Transcript Wounds • Nursing Fundamentals • Chapter 28

Wounds
• Nursing Fundamentals
• Chapter 28
Wound
• A break in the continuity of soft parts of
body structures caused by violence or
trauma to tissues
• Damaged skin or soft tissue
Skin
• Called the Integumentary System
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The largest organ of the body
Skin is necessary to:
Protect against infection
Protect against dehydration
Regulates body temperature
Collection of sensory information d/t nerve
endings
Examples of tissue trauma
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Cuts
Blows
Poor circulation
Strong chemicals
Excessive heat or cold
• Such trauma produces 2 types of wounds
Open Wounds vs. Closed Wounds
• Open – the surface of the skin or mucous
membrane is no longer intact perhaps due to a
surgeon that incises the tissue (to cut cleanly as
with a sharp instrument)
• Closed – there is no opening in the skin or mucous
membrane. These wounds occur more often from
blunt trauma or pressure
Open Wound- Abrasion
Closed Wound
Contusion-Note Ecchymosis
Healing or wound repair
• Regardless of the type of injury, the body
immediately starts to heal the injury. The
process of wound repair happens in 3
sequential phases:
• Inflammation
• Proliferation
• Remodeling
Inflammation
• The physiologic defense immediately after
tissue injury
• This lasts approximately 2-5 days
Purpose of inflammation
• To limit the local damage
• To remove injured cells and debris
• To prepare the wound for healing by
sending protein, WBC’s to site to heal
Several stages of Inflammation
• First, local changes occur
• Blood vessels constrict to control blood loss and
confine damage
• Then, blood vessels dilate to deliver platelets to
form a loose clot
• Discomfort starts d/t the membranes of the
damaged tissue release plasma and a chemical
substance
• The person has the signs & symptoms of
inflammation
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Signs & Symptoms of
Inflammation
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Swelling
Redness
Warmth
Pain
Decreased function
2nd step of inflammation
• Leukocytes and macrophages migrate to the
site of injury
• The body then produces more and more
WBC’s to go to the injury site
• Blood work can be obtained to check WBC
levels
WBC – lab values
• Leukocytosis – increased production of WBC’s
• An increase in the WBCs, neutrophils and
monocytes, suggest an inflammatory or even
infectious process
• Neutrophils are responsible for phagocytosis.
They consume pathogens, coagulated blood, and
cellular debris.
• Neutrophils and monocytes clean the injured area
ansd prepare the site for wound healing
Inflammation
Proliferation
• Period in which new cells fill and seal the
wound
• This occurs 2 days to 3 weeks after the
inflammatory phase
• It’s characterized by the formation of
granulation tissue
• Repair depends on the type and extent of
damage
Granulation Tissue
• This tissue is pink to red in color because of the
extensive projections of capillaries in the area
• Granulation tissue grows from the wound margin
toward the center
• This granulation skin is fragile and can be easily
disrupted
• Fibroblasts produce collagen which is a tough,
protein substance
• The adhesive strength of the wound increases
At the end of the proliferative
phase
• The new blood vessels degenerate causing
the previous pink color to regress
What happens in skin repairing
(general)
• Resolution- process by which damaged
cells recover and re-establish their normal
function
• Regeneration – cell duplication
• Scar formation – replacement of damaged
cells with fibrous tissue
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Remodeling
• Period in which the wound undergoes
changes and maturation, the wound
contracts and the scar shrinks
• This follows the proliferative phase
• This phase can last 6 months – 2 years
Wound Healing
• The speed of wound repair and extent of a
scar depends on whether the wound heals
by 1st, 2nd or 3rd intention
Some scars form keloids
• Keloids are a collection of collagen in one
area over a scar
• Some people form keloids and some people
do not
• Can be lasered off for cosmetic purposes
– Keloids
• Exuberant amounts of
collagen giving rise to
prominent raised scars
• Genetic
First Intention healing
(easiest method of healing)
• This is a reparative process
• The wound edges are directly next to each
other
• The space between the edges is so small,
only a small amount of scar tissue forms
• This looks like most surgical wounds
First Intention Healing
First Intention Healing
Second Intention
• The wound edges are widely separated, this leads
to more time consuming and complex reparative
process
• The granulation tissue between the widely spread
edges, needs additional time to extend across the
expanse of the wound
• Healing by 2nd intention takes even longer if body
fluid or other debris is present
• Wound care must be done cautiously as to not
disrupt the new granulation tissue and retarding
the healing process
Second Intention Healing
Gaping irregular Granulation
wound
epithelium
grows over
scar
Second Intention Healing
• Third intention healing
occurs when the edges
are surgically brought
together later after
healing has begun
Third intention
• The wound edges are widely separated and are
later brought together with some type of closure
material
• This results in a broad, deep scar
• These wounds are deep and contain extensive
drainage and tissue debris
• To speed healing, these wounds are packed with
absorbent gauze and may even contain a drainage
device
Third Intention
Wound
Increased
Granulation
Late suturing with
wide scar
Third Intention Healing
What type of diet is needed for
skin repair?
