1. Chapter 26 Wound Care

2. Terminology Related to Wound Healing
Dehiscence: Partial or complete separation of outer wound layers
Evisceration: The rupturing of a wound
Eschar: Hard, dry, leathery dead tissue
Granulation tissue: New tissue that grows and fills in a wound
Sinus tract: Tunnel that develops between two cavities or between an infected cavity and the skin’s surface
Objective #1: Define various terms related to wound care.
Define the following terms related to wound healing:
Dehiscence
Evisceration
Eschar
Granulation tissue
Sinus tract
In addition, discuss other terms in italics or bolded within the chapter to help students understand terminology. Ensure that they understand the meanings of each.

3. Wound Conditions Edema: Swelling Erythema: Redness
Necrotic: Dead tissue
Ischemia: Reduced blood flow
Purulent: Containing pus
Objective #1: Define various terms related to wound care.
Discuss terms related to wound condition, including edema, erythema, necrotic, ischemia, and purulent.
In addition, discuss other terms in italics or bolded within the chapter to help students understand terminology. Ensure that they understand the meanings of each.

4. Multiple Choice Question
A nurse examines a patient’s wound and notes that there is a tunnel extending from the wound toward the bladder. The nurse documents this condition as A. Dehiscence B. Eschar C. Evisceration D. Sinus tract
Objective #1: Define various terms related to wound care.

5. Answer
D. Sinus tract Rationale: A sinus tract is a tunnel or fistula developing between two cavities. Dehiscence is the separation of wound layers. Eschar is leathery dead tissue. Evisceration occurs when a wound pulls apart. Purulent is pus-containing.
Objective #1: Define various terms related to wound care.

6. Classifications of Wounds
General Wounds
Contusions
Abrasions
Puncture wounds
Penetrating wounds
Lacerations
Other Wounds Commonly Found in Hospitalized Patients
Stasis ulcers
Sinus tracts
Surgical incisions
Objective #2: Contrast contusion, abrasion, puncture, penetrating, and laceration wounds, and also pressure ulcers.
Teach your students that wounds are categorized as either open or closed. State that a wound in which the skin remains intact is considered a closed wound, and a wound in which the skin integrity has been breached is an open wound.
Note that in addition to being categorized as open or closed, wounds may also be classified as contusions, abrasions, puncture wounds, penetrating wounds, or lacerations. (Refer to Figure 26-1.)
Objective #7: Describe other types of wounds: stasis ulcers, sinus tracts, and surgical incisions.
Teach your students that stasis ulcers develop when the venous blood flow is sluggish, generally in the lower extremities, allowing deoxygenated blood to pool in the veins.
Explain that the resulting edema damages surrounding tissues and causes ulcers to develop. This chronic condition is very difficult to heal.
Tell your students that a sinus tract is a channel or tunnel that develops between two cavities or between an infected cavity and the surface of the skin, sometimes known as a fistula. A sinus tract that forms due to infection usually produces purulent drainage that is thick and yellow or green.
Explain that surgical incisions, intentionally made with sharp instruments, are linear with more sharply defined edges than most wounds. The two edges of an incision should have good approximation, meaning they should be close together.
Student Assignment: Divide the class into six groups. Assign one of the following categories of wounds to each group: contusions, abrasions, puncture wounds, penetrating wounds, or lacerations. Ask the students to research their topic in journals or on the Internet to learn new methods of treating each type of wound. Have the groups meet for a class discussion and devise a care plan for a patient with the type of wound they researched. Share the care plans of each group with the rest of the class.

7. Multiple Choice Question
A nurse is caring for a patient in the ER who cut his hand with a kitchen knife and needs stitches. The nurse documents this wound as A. Contusion B. Laceration C. Puncture wound D. Penetrating wound
Objective #2: Contrast contusion, abrasion, puncture, penetrating, and laceration wounds, and also pressure ulcers.
Teach your students that wounds are categorized as either open or closed. State that a wound in which the skin remains intact is considered a closed wound, and a wound in which the skin integrity has been breached is an open wound.
Note that in addition to being categorized as open or closed, wounds may also be classified as contusions, abrasions, puncture wounds, penetrating wounds, lacerations, or pressure ulcers. (Refer to Figure 26-1.)

