Metro Community College
Nursing Program
Nancy Pares, RN, MSN
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Age
◦ Elders: less elastic, drier, circulation impairment
longer regeneration
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Mobility
◦ Increased pressure leads to breakdown
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Nutrition
◦ Poor nutrition, less regeneration, dehydration leads
to poor turgor, increase risk of infection
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Sensation level
– Increased risk for pressure and breakdown
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Impaired circulation
– Decreased O2 supply impacts healing ability, vessel
disease, smoking
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Medications
– Side effects: itching, rashes
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Diabetes
– Impairs inflammatory response from hypoglycemia;
must maintain control of BS
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Moisture
– Leads to maceration
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Obesity
– Less blood supply in adipose tissue
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Fever
– Affects moisture and metabolic rate
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Infection
– Impedes healing
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Lifestyle
– Tanning, bathing, piercings
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Based on length of time wound existed and
the condition of the wound
Open/closed
– No breaks in skin vs. true break in skin
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Acute/chronic
– Short vs. prolonged healing
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Clean/contaminated/infected
– Uninfected vs. open traumatic vs. evidence of
infection
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Superficial
◦ Epidermis: friction, shearing, burns
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Partial
◦ Extend into dermis
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Full
◦ Extend into subcutaneous tissue
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Penetrating
◦ Involves internal organs
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Serous: clear-straw colored, watery
◦ Clean wounds
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Sanguinous: bloody
◦ Deep wounds
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Serosanguinous: pale pink (mixed)
◦ New wounds
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Purulent: yellow or green tinged pus
Purosanguinous: red tinged pus
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Regeneration
◦ Same process regardless of injury or tissues
◦ When wound involves only epidermis
◦ No scar
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Primary intention
◦ Minimal scarring
◦ Clean, surgical incision; edges well approximated
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Secondary intention
◦ Extensive tissue loss
◦ Wound not well approximated; heals from inner
surface to outer; epithelial tissue may look like
sign of infection
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Tertiary intention (delayed closure)
◦ Granulating tissue is brought together; initially
wound heals by secondary intention then is
sutured; moderate scarring
•
Inflammatory: cleansing stage lasts 1-5 days
– Hemostasis; vasoconstriction, platelets arrive at
site, clotting occurs
– Inflammation: vasodilatation, phagocytosis, scab
formation
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Proliferative: granulation stage lasts 5-21
days
– Fibroblasts form a bed of collagen
– Fills defects and produces new capillaries
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Maturation: epitheliazation, begins 2nd or 3rd
wk
– Contraction of wound edges; scar tissue formation;
scar tissue is 80% strong as original tissue.
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Hemorrhage
Infection
– 2-3 days in contaminated wound; 4-5 days post op
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Hematoma
Dehiscence: likely during inflammatory phase
Evisceration
– Place sterile saline soaked 4x4 over area
– Call MD or notify charge/ surgical emergency
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Fistula: abnormal passageway often from
infection
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Location
– Anatomic terms
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Size
– Length and width
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Appearance
– Type, color (Red, yellow black), condition,
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Skin around the wound
Drainage
Patient pain
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Cleansing and irrigation
◦ Use saline, dilute antimicrobial or commercially
prepared cleansers—no hydrogen peroxide, alcohol
or iodine; gentle is best;
hydrotherapy=debridement
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Caring for drainage devices : Vol 2
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Sharp
◦ MD or PT at bedside or OR
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Mechanical
◦ Wet to dry dressing-used less
◦ Hydrotherapy
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Enzymatic
◦ Topical agent
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Autolysis
◦ Uses body out mechanisms
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Gauze
Transparent
◦ Clear, semi permeable, non absorbent, often used
for IV sites
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Hydrocolloids/hydrogels
◦ Water loving particles that form a gel with exudate
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Absorption
See page 840 table
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Securing dressings
– Tape, Montgomery straps
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Binders
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Important Nursing interventions
– See 34-6,7 Vol 2
– Inspect skin, assess and change dressings as
ordered
– Always ACE wrap distal to proximal
– Assess for circulatory impairment
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Clients at risk
– Very old or very young
– Sensory impairment
– Body areas: highly vascular—fingers, hands, face
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Moist heat
•
Dry heat
– Moisture amplifies the treatment; vasodilates,
reduces muscle tension
– Use with great caution
•
Vasoconstriction
– Decreases edema and inflammation
– Acts as a local anesthetic
– Slows bacterial growth
– Used in the first 24 hrs following injury
– R-est
– I-ce
– C-ompress
– E-levate
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Surgical asepsis
◦ Absence of all microorganisms
◦ Slightest break in technique=contamination
◦ Sterile object is only sterile when touched by
another sterile object
◦ When in doubt….throw it out….
◦ Place only sterile objects on a sterile field
◦ Sterile object or field that is out of visual range is
contaminated
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If exposed to air for a prolonged
time=contaminated
Sterile border =field plus 1 inch
Do not reach over a sterile field
Keep hands in front and above waist in field
of vision
Procedures which require sterile technique
◦ Injection preparation , catherizations