Wound Care

Introduction to Wound Care and Unit Objectives

• Definition of Wound: A wound is defined as a disruption in the continuity of body tissues. This disruption can affect skin, muscles, organs, or other tissues.
• Significance: Proper wound care is considered essential to promote healing and prevent complications. It is a fundamental nursing skill for all Licensed Practical Nurses (LPNs).
• Source Material Date: MARCH 2025.
• Unit Objectives:
  • Define terminology specifically related to Wound Care.
  • Compare and contrast different types of wounds.
  • Identify risk factors and staging associated with pressure injuries.
  • Describe nursing interventions designed to prevent and care for pressure injuries.
  • Compare and contrast the different phases of wound healing.
  • Discuss various wound treatments and management strategies.
  • Describe and document the data collection process concerning wounds.

Key Terms in Wound Care

• Debridement: The removal of dead (necrotic) tissue from a wound to promote healing and prevent infection.
• Granulation: The formation of new connective tissue and tiny blood vessels that occur during the healing process.
• Epithelialization: The process where epithelial cells grow across the wound surface to facilitate closure.
• Exudate: Fluid that seeps from blood vessels into nearby tissues during the inflammatory process.

Types of Wounds: Definitions and Classifications

• Contusion: A bruise caused by blunt force trauma. In this injury, blood vessels break under intact skin, resulting in discoloration.
• Abrasion: A scrape that removes the surface layers of the skin; it is typically shallow but can cover a large surface area.
• Puncture: A small hole made by a sharp, pointed object. While the entry point is small, the wound can be deep.
• Penetrating Wound: An injury where an object enters and subsequently exits the body, creating both entry and exit wounds.
• Laceration: A tear in the tissue characterized by jagged, irregular edges, often caused by trauma from a sharp object.
• Pressure Injury: Localized damage to the skin and underlying tissue, usually occurring over a bony prominence due to pressure or shear.

Wound Classifications

• 1: Clean: Uninfected wounds with no inflammation. These wounds do not enter the respiratory, gastrointestinal (GI), or genitourinary (GU) tracts.
• 2: Clean-Contaminated: Wounds where the respiratory, GI, or GU tracts are entered under controlled conditions.
• 3: Contaminated: Open, fresh, accidental wounds or those involving major breaks in sterile technique.
• 4: Infected: Old traumatic wounds containing dead tissue or those with existing clinical infection.
• 5: Colonized: Wounds containing bacteria without tissue invasion or a host immune response.

Open versus Closed Wounds

• Open Wounds:
  • The skin is broken, exposing underlying tissues.
  • Associated with a higher risk of infection.
  • Examples include lacerations and abrasions.
  • Treatment involves cleaning, debridement, and protection.
• Closed Wounds:
  • The skin remains intact, but the underlying tissues are damaged.
  • Examples include contusions and hematomas.
  • Treatment requires monitoring for hidden damage.

Staging of Pressure Injuries

• Stage I: Characterized by non-blanchable erythema of intact skin. The area appears red and does not briefly turn white when pressed.
• Stage II: Involves partial-thickness loss of the dermis. It presents as a shallow open ulcer with a red-pink wound bed.
• Stage III: Full-thickness tissue loss. Subcutaneous fat may be visible, but bone and muscle are not exposed.
• Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle. This stage often includes tunneling and undermining.

Risk Factors and Prevention of Pressure Injuries

• Primary Risk Factors:
  1. Sensory Impairment: The inability to feel pain or pressure.
  2. Incontinence: Moisture weakens skin integrity.
  3. Poor Nutrition: Inadequate intake of protein and vitamins.
  4. Immobility: Prolonged pressure on tissue.
• Additional Factors: Advanced age, vascular disease, and certain medications. Each factor compounds the overall risk.
• Nursing Interventions for Prevention:
  • Repositioning: Turn immobile patients every $2$ hours. Utilize a $30$-degree lateral position to reduce pressure.
  • Skin Care: Keep skin clean and dry. Use mild cleansers and moisturizers to maintain integrity.
  • Nutrition: Ensure adequate intake of protein, vitamin C, and zinc. Monitor hydration status closely.
  • Support Surfaces: Utilize specialized mattresses, cushions, and positioning devices to redistribute pressure.