8. Answer
B. Laceration Rationale: A laceration is an open wound made by accidental cutting of tissue. A contusion is a closed wound caused by trauma. A puncture wound is an open wound made with a sharp object such as a needle or nail. A penetrating wound is similar to a puncture wound, but the object is imbedded in the tissue.
Objective #2: Contrast contusion, abrasion, puncture, penetrating, and laceration wounds, and also pressure ulcers.
Teach your students that wounds are categorized as either open or closed. State that a wound in which the skin remains intact is considered a closed wound, and a wound in which the skin integrity has been breached is an open wound.
Note that in addition to being categorized as open or closed, wounds may also be classified as contusions, abrasions, puncture wounds, penetrating wounds, lacerations, or pressure ulcers. (Refer to Figure 26-1.)

9. Categories of Wound Contamination
Clean: Not infected
Clean-contaminated: Has direct contact with normal flora and potential for infection
Contaminated: Grossly contaminated by breaking asepsis
Infected: Infectious process established
Colonized: High number of microorganisms present without signs of infection
Objective #3: Differentiate between clean, clean-contaminated, contaminated, infected, colonized, open, and closed wounds.
Review the following categories of wound contamination:
Clean
Clean-contaminated
Contaminated
Infected
Colonized
Discuss differences in categories of wound contamination. Ask students to brainstorm situations in which a wound would fall under one of these categories and why it would belong there.
Discuss reasons that some facilities might institute policies to treat colonized wounds with clean technique rather than sterile technique.

10. Risk Factors for Pressure Ulcer Development
Being elderly
Being emaciated or malnourished
Being incontinent of bowel or bladder
Being immobile
Having ismpaired circulation or chronic metabolic conditions
Objective #4: Identify risk factors for pressure ulcers.
Teach your students that a pressure ulcer, also known as a decubitus ulcer or bedsore, occurs when external pressure is exerted on soft tissues, especially over boney prominences, for a prolonged period of time. (Refer to Figure 26-2.)
Discuss risk factors for pressure ulcers.
Discussion Point: Discuss the types of patients who are prone to develop pressure ulcers. Brainstorm with the class to devise a list of medical conditions that predispose patients to these types of wounds.

11. Stage of Pressure Ulcers
Deep tissue injury: Area over a bony prominence that differs from surrounding tissue; may be blister-like or a discoloration
Stage I: Erythema
Stage II: Partial-thickness loss of dermis
Stage III: Full-thickness loss; damage to epidermis, dermis, and subcutaneous tissue
Stage IV: Full-thickness loss; damage to deep tissue, muscle, fascia, tendon, joint capsule, and/or bone
Unstageable: Eschar covers the wound, making it impossible to tell the depth
Objective #5: Correctly stage pressure ulcers.
Review the stages of pressure ulcers, including:
Deep tissue injury
Stage I: Erythema
Stage II: Partial-thickness loss of dermis
Stage III: Full-thickness loss; damage to epidermis, dermis, and subcutaneous tissue
Stage IV: Full-thickness loss; damage to deep tissue, muscle, fascia, tendon, joint capsule, and/or bone
Unstageable: Presence of eschar over wound; depth of injury cannot be determined until the eschar is removed (Refer to Figure 26-3.)

12. True/False Question
A nurse documents the following wound condition: broken blisters revealing a shallow, shiny, pink ulceration with erythema surrounding the skin break
This would be classified as a stage III pressure ulcer.
A. True
B. False
Objective #5: Correctly stage pressure ulcers.
Review the stages of pressure ulcers, including:
Deep tissue injury
Stage I: Erythema
Stage II: Partial-thickness loss of dermis
Stage III: Full-thickness loss; damage to epidermis, dermis, and subcutaneous tissue
Stage IV: Full-thickness loss; damage to deep tissue, muscle, fascia, tendon, joint capsule, and/or bone
Unstageable: Presence of eschar over wound; depth of injury cannot be determined until the eschar is removed (Refer to Figure 26-3.)

