Wound Assessment and Care r/t Nursing
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| Regenerative/ epithelial healing | Wound effects only epidermis. New skin is formed and no scar is present.
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| Primary intention healing | Wound involves minimal tissue loss with well approximated edges. Minimal scarring. Ex: Clean surgical scar.
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| Secondary intention healing | Wound involves tissue loss. Edges not approximated / wound should not be closed due to infection. Heals slowly by filling with granulation tissue from the bottom up, prone to infection. More scar tissue. Ex: Pressure ulcer, infected wound.
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| tertiary intention healing | Wound is contaminated/ clean-contaminated. Follows secondary intention healing. When there is no edema, infection or debris, two surfaces of granulation tissue are sutured together. Strict aseptic technique - prone to infection. Less scar than secondary.
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| Inflammatory phase "cleansing" (days 1-5) | 1.Hemostasis: vessels constrict limiting hemo. Platelets aggregation & Clotting mechanism. 2.Inflammation:edema, erythema, pain, warmth, WBC migration. macrophages engulf debris & pathogens. Scab formed.
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| Proliferation Phase "granulation" (days 5-21) | New cells fill the wound. Fibroblasts form collagen for strenth. Blood & lymph vessels are re-formed, resulting in formation of granulation tissue. Epithelialization begins.
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| Maturation phase "epithelialization" (2nd or 3rd week until healed) | Collagen fibers are remodeled into an organized structure (scar), increasing tensile strength. Epithelialization continues. *Scar is only 80% as strong as original tissue*
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| Hemorrhage/Hematoma (major complication) | may indicate a clotting issue,infection,slipped suture,internal bleeding
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| Dehiscence (major complication) | separation of one or more layer. RN intervention: Apply a binder & modify activity to prevent evisceration.
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| Evisceration (major complication) | total separation w/ protrusion of viscera. surgical emergency. Cover opening w/ sterile saline soaked sterile towels, notify the surgeon, and prep pt for surgery.
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| Fistula (major complication) | abnormal passage between two body cavities or a body cavity + the skin that is created by an abscess.
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| Infection (major complication) | contaminated/traumatic wound s/sx: 2-3 days;
clean surgical wound s/sx: 4-5 day post op.
s/sx: edema, erythema, warmth, pain, fever above 100.4, odor, purulent drainage, color change in drainage.
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| serous exudate | consists of serum. Staw colored fluid w/ watery consistency that separates out of blood when a clot is formed. Uusally present in a clean wound.
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| sanguineous | bloody drainage. Indicates damage to capillaries. Usually present with deep wounds or highly vascular areas.
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| serosanguineous | combination of bloody and serous drainage. Common in new wounds.
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| Purulent exudate | yellow (or sometimes blue-green), thick drainage from infected wounds commonly caused by infection of a pyogenic (pus-forming) bacteria such as strep or staph. Possibly malodorous. Contains pus (WBCs, bacteria, and cellular debris)
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| Predisposing for evisceration/ dehiscence | Usually in inflammatory phase before collagen reinforced. Assoc w/ abd. wound, obesity (Fat does not heal quickly), malnutrition, inadq muscle closeure, or infection. Triggered by coughing, vomiting& change in position.
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| Stage I Pressure Ulcer | nonblanchable erythema on intact skin (Dark skin=red/blue/purple hue) that remains for more than 30 minutes after pressure is relieved.
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| Stage II Pressure Ulcer | Involves partial-thickness skin loss of the epidermis, dermis or both. Abrasion, blister, or shallow crater.
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| Stage III Pressure Ulcer | Full-thickness skin loss involving damage or necrosis of sub-q tissue. May extend down to fascia (but not through) Deep crater with poss undermining.
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| Stage IV Pressure Ulcer | Full thickness skin loss with extensive destruction, necrosis, or damage to muscle, bone or support structures. Presence of undermining and sinus tracts common.
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| Eschar | Black, leathery covering of necrotic tissue and plasma proteins that forms when a wound cannot close by epithelialization.
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| Preventing Pressure Ulcers | Daily skincare, warm water(not hot) for high risk pts. Use soap only as needed. Lotion if dry. Keep linen free of wrinkles. Adq calories & protein. Reposition q2h using the rule of 30 degrees. Therapeutic mattresses and cushions. Family teaching.
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| RYB color code system (wound mgmt) RED | Granulation.
RN goal=Protect the wound
Activites=Keep the wound moist and covered
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| RYB color code system (wound mgmt) YELLOW | Moist, devitalized tissue (slough)
RN goal=cleanse the wound
Activites=irrigation and dressings. Poss debridement
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| RYB color code system (wound mgmt) BLACK | Eschar
Debride the wound
Sharp, mechanical, ensymatic, or autolytic debridement.