• High protein helps
Factors that delay wound healing
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Nutritional deficiencies
Inadequate blood supply
Corticosteroid drugs
Infection
Mechanical friction on wound
Advanced age
Diabetes Mellitus
Anemia
Wound Management
• Primary goal of wound management is to
re-approximate the tissue to restore its
integrity
Pressure Ulcer
• A wound caused by prolonged capillary
compression that impairs circulation to the
skin and underlying tissue
Pressure Points
Causes
Pressure Effect
Pressure sores have 4 stages with
obvious signs & symptoms
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Stage 1
Stage 2
Stage 3
Stage 4
Stage 1
• Persistent redness
Stage 1
Stage 2
• Skin tear
Stage 2
Stage 3
• Shallow crater, drainage, relatively painless
Stage 3
Stage 4
• Deep ulceration down to muscle or bone
Stage 4
Hip – stage 4 healing
Pressure from equipment, why is
this here?
Preventing Ulcers
Heel Decubitus
Decubitus
Caring for the skin of a patient
Promoting Healthy skin
• Nurses are responsible for the promotion of
healthy skin
• When we identify a sore, WE MUST ACT
ON IT IMMEDIATELY
Positioning
Interventions of a wound
• Observation of symptoms
• Fever, could be infected
• Assess wound and document
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Consistency
Color
Odor
Drainage
Wound Management
The use of supplies
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Steri-strips
Dressings
Gauze
Tape
Montgomery straps
Ace wraps
Kerlix
Duoderm
Transparent dressings
Steri-strips hold an incision
closed
• These are usually placed on a patient in surgery
and these are not removed for approximately 2-3
weeks
• Tell patient to shower and let water and shampoo
wash over strips. Strips will peel off on own.
