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WOUND CARE

WOUND CARE. By Helen Harkreader, RN, PhD. Wound Healing Processes . Types of Wound Closures Primary Intention Sutures, staples, skin bonds, etc. Secondary Intention Partial thickness Regenerate specific cells Epithelialize Full thickness Regranulate Epithelialize Remodel

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WOUND CARE

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  1. WOUND CARE By Helen Harkreader, RN, PhD

  2. Wound Healing Processes • Types of Wound Closures • Primary Intention • Sutures, staples, skin bonds, etc. • Secondary Intention • Partial thickness • Regenerate specific cells • Epithelialize • Full thickness • Regranulate • Epithelialize • Remodel • Tertiary Intention • Processes Involved in Wound healing • Acute phase • Hemostasis • Inflammation • Proliferation • Remodeling • Chronic phase • Stalls for 2 weeks • Change Tx • Reassess full body, meds, labs.

  3. Wound Assessments • Etiology - watch those with ischemia • Size – consistent measure from nurse to nurse • L x W x D in centimeters (head to toe, 9 to 3 o’clock) • Locations of tunnels & undermining by the clock • Drainage – type (color, amount, consistency, odor) • Wound bed % of red, yellow, black tissues • Granulation, Slough, Eschar or tan crust or blister • Wound edges – rolled (epiboly), macerated • Peripheral tissues – discoloration, stains, scars? • Edema, induration, scaling (peeling), plaques? • Contaminated or infected?

  4. Wound Culturing • Cleanse the wound with saline • Irrigate till clear if it is a deep wound. • Use culturette that has 2 swabs • Wipe tissue in 1 cm2 area • Infection causing Bacteria is in the tissue • Do not get just a sample of the drainage • Multiple bacteria from peripheral tissues can be in the drainage • Submit to lab

  5. Nutrition for Wound Healing • Assessment of Nutrition - labs • Serum Albumin 18 to 20 days half-life • Affected by hydration (> if dehydrated, < if overhydrated) • Transferrin – 8 to 10 days half-life easily affected by other factors. • Prealbumin – 2 days half-life – best predictor • Nutrients needed for Wound healing • Calories –enough to support healing and other present disease processes • Protein • Vitamins

  6. Nutrients • Protein – fibroplasia, neogenesis, collagen formation, remodeling • Carbohydrates – energy and protein sparing • Fat - cell walls • Vitamins – A, B, C, D, E, K • Copper, Iron, Magnesium, Zinc

  7. Types of Wounds • Open wounds • Incisions, dehisced or delayed closure • Pressure ulcers • Arterial ulcers • Venous stasis ulcers • Neuropathic ulcers • Diabetic ulcers • Abcesses • Fistulas • Ostomies • Trauma, Burns • Closed Wounds • Incisions • Stitched, Stapled, Steri-stripped or Skin bonded • Pressure ulcers • Hematomas • Abcesses, nodules, various dermatologic types. http://www.medicaledu.com/pictures.htm

  8. Pressure Ulcers • Braden Scale – 16 points or below is considered a risk • Sensory Perception 4pts • Completely, very, slightly, not impaired • Moisture (4pts) • Constantly, very, occasionally, rarely moist • Activity (4pts) – bedfast, chairfast, walks occ, freq. • Mobility (4pts) • Completely, very, slightly immobile, no limitation • Nutrition (4pts) • Very poor, probably Inadequate, adequate, excellent • Friction & Shear (3pts) • Problem, potential problem, no apparent problem

  9. Pressure Ulcers • Stages • 1 intact, persistent redness • 2 partial thickness loss or blister • 3 full thickness loss to but not through fascia • 4 full thickness loss to muscle, bone, etc. • Unstageable –purple, yellow or black-must be removed before staging • Never back stage. • Prevention and treatment • Turn every 2 hours when in bed • Move every 15 minutes or at least every hour in wheel chair or chair • Apply appropriate dressing to manage drainage • Educate patient and family on reasons for treatment and causes of pressure ulcers. • Monitor q shift

  10. Stage 1 • Reddened boggy heel

  11. Stage 2 • Partial thickness loss • Or blister

  12. Stage 3 • Down to but not through the facia

  13. Stage 4 • To muscle, bone, tendons, etc.

  14. Unstageable Pressure Ulcers • Purple, yellow, black

  15. Other Ulcers • Arterial • Venous

  16. Other ulcers • Neuropathic • Diabetic

  17. Stay open-minded • Remain alert to all possibilities.

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