NUR350 Week 4: Wound Care: Acute Wounds (TS)

what is an acute wound?

- a wound that progresses through normal stages of healing within an expected time frame (ex. surgical incision, wound via trauma, etc)

- may see initial redness, swelling, or drainage, but expected overall trajectory to be one of gradual improvement and healing

what is a chronic wound?

- wound that has not progressed through healing as expected

- causes a prolonged wound due to underlying problems interfering with tissue healing, such as poor circulation, inflammation, infection, or repeated pressure on the wound

what are two ways to characterize wounds?

- by the amount of tissue loss (primary vs secondary)

- by the depth of tissue loss (partial- vs full-thickness)

what is a primary wound?

- wound with little tissue loss, wound edges approximated (close together)

- ex. clean surgical incision - edges brought together via stitches and because edges are approximated, there is little tissue loss, heals quicker, less scarring, and lower infection risk

what is a secondary wound?

- wound involving tissue loss, wound edges not approximated (wound remains open)

- new tissue fills from the bottom and the sides until surface eventually closes (ex. Burns, pressure injuries, and severe lacerations)

- larger area to repair, therefore healing takes longer and carries greater risk of infection and more scarring

what is a partial-thickness wound?

- involves mainly the epidermis

- Since some of the structures for regeneration remain in tact, these wounds heal primarily through regeneration of epithelial cells

what are the three processes of healing a partial-thickness wound?

1. Inflammatory response first 24 hours - blood vessels respond to damage, leading to swelling, changes in skin colour, drainage, warmth, tenderness

2. Epithelial proliferation & migration - new epithelial cells reproduce and migrate across the wound surface

3. Re-establishment of the epidermal layers - new epithelial surface is thin to begin with, but over time the cells re-organize and epidermis gradually returns to normal thickness

what is a full-thickness wound?

wound extends into the dermis

what are the three processes of healing a full-thickness wound?

1. Inflammatory Phase: occurs at the time of injury and lasts ~3 days; body works to control bleeding, deliver immune cells to injured area

2. Proliferative Phase: ~3-24 days, granulation tissue/collagen fills the wound, wound contracts, new epithelial cells resurface the wound

3. Remodelling Phase: up to 2 years, collagen fibres re-organize and scar tissue gradually gains strength

how are acute wounds assessed?

- wound appearance

- character of wound drainage

- presence of drain

- wound closures

- wound palpation

- pain

how is wound appearance assessed?

- edges: approximated or separated

- size: length, width, depths

- shape: helps communicate what the wound looks like at the moment and monitor changes over time

- colour: colour of wound an peri-wound region - inflammation around edges can be expected in the first few days, but continually monitor redness, swelling, bruising, or any colour changes

what is wound drainage assessed?

assessed for amount, colour, consistency, and odour

- serous

- serosanguinous

- sanguinous

- purulent

what is a serous wound?

clear/pale, thin, water-like

what is a serosanguinous wound?

mixture of serous fluid and blood - light red/pink; seen in healing wounds

what is a sanguinous wound?

mainly blood, bright/dark red, expected shortly after injury or surgery, but persistent or increasing blood discharge may indicate active bleeding

what is a purulent wound?

thicker, yellow/green/tan/brown - associated with infection, especially when combined with other findings, such as strong odour, increasing pain, redness, swelling, or warmth

what are surgical drains?

- When a wound is expected to have a large amount of drainage, the surgeon may insert a surgical drain to remove fluid from the wound and prevent it from collecting in wound tissues

- Nurses are responsible for assessing the drain insertion site and monitoring the amount and characteristics of the drainage + prevent accidental dislodgement, check it is flowing as expected, check

what are the common types of surgical drains?

- Jackson-Pratt (JP)

- Hemovac

- Penrose

what is a Jackson-Pratt drain?

- uses gentle suction created by compressing the bulb

- secured with suture

- nurses empty bulb reservoir, document the drainage, and re-establish suction according to institutional policy (self-suction, not attached to wall)

What action would maximize the suction produced by the Jackson-Pratt drainage system after the system has been emptied?

Compressing the bulb while replacing the port cap

what is a Hemovac drain?

- uses suction into a compressed collection chamber that recoils

- negative pressure helps draw fluid out from the wound into the device (self-suction, not attached to wall)

What is the nursing action to set up suction for a Hemovac drainage system?

Compress the hemovac, creating suction.

what is a Penrose drain?

- soft, flexible drain that allows fluid to drain passively onto the dressing

- no closed collection chamber, drains onto the dressing;

- as drainage decreases, it can be removed completely or gradually withdrawn, allowing healing to occur deep within the wound site

What is the proper method for cleansing the evacuation port of a wound drainage system?

