Wound Care Pt. 1

Goal of Wound Care Management

  • Objective: To manage wound care successfully

  • Aim: To abate or reduce infection potential and tissue damage

  • Assess: Client's nutrition, health status, medication use to optimize healing

  • Knowledge: Importance of various products for cleansing and protecting wounds

  • Aseptic Practice: Essential to prevent microorganism transfer

Techniques Promoting Wound Healing

  • Various techniques will be performed to encourage healing

  • Encourage healthy personal habits and self-care practices

Wound Assessment

Components of Wound Assessment

  • History Taking: Must include pertinent questions

    • Onset of the wound

    • Acute injury or known cause

    • Associated manifestations (e.g., pain, itching)

    • Changes over time and major health problems affecting healing

  • Physical Examination: Involves multiple senses

    • Visual inspection of location, shape, size, colors, and presence of exudate

    • Definition of Exudate: Fluid or semi-solid material released by blood vessels or tissues due to inflammation or injury

    • Assessment of bleeding, necrosis (cell death due to lack of blood supply), and tissue condition (e.g., granulating tissue, clean wound edges)

    • Temperature Variation: Warm indicates infection; cold suggests vascular compromise

    • Textural Changes: Rough or deep wounds disrupt skin contour

    • Importance of Odor: A critical factor for detecting infections or identifying causes

    • Evaluation of periwound skin condition

    • Regular evaluation of psychosocial impact of wounds

Psychosocial Assessment

  • Evaluate client's coping with stress, body image, self-concept and sexuality

  • Consider available resources for adaptation

Assessment Tools & Guidelines

  • Use of assessment charts/scales for pressure injury risk and healing process monitoring

  • Measurement standards: Length, width, depth recorded in milliliters or centimeters

  • Separate measurements for tunnels and undermining areas

Pressure Injuries

Definition and Classification

  • Definition: Area of compromised skin integrity on bony prominence due to prolonged pressure

  • Common sites include: occipital bone, spinous process, sacrum, ischium, heel, trochanter, and malleolus (medial/lateral)

  • Classification of pressure injuries based on NPIAP's system into six stages:

    1. Suspected Deep Tissue Injury

    2. Stage One: Nonblanchable redness over bony prominence

    3. Stage Two: Partial thickness skin loss with visible injury or blister

    4. Stage Three: Full thickness tissue loss without exposed bone/muscle

    5. Stage Four: Full thickness tissue loss with exposed bone/muscle

    6. Unstageable: Stage cannot be determined due to eschar/slough obscuring it

Risk Factors for Pressure Injuries

  • Measured using the Braden Scale

    • Factors include friction, shear, moisture, sensory perception, mobility, activity, nutrition

  • Two significant risk factors:

    • Friction: Damage caused when skin rubs against surfaces

    • Shear: Skin stays in place while subcutaneous tissue shifts (e.g., client sliding down in bed)

    • Example: Shear can stretch and damage blood vessels leading to ischemia

    • Risk reduction: Keep head of bed under 30 degrees to minimize shear

    • Moisture increases risk due to decreased skin resistance (e.g., from incontinence, drainage)

Influence of Sensory and Nutritional Factors

  • Altered sensory perception affects damage detection and communication

  • Poor nutrition (deficiency in protein, vitamins) increases risk

Client Repositioning for Injury Prevention

  • Essential for clients with limited mobility = must assist transitioning in sitting and bed locations

Phases of Wound Healing

Phases Overview

  1. Hemostasis

  2. Inflammatory Phase

    • Duration: Begins at injury, lasts about 24 hours

    • Characteristics: Skin color changes, heat, swelling, pain, loss of function

    • Key Cells: Neutrophils, lymphocytes, macrophages, mast cells, plasma proteins

    • Function: Immune response protecting from infection, expediting healing

    • Role of Neutrophils: Arrive early to kill bacteria; elevated count indicates greater bacterial presence

    • Role of Macrophages: Phagocytosis, debris ingestion, attraction of fibroblasts using growth factors

    • Role of Mast Cells: Secrete histamine, increasing vascular dilation, stimulating collagen formation

  3. Proliferative Phase

    • Complete restoration of skin integrity by filling in wounds with new tissues

    • Process includes angiogenesis (new blood vessel formation), granulation tissue formation, and epithelialization

    • Contribution of fibroblasts to collagen deposition for scaffolding of scar formation

    • Myofibroblast involvement leading to contraction of wound edges

    • Risk factors: Dehiscence (wound reopening) and evisceration (organ protrusion) during this phase

  4. Maturation Phase

    • Final phase lasting over a year

    • Remodeling and reorganization of collagen, increasing strength and integrity of scar

    • Scar color evolution: From red/pink to white in light skin and more pigmented in darker skin

    • Aging of scar tissue: Thinning occurs over time

Intrinsic and Extrinsic Factors Affecting Healing

Intrinsic Factors

  • Age: Diminished cell function with age contributes to slower healing

  • Chronic Illness: Affects healing ability; oxygen-rich environments promote wound healing

  • Immune suppression affects necessary cellular functions

  • Reduced sensory perception results in unawareness of injuries

Extrinsic Factors

  • Medication impact: Aspirin affects platelet actions; corticosteroids suppress immune function

  • Cancer treatments (radiation, chemotherapy) may slow healing

  • Inadequate nutrition, particularly lack of protein and vitamins

  • Stress influences body’s healing response

Chronic vs. Acute Wounds

  • Chronic wounds = prolonged healing time; acute wounds heal faster

  • Primary Intention: Tissue edges touch and approximate during surgical closure

  • Secondary Intention: Wound edges do not touch, healing involves granulation tissue formation and contraction

  • Chronic wound proliferation stage characterized by inefficiencies

  • Higher concentrations of fluid and inflammatory cytokines slow healing; repeated trauma increases difficulty

Wound Dressings and Care

Sterile Wound Irrigation Steps

  • Preparations: Ensure privacy, verify ID, allergies, provide client education, assess pain, gather supplies, adjust bed

  • Technique: Remove old dressings, clean wound, apply solution using sterile methods, and document all findings and actions

Types of Dressings

  • Dry Dressings: Composed of gauze, secure with tape; good for wounds with small exudate, however can stick to heavily exudative wounds

  • Wet to Dry Dressings: Once common for debridement but now less favored; non-selectively removes healthy and non-healthy tissues, causes pain, and is costly

  • Specialty Dressings: Include chemical impregnated (e.g., silver, iodine, collagen) and foam dressings; consult specialists for appropriate use

  • Alginate Dressings: Made of seaweed, suitable for exudative wounds, require secondary dressing

  • Hydrogel Dressings: Absorb exudate; should not be used in dry wounds; can be costly

  • Wound Fillers: Available as paste, powders, gels; assist in maintaining moist environment

  • Transparent Film Dressings: Allow oxygen exchange; used for superficial wounds

  • Hydrocolloid Dressings: Provide moist environments; not recommended for infected wounds; can stay in place for up to seven days.