Best to remove them in the shower
• TELL PT TO NOT PULL STRIPS OFF TO
SOON, reopening of wound is possible
Applying Dressings to wounds
• Several different types of dressings will
work
• Dr. orders the type
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• Skin care team is involved and orders the
treatment
Gauze Dressings
• Gauze is made of woven fibers and is used
for absorption
• Granular tissue may adhere to the gauze and
may be pulled off during a dressing change
• We try not to moisten the dry gauze as to
not pull off good, new, healing skin
Non-stick dressings
• Such as Telfa, has a plastic-type backing on
it that goes directly over the wound to
enable to dressing NOT to stick
Xeroform
• This type of dressing has a yellow layer of
vaseline type gel on it, again, wounds won’t
stick to this, good for tissue healing
Xeroform
Tegaderm
• Usually used over IV sites
• Problem with this type of dressing is that it
is not absorbent
Transparent Dressing (Vac
Dressing)
Transparent Dressing
Hydro-colloidal Dressings
• Hydro – water, these dressings are self
adhesive, won’t come off with water, these
types keep wound moist and occludes
debris. The hydro portion of the dressing
aids in healing of the skin with the dressing
on
• This is Duoderm
Colloid Dressing - Duoderm
Colloid dressing used to protect
skin, can place this on the skin 1st
then tape the topper down over
the duoderm
Wound Drainage
• When changing the dressing of a wound,
the nurse must note the color of the
drainage on the dressing
• Must record what you see
• May have pus or blood in the dressing
Dry Dressing (AV)
Wet to Dry dressing, what are the
things that are wrong
Pressure Dressing (AV)
Drains
• Drains are used to keep body fluid away
from the wound so that effective healing
can occur
• There are several different types of drains
• Nurses MUST be aware of how to manage
these drains
Drainage Tube Dressing (AV)
Penrose Drain
• Looks like a floppy macaroni noodle
• This drain is usually covered loosley with a
topper dressing
• The nurse changes the topper dressing
frequently and weighs the gauze and
records this as output
Safety pin
keeps drain
from slipping
into wound
Drain sponge
Jackson-Pratt Drain
• This drain looks like a gernade
• There is a plastic ball that is squeezed and
the end is closed. The drain will inflate
itself (the squeezed ball opens up) and as it
does, it pulls drainage away from the patient
• This drain must be empties frequently in
order to keep working
Emptying JP Drain (AV)
Hemovac Drain
• This drain looks similar to a frisby or a disc
• You pull the tab to empty the drain and then you
squeeze the disc down and plug it up.
• Again, when the drain inflates, it pulls drainage
away from the pt
• This must be emptied several times during a shift
to work effectively
Hemovac
Hemovac
Sutures and staples
• Nurses can remove
staples with a staple
remover, this procedure
pinches a bit
• Doctors must remove
sutures
Problems with Wounds
• If skin is not healthy and pt is not eating
enough protein, 2 things can happen:
• 1. Dehiscence
• 2. Evisceration
Dehiscence
• Separation, gaping,
splitting open of a
surgical wound
• This leaves room for
infection, lots of
bleeding and potential
for infection
Evisceration
• The spilling out of the abdominal contents or
intestine through a surgical wound
• This is somewhat of an emergency, the Dr. must
be called STAT. The wound is covered in a moist
sterile towel. NS must be used. Pt is put in semifowlers position with knees bent to relieve
abdominal pressure
• IVFs are started and VS are obtained
• The pt is prepared for the O.R.
Dehisence
Evisceration
Different types of wounds
Abscess Before Debridement
Abscess Debrided
Slough
Necrotic Tissue
Eschar
Sacral decubitus before
debridement
Sacral decubutis after
debridement
Open wound, what do you think
about healing?
Healing after debridement
Continued Healing
Assessment of wound
How to care for a wound
• ALWAYS MEASURE THE WOUND
• Wounds must be cared for in special ways
• Some wounds must be packed, some must
be dressed with a simple topper , some must
be irrigated and then packed and then
dressed with a topper
How to secure gauze
• We can secure gauze with tape
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• Montgomery straps, these prevent usage of
too much tape.
• Montgomery straps can hold a large
dressing in place
Montgomery Straps (AV)
Other measures that secure
dressings
• Abdominal binders are a stiff ace wrap that
is actually wrapped around the patient’s
waist and is used to secure a large dressing
to the abdomen
• This dressing is also used when a pump is
inserted into the abdominal cavity, this
secures the pump under the skin so the
patient can ambulate easier
Packing of a wound
• Most wounds heal rapidly with
conventional care
• Some wounds need debridement which is
removal of dead tissue to promote healing
4 methods for debriding a wound
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1. Sharp debridement
2. Enzymatic debridement
3. Autolytic debridement
4. Mechanical debridement
Sharp Debridement
• This is the removal of necrotic
tissue (non-living tissue)
• The use of sterile scissors, forceps or other
instruments are used
• This method is preferred when the wound is
infected because it helps the wound heal quickly
• This can be painful and the wound may bleed
afterward
• Can be done in the O.R. or at the bedside
Enzymatic Debridement
• This involves the use of topically applied
chemical substance that break down and
liquefy wound debris
• A dressing is used to keep the enzyme in
contact with the wound and to help absorb
drainage
• This is used for people who can’t take the
pain from the sharp debridement
Enzymatic debridement
• Panafil Ointment is an enzymatic debridinghealing ointment which contains standardized
Papain, Urea and Chlorophyllin Copper
Complex Sodium in a hydrophilic base.
