WOUND CARE
WOUND- Damaged skin/soft tissue resuls from trauma (injury)
EX: Cuts, blows, poor circulation, excessive heat/cold/ blows
Open wound is surface of skin is not longer intact
ex: a surgeon makes incises on tissue
CLOSE WOUND- no opening in skin
ex: blunt trauma or pressure aka BRUISE
WOUND REPAIR
-consist of 3 phases INFLAMMATION, PROLIFERATION, AND REMODELING
INFLAMMTION- process after tissue injury, lasts 2-5 days
purpose: limit the local damage, remove injured cells/debri, and prepare wound
for healing.
1st stage of inflammation -BLOOD vessels constrict to control blood loss and control damage. Then the blood
vessel dilate to deliver platelet that form loose clot. damage cells become permable,
causing release of plasma/chemical substance that feels of discomfort.
2ND STAGE
when polymorphonuclear leukoctyes (neutrophils) and macrophages(monocytes) which white blood cells move to site of injury, and body produce more WBCs to
take their palce. Leukocytosis is increased production of WBCs is then confirmed
monitored by counting number and type of WBCs in sample of client blood. the LAB
test is called WBCs count and differential count. Increased production of WBCs suggest infammatory, infectionious process
NEUTROPHILS and MONOCYTES are responsible for phagocytosis (a process that cells emigrate from blood vessels to consume pathogens, coagulated blood,
and cellular debris. Consumed substancr are enclosed within lysosomes, enzymatic
sac, inside phagocytes that digest the engulfed matter. Once digestion occur, the degraded produced goes to extracellular fluid.* N AND M clean the injured area and
prepare the site for wound healing*
PROLIFERATION -period during new cells fill and seal a wound this occurs from 2-3 weeks after antiflamatorry phase. It is chactrazcited by the appearance of granulation tissue( combo of new blood vessels ,fribroblasts, and
epithelial cells) that form in the bed of open wound. *Granulation is irregular surface
and look bright pink to red b/c of extensive projections of capillaries in the area
GRANULATION tissue grows from outside margin of wound and move toward
center. It is fragile and easily disrupted by chemical and physical mean. As more fibroblast produce collagen (tough protein substance) the strength of ound increase
Toward the end of proliferation, new blood vessels degenerate, causing the pink
color to regress. Epithlelial cells use previously formed granulation as a surface to move
across as thry cover the sound again.
SKIN damaged/ tissues are restored by RESOULTION (process damaged cells
recover and reestablish normal function. REGENERATION (cell duplication)
SCAR FORMATION (replacement of damaged cell with frbrous scar tissue)
Fribrous scar tissue acts as nonfunctioning patch. The extend of scar tissue forms
depend on the magnitue of tissue damage and manner of wound healing.
REMODELING -period during wound undergoes changes and maturation this last 6 months to 2 years which wound contracts and scars shrink.
FIRST INTENTION HEALING
-a reparative process which wound edges are directly next to each other so because
the space between wound is so narrorow, only SMALL scar tissue forms. ex: STICHING a cut.
SECOND INTENTION HEALING
-wound eges are widely seperated, leading to more time consuming/ complex reparative process. granulation tissue need more time to extend the wound
THIRD INTENTION HEALING
-wound edges are intentionally left widely seperated and later brought togerher w/ some type of closure material. this result in broad, deep scar. 3rd intention
are deep and likely need drainge and tissue debris. drainage devices/ be packed w/
absorbent gauze to speed healing.
WOUND-HEALING COMPLICATIONS.
*keep to wound healing is enoigh blood flow to injured tisue.
factos that can cause disruptions are compromised circulation, infections, and purulent
(which is bloody, serous fluid) that prevent skin/tissue from healing. Pulling/turging at would can delay healing.Secondary conditions factors are:
impaired inflammory/immune response, poor nutrition, related to drugs like
carticosteroids, and obesitiy.
WHEN assessing wound alway important to look for :
undermining -eroison of tissue from underneath intact skin at wound edge
slough-dead tissue on wound surface thats moist, yellow,gray,green, stringy
necrotic tissue- dry,brown, or black devitalized tissue.
SLOUGH AND NECROTIC TISSUE MUST BE REMOVED TO PROMOTE
HEALING.
2 surgical wound complications are DEHISCENCE AND EVISCERATION
dehiscence- the seperation of wound edges
eviceration- wound seperation w/ the protrusion of organs.
They can cause insuffiencet dieratry intake of proten and sources of VIT C,
premature removal of sutures /staples, unusual strain on incision from severe coughing,
sneezing,vomiting, dry heaves, or hiccups
Pinkish drainage appear suddently on dressing.
if wound disrueption is suspected, nurse must posotion client to put least amount
of strain on open area.
IF evisceration occurs, nurse place serile dressing moistened w/ normal saline over
the protruding organs/tissue. NOTIFY physcian of any wound disruptions.
nurse must be alerted for sgin/symptons of impairfed blood flow such as swelling,
localized pallor, or mottled appearance, and coolness of tissue.
WOUND MANAGEMENT -technique to promote wound healing.
