Wound Management

1
Wound Management
2
Wounds

• disruption of normal anatomical structure and
  function that results from pathological processes
  beginning internally or externally to the
  involved organ(s). (PP, p. 1487.

3
Wound Classification

• Helps nurse understand associated risks and care
  implications

4
Acute Wound

• Follow normal healing process in an orderly and
  timely manner
• Examples
• Traumatic wound (laceration)
• Surgical wound

5
Chronic Wound

• Healing time frame is delayed, repair fails to
  occur and return to normal function is slowed.

6
Wound Healing Process

• Nature of healing same for all wounds
• Variations depend on location, severity, and
  extent of injury

7
Wound Types

• Without loss of tissue
• Clean surgical wound
• Abrasions
• Puncture wounds
• With loss of tissue
• Burn
• Pressure ulcer
• Severe laceration

8
Healing by Primary Intention

• Skin edges approximated
• Low risk of infection
• Healing occurs quickly
• Inflammation subsides within 24 hours
• Resurfaced between day 4 and 7

9
Healing by Secondary Intention

• Wound left open to fill with scar tissue
• Healing takes longer
• Greater risk for infection
• Severe scarring can lead to permanent loss of
  tissue function

10
Partial Thickness Wound Repair

• Inflammatory response
• Triggered by tissue trauma
• Redness, swelling, moderate serous exudate
• Epithelial proliferation and migration
• Wound edges and epidermal cells lining the
  epidermal appendages (quick resurfacing)
• Open to air 6 - 7 days
• Moist 4 days
• Reestablishment of the epidermal layers
• Reestablishing normal thickness

11
Full Thickness Wound Repair

• Inflammatory Phase
• 3 day duration
• Hemostasis, fibrin matrix, macrophage activity,
  fibroblast activity, collagen
• Proliferative
• Begins with appearance of new blood vessels
• 3 to 24 days duration
• Granulation, contraction, epithelialization
• Remodeling
• Maturation
• Up to one year duration

12
Complication of Wound Healing

• Hemorrhage
• Infection
• Dehiscence
• Evisceration
• Fistula

13
Types of Drainage

• Serous
• Sanguineous
• Serosanguineous

14
Wound Assessment

• Approximation
• If open, condition of wound base tissue
• Inflammation (redness, warmth, swelling,
  tenderness)
• Closures (staples, sutures)

15
Drainage Assessment

• Amount
• Color
• Odor
• Consistency

16
Palpation of Wounds

• Wear gloves
• Lightly palpate wound edges
• If fluid expressed, note character of drainage

17

• Drains
• Used when large amount of drainage is expected
• Requires careful dressing changes
• Monitor amount closely
• Wound closures
• Staples, sutures, wound closures
• Wound cultures
• Used to determine presence of infectious organism

18
Wound Management

• Goal
• maintenance of a physiological wound
  environment
• Principles to address
• Prevent and manage infection
• Cleanse wound
• Remove nonviable skin
• Manage exudate (drainage)
• Protect the wound

19
Dressings

• Protect wounds from contamination
• Aid hemostasis
• Promote healing
• Absorbs drainage
• Debridement
• Support/splint wound site
• Thermal insulation
• Provides moist environment

20
Skin Cleansing Principles

• Cleanse in direction from least contaminated area
• Use gentle friction when applying solutions
  locally to skin
• When irrigating, allow solution to flow from the
  least to the most contaminated area

21
Bandages and Binders

• Provide extra protection
• Create pressure over a body area
• Immobilize a body part
• Reduce or prevent edema
• Secure a splint
• Secure dressings

22
Principles of Bandage or Binder Application

• Inspect skin prior to application
• Cover exposed wounds/abrasions
• Assess condition of underlying dressings
• Assess circulatory status of skin areas that will
  be distal to the bandage
• Nurse may loosen a bandage that he/she has
  applied, must have a physician order to loosen or
  remove bandage applied by a physician

23
Heat and Cold Therapy

• Assess for intolerance to heat or cold therapies
  and response to stimuli before initiating
  treatment
• Baseline skin assessments guide evaluation for
  changes
• Contraindications to heat active bleeding, acute
  localized inflammation (appendicitis),
  cardiovascular problems
• Contraindications to cold injured area already
  edematous, neuropathy, shivering

24
Effects of Heat and Cold Application

• Heat
• Improved blood flow to injured area
• (prolonged exposure reflex vasoconstriction)
• Cold
• Diminish pain and swelling
• (prolonged exposure reflex vasodilation)
• Box 47-17 Choice of Dry or Moist Applications