reserved.

Learning Objectives Clinical Practice Perform wound care, including emptying a drainage device and applying a sterile dressing. Provide appropriate care for a pressure ulcer. Perform wound irrigation. Remove sutures or staples from a wound and apply Steri-Strips. Give a heat or cold treatment to a patient. Copyright © 2014 by Elsevier Inc. All rights reserved.

Wound Closures Sutures and staples hold edges of a surgical wound together until wound can heal Silver wire clips also sometimes used Large retention sutures may be used Steri-Strips can be used if the wound is small Dermabond is a synthetic, noninvasive glue What would be the nursing responsibilities concerning staples or sutures or a wound closure? (assessing the wound at every shift; encouraging the patient to use a pillow or folded blanket for splinting [coughing, deep-breathing]; documenting wound appearance; notifying physician of problems) Copyright © 2014 by Elsevier Inc. All rights reserved.

Open Wound Classifications
Red wounds Clean and ready to heal; protective dressing should be used Yellow wounds Have a layer of yellow fibrous debris and sloughing; need to be continually cleansed and have an absorbent dressing Black wounds Need débridement of dead tissue, usually caused by thermal injury or gangrene Why is this type of classification easier for documentation? (It provides a description of the wound, regardless of the cause or dimensions.) Copyright © 2014 by Elsevier Inc. All rights reserved.

Drains and Drainage Devices
Provide an exit for blood and fluids that accumulate during the inflammatory process May be active or passive Penrose drain is a flat rubber tube Plastic drainage tubes can be connected to a closed drainage system Hemovac and Jackson-Pratt What is the purpose of the drains? (to allow accumulated blood and fluids to exit the wound—not build up under the skin) How often should the drains be emptied? (every shift) Copyright © 2014 by Elsevier Inc. All rights reserved.

Figure 38-6: Hemovac-type drainage system
How will a Hemovac-type drainage system help to prevent complications? Copyright © 2014 by Elsevier Inc. All rights reserved.

Figure 38-7: Jackson-Pratt–type drainage device
Explain the difference between a Hemovac and Jackson-Pratt drainage device. Copyright © 2014 by Elsevier Inc. All rights reserved.

Dressings Protective coverings placed over wounds Prevent microorganisms from entering the wound Absorb drainage Control bleeding Support and stabilize tissues Reduce discomfort Who decides the type of dressing and changing frequency? (the physician, unless standard protocol is already in place) What abnormal findings does a nurse need to report to the physician? (profuse drainage, pain not being controlled by prescribed pain medications, VS abnormal) Copyright © 2014 by Elsevier Inc. All rights reserved.

Dressings (cont’d) A wide variety of dressing materials are available Dry sterile gauze Telfa and other nonadherent dressings Surgi-Pads or abdominal pads Foam dressings Transparent film dressings Hydrocolloid dressing What are the different properties for the dressing listed? Telfa and Surgi-Pads are nonadherent and provide good absorption. Transparent dressings, often used for IV sites, are nonabsorbent and allow the wound to be assessed without removing the dressing. Hydrocolloid dressings are water- and air-occlusive and self-adhesive, and keep a wound moist. Copyright © 2014 by Elsevier Inc. All rights reserved.

Figure 38-8: Various types of available dressings
Explain the use of each type of dressing. Copyright © 2014 by Elsevier Inc. All rights reserved.

Treatment of Wounds Wound cleansing should be performed with warmed isotonic saline. Grossly contaminated wounds are cleaned at each dressing change Antibiotic solutions may be ordered for wound irrigation Surgical wounds and open wound dressing require sterile technique May require hydrocolloid or wet-to-dry dressings What is the advantage of warmed versus cold solution for wounds? (Heat increases the blood supply in the area, reducing pain by reducing pressure on the nerve endings. Cold decreases swelling, decreasing pain by decreasing cellular activity, which leads to numbing effect.) Why is a wound not allowed to dry? (Staying moist will promote healing.) Copyright © 2014 by Elsevier Inc. All rights reserved.

Débridement Removing necrotic tissue from a wound so that healing can occur May be performed with scissors and forceps May be enzymatic, in which an enzyme is used to liquefy dead tissue Mechanical débridement uses wet-to-dry dressings or whirlpool treatments Débridement can be done in the operating room or in the patient’s room, depending on the size of débridement that needs to be done. How can the nurse assist as the physician performs a débridement? (Assist with the sterile technique by opening packages for the physician; assist with patient’s comfort or position.) Copyright © 2014 by Elsevier Inc. All rights reserved.

Securing Dressing Dressing may be secured with: Stretch gauze such as Conform, Kerlix, Kling Mesh netting Elastic bandage Montgomery straps Binders Tape What are the advantages of a secured dressing? A wound stays moist with ordered dressing. Montgomery straps prevent the reuse of tape on skin. Binders can help prevent dehiscence; patient can move around without dressing coming off or apart. Copyright © 2014 by Elsevier Inc. All rights reserved.

Figure 38-10: Montgomery straps hold a dressing in place
How would a Montgomery strap help reduce pain? Copyright © 2014 by Elsevier Inc. All rights reserved.

Figure 38-11: An abdominal binder after surgery with a large incision
What are the differences between an abdominal binder and a Montgomery strap? Copyright © 2014 by Elsevier Inc. All rights reserved.

