NRSG 1302- Wound Care 1 and Injury Care

inflammatory phase/ initial phase

occurs within the first few minutes after injury and lasts up to 3 days

-in a clean wound this phase controls bleeding through hemostasis and establishes a clean wound bed (WBCs and platelets start to come in to repair)

what signs can be seen during the inflammatory phase?

-redness

-edema

-warmth

-throbbing

proliferation phase/ granulation phase

the wound is filling with granulation tissue, contraction of the wound, and resurfacing of the wound

-lasts 3-24 days

-occurs because new blood vessels are forming

when is the proliferation phase finished?

is completed when the vascular bed has been re-established, area is filled with granulation tissue, and the surface has been repaired with epithelial tissue

-the wound is still fragile at this point

remodelling phase/ maturation phase

scar tissue continues to gain strength for several month

-can take up to 2 years depending on the extent and depth of the wound

how strong is scar tissue?

only 80% as strong as the original tissue

-area is largely avascular and paler in colour

what is primary intention healing?

-the wound edges are neatly approximated

-homeostasis may be achieved with sutures or staples

-typically clean surgical wounds with minimal tissue loss

what is secondary intention healing?

-wounds are wide or irregular wound margins that cannot be well approximated

-inflammatory phase is often greater; more debris, cells and exudate are seen in these wounds

-wound needs to be debrided before any healing can happen

-wound heals from bottom up, so greater granulation tissue, longer time it takes, so a larger scar will form

what is tertiary intention healing?

the wound is intentionally left open to heal

-left open because healing is impaired by: contamination, infection/ high risk of infection, edema, and poor circulation

-leaves a much deeper and larger scar compared to primary and secondary healing

what is compartment syndrome?

A condition where increased pressure within a muscle compartment compromises circulation and function

-fasciotomy is needed to relieve the pressure, and it heals by tertiary intention

-wound is repaired/ closed up once the issue is completed/ resolved

what are superficial wounds?

the wound only affects the epidermis level

-ex. skin tear

what are partial thickness wounds?

the wound extends further into the dermis

-ex. falling while running and getting road burn

what are full thickness wounds?

the wound extends into the subcutaneous tissue and sometimes into the fascia, muscle, tendon, or bone

what are acute wounds?

the wounds usually heal without complication and within a timely manner

-heals through primary intention

-ex. surgical wound

what are chronic wounds?

occurs over a longer duration and/ or with frequent recurrences

-usually a result of endogenous mechanisms

-healing phases are delayed so there is a failure in the normal healing process

-ex. venous stasis ulcers

what is a open wound?

a break in the skin

-ex. laceration

what is a closed wound?

there is no break in the skin, but injury is to the underlying tissue

-ex. bruise, hematoma

what is a penetrating wound?

break in the epidermal, dermal, and deeper tissues and organs

-ex. stab wounds

infection of a wound...

wounds are susceptible to infection if it contains necrotic tissue, blood supply is decreased, immune function is decreased, client is malnourished or has diabetes

-common complication

how can you tell if a wound is infected?

-fever

-tenderness

-pain at incision

-increased WBC count

-edges look inflamed

-drainage may have odor

-purulent exudate

what is dehiscence of a wound?

the partial or total rupturing of a surgical wound

-occurs most often 4-5 days post op

-typical in abdominal wounds

what factors put someone at risk for dehiscence?

-obesity

-smoking

-poor nutrition

-multiple traumas

-failure of suturing

-sneezing

-excessive coughing

-vomiting

-dehydration

how do you know dishensce is about to or has occured?

a large amount of serosanguineous drainage from the wound site, and the patient reports that "something has given away"

what is evisceration of a wound?

the protrusion of the internal viscera through an incision opening

-the wound must be quickly supported with large sterile dressings soaked in normal saline

-client is in bed with knees bent, NPO, and treated for any signs of shock

what is adhesion of a wound?

internal scar tissue around or between organs due to disturbance of the tissues or organs

-can result in another surgery to release them

-but more surgeries will result in more adhesions

what are contractures of a wound?

excessive amount of wound contracture during the healing process that can lead to deformities

-commonly seen in burn patients

-decreases mobility, especially when the contracture is over a joint

what are hypertrophic wounds?

excessive collagen formation that makes the scar lumpy and large (forms over the wound edges)

-also known as keloids

what is NERDS identification of a wound?

