WOUND CARE- skin is the body’s first line of defense protecting the underlying structures from invasions by organisms- intact skin surface is important, because a break or disruption is potentially dangerous and possibly life

threatening- nurses play a major role in maintaining skin integrity by identifying risk factors that predispose a patient’s

risk for impaired skin integrity, and in providing specific wound care when breaks in integrity arise- knowledgeable and skilled wound care is essential- individualized plan of care is developed to asses, to identify and prevent, and to provide physical and

emotional support

wounds – break or disruption in the normal integrity of the skin and tissues- range from a small cut on the finger to a third-degree burn covering almost all of the body- result from mechanical forces (ex. surgical incisions) or physical injury

WOUND CLASSIFICATIONIntentional – result of planned invasive therapy or treatment

- wound edges are clean and bleeding is usually controlled, risk for infection is decreased

Unintentional – occur from unexpected trauma, such as accidents, forcible injury (ex. stabbing or gunshot), and burns- wound occur in an unsterile environment, contamination is likely- edges are usually jagged, multiple trauma is common and bleeding is uncontrolled- high risk for infection and longer healing time

Open – occurs from intentional or unintentional trauma- skin surface is broken with bleeding, tissue damage- increased risk for infection with the possibility of delayed healing

Closed – results from a blow, force, or strain caused by trauma such as a fall, an assault, or a motor vehicle crash- skin surface is not broken, but soft tissue is damaged, internal injury and hemorrhage may occur

Acute – ex. surgical incisions, usually heal within days to weeks- wound edges are well approximated, risk for infection is lessened

Chronic – do not progress through the normal sequence of repair- edges are often not approximated, risk of infection is increased- normal healing time is delayed- include deep pressure ulcers and peripheral vascular arterial or venous ulcers

Partial-thickness – all or portion of the dermis is intactFull-thickness – dermis and underlying subcutaneous fat tissue is also damaged or destroyed

WOUND HEALING- injured tissues are repaired by physiologic mechanisms that regenerate functioning cells and replace

connective tissue cells with scar tissue- fills the gap caused by tissue destruction, restoring the structural integrity of the damaged tissue through

the orderly release of growth factors and chemical mediators- chemical substances help to increase the blood supply to the damaged area, wall off and remove cellular

and foreign debris and initiate cellular developmentPHASES OF WOUND HEALING

Epithelialization – fill in, cover or seal a wound

- intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention

- large or open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention

- if healing by first intention becomes infected, it will heal by secondary intention- connective tissue healing and repair have differences that include the length of time required for each

phase and the extent of granulation tissue formed

Inflammatory Phase – begins at the time of injury and prepare the wound for healing- activities include hemostasis (blood clotting) and vascular and cellular phase of inflammation- blood vessels dilate and capillary permeability increases to allow plasma and blood components to

leak out into the area that is injured, forming a liquid called exudate- exudate causes swelling and pain- increased perfusion results in heat and redness- if wound is small, the clot loses fluid and a hard scab forms to protect the injury

- macrophages are essential to the healing process- not ingest debris but also release growth factors that are necessary for the growth of

epithelial cells and new blood vessels and for attracting fibroblasts that help to fill in the wound

- generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise

Proliferative Phase – begins within 2 to 3 days of injury- new tissue (granulation tissue) forms the foundation for scar tissue development

- highly vascular, red, and bleed easily- adequate nutrition and oxygenation, as well as prevention of strain on the suture line, are important

patient care considerations

Remodeling Phase – final stage that begins about 3 wks. after the injury, possibly continuing for as long as 6 months- collagen is haphazardly deposited in the wound, making the healed wound stronger and more like

adjacent tissue

scar – avascular collagen tissue that does not sweat, grow hair, or tan in sunlight

FACTORS AFFECTING WOUND HEALINGAge – children and healthy adults heal more rapidly than older adults

- older adults are more likely to have one or more chronic illnesses, with pathologic changes that impede the healing process

