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Wound Care

Chapter 13

Phases of wound healing Inflammatory Response >Vascular response >Cellular response > Formation of Exudate > Healing
Inflammatory phase Vascular Response Transient Vasoconstriction-> Histamine Release -> Vasodilation (Increased blood flow which raises filtration pressure) --> Increased capillary permeability (facilitate movement from capillaries into tissue spaces)-> Fibrin-> Growth Factors
What is Fibrin fibrous, non-glabular protein involved in clotting of blood
Vasodilation and Increased capillary permeability responsible for: redness, heat, and swelling
What is Exudates any fluid that filters from the circulatory system into lesions or areas of inflammation
Cellular Response >Neutrophils >Monocytes and Macrophages >Lymphocytes and other WBCs
Neutrophils in Cellular Response >First to arrive (6-12 hours)--> Engulf bacteria, other foreign material & damaged cells --> short life span (24-48 hours) --> dead neutrophils accumulate w/digested bacteria & other cell debris = creamy substance (pus)
Monocytes and Macrophages in Cellular Response second to migrate from circulating blood. >arrive (3-7 days) after onset of inflammation >on entering tissue space monocytes transform int macrophages --> engulf inflammatory debris >the role--> cleaning area before healing can occur > long life span
Lymphocytes and other WBCs in Cellular Response arrive later at injury
Types of inflammatory exudate Serous Results from outpouring of fluid; seen in early stages of inflammation or when injury is mild. Examples: skin blisters, pleural effusion
Types of inflammatory exudate Serosanguineous Found during the midpoint in healing after surgery or tissue injury. Composed of RBCs and serous fluid. This fluid is semiclear pink and may have red streaks. Examples: Surgical drain fluid
Types of inflammatory exudate Fibrinous Occurs with increasing vascular permeability and fibrinogen leakage into interstitial spaces. Excessive amounts of fibrin that coats tissue surfaces may cause them to adhere. Examples: Adhesions, gelatinous ribbons seen in surgical drain tubing
Types of inflammatory exudate Hemorrhagic Results from rupture or necrosis of blood vessel walls Examples: Hematoma, bleeding after surgery or tissue trauma
Types of inflammatory exudate Purulent (pus) Consists of WBCs, microorganisms (dead and alive) liquefied dead cells, and other debris. Examples: Furuncle (boil), abscess, cellulitis (diffuse inflammation in connective tissue).
Types of inflammatory exudate Catarrhal Found in tissues where cells produce mucus. Mucus production is accelerated by inflammatory response. Examples: runny nose associated with upper respiratory tract infection
Healing Process Regeneration replacement of lost cells and tissues with cells of same type
Healing process Repair healing as a result of lost cells being replaced by connective tissue (most common results in scar formation)
Healing process Regeneration Labile Cells >Labile cells->divide constantly -> rapid regeneration (ex: skin, mucous membranes of GI, bone marrow)
Healing process Regeneration Stable Cells >Stable cells (retain their ability to regenerate but do so only if organ is injured) (ex: liver, pancreas, kidney)
Healing process Regeneration Permanent Cells Permanent Cells (do not divide) (ex: CNS, Cardiac, and skeletal muscle cells) -permanent loss if damaged - CNS neurons destroyed replaced by glial cells -Cardiac & skeletal replace by scar tissue
Healing process Repair Primary Intention Surgical incision or papercut 1. Initial 2. Granulation 3. Scar Contracture
Healing process Repair Primary Intention Initial Phase 1. Initial: (3-5 days) approximation of incision edges; migration of epithelial cells; clot serving as meshwork for starting capillary growth
Healing process Repair Primary Intention Granulation Phase 2. Granulation (5 days to 4 weeks) Migration of fibroblasts; secretion of collagen; abundance of capillary buds, fragility of wounds
Healing process Repair Primary Intention Scar Contracture 7 days to several months. Remodeling of collagen; strengthening of scar
Healing Process Repair Secondary Intention wounds that occur from trauma, ulceration, or infection have large amounts of exudate & wide irregular wound margins with tissue loss -edges that can be brought together -clean debris before healing
Healing process Repair Tertiary Intention Delayed primary intention -contaminated wound is left open & sutured closed after infection is controlled -larger scar than primary and secondary
Clinical Manifestations of Wounds Local reactions -Redness -Heat -Pain -Swelling -Loss of Function Systemic -Leukocytosis -Fever
Clinical Manifestation Redness hyperemia from vasodilation
Clinical Manifestation Heat increased metabolism at inflammatory site
Clinical Manifestation Pain Change in pH, nerve stimulation by chemicals (histamine, prostaglandins) pressure from fluid exudate
Clinical Manifestation Swelling Fluid shifts to interstitial spaces, fluid exudation accumulation
Clinical Manifestation Loss of function Caused by pain and swelling
Clinical Manifestation Leukocytosis increase release of leukocytes from bone marrow (nausea, malaise, anorexia, fatigue)
Phases of healing >New capillary networks >Granulation Tissue >Epithelialization >Action of fibroblasts
