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Fundamentals
Surgical Wound Care
| Term | Definition |
|---|---|
| Phases of Wound Healing | 1. Homeostasis 2. Inflammatory phase 3. Reconstruction Phase 4. Maturation Phase |
| Nutrition | Nutrition needs fluids and rest and activity |
| Complications of Wound Healing | Impaired wound healing requires accurate observation and ongoing interventions Wound bleeding wound infection |
| Process of wound healing | Primary intention Secondary intention Tertiary intention |
| Wound classifcations | Cause Severity of injury amount of contamination size CDC has classified surgical wounds from class 1 (clean) to class IV (dirty infected) |
| Surgical wound care | Selection of the site Standard steps in care Care of incision |
| Dressings (wound) | Dry dressing: May be chosen for management of a wound w/ little exudate/ drainage Wet to dry dressing: Primary purpose is to mechanically debride a wound. As the dressing dries it adheres to the wound & debrides it when the dressing is removed |
| dressing wound pt2 | Transparent dressing: self adhesive transparent film is a synthetic permeable membrane that acts as temp secondary skin |
| Dehiscence | Wound layers sperate. Pt must say that something has "given way". It mat result after periods of sneezing, coughing, or vomiting. It may be preceded by serosanguineous drainage . Pt should remain in bed & receive nothing by mouth be told not to cough |
| Dehiscence pt2 | and reassured. The nurse should place warm , moist sterile dressing over the area until the provider evaluates the site |
| Evisceration | Abd organs protrude through an opened incision. Pt is to remain in bed and the wound & contents should be covered w/ warm sterile saline dressing. The surgeon is notified immediately. Medical emergency and the wound requires surgical repair. |
| Staples and sutures | the surgeon goal is to enter the cavity involved repair the injured or diseased area & minimize trauma as quickly as possible. Many options are available to the surgeons for closing the surgical incision. Sutures & staples are generally removed within |
| Staples and sutures pt.2 | 7-10 days after surgery or sooner if healing is adequate. The provider determines & orders removal of the sutures or staples 1 at a time or removal of every suture or staple & replacement within steri-strip as the 1st phase with the remainder removed |
| Exudate and Drainage | Serous Sanguineous Serosanguineous If the tissue is infected, exudate/ drainage may be brown-green purulent Exudate/drainage from organs has its own particular color (bile from the liver and gallbladder is green-brown) |
| Exudate and Drainage pt2 | Assess color, amount, consistency, and odor |
| Drainage systems | They are used in procedures in which organs were moved or repaired. requires close monitoring closed drainage open drainage suction drainage |
| Wound Irrigations | Wound cleansing and irrigation is accomplished using sterile or clean technique Cleansing solution is introduced directly into the wound with a syringe, syringe and catheter, shower, or whirlpool |
| Wound Irrigations pt2 | Fluid retention is avoided by positioning the patient on his or her side to encourage the flow of the irrigate away from the wound |
| Wound irrigations pt3 | Promote wound healing through removing debris from a wound surface, decreasing bacterial counts, and loosening and removing eschar Cleanse in a direction from the least contaminated area to the most contaminated area |
| Wound Vacuum-Assisted Closure | Uses negative pressure to remove fluid from surrounding the wound |
| Bandages and Binders | After a bandage is applied, the nurse should Assess, document, and immediately report changes in circulation, skin integrity, comfort level, and body function such as ventilation or movement |
| Bandages and Binders pt2 | Loosen or readjust as necessary Have an order to remove or loosen a dressing applied by a provider Explain to the patient that any bandage or binder feels relatively firm or tight |
| Bandages and Binders pt3 | Assess to be sure it is properly applied and is providing therapeutic benefit; soiled bandages should be replace |
| Nursing Process | Nursing dx: Impaired skin integrity Imbalanced nutrition: more than body requirements imbalanced nutrition: less than body requirements ineffective tissue perfusion (specify type) |
| How does wound healing from primary intention differ from healing by secondary intention? | Wound healing by primary intention involves the closure of a surgical would (incision) primary intention involves epithelization the wound generally heal quickly w/ minimal scar formation. Wound healing is secondary intention follows a predictable s |
| How does wound healing from primary intention differ from healing by secondary intention? pt 2 | sequence of inflammation proliferation and remodeling in other words the body's natural process for healing wound. DO NOT confuse secondary w/ approximation which is term used to describe wound edges that are touching as when surgical wound is closed |
| why do pressure injuries never change even though they seem to go through different stages as they heal? | Pressure injury staging criteria have been used to describe the depth & degree of tissue damage caused by pressure the current recommendation from National pressure injury Advisory Panel is to use the stage 1 to 4 criteria |
| why do pressure injuries never change even though they seem to go through different stages as they heal? pt2 | with the addition of two criteria for DEEP tissue injury & unstageable pressure injuries. The reason that these injuries cannot reverse in stage is that as the injuries heal the natural tissues are replaced w/ granulation and scar tissue |