Circulation and Oxygenation – adequate blood flow to deliver nutrients and oxygen and to remove local toxins, bacteria, and other debris is essential for wound healing- large amounts of subcutaneous and tissue fat (which has fewer blood vessels) may slow healing

because fatty tissue is more difficult to suture, more prone to infection, and takes longer to heal

- oxygenation of tissue is decreased in people with anemia or chronic respiratory disorders and in those who smoke

Nutritional Status – healing requires adequate proteins, carbohydrates, fats, vitamins, and minerals to rebuild cells and tissues- healing is slowed or inadequate in the patient with poor nutritional status and fluid balance

Wound Condition – infected wounds or wounds that retain foreign bodies heal slowly

Health Status – corticosteroids decrease the inflammatory process, delaying healing- radiation depresses bone marrow function, resulting in decreased leukocytes and an increased risk

of infection- chronic illness (ex. cardiovascular disease) or impaired immune function can impair healing

WOUND COMPLICATIONSInfection – bacteria can invade a wound at the time of trauma, during surgery, or at any time after the initial

wound occurs- symptoms of infection usually become apparent within 2 to 7 days after the injury or surgery

- symptoms include purulent drainage, increased drainage, pain, redness, and swelling in and around the wound, increased body temperature, and increased white blood cell count

Hemorrhage – may occur from a slipped suture, a dislodged clot from stress at the suture line or operative site, infection, or the erosion of a blood vessel by a foreign body (such as a drain)- dressing (and wound) must be checked frequently during the first 48 hours after surgery and no

less than every 8 hours thereafter

Dehiscence – partial or total disruption of wound layersEvisceration – protrusion of viscera through the incisional area

- the most serious postoperative wound complications- patients at greater risk for these complications are those who are obese or malnourished, have

infected wounds, or experience excessive coughing, vomiting, or straining- if either complication occurs, cover the wound area with sterile towels soaked in sterile 0.9%

sodium chloride solution and notify the physician immediately- emergencies that require prompt surgical repair

Fistula Formation – abnormal passage from an internal organ to the skin or from one internal organ to another- postoperative fistula formation is most often the result of delayed healing, commonly manifested by

drainage from an opening in the skin or surgical site

PSYCHOLOGICAL EFFECTS OF WOUNDSPain – often increased by activities such as ambulating, coughing, moving in bed, and dressing changes

Anxiety and Fear – apprehension about the possibility of the wound opening, how much privacy will be lost as the wound is being cared for, and how they and others will react to the appearance and smell of the wound

Changes in Body Image – when the skin and tissues are traumatized, that image is changed, requiring the person to adapt and reformulate the concept of self- wounds and scars that are visible can result in feelings of conspicuousness, ugliness, and

diminished self-worth- large scars, such as from removal of a breast or from creation of colostomy opening, can seriously

affect the person’s sexuality, social relationships, and self-concept

NURSING PROCESS FOR WOUND CAREAssessing – involves inspection (sight and smell) and palpation for appearance, drainage, and pain

- includes sutures, any drains or tubes, and manifestations of complications

Appearance – approximation of wound edges, color of the wound and surrounding area, drains or tubes, staples or sutures, and signs of dehiscence or evisceration- healthy healing surgical wound appears clean and well approximated

- initially edges are reddened and slightly swollen- after approx. 1 wk, the skin is closer to normal in appearance with wound edges

healing together- may at first be bruised but this too returns to normal as blood is restored

- when infection is present, the wound is swollen and deep red- feels hot on palpation and drainage is increased and possibly purulent- foul odor may also be noted- if dehiscence is impending or present, the wound edges are separated

Drainage – inflammatory response resulting in the formation of exudate, which then drains from the wound- exudate is described as:serous = primarily clear, serous portion of the blood and from serous membranes

- clear and watery

sanguineous = large numbers of red blood cells and looks like blood- bright red drainage is indicative of fresh bleeding- darker drainage indicates older bleeding- surgical wounds most commonly have a mixture of serum and red blood cells

