1. Chapter 28
Wound Care

2. Question Is the following statement true or false?
Macrophages are types of white blood cells.

3. Answer
True.
Macrophages are types of white blood cells.

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

5. 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

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

7. 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

8. The Inflammatory Response

9. 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

10. 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

11. Wound Repair

12. 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

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

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

15. 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

16. 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

17. Question
Which dressing is ideal for covering fresh wounds that are likely to bleed?
a. Gauze
b. Transparent
c. Hydrocolloid
d. Dressing

18. Answer
a. Gauze
Gauze dressing is used for covering fresh wounds. Transparent dressings are used to cover IV insertion sites. Hydrocolloid dressings keep wounds moist. Dressing changes are done when a wound requires assessment, care, or is saturated with drainage.

19. Wound Management
Drains
Open drains
Closed drains
Sutures and staples

20. Question Is the following statement true or false?
Steri-Strips can be used to close superficial lacerations instead of sutures or staples.

21. Answer
True.
Steri-Strips are also used to close superficial lacerations instead of sutures or staples.

22. 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

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

24. 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

25. 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

26. Question
Which type of debridement breaks down and liquefies wound debris?
a. Autolytic
b. Sharp
c. Mechanical
d. Enzymatic

27. Answer
d. Enzymatic
Enzymatic debridement involves the use of topically applied chemical substances. Autolytic debridement allows the body’s enzymes to soften, liquefy, and release devitalized tissue. Sharp debridement is the removal of necrotic tissue with sterile scissors, forceps, or other instruments. Mechanical debridement involves physical removal of debris.

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

29. 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

30. 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

31. 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

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

33. General Gerontologic Considerations
Wound healing is delayed in older adults; regeneration of healthy skin takes twice as long for an 80-year-old as it does for a year-old
Age-related changes affecting wound healing include thinning dermal layer of skin; decreased subcutaneous tissue
Signs of inflammation may be more subtle in older adults

34. General Gerontologic Considerations (cont’d)
Diminished immune response from reduced T-lymphocyte cells predisposes older adults to wound infections
Conditions that interfere with circulation increase the older adult’s susceptibility to delayed wound healing and wound infections
Diminished mobility requires aggressive skin care to prevent pressure ulcers

35. General Gerontologic Considerations (cont’d)
Due to decreased blood supply to the skin, older adults may need position changes every 60 to 90 minutes, instead of every 20 minutes
Use special care when moving older adults; avoid friction on the skin
Depression, poor appetite, cognitive impairments, and physical/economic barriers interfering with adequate nutrition may impair wound healing