13. Answer
B. False
Rationale: A stage II pressure ulcer occurs when there is a partial-thickness loss of dermis. This would include intact serum-filled blisters and broken blisters that reveal a shallow pink or red ulceration that can be either shiny or dry. Generally there is erythema surrounding the skin break.
Objective #5: Correctly stage pressure ulcers.
Review the stages of pressure ulcers, including:
Deep tissue injury
Stage I: Erythema
Stage II: Partial-thickness loss of dermis
Stage III: Full-thickness loss; damage to epidermis, dermis, and subcutaneous tissue
Stage IV: Full-thickness loss; damage to deep tissue, muscle, fascia, tendon, joint capsule, and/or bone
Unstageable: Presence of eschar over wound; depth of injury cannot be determined until the eschar is removed (Refer to Figure 26-3.)

14. Assessment Parameters: Pressure Ulcers
Pallor: Related to impaired circulation
Erythema: Increased capillary blood flow due to inflammation
Jaundice: High serum level of bilirubin; skin is more susceptible to loss of integrity
Bruising: Note any discolored areas that are found to determine if new breakdown occurs
Objective #6: Outline nursing interventions to prevent pressure ulcers.
Stress that patient skin assessment should be done on a daily basis. Note that many facilities use standardized scales of assessment, such as the Braden Scale. (Refer to Figures 26-4 and 26-5.)
Note the assessment parameters for pressure ulcers.
Discussion Point: The majority of pressure ulcers can be prevented with good nursing care, which starts with thorough assessment of the skin and pressure points. Discuss the types of nursing interventions that can be used to prevent pressure ulcers.

15. Three Phases of Wound Healing
Inflammatory
Occurs when the wound is fresh; includes both hemostasis and phagocytosis
Reconstruction (proliferation)
Occurs when the wound begins to heal, about 21 days after injury
Maturation (remodeling)
Occurs when the wound contracts and the scar strengthens
Objective #8: Explain the three phases of healing.
Tell your students that to accurately assess a wound, they must know how a wound heals. Note that whether the wound is a surgical incision, pressure ulcer, or due to trauma, the steps in the healing process are the same and occur in three phases: inflammatory, reconstruction, and maturation.
Student Assignment: Ask your students to write a brief report describing the stages of wound healing and nursing interventions appropriate for each stage.

16. Types of Wound Closures for Healing
First intention
Wound is clean with little tissue loss, edges are approximated, and wound is sutured closed
Second intention
There is greater tissue loss, wound edges are irregular, and wound is left open
Third intention
Wound is left open for some time to form granulation tissue and then sutured closed
Objective #9: Compare first-, second-, and third-intention wound closures.
Teach your students that when a wound must be closed to promote healing, one of three methods will be employed: first-, second-, or third-intention closure. (Refer to Box 26-1 and Figure 26-8.)

17. Factors Affecting Wound Healing
Age
Chronic illness
Diabetes mellitus
Hypoxemia
Lifestyle choices
Lymphedema
Objective #10: Explain how different factors affect wound healing.
Discuss the factors that affect wound healing. (Refer to Table 26-1.)

18. Factors Affecting Wound Healing (cont.)
Medications
Multiple wounds
Nutrition and hydration
Radiation exposure
Wound tension
Objective #10: Explain how different factors affect wound healing.
Discuss the factors that affect wound healing. (Refer to Table 26-1.)
Discussion Point: Ask students to explain how medications, nutrition, and hydration could affect wound healing.

19. Complications of Wound Healing and Nursing Responses
Infection:
Inspect and assess wounds every 8 hours; notify physician of findings of infection
Wound dehiscence and evisceration:
Place patient in supine position; notify physician; react to evisceration immediately
Hemorrhage:
Notify physician immediately; place in Fowler’s position with knees flexed; apply pressure to bleeding; administer oxygen
Objective #11: Describe possible complications of wound healing and appropriate nursing care for each.
Stress the point that several types of complications can occur as a wound heals, and it is the nurse’s responsibility to differentiate between normal healing and the presence of complications.
Discuss the importance of recognizing the signs of infection early, of correctly obtaining an ordered wound culture, and how the culture is processed to determine appropriate treatment for the wound. (Refer to Skill 26-4.)
Discuss complications of wound healing. Ask students what they would do FIRST in each situation. Explain how not knowing what to do in the case of hemorrhage or evisceration could be life-threatening to the patient.

