WOUNDS

Wounds

  • Definition and Classification of Wounds

    • Wounds can be classified as either:

    • Open Wounds: Skin integrity is broken, making them more susceptible to infection and requiring careful management. Examples include lacerations, abrasions, puncture wounds, and surgical incisions.

    • Closed Wounds: Skin is intact, with underlying tissues damaged, and might not be immediately visible. Examples include contusions (bruises) and hematomas.

    • Types of Wounds:

    • Acute Wounds: Generally heal quickly, following a predictable pattern of healing in a timely manner (e.g., surgical cuts, abrasions, burns).

    • Chronic Wounds: Do not follow the normal healing process; persist for extended periods (e.g., diabetic ulcers, venous ulcers, pressure injuries).

  • Phases of Wound Healing (referenced as page 1156):

    • Phase 1: Hemostasis

    • Duration: Immediate response to injury, typically within minutes.

    • Description: Local vasoconstriction reduces blood flow, followed by platelet aggregation to form a plug. Fibrin threads then reinforce the platelet plug, forming a stable clot to stop bleeding.

    • Phase 2: Inflammation

    • Duration: Typically lasts 3−53-5 days, but can extend if foreign bodies or infection are present.

    • Description: Characterized by redness, heat, swelling, and pain due to vasodilation and increased capillary permeability. White blood cells (neutrophils and macrophages) migrate to the site to remove debris, bacteria, and damaged tissue through phagocytosis.

    • Phase 3: Proliferation

    • Duration: Usually 55 days to 33 weeks (or longer, depending on wound size).

    • Description: New tissue forms, characterized by granulation tissue (beefy red, bumpy appearance due to new blood vessels and fibroblasts). Fibroblasts produce collagen, and epithelial cells begin to migrate from the wound edges to cover the wound (epithelialization).

    • Phase 4: Maturation

    • Duration: May last for months to years (33 weeks to over 11 year).

    • Description: The wound fully closes, and collagen fibers reorganize, strengthen, and remodel. The tensile strength of the scar tissue gradually increases, but it may never regain its full original tensile strength (typically up to 8080\% of original tissue strength).

  • Identifying the Stage of Wound Healing (reference 1156):

    • Assessment involves noting characteristics such as color, size, depth, tissue type, and drainage.

    • Staging description:

    • Stage 1: Non-blanchable erythema (redness) of intact skin. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue.

    • Stage 2: Partial-thickness loss of dermis, presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or ruptured serum-filled blister.

    • Stage 3: Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present. Undermining and tunneling may occur.

    • Stage 4: Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Often includes undermining and tunneling.

    • Unstageable: Full-thickness tissue loss in which the base of the wound is obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black). The actual depth of the wound cannot be determined until enough slough and/or eschar are removed. Stable eschar on the heels should not be removed.

  • Factors Impacting Wound Healing (reference 1157):

    • Impairing factors:

    • Poor nutrition: Deficiencies in protein, vitamins (especially Vitamin C), and minerals (like zinc) impair collagen synthesis and immune function.

    • Infection: Prolongs the inflammatory phase, increases tissue damage, and competes for nutrients.

    • Age: Reduced collagen synthesis, decreased immune response, and thinning skin in older adults.

    • Comorbidities: Conditions like diabetes mellitus (poor circulation, neuropathy), peripheral vascular disease, and immunosuppression hinder healing.

    • Promoting factors:

    • Adequate nutrition and hydration: Essential for tissue repair, immune function, and maintaining skin turgor.

    • Proper wound care: Including cleansing, debridement of non-viable tissue, and appropriate dressings to maintain a moist wound environment.

  • Signs and Symptoms (S/S) of an Infected Wound:

    • Increased redness (erythema) spreading beyond the wound edges, warmth, swelling (edema), increased pain or tenderness, purulent discharge (pus), and systemic signs such as fever, chills, and elevated white blood cell count.

  • Types of Wound Drainage:

    • Serous: Clear, watery plasma that typically indicates normal healing.

    • Sanguineous: Contains red blood cells; appears bright red (fresh bleeding) or dark red (old bleeding).

    • Serosanguineous: Mixture of serum and red blood cells; light pink or reddish and watery. Common in new wounds.

    • Purulent: Thick, often yellow, green, or brown; indicates infection. May have a foul odor.

Pressure Injuries

  • Definition:

    • Pressure injuries, often referred to as bedsores or pressure ulcers, are localized damage to the skin and underlying soft tissue, primarily caused by prolonged pressure, or pressure in combination with shear.

  • Risk Factors:

    • Immobility: Inability to change positions independently.

    • Incontinence: Moisture from urine or feces can macerate the skin, making it more susceptible to breakdown.

    • Poor nutrition: Lack of protein, calories, and micronutrients compromises skin integrity and healing.

    • Decreased sensation: Inability to perceive pain or pressure, leading to prolonged pressure.

    • Age-related skin changes: Thinner, less elastic skin in older adults.

  • Braden Scale:

    • Purpose: An evidence-based tool used to assess a patient's risk for developing pressure injuries by evaluating six subscales.

    • Scoring: Ranges from 6 to 23, with each subscale rated from 1 to 4 (or 1 to 3 for friction/shear). Lower scores indicate higher risk.

    • Categories: Sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

    • Good Score (15−2315-23): Indicates low risk of pressure injury.

    • Bad Score (6−146-14): Indicates high risk of pressure injury, requiring aggressive preventative interventions.

  • Preventive Measures:

    • Regular repositioning: Turn bed-bound patients at least every 22 hours, and encourage chair-bound patients to shift weight or be repositioned every 15−3015-30 minutes.

    • Maintaining skin hygiene: Gentle cleansing with mild soap and water, ensuring skin is dry, and using moisturizers to prevent dry skin.

    • Ensuring adequate nutrition and hydration: Provide a diet rich in protein, vitamins, and fluids.

    • Use of pressure-relieving devices: Utilize specialty mattresses, cushions, and heel protectors to redistribute pressure.

    • Education of patients and caregivers: Teach proper skin assessment techniques to identify early signs of breakdown and the importance of adherence to prevention strategies