1. Providing Wound Care and Treating Pressure Ulcers
Chapter 38
Providing Wound Care and Treating Pressure Ulcers

2. Chapter 38
Lesson 38.1

3. Learning Objectives Theory
Describe the physiologic process by which wounds heal
Discuss factors that affect wound healing
Describe four signs and symptoms of wound infection
Discuss actions to be taken if wound dehiscence or evisceration occurs

4. Wounds Occur in a variety of ways: May be open or closed
Trauma
Surgery
Pressure
Burns
May be open or closed
All bring the risk of infection or permanent damage
Why is basic skin care such an important aspect of wound care and preventing pressure ulcers? (prevents tissue breakdown)
How can these wounds occur? (motor vehicle accident, skateboard accident, appendicitis, house catches on fire)
What is the difference between an open and closed wound? (open wound occurs through the skin; closed wound occurs without a break in the skin)

5. Wound Types Closed Open Contusion (bruise) Hematoma Sprain Incision
Laceration
Abrasion
Puncture
Penetrating
Avulsion
Ulceration
What are the characteristics of the closed types?
What are the characteristics of the open types?

6. Wounds Partial-thickness wounds Full-thickness wounds
Superficial wounds
Heal more quickly by producing new skin cells
Fibrin clot forms framework for growing new cells
Full-thickness wounds
No dermal layer present except at margins of wounds
All necrotic tissue must be removed
Wound heals by contraction
Wounds can be clean or dirty, depending on whether they host a large number of microorganisms.
Does replacement tissue have the same functional characteristics as the tissue lost? (No, generally the fibrous connective tissue is not the same as original tissue.)

7. Phases of Wound Healing
Regardless of the cause, there are three distinct phases of wound healing
1. Inflammatory phase
2. Proliferation or reconstruction phase
3. Maturation or remodeling phase
How would a nurse explain these terms to a patient who has a limited education?

8. Inflammation Phase Wound Healing
Begins immediately and lasts 1 to 4 days
Swelling or edema of the injured part
Erythema (redness) resulting from the increased blood supply
Heat or increased temperature at the site
Pain stemming from pressure on nerve receptors
A possible loss of function resulting from all these changes
How could a nurse explain this part of the inflammation phase to elementary-age students? (have visuals and pictures or posters showing the platelets, fibrin, and phagocytes)

9. Proliferation Stage Wound Healing
Begins on 3rd or 4th day; lasts 2 to 3 weeks
Macrophages continue to clear the wound of debris, stimulating fibroblasts, which synthesize collagen
New capillary networks formed to provide oxygen and nutrients to support the collagen and for further synthesis of granulation tissue
Tissue is deep pink
A full-thickness wound begins to close by contraction as new tissue is grown
Scarring influenced by degree of stress on the wound
What would be the importance of wound care during this phase? (debris continues to be cleared; the collagen, which is the protein of all connective tissue, is forming; healthy tissue is formed by oxygen and nutrients support)

10. Maturation Phase Wound Healing
Final phase begins about 3 weeks after injury
May take up to 2 years
Collagen is lysed (broken down) and resynthesized by the macrophages, producing strong scar tissue
Scar maturation, or remodeling
Scar tissue slowly thins and becomes paler
What would cause some wounds to take up to 2 years to heal, whereas others take a short time? (depends on the type of injury and whether the wound heals by first, second, or third intention)

11. Phases of Wound Healing: Surgical incision
First intention
A wound with little tissue loss
Edges of the wound approximate, and only a slight chance of infection
Second intention
A wound with tissue loss
Edges of wound do not approximate; wound is left open and fills with scar tissue
Third intention
Occurs when there is delayed suturing of a wound
Wounds sutured after granulation tissue begins to form

12. Factors Affecting Wound Healing
Age
Children and adults heal more quickly than the elderly
Peripheral vascular disease
Impaired blood flow
Decreased immune system function
Antibodies and monocytes necessary for wound healing
Reduced liver function
Impairs the synthesis of blood factors
Which nursing interventions are used to assist a patient with PVD? (Keep patient's legs in proper position for blood flow.)
With decreased immune system? (Keep patient away from other sick people and practice good handwashing.)