(serosanguineous)

purulent – made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria- drainage is thick, often has a musty or foul odor, and varies in color (such as dark

yellow or green), depending on the causative organism

- amount and color depend on the wound location and size- drainage can be assessed on the wound, on the dressings, in drainage bottles or

reservoirs, or possibly under the patient

Pain – increased or constant pain from the wound require further assessment- pain may indicate delayed healing or an infection

Sutures and Staplesskin sutures – may be black silk, synthetic material, fine wire, metal skin clips, or metal

stapes to hold tissue and skin together- typically removed in 6 to 8 days

retention sutures are used to provide extra support for obese patients or wounds with an increased risk of dehiscence

- removed when the wound has developed enough tensile strength to hold the wound edges together during healing- this stage varies from patient to patient, depending on age, nutritional status, and

wound location- small adhesive wound closure strips (Steri-strips) may be applied directly to the wound to

help hold it together

Related Assessments – evaluate the patient’s general condition and laboratory test results- be alert for signs and symptoms of infection which may cause generalized malaise,

increased pain, anorexia, and an elevated body temperature and pulse rate

DiagnosingImpaired Skin Integrity – state in which an individual has altered epidermis or dermis

Outcome Identification and Planning - plan of care is directed toward facilitating the patient’s return to health by providing interventions that facilitate wound healing, reduce the risk for complications, and

promote psychosocial adaptation

Implementing - nursing interventions focus on preventing infection and promoting would healing; preventing further injury or alteration in skin integrity; promoting physical and emotional comfort; facilitating coping

Changing Dressings- goal of wound care is to promote tissue repair and regeneration so that skin integrity is

restored- moist environment is best for wound healing

dressing – protective cover over a wound- closed method uses a dressing- open method does not use a dressing- most dressings, especially those used for surgical wounds, consist of three layers

contact layer – dressing applied directly over the wound, allows drainage to pass into the middle layer- this layer should be able to be removed without causing further tissue damage

middle layer – absorbs the drainageouter layer – keeps the two inner layers in place

Purposes: * provide physical, psychological, and aesthetic comfort* remove necrotic tissue * prevent, eliminate, or control infection* absorb drainage * maintain a moist wound environment* protect the wound from further injury* protect the skin surrounding the wound

Supplies – items needed vary with the type, location and amount of wound drainagecleaning agents – sterile 0.9% sodium chloride solution is usually the agent of choice

- any agent other then o.9% sodium chloride may have possible caustic effects on the skin, tissues, and granulation tissue

dressing materials – number and types used depend on the location and size of the wound as well as the amount and type of drainage- incision line is often covered with sterile petrolatum gauze or a special gauze

called Telfa (shiny outer surface is applied to the wound and allows drainage to pass through)

- protective dressings prevent outer dressings from adhering to the wound and causing further injury when removed- gauze dressings are commonly used to cover wounds- special gauze dressings are precut halfway to fit around drains or tubes- larger dressings are placed over the smaller gauze and absorb drainage and protect the wound- transparent dressings are applied directly over small wounds or tubes

- occlusive, decreasing the possibility of contamination while allowing visualization of the wound- used over intravenous sites, subclavian catheter insertion sites, and noninfected healing wounds

tape - materials used to secure the dressing and support the wound- come in wide varieties of sizes and types

Cleaning a Wound and Applying Clean Dressing- prepare the patient for the dressing change before starting the procedure by explaining what will be

done- help the patient into a position that is comfortable and also convenient for changing the dressing- expose only the area necessary to perform the wound care while maintaining proper draping- use appropriate aseptic techniques

- be especially vigilant in performing hand hygiene before and after changing dressings- no standard frequency for how often dressings should be changed

- depends on the amount of drainage, physician’s preference, and nature of the wound- physician to perform the first dressing change, usually within 24 to 48 hrs after surgery,

with nurses doing the needed or daily changings- frequency of dressing changes is noted on the patient’s plan of care

- remember, wound contamination occurs through a moist medium- always replace dressings with fresh dressings or reinforce the dressing with additional

dressings before drainage causes saturation

Wound Drains, Tubes, and Catheters- variety of drains, catheters, or tubes may be inserted into or near a wound when it is anticipated

that a collection of fluid in a closed area would delay healing- ex. Penrose drain – open drainage system consisting of a hollow open-ended tube

