Fundamentals for Nursing Chapter 55: Pressure Injury, Wounds, and Wound Management

Wounds are a result of injury to the....

skin

Stages of wound healing

1. Inflammatory stage

2. Proliferative stage

3. The maturation or remodeling stage.

Stages of Wound Healing: Inflammatory Phase

Begins with injury and lasts 3 to 6 days

Stages of Wound Healing: Proliferative Phase

Lasts the next 3 to 24 days after the inflammatory phase

Stages of Wound Healing: Maturation Phase

Occurs on or about day 21 and involves the strengthening of the collagen scar and the restoration of a more normal appearance.

It can take more than 1 year to complete, depending on th extent of the original wound.

Inflammatory phase of wound healing: Effects to the wound

Controlling the bleeding with vasoconstriction, retraction of blood vessels, fibrin accumulation, and clot formation.

Delivering oxygen, white blood cells, and nutrients to the area via the blood supply.

Macrophages engulf microorganisms and cellular debris (phagocytosis)

This phase is prolonged when there is too little inflammation or when there is too much inflammation

Proliferative phase of wound healing: Effects to the wound

Replacing lost tissue with connective or granulated tissue and collagen

Contracting the wound's edges to reduce the area that requires healing

Resurfacing of new epithelial cells

Healing processes: Primary intention

little or not tissue loss

edges approximated, as with a surgical incision

heals rapidly

low risk of infection

no or minimal scarring

Example of primary intention (healing processes)

Closed surgical incision with staples, sutures, or liquid glue to seal laceration

Healing processes: Secondary intention

Loss of tissue

Wound edges widely separated, unapproximated

(pressure injury, open burn areas)

Longer healing time

Increase for risk of infection

Scarring

Heals by granulation

Example of secondary intention (healing processes)

Pressure injury left open to heal

Healing processes: Tertiary intention

Widely separated

Deep

Spontaneous opening of a previously closed wound

Closure of wounds occurs when they are free of

infection and edema

Risk of infection

Extensive drainage and tissue debris

Closed later

Long healing time

Example of tertiary intention (healing processes)

Abdominal wound initially left open

until infection is resolved and then closed

Factors affecting wound healing

Age (increased age delays healing)

-loss of skin turgor

-skin fragility

-decreased in peripheral circulation and oxygenation

-slower tissue regeneration

-decrease in absorption of nutrients

-decrease in collagen

-impaired immune system function

-dehydration due to decreased thirst sensation

Overall wellness: A wound in a young, healthy client that heals faster than a wound in an older adult who has a chronic illness

Decreased leukocyte count: Delays wound healing because the immune system's function is to fight infection by destroying invading pathogens

Infection: Prolongs healing and can result in further tissue destruction

Some medications interferes with the body's ability to respond to and prevent infection

Malnourished clients: Nutrition that provides energy and elements for wound healing

Tissue perfusion: Provides circulation that delivers nutrients for tissue repair and infection control

Obesity: Fatty tissue that lacks blood supply

Chronic disease: Place additional stress on the body's healing mechanisms Examples include diabetes mellitus and cardiovascular disorders

Smoking: Impairs oxygenation and clotting

Wound stress: Puts pressure on the suture line and disrupts the wound's healing process Examples include vomiting or coughing

How does age affect wound healing?

Age (increased age delays healing)

-loss of skin turgor

-skin fragility

-decreased in peripheral circulation and oxygenation

-slower tissue regeneration

-decrease in absorption of nutrients

-decrease in collagen

-impaired immune system function

-dehydration due to decreased thirst sensation

How does overall wellness affect wound healing?

A wound in a young, healthy client that heals faster than a wound in an older adult who has a chronic illness

How does Decreased leukocyte count affect wound healing?

Delays wound healing because the immune system's function is to fight infection by destroying invading pathogens

How does infection affect wound healing?

Prolongs healing and can result in further tissue destruction

How do some medications affect wound healing?

Some medications interferes with the body's ability to respond to and prevent infection

How does Malnourished clients affect wound healing?

Nutrition that provides energy and elements for wound healing

How does tissue perfusion affect wound healing?

Provides circulation that delivers nutrients for tissue repair and infection control

How does obesity affect wound healing?