N- nonhealing wound

E- exudate

R- red and friable tissue

D- debris

S- smell after cleaning

-used with superficial wounds with increased bacteria that has formed an infections

N is NERDS...

is nonhealing

-the wound does not heal despite appropriate interventions

-size does not decrease by 20%-40% within 4 weeks

E in NERDS...

is exudate

-an increase can show a increased bacteria in the wound

-can also lead to maceration of the wound margins

R in NERDS...

is red and bleeding wound surfaces

-exuberant granulation tissue is bright red, loose, and bleeds easily

D in nerds...

is debris

-necrotic tissue, slough, and debris is nutrients for bacteria to grow within the wound

S in nerds...

is smell after cleaning

-smell comes from bacterial byproducts from tissue necrosis

what is STONEES identification of a wound?

S- size increasing

T- temperature

O- os-probes to the bone

N- new areas of breakdown

E- exudate

E- erythema and edema

S- smell after cleaning

-used for deep or chronic wounds, or when infection has spread to the periwound area

S in STONEES...

is size

-increase in size can be due to bacteria damaging the surrounding tissue

-shows that the bacteria or virus has overwhelmed the hosts ability to resist and fight it off

T in STONEES...

is temperature

-increase in temperature can indicate infection

-assessed by touch through a glove handed, infrared thermometer or scanning device

O in STONEES...

is os- probes to bone or exposed bone

-high chance of osteomyelitis if bone is exposed or a bone can be probed

-infection of the bone can be confirmed by MRI

N in STONEES...

is new areas of breakdown

-these new areas are separated from the main wound

E in STONEES...

is exudate

-result from inflammation

-increased exudate is from bacteria

-when infection is present, it often increases in quantity and looks purulent

second E in STONEES...

is erythema and edema

-result from inflammation

-mast cell degranulation causes vasodilation causes erythema

-and the leakage of fluid into the tissue to result in edema

second S in STONEES...

is smell from bacteria

-has a foul smell

-unpleasantly sweet smell from pseudomonas

-or putrid smell fro anaerobe organisms

what are factors that delay wound healing?

1. nutritional deficiencies: (vitamin C, protein and zinc)

2. inadequate blood supply: (decreased nutrients, removal of debris, and inhibits inflammation response)

3. smoking: (nicotine is a vasoconstrictor)

4. corticosteroid drugs

5. infection: (increases inflammation and tissue destruction)

6. anemia: (reduced O2)

7. advanced age: (slowed and impaired wound healing)

8. obesity: (fat tissue has limited blood supply)

9. compromised host: (illnesses delay healing)

10. poor general health

11. immobility (skin breakdown)

12. incontinence (skin breakdown from moisture)

13. friction (destroys tissue and wound margins)

14. cold temperature (decreased cellular activity and fibroblast proliferation)

15. excessive moisture (formation of hypergranulation)

what is the goal of treatment of wounds?

promote healing, prevent complications, prevent deterioration, and minimize harmful effects to both the wound and overall patient

why is it important to control intrinsic factors?

factors such as pressure, friction, shear, and moisture causes the wound to become chronic, and not heal properly unless those factors become controlled

what is one way you can identify risks for planning care?

using the BRADEN scale to determine the risk of skin breakdown

what are nursing managements to promote wound healing?

-encouraging adequate nutrition and fluid intake

-if patient is incontinent, frequent brief changes are required

-frequent repositioning to minimize skin breakdown

-ensure there is no friction to reduce shearing of the skin

what are nursing assessments to promote wound healing?

-observing the wound and periwound skin

-measuring and observing exudate

-frequent vitals

-collecting lab data (WBC count, albumin, anemia)

what are nursing promotion strategies to wound healing?

-positions to reduce pressure and shearing

-increase protein, carbohydrates, and vitamins

-increase fluid intake if applicable

-maintain adequate moisture of the wound

-prevent infection by using aseptic technique

-encourage and assist with mobility to promote circulation and blood flow

role of disinfection in wound care

-eliminates all pathogens (expect pores) using heat, chemicals or UV light

-using disinfectants on supplies (like alcohol swabs)

-antiseptics on tissues (betadine)

role of sterilization in wound care

-destroys all microorganisms including spores

-done by: steam under pressure, ethylene oxide gas, hydrogen peroxide plasma, and other chemicals

clean technique (medical aspesis)

procedures used to reduce and prevent the spread of microorganisms

-hand hygiene

-disinfection

-cleaning the environment

sterile technique (surgical apesis)

procedures used to eliminate all microorganisms including spores from an object or area

-an object/ area is considered contamination if touched by a non sterile object

what are the principles of sterile technique?

1. all objects used in a sterile field must be sterile

2. sterile object are unsterile when touched by unsterile objects

3. sterile objects out of sight or below waist are unsterile

4. sterile objects become unsterile through exposure to airborne microorganisms

5. fluids flow in the direction of gravity

6. moisture that passes through a sterile object draws microorganisms from unsterile surfaces above or below to the sterile surface, it is now unsterile

7. edges of a sterile field are considered unsterile (1in or 2.5cm border)

8. skin cannot be sterilized and is unsterile

9. conscientiousness, alertness, and honesty are essential qualities to maintain surgical aspesis

what are the basic principles of dressing changes?