- sometimes physician orders for Penrose drain to be shortened daily- closed drainage systems are used more often than incisional drains

- cuts infection rate in half when placed through a stab wound (separate opening) rather than the incision- consists of a drainage tube that may be connected to an electrical suction device or have a

portable built-in reservoir to maintain constant low suction- prevents microorganisms from entering the wound from saturated dressings- allow accurate measurement of drainage- ex. Jackson Pratt drainage tube or Hemovac

Collecting a Wound Culture – if assessment of the wound indicates a possible infection, obtain a specimen of the drainage and send it to the lab for culture and sensitivity- explain the procedure to the patient- gather equipment, don clean gloves, remove dressing, use aseptic technique to don sterile

gloves and clean wound, remove sterile gloves, use sterile cotton tipped swab to collect specimen (carefully insert swab into wound and roll gently - - use another swab if collecting from more than one site) , place inside uncontaminated culturette tube without touching outside of container, label specimen container, attach lab requisition and send to lab within 20 minutes, record collection of specimen, appearance of wound and description of drainage in chart

Irrigating and Packing a Wound - irrigation – directed flow of solution over tissues

- purposes include cleaning the area of pathogens and other debris and applying local heat or an antiseptic to the area

- nonsterile solutions are used of wound is closed- sterile equipment and solutions (0.9% sodium chloride, sterile water, antiseptic, antibiotic

solution) are used for open wounds - sterile, large volume syringe is used to direct the flow

Caring for Draining Wounds - similar to that of wounds with little or no drainage- if wound care is uncomfortable, administer a prescribed analgesic 30 – 45 minutes before

changing the dressing- also plan to change the dressing midway between meals so that the patient’s

appetite and mealtimes are not disturbed- use an ointment or paste on the surrounding clean skin to act as a protective barrier to

prevent skin irritation and excoriation from wound drainage- remove ointment or paste daily, cleaning the skin thoroughly after removal using as little rubbing as possible

- first layer of dressing material is often nonabsorbent or hydrophilic (carries moisture) applied directly to the draining wound and is less likely to stick to patient- this allows drainage from the wound to move into overlying absorbent layers, helping to prevent maceration and reinfection

- material to absorb and collect drainage is then placed over the first layer of nonabsorbent material- material acts as a wick, pulling drainage out by capillary action- cotton-lined gauze sponges soak up more liquid than unlined sponges- number of gauzes used in the dressing depends on the amount of drainage- fluffy and loosely packed dressings are more absorbent than tightly packed

- top of dressing may be further protected by surgical or abdominal pads, which are thick, absorbent pads that help to absorb profuse drainage

- draining wounds often require more frequent dressing changes than those without

Caring for Open Wounds - because cellular migration needed for tissue repair and healing is enhanced by a moist surface, a moist (rather than wet) packing for open wounds is recommended- apply packing loosely and only to the edges of the wound- cover the wound with a secondary dressing to absorb drainage

- if packing dries, soak with 0.9% sodium chloride solution before removal to prevent it from sticking to the healing tissue and causing injury

Classifications – based on assessment of wound color- wounds that have all three colors are categorized as mixed wounds- when all colors are present, treat first for the most serious color (black), followed

by yellow and finally red

Red – proliferative stage of healing and reflect the color of normal granulation tissue- protection is provided with nursing interventions that include gentle cleansing, use

of moist dressings, application of a transparent or hydrocolloid dressing, and changing of the dressing only when necessary

Yellow – characterized by oozing from the tissue covering the wound, often accompanied by

purulent drainage- nursing interventions include irrigating the wound; using wet-to-moist dressings;

using nonadherent, hydrogel, or other absorptive dressings; and consulting with the physician about using a topical antimicrobial med.

