module 17 - wounds and wound care

regeneration

lost cell and tissue replacement with the same type

repair

• healing with lost cells replaced with connective tissue

• more common/complex than regeneration

• occur by primary, secondary, tertiary intention

describe the initial phase of healing by primary intention

• 3-5 days

• incisions edges aligned

• blood fills incision area to form matric for WBC migration

• acute inflammtion

describe the granulation phase of healing by primary intention

• fibroblast migration to site to secrete collagen

• wound is pink and vascular

• surface epithelium regenerates

describe the maturation phase and scar contraction of healing by primary intention

• 7 days after injury to months/years

• fibroblast disappear as wound becomes stronger

• mature scar forms

describe healing by secondary intention

• trauma, ulceration, infections with exudate, wide, and irregular margins with tissue loss

• edges not approximated → more debris, cells, exudate

describe healing by tertiary intention

• delayed primary intention d/t delayed suturing

• contaminated wound is left open and sutured after infection is closed.

skin tears

• caused by shearing, friction, blunt force

• separation of skin layers

• common in older adults, chronically/critically ill adults

wound healing complications

• hemorrhage

• infection

• dehiscence

• hypertrophic scarring

• keloid scarring

wound healing nurse assessment

• assess on admission and regularly

• ID delayed wound healing factors

how do you measure wounds?

• in cm

• measure head to toe, side to side, then depth

• tunneling/undermining → charted in respect to a clock (12 is patients head)

wound management and dressing type depends on…

type, extent, character of wound and its healing phase

what is the purpose of wound management?

to protect a clean wound, clean the wound, and treat the infection

nursing care for clean wounds

• dressing needs to keep surface clean and slightly moist

• transparent film may be used

• granulating/re-epithelialization should be slightly moist and protected

• dryness is the enemy

• use w/ caution: topical antimicrobial and antibactericidal

what dressing do you use for a wet wound?

dry dressing

what dressing do you use for a dry wound?

WET TO DRY

• never moist to dry on a clean granulating wound except for debridement

mechanical debridement

wound irrigation or whirlpool therapy

autolytic debridement

dead tissue removal through lysis by WBC. you use supporting moisture on wound surface and transparent/hydrocolloid films are used

chemical debridement

dakin’s solution

sharps debridement

use of scalpel, scissors, etc.

negative pressure wound therapy (NPWT)

• suction removes drainage and speeds healing, promotes tissue perfusion

• monitor serum protein lvls, fluid and electrolyte balance, and coag studies

• ex, wound vac, JP drain

hyperbaric O2 therapy (HBOT)

• O2 delivery at increase atm pressure

• allow O2 to diffuse into serum

• lasts 90-120 min

• 10-60 treatments

drug therapy

becaplermin (regranex)

nutritional therapy

• high protein, carbs, vits

• moderate fat

infection prevention

• do not touch recently injured area

• keep environment free from possible contaminants

• prophylactic abx

infectional control

• wound culture

• use levine’s technique

psychological implications

• fear of scars/disfigurement

• drain/odor concerns

• be aware of your facial expressions

patient teaching for wounds

• s/s of infections

• changes in color or drainage amount

• med teaching