13. Factors Affecting Wound Healing
Decreased lung function
Reduces oxygen needed to synthesize collagen and new epithelium
Nutrition
Proteins, carbohydrates, lipids, vitamins, and minerals needed for proper wound healing
Lifestyle
The person who does not smoke and who exercises regularly will heal more quickly
How can the nurse encourage lung function? (Give patient incentive spirometer, and ambulate, if possible.)
Encourage nutrition? (Provide the patient with good choices; sit with patient and talk during meal.)
With lifestyle? (Encourage smoking cessation and provide other activities.)
With medications such as steroids? (Monitor VS and labs carefully.)

14. Factors Affecting Wound Healing
Medications
Steroids and other anti-inflammatories, heparin, and antineoplastic agents interfere with the healing process
Infection
Wound infections slow the healing process
Bacterial infections often cause wound drainage and should be assessed for color, consistency, and odor
Chronic illnesses
Diabetes, cardiovascular disease, or immune system disorders may slow wound healing
How can a nurse monitor for infection? (monitor VS, check wound site, check labs)
What part do chronic illnesses play in wound care? (Patient may not be aware of slower healing process; likely to need extra or longer care.)

15. Wound Complications Hemorrhage
All patients with fresh surgical wounds should be monitored for signs of hemorrhage
If hemorrhage is internal, hypovolemic shock may occur
Signs and symptoms of hemorrhage
Decreased BP; increased pulse rate; increased respirations; restlessness; diaphoresis; cold, clammy skin
What types of surgical wounds would be more prone to hemorrhage? (pelvic fractures or breaks in long bones)
Many patients are sent home after an accident or trauma only to continue bleeding at home and go into shock.
Carefully monitor patients prone to hemorrhage.

16. Wound Complications Infection
Wound may be infected during surgery or postoperatively. Traumatic wounds are more likely to become infected.
Localized infection is an abscess, an accumulation of pus from debris as a result of phagocytosis
Primary organisms responsible—S. aureus, E. coli, S. pyogenes, Proteus vulgaris, and P. aeruginosa
What treatment is likely for a patient who has these types of microorganisms? (a culture may be taken and sent to lab; antibiotics may be administered; patient may have to have surgical site reopened for cleaning out wound)

17. Figure 38-4: Take a specimen from the wound for a culture

18. Wound Complications Cellulitis Fistula Sinus
Inflammation of tissue surrounding the wound, characterized by redness and induration
Fistula
An abnormal passage between two organs or an internal organ and the body surface
Sinus
A canal or passageway leading to an abscess
What are the nursing interventions to carry out for these wound infections? (use sterile equipment, wash hands, keep hair up, avoid talking while dressing wound)

19. Wound Complications Dehiscence The spontaneous opening of an incision
A sign of impending dehiscence may be an increased flow of serosanguineous drainage
Evisceration
Protrusion of an internal organ through an incision
What are some possible causes of dehiscence or evisceration? (Patient may sneeze, cough, or move into a compromising position; sutures may not hold.)

20. Evisceration If evisceration occurs
Place the patient in supine position
Place large sterile dressings over the viscera
Soak the dressings in sterile normal saline
Notify the surgeon immediately
Prepare the patient for return to surgery
Keep NPO
When is the patient most at risk for dehiscence or evisceration? (on fourth or fifth postoperative day)

21. Chapter 38
Lesson 38.2

22. Learning Objectives Theory
Identify the advantages of vacuum-assisted wound closure
Explain the major purpose of a wound drain
Compare and contrast the therapeutic effects of heat and cold

23. Learning Objectives Clinical Practice
Perform wound care, including emptying a drainage device and applying a sterile dressing
Provide appropriate care for a pressure ulcer
Perform a wound irrigation
Remove sutures or staples from a wound and apply Steri-Strips
Give a heat or cold treatment to a patient

24. Wound Closures Wound closure
Sutures and staples hold edges of a surgical wound together until wound can heal
Silver wire clips also sometimes used
Large retention sutures may be used
Steri-Strips can be used if the wound is small
Dermabond is a synthetic, noninvasive glue
What would be the nursing responsibilities concerning staples or sutures or a wound closure? (assessing the wound at every shift; encouraging the patient to use a pillow or folded blanket for splinting [coughing, deep breathing]; documenting wound appearance; notifying physician of problems)

25. Open Wound Classifications
Red wounds
Clean and ready to heal; protective dressing should be used
Yellow wounds
Have a layer of yellow fibrous debris and sloughing; need to be continually cleansed and have an absorbent dressing
Black wounds
Need débridement of dead tissue, usually caused by thermal injury or gangrene
Why is this type of classification easier for documentation? (It provides a description of the wound, regardless of the cause or dimensions.)