Wipe it with an antiseptic swab.

what can be used to close acute wounds?

- Sutures

- Staples

- Adhesive skin closures (ex. Steri-Strips - adhere across skin to support approximation)

- Tissue adhesive (Skin glue - applied over approximated wound edges)

what are sutures?

- Intermittent (interrupted) Sutures - common method of closing a surgical wound

- Each suture is individually tied, so each provides separate support to the wound edges

- Once edges are well-approximated and healed, sutures can be removed by a nurse

how are sutures removed?

Cut close to the skin → Pull out by the knot → Keep the exposed (potentially contaminated) thread from being dragged through the tissue.

what are staples?

Keep wound edges approximated while incision heals

how are staples removed?

- positioned directly under staple and compressed --> this bends the staple in the centre and lift the ends out of the skin, allowing for gentle removal (stable changes shape with removal

- allows it to be pulled away from the skin with minimal tissue trauma

how are wounds palpated?

- Before palpating: Inspect first for swelling, drainage or edge separation

- Wear appropriate gloves

- Gently palpate the wound for areas of warmth, swelling, tenderness and fluid collection - use light pressure

- May cause fluid to be expressed if there is a pocket of drainage

how is pain assessed during wound care?

- Assess pain before, during, and after wound care using pain scale appropriate for the patient

- If needed, administer analgesic before wound care and reassess - 30-45 minutes ahead of time

what are common complications of wound healing?

- hemorrhage

- infection

- dehiscence

- evisceration

- fistula

what is hemorrhage of a wound?

- Excessive bleeding from a wound; can be external or internal

- Significant blood loss can progress into hypovolemia and shock

what is external hemorrhage of a wound?

- Visible on inspection - easier to recognize cause can see blood coming from wound or directly on the dressing

- Can monitor whether the wound is healing over time by outlining the drainage on the dressing with a pen, noting the date and time, and then monitoring any increases the area of bleeding in comparison to the penned area

what is internal hemorrhage of a wound?

- May present as swelling or distention, more drainage in drain reservoir

- Make note of systemic signs of blood loss (ex. tachycardia, decreasing BP, etc)

what are the signs a wound is infected?

- Edema

- Skin colour changes - compare to patient baseline by observing unaffected skin

- Pain/tenderness

- Purulent discharge

- Foul odour

- Warmth, fever, chills

- Increased white blood cells (WBCs)

- Delayed healing

what is dehiscence?

- Partial or total separation of wound layers

- Commonly seen with abdominal surgical wounds due to increased pressure or strain on the abdominal site when doing risk behaviours listed below

what are risk behaviours and factors for dehiscence?

- Risk behaviours include: coughing, vomiting, sitting up in a chair/bed

- Other risk factors: poor nutrition, infection, obesity, smoking

how can dehiscence be prevented?

- support or splint abdominal incision with coughing or movement

- splint = involves using a pillow or folded blanket to put slight pressure on abdominal site when coughing or moving - supports incision, reduces discomfort with movement, and decreases tension (non-invasive intervention)

what is evisceration?

Protrusion of internal organs through a wound opening

what nursing actions should be taken in the case of evisceration?

- Cover with sterile saline-soaked towels - prevents tissues from drying out and reduces risk of further injury and contamination

- Don't push organs back into wound

- Keep patient NPO (nothing by mouth), monitor closely

- Prepare for emergency surgery

what is a fistula?

- Abnormal passage between two spaces where a connection should not exist

--> Between two organs

--> Between an organ and the outside of the body

- May results from poor wound healing, disease complications, trauma or infection

- May require surgical repair

what are interventions to promote wound healing?

- wound dressings

- principles of dressing changes

- debridement

- irrigating and packing wounds

- culturing wounds

- application of bandages

what are the roles of wound dressings?

- Protect from microorganisms

- Aid in hemostasis (control of bleeding): pressure dressings - applies pressure over wound to reduce or stop bleeding

- Promote healing by absorbing drainage

- Provide moist environment for wound bed - ideal for open wound

- Support/splint wound area

- Protects patient from seeing the wound (if perceived as unpleasant) - covers the wound from being viewed

what are the three layers of a traditional surgical wound dressing?