Description/Characteristics of Red Wound -superficial or deep if clean and pink in appearance -serosanguineous drainage -pink to bright/dark red healing, or granulating tissue
Examples of red wound Skin tears, pressure ulcers (stage II), partial thickness, or second degree burns
Purpose of treatment for red wound protection and gentle atraumatic cleaning
Dressings and therapy of red wound Transparent film dressing (ex: tegaderm, opsite, duoderm, hydrogels (tegagel), gauze dressing with antimicrobial ointment or solution, telfa dressing with antibiotic ointment
Description/Characteristics of Yellow wound -slough or soft necrotic tissue -liquid to semiliquid slough with exudate ranging from creamy ivory to yellow green
Example of Yellow Wound Wounds with nonviable necrotic tissue, which creates an ideal situation for bacterial growth and therefore must be removed
Purpose of treatment for Yellow Wound Wound cleansing to remove nonviable tissue and absorb excess drainage
Dressing and therapy for Yellow Wound Absorptive dressing, hydrocolloidal dressing, hydrogel covered with gauze, wound irrigations, hydrotherapy, moist gauze dressing with or without antibiotic or antimicrobial agent
Description/Characteristics of Black Wound -Black, gray, or brown adherent necrotic tissue called eschar, possible presence of purulent drainage -risk of wound infection increases in proportion to amount of necrotic tissue present
Example of Black Wound Full-thickness or third-degree burns, pressure ulcers (stage III and IV) and gangrenous ulcers
Purpose of treatment of Black Wound Debridement of eschar and nonviable tissue
Dressing and therapy For Black Wound Topical debridement (enzyme, surgical, chemical) hydrotherapy, moist gauze dressing, hydrogel covered with gauze, absorptive dressing covered with gauze
What factors delay wound healing -Nutritional Deficiencies -Inadequate blood supply -Corticosteroid drugs -Infection -Mechanical friction -Advanced age -Obesity -Diabetes Mellitus -Anemia -Poor general health
delay wound healing -Nutritional deficiency -Vit. C (delays formation of collagen fibers and capillary development) -Protein (Decreases supply of amino acids for tissue repair) -Zinc (impairs epithelialization)
Delay Wound Healing -Inadequate blood supply -Decreases supply of nutrients to injured area -decreases removal of exudative debris -inhibits inflammatory response
Delay Wound Healing -Corticosteroid Drugs -Impair phagocytosis by WBCs -Inhibit fibroblast proliferation and function -Depress formation of granulation tissue -Inhibit wound contraction
Delay Wound Healing -Infection Increases inflammatory response and tissue destruction
Delay Wound Healing -Smoking Nicotine is a potent vasoconstrictor and impedes blood flow to healing area
Delay Wound Healing -Mechanical Friction -Destroys granulation tissue -Prevents apposition of wound edges
Delay Wound Healing -Advanced age -Slows collagen synthesis by fibroblast -Impairs Circulation -requires longer time for epithelialization of skin -alters phagocytic and immune responses
Delay Wound Healing -Obesity Decreases bloody supply in fatty tissue
Delay Wound Healing -Diabetes Mellitus -Decreases collagen synthesis -Retards early capillary growth -impairs phagocytosis (result of hyperglycemia) -reduces supply of O2 and nutrients secondary to vascular disease
Delay Wound Healing -Poor general health Causes generalized absence of factors necessary to promote wound healing
Delay Wound Healing -Anemia Supplies less oxygen at tissue level
Complication of Healing -Hypertrophic Scars -Contracture -Dehiscence -Evisceration -Excess granulation tissue -Adhesions
Complication of Healing -Adhesions -Bands of scar tissue that form between or around organs -Adhesions may occur in abdominal cavity or between lungs and pleura -Adhesions in abdomen may cause an intestinal obstruction
Complication of Healing -Hypertrophic Scars -Occur when an overabundance of collagen is produced during healing -Forms an inappropriately large, raised red and hard scar that is non-life threatening
Complication of Healing -Contracture -Wound contraction is a normal part of healing -Complications occur when there is excessive contraction resulting in deformity -muscle or scar tissue shortening; esp. over joints, from fibrous tissue formation
Complication of Healing -Dehiscence -separation/disruption of previously joined wound edges -Occurs when healing site burst open -Caused by- infection causing inflammation-granulation tissue weak-obesity bc less blood supply in adipose fluid develop preventing wound edges coming together
Complication of Healing -Evisceration Occurs when wound edges separate & intestines protrude thru wound
Complication of Healing -Excess Granulation tissue (proud flesh) -protrudes above healing wound surface -if cauterized/cut off healing in normal manner
What are pressure ulcers? localized injury to the skin and/or underlying tissue->bony area result of pressure or pressure in combo with shear or friction
What are contributors to pressure ulcers? -Shearing force->pressure on skin when adheres to bed & skin slide in direct of body movement -Friction -> 2 surfaces rubbing - excessive moisture
Characteristics of Stage I pressure ulcer? intact skin w/ nonblanchable redness.