26. Drains and Devices Drains and drainage devices
Provide an exit for blood and fluids that accumulate during the inflammatory process
May be active or passive
Penrose drain is a flat rubber tube
Plastic drainage tubes can be connected to a closed drainage system
Hemovac and Jackson-Pratt
What is the purpose of the drains? (to allow accumulated blood and fluids to exit the wound—not build up under the skin)
How often should the drains be emptied? (every shift)

27. Figure 38-5: Penrose drain in a “stab wound” close to an abdominal incision

28. Figure 38-6: Hemovac-type drainage system

29. Figure 38-7: Jackson-Pratt–type drainage device

30. Dressings Protective coverings placed over wounds
Prevent microorganisms from entering the wound
Absorb drainage
Control bleeding
Support and stabilize tissues
Reduce discomfort
Who decides the type of dressing and changing frequency? (the physician, unless standard protocol is already in place)
What abnormal findings does a nurse need to report to the physician? (profuse drainage, pain not being controlled by prescribed pain medications, VS abnormal)

31. Dressings A wide variety of dressing materials are available
Dry sterile gauze
Telfa and other nonadherent dressings
Surgi-Pads or abdominal pads
Foam dressings
Transparent film dressings
Hydrocolloid dressing
What are the different properties for the dressing listed?
Telfa and Surgi-Pads are nonadherent and provide good absorption.
Transparent dressings, often used for IV sites, are nonabsorbent and allow the wound to be assessed without removing the dressing.
Hydrocolloid dressings are water and air occlusive and self-adhesive, and keep a wound moist.

32. Figure 38-8: Various types of available dressings

33. Treatment of Wounds
Wound cleansing should be performed with warmed isotonic saline. Grossly contaminated wounds are cleaned at each dressing change.
Antibiotic solutions may be ordered for wound irrigation
Surgical wounds and open wound dressing require sterile technique
May require hydrocolloid or wet-to-dry dressings
What is the advantage of warmed versus cold solution for wounds? (Heat increases the blood supply in the area, reducing pain by reducing pressure on the nerve endings. Cold decreases swelling, decreasing pain by decreasing cellular activity, which leads to numbing effect.)
Why is a wound not allowed to dry? (Staying moist will promote healing)

34. Débridement
Removing necrotic tissue from a wound so that healing can occur
May be performed with scissors and forceps
May be enzymatic, in which an enzyme is used to liquefy dead tissue
Mechanical débridement uses wet-to-dry dressings or whirlpool treatments.
Débridement can be done in the operating room or in the patient’s room, depending on the size of débridement that needs to be done. How can the nurse assist as the physician performs a débridement? (Assist with the sterile technique by opening packages for the physician; assist with patient’s comfort or position.)

35. Securing Dressing Dressing may be secured with:
Stretch gauze such as Conform, Kerlix, Kling
Mesh netting
Elastic bandage
Montgomery straps
Binders
Tape
What are the advantages of a secured dressing?
A wound stays moist with ordered dressing.
Montgomery straps prevent the reuse of tape on skin.
Binders can help prevent dehiscence; patient can move around without dressing coming off or apart.