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| Sharp debridement | use of a sharp instrument to remove devitalized tissue. Provides immediate improvement of the wound bed & preserves granulation tissue.
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| Wound care with drains | Remove one layer at a time carefully to avoid dislodging drains. Monitor drainage. Record amount of drainage as output. Empty container at designated volume to maintain suction.
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| Mechanical debridement. | Lavage:irrigation with a mild amount of force 4-15 psi.
Wet do dry dressings: moist dressing is allowed to dry in the wound, then removed providing nonselective debridement. Painful.
Hydrotherapy: for wounds w/ lots of nonviable tissue. Avoid water je
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| Enzymatic Debridement | clean wound w/ NS, apply topical enzymatic agent, cover w/ moisture retaining dressing. Apply product only to devitalized tissue.
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| Autolysis | use of an occlusive moisture retaining dressing and the body's own mechanisms for ridding itself of necrotic tissue. Activites: Apply dressing & observe fluid. Change q72h; cleanse wound at dressing changes.
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| Woven Gauze | Fine to coarse mesh. Absorbent. For packing wounds, wicking exudate or debridement.
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| Nonwoven gauze | for cleaning and wiping the skin or providing a layer of protection
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| Nonadherent gauze (Telfa) | Protection
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| Transparent film | clear & semiperm. keep wound moist.For wounds with min/ no drainage. Used to dress IV sites. Good for visual assessment, flexibility (joints)
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| Hydrocolloids | Wafers, pastes, powders. hydrophilic. Adhesive. Keeps wound moist.Moldable for tight spots, absorbant, promote autolysis. Good for stasis ulcers or stge II pressure ulcers. Not for infected wounds. anaerobic bacterial growth.
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| hydrogels | sheets, granules or gels with high water content. Jelly consistency; Nonadhesive. Mimimal absorbtion.. Softens slough or eschar. Can be used in infected wounds. may maserate periwound skin.
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| Absorption dressings | mod-lg exudate.Beads, pwd, paste, ribbon, alg. 2nd dressing req.
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| Heat therapy Indications | stiffness and discomfort r/t mussculoskeletal probmlems, wounds. Increases blood flow and tissue perfusion & relaxation.
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| Heat therapy assessment | Observe for faintness due to drop in BP (vasodilation).
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| Close observation of heat/cold therapy | Very Young
Very old
Sensory impairment
high risk for injury: fingers, hands, face, perineum, feet
Application to small area of intact skin is better tolerated
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| Moist heat | amplifies the intensity of the tx.
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| Cold Therapy Indications | decreases blood flow. Produces local anesthesia, decreases muscle tension. slows bacterial growth. limits edema, inflammation, pain, o2 requirements and bleeding. tx of fevers, sports injury & post op swelling.
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| Cold Therapy Assessment | May increase blood pressure. May cause shivering. Prolonged exposure may cause tissue damage.
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| Temp therapy safety measures | Avoid direct contact with skin
Apply hot/cold intermittently
No more than 15 min at a time
check skin for redness, blistering, cyanosis or blanching
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| abrasion | superficial scrape of top layers of the skin
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| abscess | localized collection of pus due to invasion from a pyogenic bacterium or other pathogen. I&D to treat
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| Contusion | Closed wound caused by blunt trauma. AKA bruise/ ecchymotic.
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| Crushing | caused by force leading to compression or disruption of tissues. Assoc w/ fx. Minimal/no break in skin.
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| incision | open, intentional wound caused by a sharp instrument
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| laceration | torn open. Wound w/ jagged margins
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| penetrating | open woudn in which the agent causing the wound lodges in body tissue
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| puncture | open wound caused by a sharp onject. Often a collapse of tissue around entry point. Prone to infection
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| Tunnel | wound with an entrance & exit site
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| Factors affecting healing | age (older=longer healing time)
impaired mobility/sensation, nutrition, hydration, poor circulation, medications, moisture, fever (increased metabolism, unavail for wound healing), contamination/infection.
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| BP meds Healing | decreases amt of pressure required to occlude blood flow to an area. Risk for ischemia
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| Anti-inflammatories | inhibit wound healing
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| Steroids | inhibit wound healing
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| Anticoagulants | may cause extravasion of blood into sub q tissue. min pressure/injury can cause a hematoma
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| chemotherapy | delay healing. toxicity
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| antibiotics, psychotherapeutic drugs, chemotherapy | increase sun sens
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| herbal products (tea tree oil, lavender) | dry out the skin.
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| for aerobic wound culture | Use sterile technique and a culturette tube
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| Low BP & increased arterial pressure are indicative of _______- | Internal Bleeding
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| Preferred dressing for dry yellow slough | Tightly adhering hydrocolloid dressing
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| Tx for fx ankle | ice
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| Nutrient to promote collagen synthesis & capillary wall integrity | Vitamin C
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