93 terms

CH 32 Wound care

a piece of soft material that covers and protects an injured part of the body
removal of dead tissue from a wound or burn site to promote healing and prevent infection
Separation of the layers of a surgical wound; may be partial, superficial, or a complete disruption of the surgical wound
second layer of skin, holding blood vessels, nerve endings, sweat glands, and hair follicles
dehydration; the process of being rendered free from moisture
Protective covering placed over a wound
the outer layer of the skin covering the exterior body surface of vertebrates protective, waterproof layer of keratin material.depends on the dermis for blood supply and nourishment and waste removal. Regenerates easily.
black or brown necrotic tissue that needs to be removed so the wound can heal
If this occurs, the nurse places serile dressings, moistened with normal saline over the protruding organs & tissue (and calls doctor), an intestine or other internal organ protruding through a wound in the abdomen
Fluid that accumulates in a wound; may contain serum, cellular debris, bacteria, and white blood cells
An abnormal passage from an internal organ to the skin or from one internal organ to another
the force that two surfaces exert on each other when they rub against each other injury looks like abrasion and can also damage superficial blood vessels in the dermis.
granulation tissue
New tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal
insufficient blood flow to an area
softening through liquid; overhydration
Death of tissue
negative-pressure wound therapy
the use of subatmospheric pressure to promote or assist wound healing or to remove fluids from a wound site or activity that promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid
pressure ulcer
Skin ulceration caused by prolonged pressure, usually in a person who is bedridden; also known as decubitus ulcer or bedsore , any lesion caused by unrelieved pressure that results in damage to underlying tissue
purulent drainage
comprised of white blood cells, liquefied dead tissue debris, and both dead and live bacteria (thick, musty foul odor)
sanguineous drainage
consists of large numbers of RBCs and looks like blood. Bright red= fresh drainage, Darker drainage= older.
After a skin lesion is repaired, normal tissue is lost and replaced with connective tissue (collagen). This is a permanent fibrotic change. Ex: healed area of surgery or injury, acne.
serosanguineous drainage
Mixture of serum and red blood cells. It is light pink and blood tinged.
serous drainage
is composed of primarily clear, serous portion of the blood and from serous membranes. (clear and watery)
The force exerted PARALLEL to the skin resulting from both gravity pushing down on the body and resistance (friction) between the client and a surface. The skin and subcutaneous layers adhere to the surface, and the layers of muscle and bone slide in the direction of body movement. The tissue damage occurs deep in the tissue, causing undermining of the dermis.
subcutaneous tissue
underlying layer that anchors the skin layers to the underlying tissues of the body
any injury that interrupts the continuity of skin or a mucous membrane
While cleaning and assessing a wound note
cleaning a Surgical Wound and Applying a dry,sterile dressing
normal saline clean
sterile dressing applied
wash hands clean gloves
remove tape and old dressing use sterile saline
do not reach over wound
take note of presence,amount,color,odor,type of any drainage that 's on the dressing.
Prepare a sterile field, put on sterile gloves clean wound from top to bottom, from center to outside,use different gauze for each wipe,and place used gauze in waste bag. Do not touch any surface with gloves or forceps, dry the same way.Place antibiotic ointment then dry sterile dressing then surge-pad,
date and time on tape of dressing
document procedure, wound assessment and patient reaction to procedure.
Irrigating a wound using sterile techniques
give patient pain medication about 40 min before you start.
position patient with a water proof pad under and angle so drainage will fall into a tub
wash hands put on gloves remove old dressing
remove gloves wash hands then set up sterile field put on sterile gloves gown mask because of splashing , pour some sterile solution out then fill syringe with sterile solution place tub under ankle, syringe sterile solution into the wound keep tip of syringe 1 inch away from wound apply until sterile solution flows out clear
dry with sterile gauze apply new sterile dressing.
document procedure wound assessment and reaction to procedure.
Stage I pressure ulcer
skin is still intact with non-blanchable redness of a localized area....usually over a bony prominence. may be painful, "mushy", and abnormally warm/cool prepared to adjacent tissue.