36. Figure 38-10: Montgomery straps hold a dressing in place

37. Figure 38-11: An abdominal binder after surgery with a large incision

38. Tape Application
Place tape so that wound remains covered by the dressing and tape adheres to intact skin
Tape should be long and wide enough to adhere firmly to intact skin on either side of dressing. Place tape at the ends of the dressing.
Place tape opposite to body action in the wound location. Tape should not go across a joint or crease.
Turn under the end, leaving a tab for easy removal
Tape is commonly used for securing dressings, but why are these particular suggestions so helpful? (to keep the tape on, to keep the dressing in place to protect the wound, and to save the nurse from retaping multiple times)

39. Figure 38-9: Tape joint across a joint or a crease

40. Figure 38-9: Tape joint across a joint or a crease

41. Suture Removal Sutures often removed by the physician
Sutures cut and pulled through the skin
Sterile technique should be used
Staple removal requires a special instrument
Steri-Strips applied after removal of sutures or staples
Parts of sutures left under the skin may cause inflammation
What type of patient might keep sutures or staples in longer? (one who is on long-term steroids, due to the delayed healing process)
Some drains have one suture that needs to be removed before the drain is removed.

42. Figure 38-15: Clip beneath the knot with the scissors to remove the suture

43. Figure 38-16: A special implement is used for staple removal

44. Figure 38-17: Apply Steri-Strips to support the incision after suture removal

45. Eye, Ear, and Vaginal Irrigations
Eye irrigations
May be performed when injury is involved and debris or a caustic substance is present in the eye
Ear irrigations
Used to remove cerumen or foreign substances
Vaginal irrigation
May be ordered for infections or surgical preparation
What would be a key point for these types of irrigations? (educating the patient with clear instructions before the irrigation, or before the patient performs the irrigation)

46. Vascular Ulcers
Clean ulcers at each dressing change. Use only normal saline; then cover ulcer with a dressing.
Stage l: thin film dressings are used to protect ulcers from shear
Stage II (noninfected): a hydrocolloid dressing is used
Stage III (draining ulcers): an absorbent dressing is used
What is important for the nurse to do after each dressing change? (Document accurately the wound’s appearance and any education provided to patient.)

47. Vascular Ulcers Infected ulcers—nonocclusive dressing is always used
Negative pressure treatment may increase healing rate by 40%
Uses a vacuum-assisted closure
Removes fluid from the wound and allows penetration of fresh blood
Keeps the wound moist
The “wound vac” is usually placed by either the physician or the wound nurse. What is the nurse’s responsibility for the wound vac? (listen for leaking air sound, in which case report so it may be refitted; output may be recorded)

48. Figure 38-13: Wound VAC unit working on a chronic leg wound

49. Figure 38-14: Wound irrigation

50. Hot and Cold Applications
Can be dry or moist
Usually requires physician’s order
Heat applied to skin provides general comfort and speeds healing process
May be used to:
Relieve pain, reduce congestion, relieve muscle spasm
Reduce inflammation and swelling
Provide comfort, elevate body temperature
See Table 38-2
What patient characteristics need to be considered before heat is applied to the wound? (age of the patient, the thickness of skin, the size of applied area, patient’s tolerance to procedure, patient’s orientation to procedure, correct timing of procedure)

51. Figure 38-18: An Aquathermia pad is applied for a heat treatment

52. Hot and Cold Applications
Effects of cold
To decrease swelling
For joint injuries or areas requiring decreased blood flow
To decrease pain
Decreases cellular activity, leading to numbing
Used in the form of compresses, ice bags, collars, or hypothermia blanket
When are cold applications used most effectively? (after surgeries, [such as total hip, knee, or shoulder], face lifts, tonsillectomies, jaw surgery)
Place barrier between skin and actual ice bag to prevent frostbite.

53. Common Nursing Diagnoses for Patients with Wounds
Impaired skin integrity related to surgical incision (or trauma)
Risk for infection related to nonintact skin or impaired skin integrity
Acute pain related to infected wound
Activity intolerance related to pain and malaise from wound infection
Disturbed body image related to wound appearance
Deficient knowledge related to care of wound
Anxiety related to need to perform wound care
What interventions would accompany these nursing diagnoses? (assessment, monitor VS, monitor labs, assess pain and administer pain medications, allow expression of feelings, educate on wound care, allow gradual learning process for wound care)

54. Examples of Goals for Patients with Wounds
Evaluative statements indicating that the previously stated goals/expected outcomes have been met are as follows:
Wound edges well approximated
Wound is clean and dry without redness or swelling
Patient states that pain is gone
Patient states that energy has returned; is up walking in the hall
Return demonstration of dressing change properly performed
What would be some examples of documentation of the above goals? (examples presented in chapter)