2. Wounds 2 categories: - surgical - traumatic

3. Wound examples Closed surgical Open surgical Closed traumatic Open traumatic

4. Infection Any incision or wound increases the risk of infection!!

5. Wound Healing First Intention Second Intention Third Intention

6. First Intention Healing Wounds with minimal tissue loss edges approximated most surgical wounds dec. infection/scar risk

7. Second Intention Healing Occurs with tissue loss edges not approximate left open to heal opening fills with granulation tissue

8. Granulation tissue Soft, pink capillary projections once begins, usually stop packing wound

9. Second Intention (cont.) Later, epithelial cells grow over granulation tissue inc. risk for scarring and infection

10. Third Intention Healing Wound intentionally kept open for time Closed surgically later Scarring common

11. Wound Healing Process Increased wbc’s during inflammation Neutrophils (wbc type) - engulf bacteria - release enzyme

12. Wound Healing (cont.) Monocytes (wbc type) - engulf bacteria, debris - live longer Fibroblast (cell type) - produce collagen

13. Wound problems Dehiscence: wound edges separate Evisceration: separation of wound with contents expelled

14. Factors affecting healing: Extent of injury Blood supply to area Type of injured area - epithelial tissue heal fastest

15. Factors affecting healing (cont.) Presence of infection Presence of debris Health of patient

16. How should primary intention look? Color Edges Sutures Bleeding / Drainage Vital signs

17. Nursing assessment Anatomic location Duration of wound Size of wound in cm. - width, length, depth Color of wound bed

18. Nursing Assessment (cont.) Presence of tunneling Presence of exudate Warm, cold, hard? C/O pain? Any foreign bodies?

19. Nursing Assessment (cont.) May draw diagram in notes if irregular Other objective assessments - body temp, Bl. tests

20. Care of closed wounds Follow hospital policy and MD orders Change dsg and do not disturb suture line

21. Care of open wounds Check MD order Must be kept moist Cleanse at each dsg change with ordered solution or sterile NSS

22. Wet-to-Dry Dsg. Debride wound Cleanse inside > out Surgical asepsis Volume of force impt. Damp - don’t saturate

23. Packing the wound Must be used for deep wound Dead space is deadly NSS on gauze OK Tissue up gauze

24. Pressure Sores Decubitis ulcers Bedsores Pressure ulcers

25. Causes: Prolonged pressure Shear Friction Stripping Urine or stool

26. More causes!! Perspiration Arterial insufficiency Wrinkles or debris in bedding

27. Nursing responsibility Early prevention and recognition is the key!!

28. Early appearance Pallor over pressure area Reddened skin Cellular death and skin breakdown

29. Stages of pressure sores Stage 1 - inflamm and erythema - no blanching - lasts for 30 min after pressure relieved

30. Stage 2 Loss of epidermis Damage to dermis Shallow crater or blister Swollen and painful

31. Stage 3 Subcutaneous involved Not painful May have foul drainage

32. Stage 4 Extensive damage to underlying structures Tendons, muscle, bone

33. Prevention ID individuals at risk Use preventative measures Adequate blood supply Nutrition

34. REMEMBER: Check MD order Check protocol Closed wounds dry Open wounds moist Cleanse inside to out

35. More to remember! NSS appropriate Irrigation is best for open wound cleansing Obliterate dead space Draining wound care