Wound/Drain

Intentional

Unintentional

Neuropathic

defined as pain that results as a direct consequence of a lesion or disease affecting abnormal functioning of the peripheral nervous system (PNS) or central nervous system (CNS).

Venous Leg Ulcer

• Common in elders

• Result of chronic venous hypertension

• Persistent inflammation

• Hemosiderin Deposits

• Lipodermatosclerosis

Diabetic Foot Ulcer

• common in diabetes

• hyperglycemia

• micro/macroangiopathy

• neuropathy

• infection

• foot deformities

Arterial Ulcer

• reduced blood supply

• ischemia, necrosis

• little exudate

• atrophic skin

• common in diabetes

• pain

Pressure Sore

• area of tissue necrosis

• caused by prolonged soft tissue compression

• Local ischemia, moisture

• Multi morbid and elderly

Stage 1

skin is unbroken but red and inflamed

Stage 2

Skin is broken on the top layers of skin only

Stage 3

Injury extends down to the tissue under the skin

Stage 4

Loss of skin and tissue; exposed bones, cartilage or tendon.

Open Wound

Closed Wound

Acute

Chronic

Incision

Cutting or sharp instrument; wound edges well approximated and aligned; surrounding tissue undamaged; bleeds freely and least likely to become infected

Contusion

Blunt instrument, overlying skin remains intact, with injury to underlying soft tissue; possible resultant bruising and/or hematoma

Abrasion

Friction; rubbing or scraping epidermal layers of skin; top layer of skin scraped away; dirt and germs often embedded and can become infected

Laceration

Tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue; frequently contaminated with dirt or other material ground into the wound and likely to become infected

Puncture

Blunt or sharp instrument puncturing the skin; intentional (such as venipuncture) or accidental; consider penetrating object when considering infection probability

Penetrating

Foreign object entering the skin or mucous membrane and lodging in underlying tissue; fragments possibly scattering throughout tissues

Avulsion

Tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structures

Chemical

Toxic agents such as drugs, acids, alcohols, metals, and substances released from cellular necrosis

Thermal

High or low temperatures; cellular necrosis as a possible result

Irradiation

Ultraviolet light or radiation exposure; can cause wet or dry desquamation

Venous Ulcer

Injury and poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction; frequently have significant drainage; compression essential (after arterial flow verified)

Wound

a break or disruption in the normal integrity of the skin and tissues.

Pressure Ulcer

Compromised circulation secondary to pressure or pressure combined with friction; classified by Stages 1–4, Unstageable, and Deep Tissue injury

Arterial ulcers

Injury and underlying ischemia, resulting from a lack of blood flow to the lower extremities secondary to conditions such as atherosclerosis or thrombosis; many have black eschar; increasing blood flow essential for treatment

Diabetic ulcers

Injury and underlying diabetic neuropathy, peripheral arterial disease, diabetic foot structure; located below the ankle

Principles of wound healing

intact skin, careful hand hygiene, body responds adequate blood supply, normal healing is promoted, and extent of damage and the person’s state of health, response to wound is more effective.

Phases of the wound (in order)

• Homeostasis

• Inflammatory

• Proliferation

• Maturation

Homeostasis

Occurs immediately after initial injury

Inflammatory Phase

begins shortly after hemostasis and lasts about 2 to 3 days

Proliferation

(repair phase) Lasts for several weeks, new tissue is built to fill the wound space through the action of fibroblasts

Maturation

(remodeling) final phase begins about 3 weeks after injury and can continue for months or years

Local Factors Affecting Wound Healing

• Pressure

 Desiccation (dehydration)

 Maceration (overhydration)

 Trauma

 Edema

 Infection

 Excessive bleeding

 Necrosis (death of tissue)

 Presence of biofilm (thick grouping of

microorganisms)

Systemic Factors (affecting the whole body)

• Age

• Circulation and Oxygenation

• Nutritional status

• Wound Etiology

• Health status

• Immunosuppression/Proinflammatory Conditions

• Medication Use

• Adherence to treatment plan

Wound Complications:

• infections

• hemorrhage

• Dehiscence and