1. Bell Ringer
T or F-Remodeling follows the inflammatory phase of wound healing and may last 6 months to 2 years.
T or F- A stage III pressure ulcer may be accompanied by serous drainage or purulent drainage caused by a wound infection.
T or F- Gastric sump tubes, which are double-lumen tubes, are used almost exclusively to remove fluid and gas from the stomach.
T or F- Intestinally placed tubes may lead to dumping syndrome.

2. Chapter 28:
Wound Care

3. Wounds Wound: damaged skin or soft tissue resulting from trauma
Open wounds: mucous membrane is no longer intact- cause: accidental or intentional- surgical incision
Closed wounds: no open mucous membrane- cause: blunt trauma or pressure
See table 28-1 on page 634

4. 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

5. 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

6. 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

7. Inflammatory Response
Swelling
Redness
Warmth
Pain
Decreased function

8. Phagocytosis
Neutrophils and monocytes(White blood cells) are primarily responsible for phagocytosis, which is a process by which these cells emigrate from blood vessels to consume pathogens, coagulated blood, and cellular debris.

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, may have extensive drainage and tissue debris

10. (A) First-intention healing.
(B) Second-intention healing.
(C) Third-intention healing.

11. 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

12. Wound Healing Complications
Undermining
Slough
Necrotic tissue

13. Wound Healing Complications
Dehiscence-separation of wound edges
Evisceration-separation of wound edges 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

20. Vacuum assisted Closure
Wound Management
Vacuum assisted Closure
Sutures; Staples

21. 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

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

23. Roller bandage application
A circular and spiral turn.
A spiral-reverse turn.
A figure-of-eight turn.
A spica turn.
(E) A recurrent turn.

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

26. 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

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

28. 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.

29. Heat and Cold Applying heat Provides warmth Promotes circulation
Speeds healing
Relieves muscle spasm
Reduces pain

30. Heat and Cold cont. Applying cold Reduces fevers Prevents swelling
Controls bleeding
Relieves pain
Numbs sensation

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

32. 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

35. 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

36. Pressure sore stages. (A) Stage I. (B) Stage II. (C) Stage III
Pressure sore stages. (A) Stage I. (B) Stage II. (C) Stage III. (D) Stage IV.

37. 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