Black – wounds covered with thick eschar (necrotic tissue) which is usually black but may also be brown, gray, or tan- requires debridement (removal) before wound can heal

sharp debridement (using a scalpel or scissors to cut away the dead tissue)

mechanical debridement (scrubbing the wound or applying a wet to-moist dressing)

chemical debridement (using collagenase enzyme agents)autolytic debridement (using a dressing that contains wound moisture to

help the body produce enzymes to break down the eschar)

Caring for Chronic Wounds – follow the same general procedures for any other wounds

- moisture-retentive materials, and different treatments, such as vacuum-assisted closure therapy, many be used- vacuum-assisted closure therapy is the application of negative pressure to pull the

cells closer together- allows epithelial cells to multiply rapidly and form granulation tissue- increases cell proliferation, stimulates blood flow to wounds, and stimulates the

growth of new blood vessels

HEAT AND COLD THERAPY- heat / cold applied to bring about local or systemic change in body temperature for various therapeutic

purposes- physiologic responses are modified by method & duration of app., degree of heat & cold applied, patient’s

age & physical condition, and amount of body surface covered by app.- initially, heat and cold skin receptors are strongly stimulated by sudden changes in temperature- inform patients that increasing the temperature or lengthening the time of application can seriously damage

tissues

EFFECTS OF APPLYING HEAT- dilates peripheral blood vessels, increases tissue metabolism, reduces blood viscosity and increases

capillary permeability - vasodilation increases local blood flow → oxygen and nutrients to area is increased → venous

congestion is decreased → viscosity of blood is reduced and capillary permeability improves delivery of leukocytes and nutrients → removal of wastes increases → prolonged clotting time (all together accelerate inflammatory response to promote healing)

- reduces muscle tension to promote relaxation and helps to relieve muscle spasms and joint stiffness- helps relieve pain by stimulating specific nerve fibers, closing the gate that allows the transmission of pain

stimuli- used to treat infections, surgical wounds, inflamed tissue, arthritis, joint and muscle pain, dysmenorrheal,

and chronic pain- systemic effects include increased cardiac output, sweating, increased pulse rate, and decreased blood

pressure- produces vasodilation in 20 – 30 minutes, if continued beyond that time, tissue congestion and

vasoconstriction occur

EFFECTS OF APPLYING COLD- application constricts peripheral blood vessels: reduces blood flow to tissues and decreases the local

release of pain-producing substances such as histamine, serotonin, and bradykinin which in turn reduces the formation of edema and inflammation

- reduces muscle spasms, alters sensitivity (producing numbness), and promotes comfort by slowing the transmission of pain stimuli

- used after direct trauma, for dental pain, for muscle spasms, after sprains, and to treat some chronic pain syndromes

- maximum vasoconstriction occurs when the skin reaches 15°C (60°prolongedF) then vasodilation begins- exposure produces systemic effects of increased blood pressure, shivering and goose bumps

NURSING PROCESS FOR APPLYING HEAT / COLDAssessing – carefully evaluate factors influencing the patient’s ability to tolerate heat and cold apps.

* How long will the application be? * What body part is involved?* Is the skin intact? * How large is the area?* What’s the patient’s age? * What is the patient’s physical condition?

Before initiating heat or cold therapy, assess:a. patient’s physical and mental status – include obtaining health history and completing a physical

exam

- cardiovascular or peripheral vascular impairment, sensory impairment, and alterations in mental status (confusion or decreased level of consciousness) indicates the need for caution when using heat or cold because of danger of tissue damage

- assessments include response to stimuli (sharp and dull), color and appearance of body tissues, circulation (pulses, blanching sign, temperature, and color), level of consciousness, and orientation

- heat should not be applied to an open wound immediately after trauma; during hemorrhage; over noninflammatory edema; to an acutely inflamed area, a localized malignant tumor, the testes, or the abdomen of a pregnant woman; or over metallic implants

