Wounds

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Wounds

• Nursing Fundamentals
• Chapter 28

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Wound

• A break in the continuity of soft parts of body
  structures caused by violence or trauma to
  tissues
• Damaged skin or soft tissue

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Skin

• Called the Integumentary System
• 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

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Examples of tissue trauma

• Cuts
• Blows
• Poor circulation
• Strong chemicals
• Excessive heat or cold
• Such trauma produces 2 types of wounds?

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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

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Open Wound- Abrasion
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Closed WoundContusion-Note Ecchymosis
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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

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Inflammation

• The physiologic defense immediately after tissue
  injury
• This lasts approximately 2-5 days

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Purpose of inflammation

• To limit the local damage
• To remove injured cells and debris
• To prepare the wound for healing by sending
  protein, WBCs to site to heal

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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

• Swelling
• Redness
• Warmth
• Pain
• Decreased function

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2nd step of inflammation

• Leukocytes and macrophages migrate to the site of
  injury
• The body then produces more and more WBCs to go
  to the injury site
• Blood work can be obtained to check WBC levels

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WBC lab values

• Leukocytosis increased production of WBCs
• 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

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Inflammation
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Proliferation

• Period in which new cells fill and seal the wound
• This occurs 2 days to 3 weeks after the
  inflammatory phase
• Its characterized by the formation of
  granulation tissue
• Repair depends on the type and extent of damage

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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

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At the end of the proliferative phase

• The new blood vessels degenerate causing the
  previous pink color to regress

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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

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Wound Healing

• The speed of wound repair and extent of a scar
  depends on whether the wound heals by 1st, 2nd or
  3rd intention

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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

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• Keloids
• Exuberant amounts of collagen giving rise to
  prominent raised scars
• Genetic

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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

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First Intention Healing
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First Intention Healing
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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

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Second Intention Healing
Gaping irregular Granulation epithelium
wound grows over
scar
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Second Intention Healing

• Third intention healing occurs when the edges are
  surgically brought together later after healing
  has begun

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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

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Third Intention
Wound
Increased Granulation
Late suturing with wide scar
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Third Intention Healing
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What type of diet is needed for skin repair?

• High protein helps

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Factors that delay wound healing

• Nutritional deficiencies
• Inadequate blood supply
• Corticosteroid drugs
• Infection
• Mechanical friction on wound
• Advanced age
• Diabetes Mellitus
• Anemia

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Wound Management

• Primary goal of wound management is to
  re-approximate the tissue to restore its integrity

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Pressure Ulcer

• A wound caused by prolonged capillary compression
  that impairs circulation to the skin and
  underlying tissue

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Pressure Points
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Causes
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Pressure Effect
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Pressure sores have 4 stages with obvious signs
symptoms

• Stage 1
• Stage 2
• Stage 3
• Stage 4

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Stage 1

• Persistent redness

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Stage 1
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Stage 2

• Skin tear

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Stage 2
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Stage 3

• Shallow crater, drainage, relatively painless

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Stage 3
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Stage 4

• Deep ulceration down to muscle or bone

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Stage 4
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Hip stage 4 healing
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Pressure from equipment, why is this here?
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Preventing Ulcers
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Heel Decubitus
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Decubitus
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Caring for the skin of a patient
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Promoting Healthy skin

• Nurses are responsible for the promotion of
  healthy skin
• When we identify a sore, WE MUST ACT ON IT
  IMMEDIATELY

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Positioning
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Interventions of a wound

• Observation of symptoms
• Fever, could be infected
• Assess wound and document
• Consistency
• Color
• Odor
• Drainage

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Wound Management
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The use of supplies

• Steri-strips
• Dressings
• Gauze
• Tape
• Montgomery straps
• Ace wraps
• Kerlix
• Duoderm
• Transparent dressings

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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

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Applying Dressings to wounds

• Several different types of dressings will work
• Dr. orders the type
• Or
• Skin care team is involved and orders the
  treatment

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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

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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