| why do pressure injuries never change even though they seem to go through different stages as they heal? pt3 | Which is not the same as the original tissue present prior to the development of the injury |
| inflammatory stage | Begins with the injury and lasts 3-6 days Effects to wound- controlling bleeding with vasoconstriction, retraction, of blood vessels, fibrin accumulation, and clot formation. Delivering oxygen, WBC and nutrients to the area via the blood supply. |
| inflammatory stage part 2 | Macrophages engulf microorganisms phase is prolonged when there is too little inflammation or when there is too much inflammation |
| Proliferative stage | Last 3-24 days Replacing lost tissue with connective or granulated tissue with collagen Contracting the wounds edges to reduce the area that requires healing. Resurfacing of new epithelial cells. |
| Maturation or remodeling stage | Occurs on or about day 21 and involves strengthening of the collagen scar and the restoration of a more normal appearance. it can take more than 1 year to complete. depending on the extent of the original wound |
| Primary intention | Little or no tissue loss edges approximated as with a surgical incision heals rapidly low risk of infection no or minimal scarring example: closed surgical incision with staples. sutures, or liquid glue to seal laceration |
| Secondary intention | Loss of tissue Wound edges widely separated approximated (pressure ulcer, open burn area) longer healing time increase of risk of infection scarring heals by granulation example: pressure injury left open to heal |
| Tertiary intention | Widely separated Deep Spontaneous opening of a previously closed wound Closure of wounds occurs when they are free of infection and edema risk of infection extensive drainage and tissue debris closed later long healing time example: abd wound |
| Factors affecting wound healing | Age Overall wellness Decreased leukocyte count Infection Some medication (anti inflammatory and antineoplastic) Malnourished clients tissue perfusion low high levels obesity chronic diseases smoking wound stress |
| General principle's of wound management | Wound impair skin integrity Inflammation is localized protective response to injury or destruction of tissue Wound heals by various processes and in stages Wound infections result from invasion of pathogenic micro organisms |
| Appearance | Note the color of open wounds: Red- healthy regeneration of tissue yellow-presence of purulent drainage and slough black-Presence of eschar that hinders healing and requires removal Asses length, width, and depth any undermining sinus tracts or tunnel |
| Appearance part 2 | Use the RYB color code guide for wound care: Red (cover) yellow (clean) black (debride, remove necrotic tissue) Close wounds: skin edges should be well approximated |
| Pressure injury | Deep tissue pressure injury, persistent nonblanchable deep red, marron, or purple discoloration Stage 1- Nonblanchable erythema of intact skin Stage 2-partial thickness skin loss w/ exposed dermis Stage 3-full thickness skin loss |
| Pressure injury part 2 | Stage 4- Full thickness skin and tissue loss Unstageable obscured, full thickness skin and tissue loss |
| Assessment/data collection | The primary focus of prevention and treatment of pressure injury is to to relive the pressure and provide optimal nutrition and hydration |
| Nursing intervention- | Avoid skin trauma Provide supportive devices Maintain skin hygiene Encourage proper nutrition |
| Treatment for suspected deep tissue injury and stage 1 | Relive pressure encourage frequent turning and repositing use pressure relieving devices (an air fluidized bed) Implement pressure reduction surfaces (air mattress and foam mattress) |
| Treatment for suspected deep tissue injury and stage 2 | Maintain a moist healing environment (saline + occlusive dressing ) Promote natural healing while preventing the formation of scar tissue Provide nutritional supplements administer analgesics |
| Treatment for suspected deep tissue injury and stage 3 | Clean and or debride with the following prescribed dressing surgical intervention Proteolytic enzymes Provide nutrition supplements administer analgetic administer antimicrobials (topical or systemic) |
| Treatment for suspected deep tissue injury and stage 4 | Clean and or debride with the following prescribed dressing surgical intervention Proteolytic enzymes Perform nonadherent dressing changes ever 12hrs Treatment can include skin grafts or specialized therapy (hyperbaric oxygen) |
| Treatment for suspected deep tissue injury and stage 4 part 2 | Provide nutrition supplements administer analgetic administer antimicrobials (topical or systemic) |
| Treatment- Unstageable | Debride until staging is possible |
| Complications/Nursing implications Deterioration of higher stage ulcerations of infection | Check injury frequently and report an increase in the size or depth of the lesion changes in granulation tissue (color, texture)and changes in exudate (color quantity order) |
| Systemic infection | Monitor for indications of sepsis (changes in level of consciousness, persistent recurrent fever, tachycardia, tachypnea, hypotension and oliguria increase in WBC count |
| Systemic infection pt 2 | Prevent infection by using aseptic technique when preforming injury treatment and dressing changes Provide optimal nutrition to promote immune response Provide for adequate rest to promote healing admin. antibiotic therapy after collecting specimens |
| Systemic infection pt 3 | for culture and sensitivity testing |
Created by:
BriAnnaNM
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