N300 Pressure Injury, Wounds and Wound Management

phases of wound healing

inflammatory

proliferation

maturation

inflammation stage

Last several days, bleeding, redness, swelling, and heat,

maybe a few days, pain

Proliferation

Granulation tissue, collagen synthesis, contraction of wound edges

new growth, “red” look, heal from inside out

Maturation

Final stage, remodeling, scar formation

tertiary wound

ex. Wound left open due to infection, swelling, or risk for infection, closed later

primary wound

secondary wound 

Factors Affecting Wound Healing

•Age

•Overall wellness and Co-morbidities

•vascular problems- ex. Peripheral vascular disease, diabetes

•Immunocompromised- neutropenic

•Infection

•Dehydration

Medications- steroids

•Malnutrition

•Anemia

•Obesity

•Smoking

•Wound stress- ex. Coughing, vomiting

assessing a wound

color: red, yellow, or black

measure: legth, width, depth

presence of sinus tract or tunneling or undermining

losed wounds - edges well approximated

condition of surrounding skin

drainage, wound closure, drains/tubes/vaccumes

drainage assessment

serous, sanguineous, serosanguineous mix of yellow and blood

purulent

prosanguinous thick and bloody

drainage systems

wound vacuum

jackson pratt (JP)

hemovac

penrose

measure output of drainage

wound support

•Montgomery Straps

•Abdominal Binder

•Elastic Roller Bandage

•Assessment distal from bandage

•Assess for complications

•Wrap distal to proximal

interventions for wound healing 

•Hygiene-tepid bath, lotion, non-drying soaps, avoid pruritus

•Protect from sun, extreme heat or cold

•Splinting, abd binders, wound support

•Debridement

•Dressings

•Nutrition

•fluid intake 2,500 mL/day

interventions pt. 2

pain meds prior to dressing changes

wound cleansing and irrigation

change dressings

how to clean a wound

clean from least contaminated to most contaminated

gentle friction, avoid irrigating skin or causing bleeding

isotonic solution - 0.9% sodium chloride, lactated ringers

antibiotic solutions

30-60 mL syringe for irrigation

mechanical debridement

•Woven gauze sponge

•Moderately absorbent

•Good for wound packing, sterile or non-sterile 

•Don’t allow gauze to dry, use NS to wet gauze it sticking to wound

•Doesn’t provide any bacterial barrier

Sharp Debridement

•Performed by physician or trained nurse

•Sterile technique in operating or treatment room

•Remove slough or eschar

•Do NOT debride eschar on heels from pressure ulcers

•Debride to level of bleeding tissue

•Risk for infection

•Some wounds may need skin grafts 

Hydrocolloid

occlusive, okay with mild drainage

Hydrogel

•gels after contact with moisture, good for infected wounds

Alginates

•absorbs moisture, assist with debridement

Collagen dressing

•(powder, pasts, sheets, gels) promotes healing

foam dressings

•Partial or full thickness wounds or infected wounds

•Allevyn and Mepilex (common brands)

•Absorptive

•Used with wounds with minimal to heavy drainage

•Weeping ulcers (venous stasis ulcers)

•Can be used under compression dressing

•Usually doesn’t stick to wounds

•Less frequent dressing changes

•Do not use with dry eschar

•Used for preventative for pressure ulcers in high risk pts

•Betadine

•Used as a skin prep for intact skin or clean contaminated wounds

•Does not penetrate eschar, retards healing

•Chlorhexadine gluconate

•Used as a skin prep, antimicrobial

•Dakin’s solution –sodium hypochlorite

•Used to disinfect wounds

•May damage healthy tissue

•Retards wound healing

Dehiscence-

•separation of wound

Evisceration

protrusion of organs

Hemorrhage

•excessive bleeding

Partial thickness wounds

•involves the epidermis, dermis or both

•may be superficial and present as a shallow crater, abrasion or blister

Full thickness wounds

•Tissue destruction extending through dermis, involves subcutaneous tissue and possibly muscle or bone

• tissue can appear snowy white, gray, or brown, with a firm leathery texture.

pressure injury risk factors

•Shear

•Friction

•Impaired mobility

•Altered LOC

•Moisture

•Impaired sensory perception

pressure injury Etiology

•Pressure

•Tissue ischemia

•Decrease sensation

Pressure Injury Stage 1

•Intact skin

•Non-blanchable redness over bony prominence

•Darker skin may look discolored

•Skin-painful, firm or soft, warm or cool

•Compare to adjacent tissue

•Do NOT massage area

Stage 2 pressure injury

•Partial thickness -Loss of dermis

•Shallow blister (can be intact) , crater or ulceration

•located over bony prominence

•Pink or red in wound base

Stage 3 pressure injury 

•Full thickness loss

•Sub-Q fat visible

•NO bone, muscle or tendon exposed

•Slough

•May include undermining or tunneling

stage 4 pressure injury

•Full thickness loss

•Exposed bone, tendon or muscle

•Slough or eschar present

•Undermining and tunneling may be present

•Risk for osteomylitis

Unstageable pressure injury

•Full thickness loss but covered with slough or eschar in wound bed

•True depth is undetermined until slough or eschar removed

•Do not remove eschar from heels

Suspected Deep Tissue Injury

•Purple or maroon

•Discolored intact skin or blood filled blister

•Damage deep in soft tissue from pressure or shear

•Present: painful, firm, mushy, may be warmer or cooler than surrounding tissue

•Evolution often rapid to deep tissue

who is at risk for other types of ulcers

•Diabetics

•Vascular disease

Location of other types of pressure injuries

usually pressure points on bottom of feet, sides of lower l

appearance of pressure injuries

•Varies- red/pink or brown/ black

•Punched out look, surrounding skin looks calloused

what scale do you use for pressure injuries

braden scale

pressure ulcer prevention

•Braden scale- implement interventions based on score and category

•Increase mobility

•Turning schedules

•Recommended 30-degree lateral position

•Specialty beds and mattresses

•Never massage reddened areas

•Keep skin dry and clean

•Apply moisture barrier ointment

•Adequate nutrition and hydration