20. Signs of Wound Infection
Redness or increased warmth
Swelling
Wound drainage
Unpleasant smell
Pain around wound
Fever above 100°F
Objective #11: Describe possible complications of wound healing and appropriate nursing care for each.
Ask students to explain why each of these are part of the inflammatory process and why they are indicative of infection.
Discussion Point: Discuss the Laboratory and Diagnostic Connection that explains the testing done to determine wound infection. Refer to Skill 26-4 and discuss why it is so important to correctly obtain a wound culture without contaminating it.

21. Wound Treatments Sutures and staples for closure
Drains to remove drainage
Types of wound drainage
Objective #12: Discuss wound treatments and nursing responsibilities for each.
Remind your students that surgical wounds and traumatic wounds with intact tissue are generally closed using some type of closure material, including sutures, staples, surgical adhesive, and sterile adhesive strips.
Discussion Point: Tell your students that some wounds contain dissolved necrotic tissue and pus; others may hold tissue fluid and blood (exudate). In these situations, the nurse will anticipate physician’s orders to clean the wound with dressing changes. Discuss using proper irrigation techniques, obtaining cultures, cleaning around drains, and cleaning incisions. Ask for volunteers to explain and/or demonstrate these nursing interventions. (Refer to Skills 26-2 and 26-3.)

22. Nursing Care for Sutures/Staples
Assessment of sutures every 8 hours
Note loosening, gaps, and redness
May be responsible for removing suture/staples when the wound is healed
Objective #12: Discuss wound treatments and nursing responsibilities for each.
Remind your students that surgical wounds and traumatic wounds with intact tissue are generally closed using some type of closure material, including sutures, staples, surgical adhesive, and sterile adhesive strips.
Review nursing responsibilities for suture/staple care. (Refer to Skill 26-1.)
Discussion Point: Ask students how best to remove sutures and staples to ensure that the wound will not gap open when they are taken out. Ensure that students understand the need for removal of every other suture or staple.

23. Types of Drains Hemovac: Active drain uses suction
Jackson-Pratt: Active drain uses suction
T-tube: Passive drain uses gravity
Penrose: Open drain; not commonly used because can provide pathway for pathogens
Objective #12: Discuss wound treatments and nursing responsibilities for each.
Discuss the types of drains that are used when a wound is expected to produce significant drainage. (Refer to Figure )
Different types of drains are placed in wounds to allow drainage to be removed. If drainage remains in the wound, it will not be able to heal.
Ensure that students know what each drain looks like, how to correctly empty the first three drains, and safety issues related to drains. (Refer to Skill 26-2.)

24. Wound Drainage Sanguineous Serous Purulent Bilious Serosanguineous
Seropurulent
Objective #13: Accurately assess a wound and wound drainage.
Discuss the signs and symptoms of wound infection, including redness, swelling, wound drainage, unpleasant smell, pain, and fever.
Discussion Point: Ask students to describe each type of wound drainage. Discuss combination types of drainage and what they contain.

25. Wound Assessment Site Wound type Wound closure Condition of wound bed
Condition of skin surrounding wound
Pain
Drainage
Objective #13: Accurately assess a wound and wound drainage.
Emphasize that assessing a wound is the only way to determine whether the wound is healing or if there are complications such as infection. Review the assessment parameters for wound healing. (Refer to Box 26-3.)
Ensure that students understand that all these areas must be assessed each time a wound is assessed. The condition of the wound bed can only be assessed when the dressing is removed, so that must be performed with every dressing change. (Refer to Box 26-3.)  
Tell your students that after traumatic injury or surgery, wounds generally produce drainage. Note that at first, this drainage looks like blood (sanguineous), then it looks pink (serosanguineous), and finally, as the wound heals, the drainage becomes clearer to slightly yellow fluid (serous). (Refer to Box 26-2.)
Remember to measure the wound when the dressing is removed. With open wounds, this is how to document that the wound is healing---when the measurements become smaller.