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Autolytic Debridement
• This is a painless
physiologic process that
allows the body’s enzymes
to soften, liquefy and release
devitalized tissue
• It is used for people who
have small infections
• An occlusive dressing keeps
the wound moist
• Removal of tissue debris is
slow in this process
Mechanical Debridement – 3
types of this
• 1. This involves physical removal of debris
• This is done by applying wet-dry dressings
• The wound is packed with wet gauze and then 6-8
hrs later, the gauze dries. Debris attaches itself to
the wet and then dry gauze and is removed when
the dressing is changed
• This procedure can be painful and at times, it
disrupts the new formation of granulation tissue
Mechanical Debridement
• 2. Hydrotherapy – the use of agitating water
contains antiseptic and softens the dead
skin.
• Loose debris that remains attached, is then
removed by sharp debridement
Mechanical Debridement, type 3
• 3. Irrigation – technique for flushing debris
• This technique is best used when
granulation tissue has formed
Packing the wound
Packed wound (AV)
Packed wound continued (AV)
Removing Packing
Packing a decubitus (AV)
Providing Comfort to the patient
• Teach the pt how to splint his incision for
easier ambulation
• Teach pt to place a pillow or blanket over
abdomen and to push gently to support the
abdominal muscles
• This splinting is also used when pt must
cough or sneeze
Wound from an ace wrap clip
Wound culture (AV)
Comfort Measures for Wound
care patients
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Heat & Cold Applications
Ice Bag & Ice Collar
Chemical Packs
Compresses
Aqua-thermia pads
Soaks & Moist packs
Therapeutic Baths
Heat vs. Cold
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Provides warmth
Promotes circulation
Speeds healing
Relieves muscle spasms
Reduces pain
Cold
reduces fever
prevents swelling
controls bleeding
relieves pain
numbs sensation
Cold Treatment (AV)
Ice Packs
• Come as disposable sacs that you can fill,
empty out and re-fill
• These provide comfort to pts and have
various uses
Moist Heat (AV)
Sitz Bath
• A container is placed under the rim of the
toilet seat to allow warm water to squirt
onto the pt’s underside for example to
alleviate hemorrhoids or vaginal tear after
delivery
• The water soothes the perineum, or anus
Sitz Bath (AV)
Heating Pad (K-Pad)
• This is a device used to provide comfort
• The machine is filled with water that heats and the
the water filters into a blanket and the pt can either
sit on the blanket or lay the blanket over them
• Temperature is pre-programmed to deliver one
temperature, the water never seems to get warm
enough
K-Pad
Heating Blanket
• Again, usually the pt can lay on this to
provide comfort
Chemical warm or cool packs
• These provide temporary relief and may decrease
swelling
• These can be used if an IV falls out of place and
the fluid is in between spaces causing pain
• YOU MUST ALWAYS SQUEEZE THESE
AWAY FROM THE PATIENT TO ACTIVATE
THEM TO AVOID THEM EXPLODING ON
THE PT
Measures of comfort to provide
to the pt with a wound or ulcer
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Rest and immobilization
Elevation
Oxygenation
Heat/Cold
Wound management
Prevent infection
Recording and Documenting
• Once the old dressing has been removed and the
wound is assessed and re-dressed, the nurse must
properly dispose of the supplies, wash hands and
record what the wound looked like
• Be as specific as you can, explaining what you
saw and what you did to that wound. If wound
needs to me measured, then do so and record your
findings
The End