The Wound Healing Process

• Phases of Healing:
  1. Inflammatory Phase: Begins immediately after injury and lasts $2-5$ days. Hemostasis occurs via clotting, and neutrophils and macrophages fight infection.
  2. Proliferative Phase: Lasts $2-3$ weeks. New tissue formation begins with the development of granulation tissue, re-epithelialization, and angiogenesis.
  3. Remodeling Phase: Can last for months or years. Collagen reorganizes for strength, scar tissue matures, and tensile strength improves.
• Types of Wound Closure:
  • Primary Intention: Edges are approximated with sutures, staples, or adhesives. Typical for clean surgical wounds; results in minimal scarring.
  • Secondary Intention: The wound is left open to heal from the bottom up. Used for contaminated wounds; involves more granulation tissue formation.
  • Tertiary Intention (Delayed Primary Closure): Involves initial cleaning and drainage followed by closure days later. Used for contaminated wounds.

Factors Affecting Healing and Potential Complications

• Factors Affecting Healing:
  • Age: Older patients have thinner skin and reduced cellular activity, which slows healing.
  • Nutrition: Deficiencies in protein, vitamin C, and zinc impair healing. Hydration is essential for repair.
  • Circulation: Poor blood flow (common in diabetes and peripheral vascular disease) reduces oxygen and nutrient delivery.
  • Medications: Steroids and immunosuppressants delay healing; anticoagulants increase bleeding risk.
• Complications:
  • Infection: Symptoms include increased pain, redness, warmth, swelling, purulent drainage, and fever.
  • Dehiscence: Partial or complete separation of wound edges, often due to increased abdominal pressure or poor nutrition.
  • Evisceration: Protrusion of internal organs through an open wound. This is a medical emergency.
  • Delayed Healing: Stalled progress in the normal timeline, indicating underlying problems.

Comprehensive Nursing Care and Treatments

• Nursing Care for Complications:
  • Assessment: Measure dimensions, note drainage, check for infection, and document thoroughly.
  • Interventions: Clean as ordered, apply appropriate dressings, and position the patient to relieve pressure.
  • Monitoring: Regularly check for deterioration and monitor vital signs for systemic infection.
  • Notification: Alert the physician for fever, increasing pain, spreading redness, or significant changes.
• Wound Treatments:
  • Dressings: Must be matched to the wound type, moisture needs, and drainage amount.
  • Debridement: Removal of necrotic tissue (surgical, enzymatic, autolytic, or mechanical).
  • Negative Pressure: Vacuum-assisted closure (VAC) uses controlled suction.
  • Hyperbaric Oxygen: Increases tissue oxygenation for difficult wounds.
• General Nursing Responsibilities:
  • Perform dressing changes using aseptic technique.
  • Apply prescribed topical agents.
  • Patient education on warning signs and self-care.
  • Pain management: Administer analgesics before procedures.

Wound Assessment Frameworks

• Physical Characteristics: Measure size in centimeters ($cm$). Note depth using cotton-tipped applicators. Observe color, edges, and surrounding tissue.
• Drainage Evaluation:
  • Serous: Clear.
  • Sanguineous: Bloody.
  • Serosanguineous: Pink.
  • Purulent: Yellow/green.
• TIME Framework:
  • T: Tissue viability.
  • I: Infection signs.
  • M: Moisture balance.
  • E: Edge advancement.

Dressing Selection and Rationale

• Gauze: Best for packing or large areas; requires frequent changes.
• Foam: Highly absorbent for moderate to heavy exudate; minimizes pain.
• Hydrocolloid: Forms a gel; provides a moist environment; waterproof.
• Alginate: Derived from seaweed; high absorption for exudate.
• Selection Matrix:
  • Dry, necrotic: Hydrogel (provides moisture for debridement).
  • Heavy drainage: Foam or Alginate (high absorption).
  • Shallow, granulating: Transparent film (protects tissue, allows visualization).
  • Infected: Antimicrobial (contains silver or iodine).