26. Purposes of Dressing Protect the incision
Absorb drainage as the wound heals
Protect the wound from further injury
Provide moist environment for healing
Fill the open space within the wound
Objective #14: Describe types of dressings and their uses.
Teach your students that dressings serve several purposes, including protecting the incision and absorbing drainage as the wound heals, protecting the wound from further injury, providing the moist environment required for healing, and filling the open space within the wound. (Refer to Table 26-2.)

27. Types of Dressings Antimicrobial with silver or dacexomer Alginate
Gauze
Foam dressings
Honey-impregnated dressings
Hydrocolloid
Hydrogel
Negative pressure wound therapy
Transparent films
Objective #14: Describe types of dressings and their uses.
Teach your students that dressings serve several purposes, including protecting the incision and absorbing drainage as the wound heals, protecting the wound from further injury, providing the moist environment required for healing, and filling the open space within the wound. (Refer to Table 26-2.)
Student Assignment: Collect the supplies needed to apply different types of dressings. Have the students take turns practicing these dressing applications on each other. (Refer to Skills 26-5 and 26-6.)

28. Protein and Wound Healing
Protein intake is required for wounds to heal.
Patients who are tube fed may not get enough protein and calories which slows wound healing.
Objective #15: Relate low serum protein levels to wound healing.
Teach your students that protein is necessary for growth of new tissue; therefore, a low hemoglobin (iron protein carried by the red blood cells) and serum protein are not conducive to rapid healing.
Discussion Point: Brainstorm with the class to develop a diet high in protein to use to promote wound healing in patients.

29. Wound Documentation Amount and color of drainage on old dressing
Length, width, diameter, and depth of wound
Sinus tracts and their length
Color of wound
Appearance of surrounding skin
Type of dressing applied
Objective #16: Identify information to document concerning wounds.
Emphasize the point that accurate documentation of wound care is extremely important. Review the information included in the documentation record.

30. Nursing Care Plan for a Pressure Ulcer
Assess the wound
Assess nutritional status of patient
Assess patient risk factors
Analyze data and make nursing diagnoses
Plan appropriate interventions
Implement and evaluate interventions
Objective #17: Develop a care plan for a patient with a pressure ulcer.
Teach your students that the first step in planning care for a patient with a pressure ulcer is to gather all of the available data regarding the wound, including the location, size, depth, color, condition of surrounding skin, drainage, odor, and discomfort level.
Discuss the factors to assess for a patient with a pressure ulcer. (Refer to Table 26-3.)
Discuss ways to personalize care for a patient with an infected wound.

31. Information in the Connection Features
Clinical Connection
Knowledge
Real World
Anatomy and Physiology
Laboratory and Diagnostic
Patient Teaching
People and Places
Supervision/Delegation
Post Conference
Objective #18: Discuss information found in the Connection features in this chapter.
Divide students into groups and have each group take one of the Connection features.
Ask the group to share the information in the feature with the class and to discuss ways that it can apply in a broader sense to their practice of nursing. 31

32. Information in the Safety Features
Why are the particular safety features so important that they are highlighted as safety issues?
What could happen if those safety guidelines are not followed?
Objective #19: Identify safety issues related to wound care.
Remind students to review the red safety features within the chapter. Point out to them that the information in those safety features is very important (and that they might see a related test question).
Ask the students why those particular items were so important that they were highlighted as safety issues. What could happen if those safety guidelines are not followed? 32

33. Information in the Skills Procedures
Review the steps of each of the skills procedures.
Make sure you understand why the steps are important.
What could happen if each of the steps are not followed or are followed out of order?
Objective #20: Answer questions about the skills in this chapter.
Ask students questions about the steps of performing the skills and the rationales for those steps. Ensure that students understand why they do what they do during the skills procedures. 33