Wound Care

Stressors that Affect Skin Integrity
Wound Care
NUR101 Fall 2008
K. Burger MSEd, MSN, RN, CNE
PPP By: Sharon Niggemeier RN MSN
Revised kburger906,907
Factors that Impair Wound Healing
 Age
 Malnutrition
 Obesity/Emaciation
 Poor circulation and oxygenation
 Immunosuppression
 Smoking
 Incontinence
 Medications ( Steroids )
 Co-morbidities ( Diabetes)
 Wound Stress
 Radiation
Wounds - Classification
 Intentional – results from planned treatment
 Unintentional wounds- results from
unexpected trauma…accident/ burns/ shooting
 Open -skin broken, portal of entry
 Closed – trauma from force, skin intact, soft
tissue damage, internal injury, possible bleeding
 Acute – goes through normal/timely healing
 Chronic – fails to go through normal stages of
healing; no timely progress in healing
Wounds –Classification
 Superficial
 Penetrating
 Perforating
 Laceration
 Puncture
 Abrasion
 Contusion
 Clean
 Contaminated
 Infected
 Colonized
 Pressure Ulcers
Stage I
Stage II
Stage III
Stage IV
Wound Assessment
Appearance: granulation tissue, eschar, slough,
edema, tunneling, undermining, sinus tracts, color
Drainage: serous, serosanguineous,
sanguineous, purulent and amount
Size & location on body
Presence of sutures/staples
Presence of drains/tubes
Wound edges
??Other Factors to Assess??
Wound - Healing
Healthy body has the ability to restore
itself, it depends on the amount of
damage and state of health of the
Referred to as regeneration (renewal)
of tissue.
There are (3) phases of regeneration
Phase I
Wound Healing
Inflammatory phase- begins immediately
after injury.
 Includes Hemostasis (cessation of bleeding) due
to vasoconstriction and platelet aggregation
 Release of histamine, increasing capillary
permeability (plasma leaking) and vasodilation
 Also phagocytosis ( process when
macrophages engulf microbes and secrete
growth factors that promote angiogenesis)
stimulates epithelial buds at the end of injured
tissue resulting in increased circulation which
sustains the healing process
Phase ICONTINUED Wound Healing
Inflammatory Response
4 Cardinal S/S
Phase I Inflammatory Response
Elevated temperature
Elevated WBC ( norms 5000-10000 )
Phase II
Wound Healing
Proliferation (Fibroplasia) Phase second phase , fibroblasts synthesize
collagens which add strength to the
wound. Begins 2-3 days after injury.
Thin layer of epithelial cells forms, blood
flow is reinstituted. Tissue forms - known
as granulation tissue. Translucent red
color/fragile/bleeds easily.
Phase III
Wound Healing
Maturation (Remodeling) Phasefinal phase begins about 3 weeks after the
Collagen originally in haphazard order
remodels and reorganizes into a a more
orderly structure.
Scar (cicatrix) forms - avascular tissue ,
doesn’t sweat, grow hair, or tan.
Keloid- abnormal amount of collagen laid
down, hypertrophic scar. ( common in dark
Types of Wound Healing
 Primary Intention: clean, straight line, edges
well approximated with sutures, rapid healing
 Secondary Intention: larger wounds with tissue
loss, edges not approximated, heals from the
inside out, granulation tissue fills in the wound,
longer healing time, larger scars
 Tertiary Intention: delay 3-5 days before injury
is sutured, greater access for pathogens to
invade, greater inflammation, more granulation,
larger scars .
Wound Complications
 Infection- S/S purulent drainage, pain, redness around
wound, edema, increased temp, elevated WBC
 Hemorrhage – S/S large amts sanquineous drainage +
other symptoms of hypovolemic shock. Check UNDER
 Dehiscence- S/S wound edges pulling away; not wellapproximated. Early sign = increasing serosanquineous
 Evisceration- S/S wound opens revealing internal organs.
Emergency rx = sterile NS gauze to cover; prepare for OR
 Psychosocial impact – Encourage verbalization of
feelings; encourage self-care as tolerated by client
Promotion of Wound Healing
Dressings: keep wound covered &
Wound bed moist / Surrounding skin
Debridement when necessary
Remove exudate:
Drains, Wound VAC, Irrigation
Pack wounds loosely
Nutritional interventions
Debridement Methods
Enzymatic ( proteolytic enzymes)
Wound Dressing
If exudate is present - Select one that
absorbs exudate.
Keep wound bed moist but surrounding
skin dry
Pack wounds loosely to avoid pressure on
new granulation tissue
Fasten securely using tape, binders etc…
OR self-adhesive type dressing materials.
Dressings for DRY wounds
 Transparent: gas exchanged between wound &
environment but bacteria prevented from
entering. Creates moist healing environment
Example: Tegaderm
 Hydrogels: High water content enhances
epithelialization and autolytic debridment.
Needs cover dressing and wound edge barrier
Example: Carrasyn
 Wet – to- Moist Gauze dressings: keeps
wound bed moist. Minimizes trauma to
granulation tissues
Dressings for DRY wounds
Wet – to Moist Gauze
Dressings for MOIST wounds
 Hydrocolloid: hydrophilic particles mix with water to
from a gel... wound stays moist. DO NOT use in infected
Example: Duoderm
 Absorption Materials: beads, powders, rope or sheets
that absorb large amount of exudate
Example: Calcium Alginate
 Foam: Made of hydrophilic material. Highly absorbent.
Example: Allevyn
 Dry Gauze: Can absorb wound drainage. Can be
impregnated with agents to promote healing
Dressings for MOIST wounds
Cleanses a wound using pressure
Sterile Normal Saline = usually prescribed
Avoid caustic agents ie: peroxide, iodine
Pressure between 4-15 pounds per
square inch (psi) i.e. 60ml syringe with
catheter tip
Other Therapies
Wound V.A.C. – negative pressure
vacuum assisted closure system.
Removes drainage and helps wounds
Hydrotherapy – Pulse lavage, Whirlpool
Aids in debridement and cleansing, warm
water vasodilation.
 Hyperbaric Oxygen
 Electrical Stimulation
Other Therapies
Electrical Stimulation:
- electrical signals direct
cell migration in wound
Bandages & Binders
Secures dressings in place
Determine size needed
Outer covering must cover entire wound
Tape to secure (initial,date time)
Heat & Cold Therapy
Heat- reduces pain & promotes healing
through vasodilation
Increases oxygen and nutrients to aid in
inflammatory response
Reduces edema by promoting removal of
excessive interstitial fluid
Promotes muscle relaxation
Heat & Cold Therapy
Cold- decreases pain by vasoconstriction
Decreased blood flow to the area
decreases inflammation and edema
Raises the threshold of pain receptors
thereby decreasing pain
Decreases muscle tension
Safety Precautions
Heat & Cold Therapy
Need physician’s order
Very young and very old
Peripheral vascular disease
Decreased LOC
Spinal cord injury
Presence of edema and/or scar tissue
NO LONGER than 20-30minutes at a time.
Rebound phenomena