1. WOUND CARE Presentation for ACC Lab March 22, 2006 By Herlinda M. Burks, RN, BA, CWCN, CCCN

2. Risk Assessments Report: focus on Hx of diseases, surgeries, how recent, present wounds, incisions. Read the H&P. 10 minute assessment What do you see? Tubes, drains, obesity, weakness, skin damage in patterns?, etc. Braden Scale Pressure Risk Assessment

3. Wound Treatments Never leave a wet open wound open to air (OTA) and unprotected. Only leave ischemic black dry wounds on the feet and toes OTA or dressed lightly with gauze.

4. Wound Healing Processes Types of Wound Closures Primary Intention Sutures, staples, skin bonds, etc. Secondary Intention Partial thickness Regenerate specific cells Epithelialize Full thickness Regranulate Epithelialize Remodel Tertiary Intention Processes Involved in Wound healing Acute phase Hemostasis Inflammation Proliferation Remodeling Chronic phase Stalls for 2 weeks Change Tx Reassess full body, meds, labs.

5. Wound Assessments Etiology - watch those with ischemia Size – consistent measure from nurse to nurse L x W x D in centimeters (head to toe, 9 to 3 o’clock) Locations of tunnels & undermining by the clock Drainage – type (color, amount, consistency, odor) Wound bed % of red, yellow, black tissues Granulation, Slough, Eschar or tan crust or blister Wound edges – rolled (epiboly), macerated Peripheral tissues – discoloration, stains, scars? Edema, induration, scaling (peeling), plaques?

6. Wound Culturing Cleanse the wound with saline Irrigate till clear if it is a deep wound. Use culturette that has 2 swabs Wipe tissue in 1 cm 2 area Infection causing Bacteria is in the tissue Do not get just a sample of the drainage Multiple bacteria from peripheral tissues can be in the drainage Submit to lab

7. Nutrition for Wound Healing Assessment of Nutrition - labs Serum Albumin 18 to 20 days half-life Affected by hydration (> if dehydrated, < if overhydrated) Transferrin – 8 to 10 days half-life easily affected by other factors. Prealbumin – 2 days half-life – best predictor Nutrients needed for Wound healing Calories –enough to support healing and other present disease processes Protein Vitamins

8. Nutrients Protein – fibroplasia, neogenesis, collagen formation, remodeling Carbohydrates – energy and protein sparing Fat - cell walls Vitamins – A, B, C, D, E, K Copper, Iron, Magnesium, Zinc

9. Types of Wounds Open wounds Incisions, dehisced or delayed closure Pressure ulcers Arterial ulcers Venous stasis ulcers Neuropathic ulcers Diabetic ulcers Abcesses Fistulas Ostomies Trauma, Burns Closed Wounds Incisions Stitched, Stapled, Steri-stripped or Skin bonded Pressure ulcers Hematomas Abcesses, nodules, various dermatologic types. http://www.medicaledu.com/pictures.htm

10. Pressure Ulcers Braden Scale – 16 points or below is considered a risk Sensory Perception 4pts Completely, very, slightly, not impaired Moisture (4pts) Constantly, very, occasionally, rarely moist Activity (4pts) – bedfast, chairfast, walks occ, freq. Mobility (4pts) Completely, very, slightly immobile, no limitation Nutrition (4pts) Very poor, probably Inadequate, adequate, excellent Friction & Shear (3pts) Problem, potential problem, no apparent problem

11. Pressure Ulcers Stages 1 intact, persistent redness 2 partial thickness loss or blister 3 full thickness loss to but not through fascia 4 full thickness loss to muscle, bone, etc. Unstageable –purple, yellow or black Never back stage. Prevention and treatment Turn every 2 hours when in bed Move every 15 minutes or at least every hour in wheel chair or chair Apply appropriate dressing to manage drainage Educate patient and family on reasons for treatment and causes of pressure ulcers. Monitor q shift

12. Stage 1 Reddened boggy heel

13. Stage 2 Partial thickness loss Or blister

14. Stage 3 Down to but not through the facia

15. Stage 4 To muscle, bone, tendons, etc.

16. Unstageable Pressure Ulcers Purple, yellow, black

17. Other Ulcers Arterial Venous

18. Other ulcers Neuropathic Diabetic

19. Stay open-minded Remain alert to all possibilities.