1. Primary/contact layer: Covers the incision

2. Absorbent layer: Collects additional secretions

3. Outer protective layer: Protect from external contamination

what are the types of dressings?

dry and moist dressings

*specific dressing and whether packing is required is determined by wound characteristics and prescribed wound care plan

what are dry dressings?

appropriate for a surgical incision that is well-approximated with little to no drainage; protects incision and absorbs any small amount of drainage that may be present

what are moist dressings?

best for open wound with larger wound bed, including some wounds that require packing

how should nurses prepare for a dressing change?

- Explain the procedure and what to expect - reduce anxiety + pt can ask questions

- Administer required analgesics so that peak effects occur during the dressing change - early enough to take effect (30-45mins prior)

- Gather all required supplies for the dressing change - complete efficiently and aseptically without having to pause

- Ensure privacy, comfort, and positioning - assess throughout dressing change

- Continue to assess pain and tolerance throughout the procedure

what are the steps of a dry dressing change?

- Apply clean gloves and appropriate PPE.

- Place disposable biohazard bag within reach, fold top to make cuff

- Remove dressing layers one at a time

- Assess wound: appearance, drainage characteristics, drainage devices, closures, palpate, pain

- Remove clean gloves, cover wound with sterile gauze, and perform hand hygiene

- Create sterile field on over-bed tray, pour prescribed solution into sterile basin --> apply sterile gloves

- Clean/irrigate wound

- Use dry gauze to blot the wound dry

- Apply dressing

how are wounds cleansed?

- Normal saline is commonly used

- Clean from the least contaminated (wound site) to the most contaminated (surrounding skin)

- Use gentle friction on surrounding skin - helps remove drainage and micro-organisms; scrubbing damages healing tissues

- Use each cleansing gauze only ONCE in one direction, then discard to prevent MO infection

what are the two methods for cleaning a wound site?

- Horizontal: cleaning begins at incision, then out to periphery (surrounding skin)

- Vertical: first pass is made directly along the incision line, with each new piece of moistened gauze, we're going to move away from incision towards peri-wound

what is wound debridement?

- Removal of necrotic, nonviable tissue to support wound healing

- Can be done in a number of ways (ex. Enzymatic debridement - use of topic enzyme preparation, sharp debridement - scalpel or scissors)

what is the purpose of wound debridement?

- Removal of infection source

- Enables visualization of wound bed

- Makes clean base for healing

what is wet-to-dry debridement?

- moistened gauze is placed in a wound and then allowed to dry, when removed, the tissue adhered to the gauze is going to be pulled away; problem with method is that it's non-selective, healthy granulation tissue is removed with the necrotic (painful, delays healing, causes trauma to wound)

- allowing wound bed to dry is no longer recommended

what is irrigation of a wound?

Used to cleanse an open wound by flushing normal saline or another cleansing solution

how should wound irrigation be performed?

- Allow solution to flow freely out of the wound; position patient to allow for gravity to assist

- Direct the flow of fluid from least contaminated to most

- Use gentle, controlled pressure; recommend 30-35 cc syringe to provide lower pressure psi (smaller syringe, like 5CC, can damage the wound bed)

what are wound cultures?

- a swab or sample of the wound to be assessed for presence of micro-organisms

- done when infection is suspected, may be ordered for purulent drainage or other signs of infection

how is a wound culture collected?

- Cleanse the wound with normal saline first

- Swab the healthiest looking tissue, do not culture old drainage, pus, scab

- Rotate swab with gentle pressure to obtain wound fluid

- Place in sterile specimen container and send to the lab

*gold standard of wound culture is tissue biopsy

what is wound packing?

a type of moist dressing where gauze is used to fill dead space of an open wound to support healing

how is wound packing performed?

- Assess the length, depth, and shape of the wound + look for undermining (pockets under the wound) and tunnelling (narrow pathway extending from wound) → will help determine the size and type of dressing material needed to pack the wound

- Pack loosely, contacting all wound surfaces and not mounding above the skin surface

- Document the type and amount of dressing used for packing

- Ensure that no packing material is left in the wound once removed/changed

what are the risks of overpacking a wound?

- excessive pressure can reduce blood flow to the wound and thus interfere with healing

- don't want peri-wound to have excessive moisture or drainage that leads to skin breakdown

when are bandages and binders used?

Used to provide support, protection or pressure over a wound or body part:

- Create pressure to help control bleeding

- Immobilize a body part (sprained ankle)

- Support a wound (abdominal binder)

- Reduce/ prevent edema

- Secure a splint

- Hold dressing in place

why is nutrition important for wound healing?

- Optimal nutrition facilitates wound healing, maintains immune competence, and decreases the risk of infection

- Poor nutrition has been associated with delayed wound healing - nutrition should be part of overall wound assessment