Tape Application Place tape so that wound remains covered by the dressing and tape adheres to intact skin Tape should be long and wide enough to adhere firmly to intact skin on either side of dressing Place tape at the ends of the dressing Place tape opposite to body action in the wound location. Tape should not go across a joint or crease Turn under the end, leaving a tab for easy removal Tape is commonly used for securing dressings, but why are these particular suggestions so helpful? (to keep the tape on, to keep the dressing in place to protect the wound, and to save the nurse from retaping multiple times) Copyright © 2014 by Elsevier Inc. All rights reserved.

Suture Removal Sutures often removed by the physician Sutures cut and pulled through the skin Sterile technique should be used Staple removal requires a special instrument Steri-Strips applied after removal of sutures or staples Parts of sutures left under the skin may cause inflammation What type of patient might keep sutures or staples in longer? (one who is on long-term steroids, due to the delayed healing process) Some drains have one suture that needs to be removed before the drain is removed. Copyright © 2014 by Elsevier Inc. All rights reserved.

Eye, Ear, and Vaginal Irrigations
Eye irrigations May be performed when injury is involved and debris or a caustic substance is present in the eye Ear irrigations Used to remove cerumen or foreign substances Vaginal irrigation May be ordered for infections or surgical preparation What would be a key point for these types of irrigations? (educating the patient with clear instructions before the irrigation, or before the patient performs the irrigation) Copyright © 2014 by Elsevier Inc. All rights reserved.

Vascular Ulcers Clean ulcers at each dressing change. Use only normal saline; then cover ulcer with a dressing Stage l: thin film dressings are used to protect ulcers from shear Stage II (noninfected): a hydrocolloid dressing is used Stage III (draining ulcers): an absorbent dressing is used What is important for the nurse to do after each dressing change? (Document accurately the wound’s appearance and any education provided to patient.) Copyright © 2014 by Elsevier Inc. All rights reserved.

Vascular Ulcers (cont’d)
Infected ulcers—nonocclusive dressing is always used Negative pressure treatment may increase healing rate by 40% Uses a vacuum-assisted closure Removes fluid from the wound and allows penetration of fresh blood Keeps the wound moist The “wound vac” is usually placed by either the physician or the wound nurse. What is the nurse’s responsibility for the wound vac? (listen for leaking air sound, in which case report so it may be refitted; output may be recorded) Copyright © 2014 by Elsevier Inc. All rights reserved.

Hot and Cold Applications
Can be dry or moist Usually requires physician’s order Heat applied to skin provides general comfort and speeds healing process May be used to: Relieve pain, reduce congestion, relieve muscle spasm Reduce inflammation and swelling Provide comfort, elevate body temperature See Table 38-2 (p. x) What patient characteristics need to be considered before heat is applied to the wound? (age of the patient, the thickness of skin, the size of applied area, patient’s tolerance to procedure, patient’s orientation to procedure, correct timing of procedure) Copyright © 2014 by Elsevier Inc. All rights reserved.

Hot and Cold Applications (cont’d)
Effects of cold To decrease swelling For joint injuries or areas requiring decreased blood flow To decrease pain Decreases cellular activity, leading to numbing Used in the form of compresses, ice bags, collars, or hypothermia blanket When are cold applications used most effectively? (after surgeries, [such as total hip, knee, or shoulder], facelifts, tonsillectomies, jaw surgery) Place barrier between skin and actual ice bag to prevent frostbite. Copyright © 2014 by Elsevier Inc. All rights reserved.

Common Nursing Diagnoses for Patients with Wounds
Impaired skin integrity related to surgical incision (or trauma) Risk for infection related to nonintact skin or impaired skin integrity Acute pain related to infected wound Activity intolerance related to pain and malaise from wound infection Disturbed body image related to wound appearance Deficient knowledge related to care of wound Anxiety related to need to perform wound care What interventions would accompany these nursing diagnoses? (assessment, monitor VS, monitor labs, assess pain and administer pain medications, allow expression of feelings, educate on wound care, allow gradual learning process for wound care) Copyright © 2014 by Elsevier Inc. All rights reserved.

Examples of Goals for Patients with Wounds
Evaluative statements indicating that the previously stated goals/expected outcomes have been met are as follows: Wound edges well-approximated Wound is clean and dry without redness or swelling Patient states that pain is gone Patient states that energy has returned; is up walking in the hall Return demonstration of dressing change properly performed What would be some examples of documentation of the above goals? (examples presented in chapter) Copyright © 2014 by Elsevier Inc. All rights reserved.

Question 3 Cara’s patient is going home with sutures. When are sutures usually removed? 3 to 5 days 5 to 7 days 7 to 10 days 14 days Answer: 3 Rationale: Sutures are usually removed in 7 to 10 days. They may remain in longer for elderly patients. Copyright © 2014 by Elsevier Inc. All rights reserved.

Question 4 Eric is about to change a dressing on his patient. Which of the following is true regarding dressing changes? Dressing changes may be performed as needed without a physician’s order. Irrigations may be done as needed without a physician’s order. Clean gloves and forceps are used for fresh sterile wounds that are touched. Wounds should be cleaned with warm water. Answer: 4 Rationale: Wounds should be cleaned with warm water because cold solution slows the healing process. Dressing changes and irrigations require a physician’s order. Sterile gloves or forceps are used whenever an open or fresh surgical wound is touched. Copyright © 2014 by Elsevier Inc. All rights reserved.

Question 5 Eric’s patient has an order for cold compress therapy. How long can cold compress therapy be applied? 10 minutes 20 minutes 30 minutes 45 minutes Answer: 2 Rationale: Cold compress therapy is applied for a maximum of 20 minutes at a time. Cold compress therapy is applied in the form of compresses, packs, ice bags, or hypothermia blanket. Copyright © 2014 by Elsevier Inc. All rights reserved.

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