Fatty tissue that lacks blood supply

How does Chronic disease affect wound healing?

Place additional stress on the body's healing mechanisms Examples include diabetes mellitus and cardiovascular disorders

How does smoking affect wound healing?

Impairs oxygenation and clotting

How does wound stress affect wound healing?

Puts pressure on the suture line and disrupts the wound's healing process Examples include vomiting or coughing

Serous drainage

the portion of the blood (serum) that is watery and clear or slightly yellow in appearance (fluid in blisters)

Sangineous drainage

Contains serum and red blood cells

It is thick and appears reddish

Brighter drainage indicates active bleeding

Darker drainage indicates older bleeding/drainage

Seroussanguineous drainage

contains both serum and blood

It is watery and looks pale and pink due to a mixture of red and clear fluid

Purulent drainage

The result of infection

It is thick and contains white blood cells, tissue debris, and bacteria.

It may have a foul odor, and its color reflects the type of organism present.

Color: Yellow, tan, green, brown

(Green for a Pseudomonas aeruginosa infection)

Purosanguineous drainage

A mixed drainage of pus and blood

(newly infected wound)

Nursing interventions for wound management

Provide adequate hydration and nutrition needs (protein, calorie needs)

Perform wound cleansing

Never use the same gauze to cleanse across the incision

remove sutures and staples

administer analgesics and monitor for effective pain management

administer antimicrobials

Document

Types of wound dressings

Woven gauze (sponges)

Nonadherent material

Damp to damp 4" x 4" dressings

Self-adhesive, transparent film

Hydrocolloid

Hydrogel

Alginates

Collagen

Hydrocolloid dressing

An occlusive dressing, that swells in the presence of exudate

Composed of gelatin and pectin, it forms a seal at the wounds surface to prevent evaporation of moisture from the skin

Can stay in place for 3 to 5 days

Maintains a granulating wound bed

How long can a hydrocolloid dressing be left in place?

3-5 days

Hydrogel dressing

Composition is mostly water

Gels after contact with exudate, promoting autolytic, debridement and cooling.

Rehydrates and fills dead space

Might require a secondary occlusive dressing

For infected, deep wounds, or necrotic tissue

Not for moderately too heavily draining wounds

Provides a moisture wound bed

Soothing and can reduce wound pain

Prevents skin breakdown in high pressure areas

What is a hydrogel dressing not meant for?

Moderately too heavily draining wounds

What is a hydrogel dressing meant for?

Infected, deep wounds or necrotic tissue

Alginates dressings

Nonadherent dressings that conforms to the wound's shape and absorbs exudate

Provides a moist wound bed

Packs wounds

Supports debridement

Collagen dressings

Helps stop bleeding

Promote healing

Powders, paste, granules, sheets, and gels

Dehiscence

A partial or total rupture (separation) of a sutured wound

Usually with separation of underlying skin layers

Evisceration

A dehiscence that involves the protrusion of visceral organs through a wound opening

Deep tissue pressure injury

persistent non-blanchable deep red, maroon, or purple discoloration.

Discoloration of non-intact or intact skin from damage, following prolonged, or intense pressure or shear.

stage 1 pressure injury

non-blanchable erythema of intact skin

stage 2 pressure injury

partial thickness skin loss with exposed dermis

stage 3 pressure injury

full thickness skin loss

Visible adipose tissue with possible granulation tissue and epibole (wound edges appear rolled under); some slough, Eschar present

Possible tunneling or undermining

No exposed muscle, tendons, ligaments, cartilage, or bone

stage 4 pressure injury

full thickness skin and tissue loss

Skin and tissue loss with cartilage, bone, fascia, muscle, ligaments, or tendons, exposed in the wound or easily palpable.

Epibole, tunneling, and undermining are common.

Epibole: wound edges appear rolled under

Epibole

wound edges appear rolled under

unstageable pressure injury

obscured full-thickness skin and tissue loss

No determination of stage because slough or eschar obscure is the wound bed.

The actual depth of injury is unknown, unless slough or eschar is removed

Pressure injury: nursing interventions

1: avoid skin trauma

2: provide supportive devices

3: maintain skin hygiene

4: encourage proper nutrition