Stage II pressure ulcer
Partial thickness loss of dermis presenting a shallowing open uler with a red pink wound bed, without slough. Presents as a shiny or dry shallow ulcer without slough or bruising. May also present as a serum filled blister.
Stage III pressure ulcer
Full thickness tissue loss. Subcutaneous fat maybe visible, but bone, tendon, or muscle are not exposed. Slough maybe present but does not obscure the depth of the tissue loss. May include undermining or tunneling.
Stage IV pressure ulcer
full thickness tissue loss which exposes bone, tendons, or muscle. slough/eschar may be present. often includes undermining and tunneling. the depth varies by anatomical location
pressure ulcer
a localized injury to the skin and/or underlying tissue usually over a bony prominence; the result of pressure or pressure in combination with shear and/or friction
unstageable pressure ulcer
Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in wound bed.

Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed.
collecting a wound culture
to identify microorganism in the wound
wash hands clean gloves remove old dressing
wash hands clean gloves take culture stick out of tube roll over the wound place in culture tube
label pt time date to be sent to lab.
Jackson Pratt drain
A Jackson-Pratt (JP) drain is used to remove fluids that build up in areas of your body after surgery or when you have an infection. The JP drain is made up of 2 parts: A thin rubber tube; A soft round squeeze bulb used after breast removal, abdominal surg.
hemovac drain
Is placed into a vascular cavity where blood drainage is expected after surgery, such as with abdominal and orthopedic surgery. The drain consist of perforated tubing connected to a portable vacuum unit. Suction is maintained by compressing a springlike device in the collection unit. After a surgical procedure, the surgeon places one end of the drain in or near the area to be drained. The other end passes through the skin via a separate incision. These drains are sutured in place. The site may be treated as an additional surgical wound, but often these sites are left open to air after the first 24. These drains are emptied every 4-8 hours
RYB wound classification
R= red=Protect
B=Black= Debride
Penrose drain
provides sinus tract--
thin walled, collapsible latex tubes, prevents fluid from collecting and forming an abcess in abdominal surgery
T-tube drain
Is sometimes placed in the common bile duct after removal of the gallbladder. The tube drains bile while the surgical site is healing. A portion of the tub is inserted into the common bile duct and the remaining portion is anchored to the abdominal wall, pass through the skin and connected to a close drainage
Gauze drain
allows healing from base of wound. ex infected wounds, after hemorrhoids
autolytic debridement
aka self-dissolution, painless, natural physiologic process that allows the body's enzymes to soften, liquefy and release devitalized tissue -- preferred when wound is small and free of infection
transparent film
NONAbsorptive of drainage
waterproof; impermeable to fluids and bacteria,
allow o2 and moisture vapor exchange promoting healing
For: superfical wounds with min exudate, protection of intact skin from f/s, autolytic debridement
ex. opSite, bioclusive, tegaderm-- used to secure IV catheter
stage #1 pressure ulcer, central venous line.
Hydrocolloid dressing
Absorb drainage, occlusive & adhesive, conforms to shape of wound & provides cushioning, can remain in place for 3-7 days. EX: Duoderm Cannot be used if wound is infected
occlusive dressing
a dressing that prevents air from reaching a wound or lesion and that retains moisture, heat, body fluids, and medication. It may consist of a sheet of thin plastic affixed with transparent tape.
