Wound Care and Treating Pressure Ulcers

Wounds

• Wounds can occur due to:
  • Trauma
  • Surgery
  • Pressure
  • Burns
• Wounds may be open or closed.

Closed Wound Types

• Hematoma
• Sprain
• Contusion

Open Wounds

• Abrasion
• Laceration
• Avulsion
• Incision
• Puncture
• Penetrating
• Ulceration
• Amputation

Types of Wounds

• Superficial wounds
  • Heal quickly by producing new skin cells.
  • A fibrin clot forms a framework for growing new cells.
• Partial-thickness wounds
  • No dermal layer present except at the margins of wounds.
  • All necrotic tissue must be removed.
  • The wound heals by contraction.
• Full-thickness wounds

Skin and Pressure Ulcers

• Assessment using the Braden Scale (pg 298).
• Caused by circulatory compromise.
• Reactive Hyperemia vs. Pressure Ulcer.

Stage 1 Pressure Ulcer

Stage 2 Pressure Ulcer

• Skin layers include subcutaneous soft tissue and bone.

Stage 3 Pressure Ulcer

• Involves skin, fat, muscle, and bone.
• Damaged Area
• Extended Enlargement of the Ulcer

Stage 4 Pressure Ulcers

• Involves skin, fat, muscle, and bone.
• Further Expansion of the Damage
• Further Enlargement of the Ulcer

Unstageable Ulcer

• National Pressure Ulcer Advisory Panel.

Suspected Deep Tissue Injury

Pressure Ulcer Risk Factors

• Immobility
• Incontinence
• Inadequate nutrition
• Lowered mental awareness
• Excessive diaphoresis
• Extreme age
• Edema

Prevention

• Reposition every 2 hours (q2h).
• Float heels.
• Use trapeze or lift sheet.
• Use pressure-reducing devices.
• Shift weight at least once an hour, preferably every 15 minutes.

What the Nurse Should or Shouldn’t Do

• Do NOT massage reddened skin or over a bony prominence.
• Wash and dry incontinent patients promptly.
• Avoid mechanical injury from casts, braces, etc.
• Avoid skin injury caused by friction and shear.
• Provide adequate nutrition and hydration.

Partial or Full Thickness

Phases of Wound Healing

• Inflammation (or) reconstruction
• Proliferation
• Maturation or remodeling

Inflammation Phase

• Begins immediately and lasts 1 to 4 days.
• Signs of inflammation:
  • Edema
  • Erythema
  • Heat
  • Pain

Proliferation Phase

• Begins on the third or fourth day; lasts 2 to 3 weeks.
• Macrophages are present.
• New capillary networks are formed.
• Tissue is formed.

Maturation Phase

• The final phase begins about 3 weeks after injury and may take up to 2 years.
• Collagen is lysed (broken down) and resynthesized by the macrophages, producing strong scar tissue.
• Scar tissue slowly thins and becomes paler.

Wound Closure

• First intention
• Second intention
• Third intention

Factors Affecting Wound Healing

• Age
• Peripheral vascular disease (PVD)
• Decreased immune system function
• Decreased lung function
• Nutrition
• Medications
• Lifestyle
• Infection
• Chronic illnesses

Wound Complications

• Hemorrhage
• Infection
• Cellulitis
• Fistula
• Sinus
• Dehiscence
• Evisceration

Wound Complications

• Fistula
• Cellulitis
• Dehiscence
• Evisceration

Wound Closures

• Sutures and staples
• Large retention sutures
• Steri-Strips
• Dermabond

Drainage Type

• Serous
• Sanguineous
• Serosanguineous
• Purulent

Wound Culture Specimen

Drains and Drainage Devices

• Purpose
• Types:
  • Penrose
  • Jackson-Pratt
  • Hemovac
  • Pratt

Dressings

• Purposes of Dressings:
  • Prevent microorganisms from entering the wound.
  • Absorb drainage.
  • Control bleeding.
  • Support and stabilize tissues.
  • Reduce discomfort.

Treatment of Wounds

• Sterile technique
• Aseptic technique

Wound Cleansing

• Water, saline, wound cleanser (as ordered).
• Irrigations
• Room temperature

Various Types of Dressings

• Surgipad
• Gauze sponges
• Combine dressing
• Dioderm
• Sofaline

Securing Dressing

• Dressing may be secured with:
  • Stretch gauze
  • Mesh netting
  • Elastic bandage
  • Montgomery straps
  • Binders
  • Tape
• Montgomery Straps
• Abdominal binder

Vacuum Assisted Closure (VAC)

• Negative pressure, applies suction to the wound.
• Draws edges together.
• Removes fluid from the wound bed, but keeps the wound moist.
• Increases blood flow.
• Nursing care

Debridement

• Purpose: Removal of necrotic tissue
• Types:
  • Sharp
  • Enzymatic
  • Mechanical

Heat Application

• Usually requires a physician’s order
• Provides general comfort
• Causes vasodilation, which speeds healing
• Indications: Muscle pain, infected wound
• Examples: Hot water bottle, K-pad, compresses
• Nursing considerations

Cold Application

• Usually requires a physician’s order
• Used to decrease swelling and decrease pain
• Causes vasoconstriction
• Often applied immediately after injury
• Indications: Sprains, nosebleeds, fractures, tonsillectomies
• Examples: Ice packs/bags, compresses, cooling blanket
• Nursing considerations

Documentation of wound care

• What do I chart?

Information needed for accurate documentation

• Anatomical location
• Size
• Surrounding skin
• Color
• Drainage
• Detailed description of wound
• Dressing used
• No interpretations, only observable data