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Xeroform

• This type of dressing has a yellow layer of
  vaseline type gel on it, again, wounds wont
  stick to this, good for tissue healing

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Xeroform
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Tegaderm

• Usually used over IV sites
• Problem with this type of dressing is that it is
  not absorbent

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Transparent Dressing (Vac Dressing)
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Transparent Dressing
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Hydro-colloidal Dressings

• Hydro water, these dressings are self adhesive,
  wont 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

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Colloid Dressing - Duoderm
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Colloid dressing used to protect skin, can place
this on the skin 1st then tape the topper down
over the duoderm
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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

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Dry Dressing (AV)
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Wet to Dry dressing, what are the things that are
wrong
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Pressure Dressing (AV)
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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

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Drainage Tube Dressing (AV)
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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

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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

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Emptying JP Drain (AV)
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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

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Hemovac
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Hemovac
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Sutures and staples

• Nurses can remove staples with a staple remover,
  this procedure pinches a bit
• Doctors must remove sutures

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Problems with Wounds

• If skin is not healthy and pt is not eating
  enough protein, 2 things can happen
• 1. Dehiscence
• 2. Evisceration

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Dehiscence

• Separation, gaping, splitting open of a surgical
  wound
• This leaves room for infection, lots of bleeding
  and potential for infection

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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
  semi-fowlers position with knees bent to relieve
  abdominal pressure
• IVFs are started and VS are obtained
• The pt is prepared for the O.R.

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Dehisence

• Evisceration

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Different types of wounds
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Abscess Before Debridement
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Abscess Debrided
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Slough
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Necrotic Tissue
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Eschar
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Sacral decubitus before debridement
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Sacral decubutis after debridement
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Open wound, what do you think about healing?
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Healing after debridement
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Continued Healing
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Assessment of wound
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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

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How to secure gauze

• We can secure gauze with tape
• Or
• Montgomery straps, these prevent usage of too
  much tape.
• Montgomery straps can hold a large dressing in
  place

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Montgomery Straps (AV)
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Other measures that secure dressings

• Abdominal binders are a stiff ace wrap that is
  actually wrapped around the patients 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

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Packing of a wound

• Most wounds heal rapidly with conventional care
• Some wounds need debridement which is removal of
  dead tissue to promote healing

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4 methods for debriding a wound

• 1. Sharp debridement
• 2. Enzymatic debridement
• 3. Autolytic debridement
• 4. Mechanical debridement

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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

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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 cant take the pain
  from the sharp debridement

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Enzymatic debridement
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• Panafil Ointment is an enzymatic
  debriding-healing 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 bodys 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

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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

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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

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Mechanical Debridement, type 3

• 3. Irrigation technique for flushing debris
• This technique is best used when granulation
  tissue has formed

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Packing the wound
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Packed wound (AV)
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Packed wound continued (AV)
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Removing Packing
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Packing a decubitus (AV)
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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

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Wound from an ace wrap clip
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Wound culture (AV)
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Comfort Measures for Wound care patients

• Heat Cold Applications
• Ice Bag Ice Collar
• Chemical Packs
• Compresses
• Aqua-thermia pads
• Soaks Moist packs
• Therapeutic Baths

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Heat vs. Cold

• Heat Cold
• Provides warmth reduces fever
• Promotes circulation prevents swelling
• Speeds healing controls bleeding
• Relieves muscle spasms relieves pain
• Reduces pain numbs sensation

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Cold Treatment (AV)
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Ice Packs

• Come as disposable sacs that you can fill, empty
  out and re-fill
• These provide comfort to pts and have various uses

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Moist Heat (AV)
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Sitz Bath

• A container is placed under the rim of the toilet
  seat to allow warm water to squirt onto the pts
  underside for example to alleviate hemorrhoids or
  vaginal tear after delivery
• The water soothes the perineum, or anus

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Sitz Bath (AV)
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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

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K-Pad
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Heating Blanket

• Again, usually the pt can lay on this to provide
  comfort

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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

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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

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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

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The End