Absorbs exudate, maintains moisture used for infected woulds. facilitates autolytic debridement. used in infected wounds.• Infected and non-infected wounds
• Wounds w/ mod. to heavy exudates
• Partial- and full- thickness wounds
• Tunneling wounds
• Moist red and yellow wounds
• Not for use with wounds with minimal drainage or dry eschar
minimal absorption. soothing, pain debridement. used in infected wounds.(burns)• Partial- and full- thickness wound
• Necrotic wounds
• Burns
• Dry wounds
• Wounds w/ minimal exudates
• Infected wounds
wet- dry gauze dressing
gauze can be moistened with saline to keep the surface of open wounds moist ( used to debride wounds)
Sliver sorb, silverlon
Reduce infection/ prevent infection, used for acute and chronic wounds.• Draining, exuding, and non-healing wounds to protect form bacterial contamination and reduce bacterial contamination
• Acute and chronic wounds
BGC Matrix, Promogran Matrix--nonadherent , require secondary dressing to secure - use with donor sites tunneling
skin grafts infected and non infected • Partial- and full- thickness wounds
• Infected and non-infected
• Skin grafts
• Donor sites
• Tunneling wounds
• Moist red and yellow wounds
• Wounds with min. to heavy exudate
• Combine 2 or more physically distinct products in single dressing w/ several functions
• Allow O2 exchange
• Facilitate autolytic debridement
• Provide physical bacterial barrier and absorptive layer
• Semi-adherent or non-adherent
• Primary or secondary dressing
Alldress, Covaderm, StrataSorb--infected wounds mixed wounds ,necrotic tissue• Partial- and full- thickness wounds
• Wounds with min. to heavy exudates
• Necrotic tissue
• Mixed (granulation and necrotic) tissue wounds
• Infected wounds
Removal of devitalized tissue and foreign material from a wound
Fluid that accumulates in a wound; may contain serum, cellular debris, bacteria, and WBC's
soft tissue due to excessive moisture
Mechanical Debridement (WET -DRY)
Deridement facilitated by mechanical device. NOT by AUTOLYTIC debridement ( as seen in various types of wound dressings)
Wound irrigation
is a directed flow of solution over tissues. they are ordered to clean the area of Pathogens and other debris and to promote wound healing.
Wet-Dry Dressing (used to debride)
-Used usually with normal saline (NS)- placed inside the wound to help promote moist wound healing + trauma to the wound.
-Squeeze out excess water from gauze before placing in the wound. It can then be covered with a normal dressing to absorb
Irregular wound care; jagged edges
Closed wound; with pain, swelling, and discoloration
Entering into the tissues/body cavity
A scraping away of the skin surface
Open cut made with a knife/scapel
Red, watery secretion; light pink
Thin, clear watery secretion
Containing RBCs;Bright Red is Fresh Bleeding; Dark Red is darker older bleeding
Containing pus foul musty odor
Primary Intention(incision)
-Low risk of infections, tend to heal quickly
-Forms a clean, straight line with Little loss of tissue
-The wound edges are well approximated with sutures
Secondary Intention
Large wound with considerable tissue loss. not well approximated; healing occurs by Granulation tissue. Scar Tissue
Tertiary Intention (Delayed Primary)
Allowed to be left open for several days to allow edema or infection to resolve or exudate to drain. they are then absorb
Granulation Tissue (Hemolytic Phase)
new tissue that is deep pink/ red and composed of Fibroblasts and small blood vessels that fill an open wound when it starts to heal.
Inflammatory Phase (4-6 days) (2nd)
LeuKocytes, macrophases-phagoctic cells. FIbroblasts fill the wound
Proliferation Phase (Weeks) (3-24days) (3 rd )
Granulation tissue forms. Good formation of connective tissue as wound heals.
Maturation Phase (3 Weeks- Months) (4 th final)
Final phase -Collagen is remodeled. Scar- tissue is formed
Accidental separation of wound edges, especially a surgical wound (Coughing)
Evisceration (emergency)
Organs are exposed through the skin. ( Cover with sterile moist towel)
Hemostasis phase (1 st)
Hemostasis involves the constriction of blood vessels and the beginning of blood clotting immediately after the initial injury, phase of the wound healing process; platelet plug formation- begins w/in 15 seconds of injury
A layer or mass of dead tissue separated from surrounding living tissue, as in a wound, sore, or inflammation.