Documentation and Safety

• Documentation Essentials: Pain levels, interventions (cleansing, dressings), wound characteristics (drainage, tissue, measurements), and anatomical location.
• Safety:
  • Hand hygiene before/after.
  • Sterile technique for deep/surgical wounds; clean technique for chronic wounds.
  • Disposal of soiled dressings in biohazard containers; double-bag highly exudative waste.

Surgical Patient Care

• Terminology:
  • Preoperative: NPO (nothing by mouth) status, informed consent.
  • Intraoperative: Anesthesia, positioning, asepsis.
  • Postoperative: Recovery, pain control, wound monitoring.
  • Discharge: Home care instructions, follow-up.
• Abbreviation Key: I&O (intake and output), POD (post-operative day).
• Types of Surgery:
  • Diagnostic: Exploratory (e.g., biopsies, exploratory laparotomy).
  • Curative: Removes/repairs damage (e.g., appendectomy, tumor resection).
  • Palliative: Relieves symptoms (e.g., nerve blocks, shunts).
  • Urgent/Emergent: Immediate intervention (e.g., trauma repair, bleeding control).

Preoperative Nursing Assessment and Teaching

• Assessment Components: Medical history, physical examination (vitals, heart/lung sounds, surgical site integrity), medication reconciliation, and functional capacity.
• Red Flags:
  • Hypertension ($> 180/110$).
  • Blood glucose $> 200\,mg/dL$.
  • Unstable angina.
  • Recent fever or respiratory infection.
  • Unexplained weight loss ($> 10\%$ in $6$ months).
• Diagnostic Testing Purposes: Surgical planning, anesthesia management, risk stratification, establishing a baseline, and disease detection.
• Teaching Points: Procedure explanation, NPO guidelines (typically nothing by mouth $8$ hours before), medication instructions (which to take/hold), and post-op expectations (pain, mobility).

Preoperative Medications and Anesthesia

• Medications:
  • Anxiolytics: Benzodiazepines (e.g., midazolam) given $30-60$ minutes before.
  • Prophylactic Antibiotics: Cefazolin (given within $60$ minutes of incision).
  • Anticoagulants: Heparin or enoxaparin for DVT prevention.
  • Cardiac: Continue beta-blockers.
• Surgical Team: Surgeon (leader), Anesthesiologist (monitors vitals), Scrub Nurse (handles instruments), Circulating Nurse (manages environment/advocate).
• Anesthesia Types:
  • General: Induces unconsciousness.
  • Regional: Numbs a specific region.
  • Local: Numbs a small area.
  • Monitored Anesthesia Care (MAC): "Twilight" sedation for minor procedures.

Intraoperative and Postoperative Care

• Intraoperative Priorities: Positioning to prevent nerve damage, maintaining a sterile field, continuous vitals monitoring, and detailed documentation.
• Postoperative Problems: Pain, respiratory complications (atelectasis, pneumonia), wound infection, and thromboembolism (blood clots).
• PACU (Post-Anesthesia Care Unit) Interventions: Airway management (clear secretions), pain assessment using scales, wound checks for bleeding, and frequent vital sign monitoring.
• Post-Surgery Priorities: Assess consciousness, track vital trends (hypotension, tachycardia, fever), manage nausea, ensure incision remains clean/dry, and promote early mobilization.

Best Practices Summary

• Assess Thoroughly: Complete all evaluations.
• Identify Risks: Address red flags early.
• Educate Effectively: Use the teach-back method.
• Collaborate: Work with the entire care team.
• Document Meticulously: Record all findings immediately.

References

• ATI (2023). Fundamentals for Nursing PN Review Module (11th ed.). St. Louis, MO.
• Burton, Marty A., and David W. Smith. (2023). Fundamental of Nursing Care (4th ed.). Philadelphia: F.A. Davis.