Wound Types & Debridement

pink granulation tissue; protect wound; maintain moist environment
moist yellow slough; remove exudate & debris; absorb drainage
black, thick eschar firmly adhered; debride necrotic tissue
Selective Debridement
involves removing only nonviable tissues from a wound; is most often performed by a sharp debridement, enzymatic debridement, & autolytic debridement
Sharp Debridement
requires the use of scalpel, scissors, &/or forceps to selectively remove devitalized tissues, foreign materials or debris from a wound; is most often used for wounds w/large amounts of thick, adherent, necrotic tissue, or in the presence of cellulitis or sepsis; the most expedient form of removing necrotic tissue
Enzymatic Debridement
refers to the topical application of enzymes to the surface of necrotic tissue; can be used on infected & non-infected wounds w/necrotic tissue; this type of debridement may be used in wounds that have not responded to autolytic debridement or in conjunction w/other debridement techniques; process can be slow to establish a clean wound bed & should be discontinued after removal of devitalized tissues in order to avoid damage
Autolytic Debridement
refers to using the body's own mechanisms to remove non-viable tissue; common methods include transparent films, hydrocolloids, hydrogels, & alginates; results in a moist wound environment that permits rehydration of the necrotic tissue & eschar & allows enzymes to digest the non-viable tissue; can be used w/any amount of necrotic tissue & is non-invasive & pain free; requires a longer period of time for overall wound healing to occur; should not be performed on infected wounds
Non-selective Debridement
involves removing both viable & non-viable tissues from a wound; often termed "mechanical" & is most commonly performed by wet-to-dry dressings, wound irrigation, & hydrotherapy (whirlpool)
Wet-to-dry Dressings
refer to the application of a moistened gauze dressing placed in an area of necrotic tissue; the dressing is then allowed to dry completely & is later removed along w/the necrotic tissue that has adhered to the gauze; most often used to debride wounds w/moderate amounts of exudate & necrotic tissue; thist type of debridement should be used sparingly on wounds w/necrotic tissue & viable tissue since granulation tissue will be traumatized in the process; removal of dressing from granulation tissue may cause bleeding & be extremely painful
Wound Irrigation
removes necrotic tissue from the wound bed using pressurized fluid; pulsatile lavage is an example that uses a pressured stream of irrigation solution; most desirable for wounds that are infected or have loose debris; most devices permit varying pressure settings & provide suction for removal of the exudate & debris
most commonly employed using a whirlpool tank w/agitation directed toward a wound that requires debridement; this process results in the softening & loosening of adherent necrotic tissue; side effects include dependent positioning of the LEs, systemic effects such as drop in BP, & maceration of surrounding skin
a wound that occurs from the scraping away of the surface layers of the skin, often as a result of trauma
an injury in which the skin is not broken; the injury is characterized by pain, swelling, & discoloration
a swelling or mass of blood localized in an organ, space or tissue, usually caused by a break in a blood vessel
a wound or irregular tear of tissues that is often associated w/trauma
Penetrating Wound
a wound that enters into the interior of an organ or cavity
a wound that is made by a sharp pointed instrument or object by penetrating through the skin into underlying tissues
a lesion on the surface of the skin or the surface of a mucous membrane, produced by the sloughing of inflammatory, necrotic tissue
Factors Influencing Wound Healing
Age, Illness, Infection, Lifestyle, and Medication
Factors Influencing Wound Healing: Age
a decreased metabolism in older adults tends to decrease the overall rate of wound healing
Factors Influencing Wound Healing: Illness
compromised medical status such as CV disease may significantly delay healing; thsi often results secondary to diminished oxygen & nutrients at the cellular level
Factors Influencing Wound Healing: Infection
an infected wound will impact essential acitvity associated w/wound healing including fibroblast activity, collagen synthesis, & phagocytosis
Factors Influencing Wound Healing: Lifestyle
regular physical activity results in increased circulation that enhances wound healing; choices such as smoking negatively impacts wound healing by limiting the blood's oxygen carrying capacity
Factors Influencing Wound Healing: Medication
there are a variety of pharmacological agents that can negatively impact wound healing; types include steriods, anti-inflammatory drugs, heparin, antineoplastic agents, & oral contraceptives; undesirable physiologic effects include delayed collagen synthesis, reduced blood supply, & decreased tensile strength of connective tissues
Scar Management
immediately after an injury, homeostasis attempts to occur & the acute inflammatory response is triggered; scars can form in an organized manner termed normotrophic scarring or in a disorganized manner such as seen w/hypertrophic or keloid scars
Proliferative/Fibroplastic Phase
includes granulation tissue formation & reepithelialization
Maturation/Remodeling Phase
includes the remodeling of the tissue & scar formation
Serous Exudate
presents as clear, light color w/a thin, watery consistency; considered to be normal in a healthy healing wound
Sanguineous Exudate
presents as red w/a thin, watery consistency; appears to be red due to the presence of blood or may be brown if allowed to dehydrate; this type of exudate may be indicative of new blood vessel growth or the disruption of blood vessels
Serosanguineous Exudate
presents as light red or pink color w/a thin, watery consistency; can be normal in a healthy healing wound
Seropurulent Exudate
presents as opaque, yellow or tan color w/a thin, watery consistency; may be an early warning sign of an impending infection
Purulent Exudate
presents as yellow or green color w/a thick, viscous consistency; generally an indicator of wound infection
Stage I Pressure Ulcer
an observable pressure related alteration of intact skin whose indicators as compared to an adjacent or opposite area on the body may include changes in skin color, skin temp, skin stiffness or sensation
Stage II Pressure Ulcer
a partial-thickness loss that involves the epidermis &/or dermis; the ulcer is superficial & presents clinically as an abrasion, a blister or a shallow crater
Stage III Pressure Ulcer
a full-thickness loss that involves damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia; the ulcer presents clinically as a deep crater w/or w/o undermining adjacent tissue
Stage IV Pressure Ulcer
a full-thickness loss w/extensive destruction, tisue necrosis or damge to muscle, bone or supporting structures (e.g., tendon, joint capsule)
Wagner Ulcer Grade 0
no open lesion but may possess pre-ulcerative lesions; healed ulcers; presence of body deformity
Wagner Ulcer Grade 1
superficial ulcer not involving subcutaneous tissue
Wagner Ulcer Grade 2
deep ulcer w/penetration through the subcutaneous tissue; potentially exposing bone, tendon, ligament or joint capsule
Wagner Ulcer Grade 3
deep ulcer w/osteitis, abscess or osteomyelitis
Wagner Ulcer Grade 4
gangrene of digit
Wagner Ulcer Grade 5
gangrene of foot requiring disarticulation
Bony Prominences Associated w/Pressure Injuries: Supine
occiput, spine of scapula, inferior angle of scapula, vertebral spinous processes, medial epicondyle of humerus, posterior iliac crest, sacrum, coccyx, heel
Bony Prominences Associated w/Pressure Injuries: Prone
forehead, anterior portion of acromion process, anterior head of humerus, sternum, ASIS, patella, dorsum of foot
Bony Prominences Associated w/Pressure Injuries: Sidelying
ears, lateral portion of acromion process, lateral head of humerus, lateral epicondyle of humerus, greater trochanter, head of fibula, lateral malleolus, medial malleolus
Bony Prominences Associated w/Pressure Injuries: Sitting (chair)
spine of scapula, vertebral spinous processes, ischial tuberosities