Wound Care Gops

7/30/2019 Wound Care Gops

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WOUND CARE


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Wounds2

A wound (damaged skin or soft tissue) resultsfrom trauma (general term referring to injury).

e.g. tissue trauma include cuts, blows, poor

circulation, strong chemicals, and excessive heator cold. Such trauma produces two basic types of

wounds: open and closed


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Wound Repair5

The process of wound repair proceeds in three

sequential phases:

Inflammation

Proliferation

Remodeling


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Inflammation6

Inflammation, the physiologic defenseimmediately after tissue injury, lasts

approximately 2 to 5 days. Its purposes are to

limit the local damage,

remove injured cells and debris, and

prepare the wound for healing.

Inflammation progresses through several stages


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Figure 28-1 The

inflammatory response. The

words in red are the five

classic signs and symptoms

of inflammation.


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During the first stage, local changes occur.Immediately following an injury, blood vesselsconstrict to control blood loss and confine thedamage. Shortly thereafter, the blood vessels

dilate to deliver platelets that form a loose clot.The membranes of the damaged cells becomemore permeable, causing release of plasma andchemical substances that transmit a sensation of

discomfort. The local response produces thecharacteristic signs and symptoms ofinflammation: swelling, redness, warmth, pain ,and decreased function.


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A second wave of defense follows the local

changes when leukocytes and macrophages(types of white blood cells) migrate to the site

of injury, and the body produces more andmore white blood cells to take their place.


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Proliferation10

Proliferation (period during which new cellsfill and seal a wound) occurs from 2 days to 3

weeks after the inflammatory phase. It ischaracterized by the appearance ofgranulation tissue (combination of new bloodvessels, fibroblasts, and epithelial cells), which

is bright pink to red because of the extensiveprojections of capillaries in the area.


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Granulation tissue grows from the wound

margin toward the center. It is fragile and easily

disrupted by physical or chemical means. As

more and more fibroblasts produce collagen(a tough and inelastic protein substance), theadhesive strength of the wound increases.


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Generally, the integrity of skin and damagedtissue is restored by:

Resolution (process by which damaged cellsrecover and re-establish their normal function),

Regeneration (cell duplication),

Scar formation (replacement of damaged cells

with fibrous scar tissue).


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Remodeling13

Remodeling (period during which the woundundergoes changes and maturation) follows

the proliferative phase and may last 6 months

to 2 years. During this time, the woundcontracts, and the scar shrinks.


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Wound Healing14

Several factors affect wound healing:

Type of wound injury

Expanse or depth of wound

Quality of circulation

Amount of wound debris

Presence of infectionStatus of the client's health


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Wound Healing Complications15

Factors that may interfere include

compromised circulation

infection

purulent

bloody

serous fluid accumulation that prevent skin and

tissue approximation drugs like corticosteroids

obesity.


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The nurse assesses the wound to determinewhether it is intact or shows evidence of unusual swelling

redness

Warmth

Drainage

increasing discomfort

Two potential surgical wound complications

includeDehiscence (separation of wound edges)Evisceration (wound separation with protrusion oforgans)


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Figure (28-4 ( A )Wound dehiscence( B )Wound evisceration).


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Wound Management18

Wound management involves

changing dressings

caring for drains

removing sutures or staples when directed by thesurgeon

applying bandages and binders

administering irrigations.


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Dressings19

A dressing purposes:

Keeping the wound clean

Absorbing drainage

Controlling bleeding

Protecting the wound from further injury

Holding medication in place

Maintaining a moist environment

The most common wound coverings are gauze,

transparent, and hydrocolloid dressings.


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Gauze Dressings20

Gauze dressings are made of woven cloth

fibers. Their highly absorbent nature makes

them ideal for covering fresh wounds that are

likely to bleed or wounds that exude drainage.

Unfortunately, gauze dressings obscure the

wound and interfere with wound assessment.


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Gauze dressings usually are secured with

tape. If gauze dressings need frequent

changing, Montgomery straps (strips of tape

with eyelets) may be used


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A) The adhesive outer edge ofMontgomery straps are applied

to either side of a wound .

B) The inner edges of Montgomery

straps are tied to hold a dressingover a wound. They prevent skin

breakdown and wound

disruption from repeated tape

removal when checking or

changing a dressing.


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Transparent Dressings23

Transparent dressings are clear wound

coverings. One of their chief advantages is

that they allow the nurse to assess a wound

without removing the dressing


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Figure 28-6 Transparent dressing.


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Hydrocolloid Dressings25

Hydrocolloid dressings are self-adhesive,opaque air- and water-occlusive wound

coverings . They keep wounds moist. Moist wounds heal

more quickly because new cells grow morerapidly in a wet environment.

If the hydrocolloid dressing remains intact, itcan be left in place for up to 1 week.


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Figure 28-7

A hydrocolloid dressing absorbs drainage into its matrix.


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Dressing Changes27

Nurses change dressings when a wound

requires assessment or care and when the

dressing becomes loose or saturated with

drainage.


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Drains28

Drains are tubes that provide a means forremoving blood and drainage from a wound.

They promote wound healing by removing fluid

and cellular debris


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Open Drains29

Open drains are flat, flexible tubes that provide a

pathway for drainage toward the dressing.