-assessment is done prior to determine necessary supplies, is done during to determine adequate cleaning, and at the end to determine wound bed, size, and any undermining or tunneling

-avoid unnecessary talking over a sterile field

-cleanse wounds from top-to-bottom, cleanest to dirtiest

-refrain from keeping the wound exposed for a long period of time

how long does it take for a wound base to return to normal healing temperatures?

the wound base can take up to 4 hours to return to normal healing temperatures

-33*C is the critical level where cell activity decreases

what are staples?

stainless steel wound closure devices

-causes less trauma

-provide more support to the wound

-must be enough distance between the skin and underlying structures to be able to use staples

what are sutures?

are threads of wire or other materials like silk, cotton or nylon

-come in different sizes

-are absorbent or nonabsorbent

plain intermittent (interrupted) sutures

individual, separated sutures are made

plain continuous sutures

is made using the same thread, with a knot only at the beginning, and the end

blanket continous sutures

made using the same thread, that passes back and forth through across the wound to create a "lock" before advancing to the next stitch

retention sutures

heavy-gauge, deep tension sutures used in complex wounds

-redistribute tension

-prevents dehiscence of large wounds (especially in abdomen)

Steri-strips

trademark for sterile adhesive strips used to approximate and hold together the edges of a wound

butterfly sutures

Sutures used for wound closure after removal.

how do you determine the type of wound closure devices?

-site of wound

-type of wound

-tissue involved

-purpose of closure

-clients history of wound healing

when can sutures and staples be removed?

generally removed in 7-10 days if the healing is adequete

when it is time to remove sutures or staples....

1. verify MD order

-alternate interrupted sutures are removed first, then the rest are removed 1-2 days later

2. inform client that the process may be uncomfortable

3. clean the incision prior to removal

important principles when removing stitches:

never pull a visible portion of a suture through the underlying tissue as that tissue is sterile

-sutures on the skin have microorganisms and debris on them

-doing this may cause infection of the wound

measuring the wound

-patients head to toe is wound length (doesn't matter shape of wound)

-side to side is wound width

-depth is measured using a cotton-tip applicator

serous exudate

watery, clear or light yellow fluid from a wound

purulent exudate

greenish or yellow colour due to pus and bacteria

-contains WBC, liquefied dead tissue, dead and living bacteria

sanguineous exudate

bloody exudate that indicates bleeding

-bright red indicates fresh bleeding

-dark red indicates older bleeding

-contains RBC

serosanguineous exudate

pale pink fluid commonly present in surgical incisions

-contains serum and RBCs

what does the exudate look like in a wound?

in a primary intention wound healing:

-exudate is first sanguineous (bloody)

-as wound heals it changes to serosanguinous (light pink)

what is the purpose of wound drains?

-to collect and measure excessive drainage from a wound to prevent the formation of an abscess

-protect the skin

-remove secretions from the surgical site

hemovac wound drain:

a 3-spring drain that works by compressing the springs to create a vacuum to suck out the fluid from the wound

-often seen in mastectomies, cranial, and orthopedic surgeries

-held in place by a single suture

Jackson-Pratt wound drain:

creates a suction vacuum using a bulb shape reservoir that is compressed to maintain a constant low suction

-portable devices that provide accurate measurement of drainage

-seen in abdominal surgeries and mastectomies

-held in place by a single suture

-bulb is to changed every 8-12hrs; or whenever it is half-full

-removed when there is less than 30cc of fluid within a 24hr period

penrose wound drain:

is a soft rubber tubing that is placed during surgery

-held in place with a sterile safety pin and have no collection device in place

-dressing are changed often because gauze is soaking up the drainage

-inspect skin integrity around the wound

bandages

material used to hold dressings in place, secure splints, and support and protect body parts

-ex. tensor, gauze, sling

binders

devices applied to hold dressings in place, provide support, apply pressure, or limit motion

-wraps a specific body part

-ex. single/double T-binder, breast binder, abdominal binder

splints

devices that can be used to immobilize injured parts when fractures, dislocations, and other similar injuries are present or suspected

-ex. board, cervical collar

compression stockings

stockings that are used to prevent swelling, promote circulation, and possibly prevent blood clots; also called antiembolic or elastic stockings.

why is documentation important for wound care?

-if it wasn't documented, it wasn't done!

-other nurses need to know how the wound is healing, or what is delaying wound healing

-what is helping with wound healing/ what isn't

-need to know what type of supplies was used last when cleaning the wound, amount of exudate, wound size, etc.