Surgical wounds result from incising tissue w/ laser or scalpel. The goal of surgical
or open wound management is to reapproximate the tissue to restore its integrity.
This involves changing dressing, caring for drains, remove suturees, or staples
whe directed by sugeon, apple bandages/binders and perform wound irragtion
Montogmery staps- strips of tape w/ eyelets
DRAINS- tubes that provide a mean for removing blood and drainae from wound
they promote wound healing by removing fluid and cellular debris.
***Some drains are placed directly on wound, the current trend is to insert them
so that they can exit from seperate location beside the wound.
this keep wound margins approxminated and avoid direct entry site for pathogens.
THE PHYSCIAN may choose to use an open or closed drain.
OPEN DRAINS
-are flat, flexibile tube that provide pathway for drainage towards the dressing
CLOSED DRAINS are tubes that terminate in a receptable.
ex: Hemovac and jackson-pratt drain.
*Closed drains are more effiencet than open drains b/c they pull fluid by creating a vccum or negativie pressure.
When caring for a wound with a drain, the nurse cleans the insertion site in a circular manner from the center outward. After cleansing, he or she places a precut drain sponge or gauze, which is open to its center, around the base of the drain. An open drain may require additional layers of gauze because the drainage does not collect in a receptacle.
VACCUM-ASSSITED CLOSUREaka NEGATIVE PRESSURE WOUND THERAP.
-foam filler within wound that is covered w/ sealed occlusive dressing connected to
a suction tube and pump. when inserted fluid and debris in entire wound bed are
pulled through foam filler into collection canister. The wound then shirnks, celliular
growth is promoted, blood flow increases, and healing imporves.Wound healing takes 6 months
SUTURES, STAPLES, ADN ADHESIVRS
SUTURES- knotted ties that hold incision togerher from silk/synthetic materials like
nylon.
STAPLES- wide metals perform similiar
glue adhesive glue- small minor cuts
adhevsive strip skin closure aka BUTTERFLIES -hold weak incision together temperatly
BANDAGES AND BINDERS bandage - strip or roll of cloth wrap around body
binder- type of cloth applied to certain body part like adomen or breast
BENEFITS: Holding dressing in place, whentape cant be use or dressing large
-supporting area around wound/injury to reduce pain
-limiting movement to promote healing
**BANDAGES dont keep wound clean, DRESSING DO. bandages hold dressing
inplace , support area, and limit movement.
ROLLER BANDAGE APPLICATION
*wrap distal to proximal direction
*elevate the limit
*keep free of wrinkles
check color /sensation of exposed finger /toes
*remove bandage for hygiene and replace twice a day
*avoid gaps
6 basic techniques used to wrap roller bandage :
circular , spiral, spiral-reverse, figure-of -eight , spica, and reccurent turn
DEBRIDEMENT
-removal of dead tissue to promote healing
4 METHODS OF DEBRIDEMENT are
sharp,enzymatic, autolytic, and mechanical
SHARP DEBRIDEMENT -removal of necrotic tissue from health area of wound w/ steril scissors,forceps or
other instruments
Very painful, may bleed.
ENZYMATIC
topically applied chemical substance that break down and liquefy wound debris.
a dressing used to keep enzyme in contact w/ wound and help absorb draiange
for: UNINFECTED WOUNDS or client who cant deal with shartp
AUTOLYTIC aka self-dissolution
-painfull, natrually phyical process that allow bodys enzyme to oft, liqueft, and release devitalized tissue. its used when sound is small and free of infection
bad nes: the time it takes achieve desired result. to accelerate autolysis
an occlusive/semicoocluve bandage is applied to keep wound moist.
MECHANICAL
-physical removal of debris from nonhealing woulds.
technique is maggot therapy
they are serilized and dumped into wou.d they secrete an enzyme that
dissolves dead tissue leaving healthy alone. When treatment is done they are
transferred to DOUBLE-BAGGED BIOHAZARD BAG
2ND TECHNIQUE
Hydropthery - the therapuetic use of water, which is submerged in a whirlpool tank
The agititation of water, containing antiseptic, soften the dead tissue. loose debris
that remain attach is remove afterward by sharp debridenemnt
3RD METHOD
IRRIGATION- A technique for flushing debris for cleaning an area of body such
as eyes,ears, and vagina.
PRESSURE ULCERS 4 STAGES
STAGE I - intact but reddened/ darkened skin.
PREVENTION /TREATMENT OF PRESSURE ULCER
STAGE II- ulcer is red and accompanied by blistering or skin tears without slough.
leads to infection of wound
STAGE III- shallow skin crater that extends to subcutaneoustissue.
It may be accompanied by serous drainage (leaking plasma) , undermining slough,
or purulent drainage (white/greenish fluid) caused by wound infection. its usually
painless despite severity of ulcer.
STAGE IV -life threatening, deeply ulcerated exposeing muscle and bone. Slough
and necrotic tissue may be evident.
1st- Identify clients w/ risk factors for ulcers
2nd- implement measures that reduce condition under ulcers are likely form
SHEARING FORCE- effect moves layers of tissue in opposite directions