Draining occurs passively by gravity and capillary

action. Sometimes a safety pin or long clip isattached to the drain as it extends from the

wound.

As the drainage decreases, the physician may

instruct the nurse to shorten the drain


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Figure 28-8 An open drain is pulled from the wound, and the excess portion is cut.

A drain sponge is placed around the drain, and the wound is covered with a gauze

dressing.


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Closed Drains31

Closed drains are tubes that terminate in a

receptacle. Some examples of closed

drainage systems are a Hemovac.

Closed drains are more efficient than opendrains because they pull fluid by creating a

vacuum or negative pressure.


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Sutures and Staples32

Sutures, knotted ties that hold an incisiontogether, generally are constructed from silk or

synthetic materials such as nylon.

Staples (wide metal clips) perform a similarfunction. Staples do not encircle a wound like

sutures; instead, they form a bridge that holds

the two wound margins together.


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Sutures and staples are left in place until the

wound has healed sufficiently to prevent

reopening. Depending on the location of the

incision, this may be a few days to as long as2 weeks.


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Figure 28-10 ( A )Technique for suture removal( .B )Technique for staple removal.


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Bandages and Binders35

A bandage is a strip or roll of cloth wrappedaround a body part. One example is Crib

bandage.

A binder is a type of bandage generallyapplied to a particular body part such as the

abdomen or breast.


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Dbridement36

Some wounds require dbridement (removalof dead tissue) to promote healing. The four

methods for dbriding a wound are sharp,

enzymatic, autolytic, and mechanical.


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Sharp Dbridement37

Sharp dbridement is the removal ofnecrotictissue (nonliving tissue) from the healthyareas of a wound with sterile scissors, forceps,

or other instruments.


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Enzymatic Dbridement38

Enzymatic dbridement involves the use of

topically applied chemical substances that

break down and liquefy wound debris.

This form of dbridement is appropriate foruninfected wounds or for clients who cannot

tolerate sharp dbridement.


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Wound Irrigation39

Wound irrigation generally is carried out just

before applying a new dressing. This

technique is best used when granulation tissue

has formed. Surface debris should be removedgently without disturbing the healthy

proliferating cells.


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Heat and Cold Applications40

Heat and cold have various therapeutic uses

The terms hot and cold are subject to wide

interpretation


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Therapeutic Baths43

Therapeutic baths (those performed for otherthan hygiene purposes) help to reduce a high

fever or apply medicated substances to the

skin to treat skin disorders or discomfort.


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The most common type of therapeutic bath is

a sitz bath (soak of the perianal area). Sitzbaths reduce swelling and inflammation and

promote healing of wounds after ahemorrhoidectomy(surgical removal of

engorged veins inside and outside the anal

sphincter) or an episiotomy (incision that

facilitates vaginal birth).


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Pressure Ulcers45

A pressure ulcer is a wound caused byprolonged capillary compression that is

sufficient to impair circulation to the skin and

underlying tissue. The primary goal inmanaging pressure ulcers is prevention. Once

a pressure ulcer forms, however, the nurse

implements measures to reduce its size and to

restore skin and tissue integrity


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Pressure ulcers or sores, also referred to asdecubitus ulcers, most often appear over bony

prominences of the sacrum, hips, and heels.

They also can develop in other locations such

as the elbows, shoulder blades, back of the

head, and places where pressure is unrelieved

because of infrequent movement


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Figure 28-17 Locations where pressure ulcers commonly form( .A )Supine

position( .B )Side-lying position( .C )Sitting position.


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The tissue in these areas is particularly

vulnerable because body fat, which acts as a

pressure-absorbing cushion, is minimal.

Consequently, the tissue is compressedbetween the bony mass and a rigid surface

such as a chair seat or bed mattress. If the

compression on local capillaries continues

without intermittent relief, the cells die from

lack of oxygen and nutrition.


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Stages of Pressure Ulcers49

Pressure ulcers are grouped into four stages

according to the extent of tissue injury


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Figure 28-18

Pressure sore stages( .A

)Stage I( .B

)Stage II( .C

)Stage III( .D

)Stage IV.


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Stage I is characterized by intact but reddenedskin. The hallmark of cellular damage is skinthat remains red and fails to resume its normalcolor when pressure is relieved.

A stage II pressure ulcer is red andaccompanied by blistering or a skin tear(shallow break in the skin). Impairment of theskin may lead to colonization and infection ofthe wound.


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A stage III pressure ulcer has a shallow skin craterthat extends to the subcutaneous tissue. It may beaccompanied by serous drainage (leaking plasma)orpurulent drainage (white or greenish fluid)caused by a wound infection. The area is relativelypainless despite the severity of the ulcer.

Stage IV pressure ulcers are life threatening. Thetissue is deeply ulcerated, exposing muscle and

bone. The dead or infected tissue may produce afoul odor. The infection easily spreads throughoutthe body, causing sepsis (potentially fatal systemicinfection).


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Prevention of Pressure Ulcers54

The first step in prevention is to identify clients

with risk factors for pressure ulcers.The

second step is to implement measures that

reduce conditions under which pressure ulcersare likely to form.


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Nursing Implications57

Acute Pain

Impaired Skin Integrity

Ineffective Tissue Perfusion

Impaired Tissue Integrity

Risk for Infection

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