Types of wounds and there causes:
• Incision - cutting or sharp instrument; wound edges in close approximation and aligned
• Contusion - blunt instrument, overlying skin remains intact, with injury to underlying soft tissue; possible resultant bruising and/or hematoma
• Abrasion - friction; rubbing or scraping epidermal layers of skin; top layer of skin abraded
• Laceration - tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue
• Puncture - blunt or sharp instrument puncturing the skin; intentional or accidental
• Avulsion - tearing a structure form normal anatomic position; possible damage to blood vessels, nerves, and other structures
• Microbial - secretion of exotoxins or release of endotoxins by living organisms
• Chemical - toxic agents such as drugs, acids, alcohols, metals, and substances released from cellular necrosis
• Thermal - High or low temperatures; cellular necrosis as a possible result
• Irradiation - ultraviolet light or radiation exposure
• Pressure ulcers - compromised circulation secondary to pressure or pressure combined with friction
• Venous ulcers - injury and poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction
• Arterial ulcers - injury and underlying ischemia, resulting from underlying conditions, such as atherosclerosis or thrombosis
• Diabetic ulcers - injury and underlying diabetic neuropathy, peripheral arterial disease, diabetic foot structure
Phases of wound healing:
1. Hemostasis
a. Occurs immediately after initial injury
b. Blood vessels constrict and clotting begins
c. After brief period of constriction, vessels dilate and plasma and blood leak out into injured area (exudates)
d. Accumulation of exudates causes swelling and pain
e. Increased perfusion causes heat and redness
2. Inflammatory phase
a. Lasts about 4-6 days
b. White blood cells (mostly leukocytes and macrophages) move to wound
c. Leukocytes ingest bacteria and cellular debris
d. Macrophages (essential to healing process) ingest debris, release growth factors that are necessary for growth of epithelial cells and new blood vessels - also attract fibroblasts
e. Acute inflammation characterized by pain, heat, redness, and swelling at the site of injury
f. During this phase pt has generalized body response - mildly elevated body temp, leukocytosis, and generalized malaise
3. Proliferation phase
a. AKA fibroblastic, regenerative, or connective tissue phase
b. Lasts for several weeks
c. New tissue is built to fill the wound space
d. Granulation tissue forms - highly vascular, red, and bleeds easily
e. Collagen synthesis and accumulation peak in about 5-7 days
f. Adequate nutrition and oxygenation are important
4. Maturation phase
a. Final stage - begins about 3 weeks after injury
b. Collagen remodeled, making healed wound stronger and more like adjacent tissue
c. Scar is formed
Factors Affecting Wound Healing
Factors Affecting Wound Healing
• Local Factors
o Pressure
o Desiccation
o Maceration
o Trauma
o Edema
o Infection
o Necrosis
• Systemic Factors
o Age
o Circulation and Oxygenation
o Nutritional Status
o Wound condition
o Medications and health status
o Immunosuppression
Wound Complications
(1) Infection (2) Hemorrhage (3) Dehiscence and evisceration (4) Fistula formation
Risks for pressure ulcer development
: (1) Immobility (2) Nutrition and hydration (3) Moisture (4) Mental Status (5) Age
• Fibrin sealants
concentrated human clottable proteins and human thrombin; used to "glue" together epidermal surfaces
• Negative-Pressure Wound Therapy
o Used for: pressure ulcers; arterial, venous, and diabetic ulcers; dehisced surgical wounds; infected wounds; skin graft sites; and burns
o Not used for: active bleeding; wounds with exposed blood vessels, organs, or nerves; malignancy in wound tissue; presence of dry/necrotic tissue; or with fistulas of unknown origin
• Growth Factors
naturally occurring proteins that are applied to wound bed to promote granulation, cell proliferation, and cell migration
• Oxygen therapy
- pt placed in hyperbaric, pressurized chamber to breathe 100% O2 - this promotes cell proliferation, blood flow to wounds, and the growth of new blood vessels, also enhances action of white blood cells
• Heat and Cold therapy
Heat accelerates the inflammatory response to promote healing; cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort
Wound with heavy exudates thats in need of autolytic debridement. Which wound dressings/products is most appropriate to use on the wound?
Alginate dressing like AlgiCell
Nurse Ruth scared one of her students who is a diabetic about care plans, the student feel in the parking lot and was run over by a car and lost her right leg what bandage would be placed on her stump or amputated leg
Recurrent turn bandages are used on stumps the last turn is anchored with a figure eight.
Figure eight bandages are used on
the elbow or knee.
A spica turn bandage is used on
the chest or trunk
Spiral turns are used by
wrapping cylindrical parts of the body such as the arms and legs.