1. Collaborative care of wounds
Depends on the causative agent
Degree of injury
Patients conditions

2. Superficial skin injuries – only need cleansing
Adhesive strips may be used instead of suture

3. Deeper skin wounds – closed by suturing the edges together
Contaminated wound – must be converted into a clean wound and treated.

4. Nutritional therapy High fluid intake
High in protein, carbohydrate and vitamin necessary for healing
Unable to eat – tube feeding -naso gastric, gastrostomy or jejunostomy
Parenteral nutrition is indicated when tube feeding are contraindicated or not tolerated

5. Client with incision
Intentionally made wounds closed with sutures, staples, glue or strips of tape
wound healing by primary intention
Incision should be assessed every 8 hours
Check the dressing for drainage and colour
Normally incisions appear – pink, swollen and small areas of indurations around the suture

6. Healing ridge – check the presence of newly synthesized collagen just under an intact suture line.
This internal scar is known as healing ridge
If this is absent after 5-7days – suspect slowed collagen synthesis
If there is fluid accumulation which threatens the healing, drainage of wound is indicated

7. Open wounds Medical management
Goal – to prepare the client and the wound for the quickest and most durable form of healing

8. A) control the cause of wound
Treatment includes-
A) control the cause of wound
- open wounds are common in impair blood flow to the legs (arteriosclerosis, venous insufficiency and diabetes) or reduce sensation (paralysis and diabetes)
- if wound healing delays because of lack of venous return – extremity requires compression and elevation

9. lack of arterial flow – extremity should be positioned flat
Is pressure is the cause – repositioning with proper comfort devices
- if protein energy malnutrition – restoration of nutrients and adequate calorie (protein, carbohydrate, iron and vitamins)

10. b) Debridement Removing devitalized tissue
dead tissue, exudates and metabolic waste from the wound
Can be accomplished by means of variety of techniques

11. 1) surgical or sharp debridement
Wounds covered with dead tissue (eschar or slough)- to be cleaned with surgical instruments – to promote healing and reduce infection
Performed under sedation, local anesthesia or GA

12. Carried out – sterile conditions usually in OT, treatment room
Scissors and scalpels
After procedure – monitor for bleeding and sepsis (unexplained fever, tachycardia, hypotension)

13. Mechanical debridement
Wet to dry dressing  
Allowing a dressing to proceed from moist to dry, then manually removing the dressing causes a form of non-selective debridement

14. Apply a moist gauze
Cover with sterile bandage
After a period of time dressing will dry out (4-6 hours) – allows the tissue to adhere to the gauze
Remove the dressing – the tissue also get removed
Non – selective debridement

16. Enzymatic debridement
uses enzyme solutions or ointments to treat the tissue
Proteolytic enzymes – cell maturation and multiplication, collagen synthesis and helps in dead tissue removal
If Surgical excision is not tolerated
Never use in infected wound

17. Apply enzymatic ointments only about 2-4suqare inches
Enzymes work best in moist environment (use moist gauze cover with dry gauze)
Should not used if major body cavity is involved, if nerves are exposed.

18. Autolytic debridment
Use of body’s own digestive enzyme to breakdown necrotic tissue
Occlusive dressing is placed over the eschar or devitalized tissue and allowed self digest
Slow process
Contraindicated in infected wound

19. Irrigations Sage and effective
Small syringes of saline with splash guard or tubing from an IV set
Removes pus, bacteria and necrotic tissue without damaging tissue.
Should use pad or containers to collect the contaminated irrigation solution
Nurse – masks or goggles with gowns and gloves

21. Adjunctive wound healing treatment
Electrical stimulation
- pulsed galvanic stimulation (diapulse) – form of electricity applied to the skins surface
The electrical current stimulate DNA synthesis, increase blood flow and promote cell migration across the wound

22. Growth factors Growth factors normally found in the wound bed
It can create in the laboratory too
Becaplermin (regranex) a platelet derived growth factor –PDGF can use in diabetic foot ulcer got approval.

23. Hyperbaric oxygen therapy (HBO)
Administration of Oxygen at greater than the atmospheric pressure
Tissue oxygen will increase
High level of oxygen promote the action of phagocytes and enhance healing and increase the action of fibroblasts

24. Negative pressure wound therapy
Application of controlled negative pressure – accelerate wound healing
Helps to remove drainage and speed up wound healing with the help of suction
Spread a non adhesive gauze over the wound
Foam sponge is placed in the wound bed above the non adhesive gauze

25. A connecting evacuation tube is attached to the external suction or canister to remove the excess fluid in the wound
An antimicrobial gauze is covered over to that and seal it with a transparent adhesive dressing
Increases healing rate by 40%

27. Drug therapy Anti inflammatory drugs Acetaminophen
NSAIDs – ibuprofen, inhibit synthesis of PGs hence reduce pain

28. Vitamins Vit A – accelerates epithelialization
Vit B complex – acts as co-enzymes
Vit C – assist in synthesis of collagen and new capillaries
Vit D- facilitates calcium absorption

29. Wound Dressings Type Product Indication for use Nursing implication
gauze
Telfa
open wounds
Second dressing or tape needed

30. Wet-to-dry debridement wound packing
Type
Product
Indication for use
Nursing implication
Gauze
Adaptive gauze
Vaseline gauze
Xeroform
Kling gauze
Nu gauze
Moist wounds
Wet-to-dry debridement wound packing
Moderately absorbent can be used as wound packing for wound

32. Type
Product
Indication for use
Nursing implication
Transparent films
Bio-occlusive
Opsite
tegaderm
Coverage of clean wound and intravenous site
Adhesive , retain moisture

33. Type
Product
Indication for use
Nursing implication
Hydrocolloids
Duoderm
Intrasite
tegasorb
Clean ulcers, donors sites, partial thickness burns
Retain moisture, donot use in infected wound

34. Type
Product
Indication for use
Nursing implication
hydrogels
Elastogel
Wound gel
Spenco
Pressure ulcer, dermal ulcer, partial thickness burns, abrasions and blisters
Have a cooling effect and maintain moisture

35. Type
Product
Indication for use
Nursing implication
Exudates absorber
absorption dressing
Deep wounds with eschar
Retain moisture and promote autolytic debridment

36. Type
Product
Indication for use
Nursing implication
Calcium alginates
Sorbsan, algiderm
Clean wounds with profuse drainage
Retain moisture, absorbent, left intact for several days

37. Type
Product
Indication for use
Nursing implication
Foams
Flexon, lyofoam, polymem
Full thickness wounds with moderate to heavy drainage , skin tears
Moisture absorbent, non adherent, left intact for several days

38. Topical agents used in open wounds
Normal saline
Indication – used to moisten dry wound bed, to separate the adhere gauze from the wound
Impact on wound healing – speeds healing because solution is iso-osmolar (water, electrolytes and other solutes) and keeps wound bed moist

39. Hydrogen peroxide
Indication – used to dissolve clotted blood in a wound.
- it must be rinsed of the wound bed with NS.
Impact – retards healing, it can damage the normal tissues also but it will reduce the multiplication of bacteria

40. Povidone – iodine (betadine)
Indications- used to clean very contaminated wounds

41. Dakin’s solution
Indication – used ¼-1/2 strength to clean contaminated wounds
Impact – helps to reduce wound infection but slows wound healing.
- used before and after the surgery to prevent microbial action

42. Acetic acid
Indication – used to treat wound contaminated with pseudomonas
Impact – useful in infected wound with pseudomonas. But delay wound healing slightly.