- cold should not be used for open wounds or for patients with impaired peripheral circulation or allergy to cold

b. area of application – risk for damage to tissues is increased if the area is traumatized or has altered integrity- assess for open lesions, blisters, wounds, edema, bleeding, or drainage or evidence of

altered circulation, such as changes in color, temperature, pulses, and sensation- tissues with decreased or absent pulses, those that appear pale or cyanotic, and those that

feel cold to the touch indicate a decrease in circulation- ongoing assessments are made to ensure patient safety and comfort

- when heat is used, assess for undesired responses, including localized redness, blistering, and pain (symptoms of burning), with possible systemic responses, such as hypotension and changes in consciousness

- when cold is used, assess for localized responses, including pallor, cyanosis, numbness, and pain

c. condition of equipment – nurse is responsible for checking the equipment used and for maintaining patient safety- condition of cords, plugs, and heating or cooling elements should be checked- DO NOT USE FAULTY EQUIPMENT

Diagnosing – possible nursing diagnoses including Ineffective Thermoregulation, Ineffective Tissue Perfusion, Acute Pain, Risk for Injury

Outcome Identification and Planning – when applications of heat or cold are part of a plan of care, the following outcomes are appropriate:* verbalize increased comfort* demonstrate evidence of wound healing, decreased muscle spasms, decreased edema, and

increased comfort* verbalize and demonstrate safe hot or cold application

Implementing – heat and cold applications may be moist or dry, using many forms and methods- prescription should include type of application, body area to be treated, and frequency & length of

time for application- explain the purpose and steps of the application and sensations that will be experienced

Applying Heat – dry and moist methods include:hot water bags or bottles – relatively easy and inexpensive to use

disadvantages = may leak, often the weight of the bag or bottle on the patient’s body part can be uncomfortable, and the danger of burns from improper use

electric heating pads – easy to apply, relatively safe to use and provides constant and even heat (improper use can result in injury)- avoid using pins to secure a heating pad- place a cover over the pad

- do not cover the heating pad with anything that might be heavy- place heating pad anteriorly or laterally to, not under, the body part- use heating pad with selector switch that cannot be turned up beyond a safe temp.- assess the skin at regular intervals for the effects of excessive exposure to heat

hot compresses or packs, sitz baths, or soaks provide moist heat by conduction

Applying Coldice bags – relatively easy and inexpensive

disadvantages = may leak, often the weight of the bag or bottle on the patient’s body part can be uncomfortable, and the danger of burns from improper use

- fill bag with small pieces of ice to about 2/3 full, then remove air- test for leaks and wipe off excess moisture- place cover on ice bag to provide comfort and to absorb moisture- apply ice bag for 30 minutes, remove for about 1 hour before reapplying- in home setting, a bag of frozen vegetables makes a good substitute

cold packs – sealed containers filled with a chemical or nontoxic substance- frozen in freezer or (if not frozen) squeezed to activate chemical that produces cold- frozen solution remains pliable and can be easily molded to fit body part- covered with ribbed cotton sleeve so that bag can be slipped onto extremity or

placed on body part- skin beneath the pack should be assessed periodically for symptoms of numbness

and painhypothermia blankets – apparatus has coils through which a refrigerated solution circulates

- place hypothermia blanket on bed and cover with a sheet - connect cooling blanket to machine and select temperature setting- insert probe into patient’s anus to monitor body temp every 15 min.

- monitor all vitals every 30 min.- set temp. control at 98.6°F (37°C), decreasing it 2° to 3° every 15 min. until

ordered temp is reached- when treatment is discontinued, turn off the machine and continue to monitor temp

every 2 hrs for 24 hrs- assess patient for shivering, fluid status, edema, and altered skin integrity

moist cold – used for injured eye, headache, tooth extraction, and sometimes hemorrhoids- texture and thickness of material used depend on area treated- change compress frequently, continuing application for 20 min.- repeat application every 2 – 3 hrs as ordered

Evaluating – expected outcomes included as part of plan of care used to evaluate effectiveness of planned interventions- nursing care considered effective if patient is able to:

* verbalize increased comfort and ability to rest and sleep* demonstrate evidence of wound healing* demonstrate decrease in symptoms of muscle spasms, inflammation and edema* verbalize and demonstrate safe hot and cold applications