Characteristics of Stage II pressure ulcer? Partial thickness loss of dermis ->shallow open ulcer w/ red-pink wound bed or blister
Characteristics of Stage III pressure ulcer? full thickness tissue loss->subcutaneous fat may be visible->no bone, tendon, muscle visible
Characteristics of Stage IV pressure ulcer? Full thickness tissue loss w/ exposed bone, tendon, muscle
What are the focused assessment of pressure ulcers? >location >Size >Color >Surrounding skin >Drainage >Temperature >Pain >Wound Closures
Characteristics of unstageable pressure ulcer? full thickness tissue loss->base of ulcer covered by slough (yellow, tan, gray, green, brown) &/or eschar (tan, brown, black) in wound bed
Diagnostic test for pressure ulcers >CBC -Leukocytosis -hemoglobin >Sedimentation rate >C reactive protein >Albumin
What are nursing interventions? >Fever >Rest and immobilization >elevation >heat/cold >oxygenation
Wound management for secondary intention? >cleansing >keeping the wound moist >filling dead space
Sharp Debridement -quick method of debridement to prevent, control, remove infection -Used when large amounts of nonviable tissue are present -prepares wound bed for healing, skin grafting, or flaps
Mechanical debridement 3 methods 1. wet to dry dressing-open mesh gauze moistening w/saline->pack on or in wound, and drys. Removing dressing removes debris. 2. Wound irrigation-make sure bacteria is not driven in wound with high pressure 3. Whirlpool-used-minimal debris present
Autolytic debridement -Semiocclusive or occlusive dressing used to soften dry eschar by autolysis. -Area around wound must be assessed for maceration when these dressings are used
Enzymatic debridement -Drugs applied topically to dissolve necrotic tissue and then covered with moist dressing (ex: saline moistened gauzed) -Ex. of drugs include collagenase, papain, urea -Process can be slow and thick eschar may need to be scored with scalpel
Dressings: Gauzes and nonwovens -Exudate absorption -Debridement if applied and kept moist -Maintain moist wound surface -Cleansing, packing, covering wound variety ex: Curity, Kling, kerlix
Dressings: Nonadherent -woven or nonwoven -impregnated with saline, petrolatum, anitmicrobials -minimally absorbent -Mainly used on minor wounds or second dressing ex: adaptic, vaseline gauze, xeroform
Dressings: Transparent films -semipermeable membrane permits gaseous exchange between wound & environment -allows wound visualization -minimally absorbent -Used for dry non infected wounds or wounds with minimal drainage ex:tegaderm, bioclusive, blisterfilm, carrafilm, omniderm
Dressings: Hydrocolloids -Wafers, powders, pastes made of gelatin, pectin, or carboxymethylcellulose. -occlusive dressing not allow O2 to wound -supports debridement & secondary infection prevention -Superficial & partial thickness wounds/infected wounds ex: Duoderm, Exuderm
Dressings: Foams -Sheets & other shapes of foamed polymer solutions with small, open cells capable of holding fluids -Absorbing of moderate to heavy amounts of exudate -Easy removal -Partial/full-thickness wounds ex: allevyn, curafoam, flexzan, hydrasorb, lyofoam
Dressings: Absorptive dressing -Absorbing exudates -Maintain moist surface -Place in wounds to destroy dead space -Partial/full-thickness wounds ex: ABD combine pads, Covaderm, Curity abdominal pads, multipad
Dressings: Hydrogel -Sheet, gel, gauze designed to donate moisture to a dry wound and maintain moist healing environment -Rehydrate wound tissue ->debridement partial or full thickness wounds, deep wounds w/minimal drainage, necrotic wounds ex: Aquasite, carrasyn gel
Dressings: Alginates -nonwoven, nonadhesive pads and ribbons made of polysaccharide fibers or xerogel derived from seaweed. -Contact with exudate, form a moist gel -Easy over irregular shape -Moderate to heavy exudates (pressure ulcer) ex: Algicell, Algisite, Carrasorb,
Dressings: Antimicrobials -Deliver iodine, silver, polyheamethylene biguanide->antibacterial properties -No resistance -Partial/Full thickness wounds (surgical incisions) ex: Acticoat, Biopatch, Curity AMD, Island wound dressing with microban
Additional therapies -Negative pressure wound therapy -Hyperbaric oxygen therapy -Positioning >HOB as low as tolerated >Support surfaces-pressure reduction > Turn q 2 hours
Created by: ygwallace