Wounds And Wound Care

Wounds and Wound Care Reference: Perry & Potter

Mary J. Aigner RN, MSN, FNPC

I. Different Types of Wound – by Cause 

Ulcers: considered chronic wounds … hard to heal    

Diabetic Venous Arterial Pressure

Prevention is easier than healing!

Traumatic or Unintentional “acute” wounds 

Minor Wounds (152627) - Handout    

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Skin Tears Abrasions Bruises Cuts

Major Traumatic Wounds 

Hemorrhage 1493

Surgical or Intentional

II. Classification Systems & Terminology 

Staging System (1488)  1, 2, 3, 4, or unable to stage

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Classification by Color (1491)  Red, yellow, black, mixed colors

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Skin Integrity  Is it Open or Closed?

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Severity  Penetrating?  Perforated?

Staging System: What stages are these?

Color System: What colors are these?

More on Wound Terminology 

Cleanliness (1490)

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Descriptives   

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Laceration Abrasion Contusion

Drainage Types (1494)

Cleanliness of Wound (1490) 

Clean 

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Clean – Contaminated 

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Presence of microorganisms likely

Infected 

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Wound made under aseptic conditions but in body cavity that normally harbors microorganisms

Contaminated 

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Contains no pathogenic organisms

Bacterial organisms usually > 100,000/gm tissue

Colonized 

Contains microorganisms – usually multiple (types)

Drainage (1494) 

Serous 

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Purulent  

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Thick Yellow, green, tan, or brown

Sanguinous 

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Clear, watery plasma

Bright red (active bleeding)

Serosanguinous  

Pale, red, watery Mixture of serous and sanguinous

III. Healing 

Barriers to healing (1498-1499)

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Nutrition (1496-1497, 1499)

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Physiology of Healing (1492-1493, 1640)

Barriers to Healing (1498-1499)          

Age Malnutrition Obesity Impaired Oxygenation Smoking Drugs Diabetes Radiation Wound Stress * Poor Care

Smoking & Healing 

Decreases functional Hgb in blood 

Hbg needed to bring O2 to cells

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Thought to increase platelet aggregation, hypercoagulability (clotting)

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Interferes with release of O2 to tissues

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*also vasoconstriction

Drugs & Healing 

Steroids

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Antiinflammatory

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Prolonged ATB use 

Risk of superinfection

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Chemotherapeutic Immunosuppressants

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Others

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IV. Who’s at Risk? 

Risk Factors for Pressure Ulcers (1496-1497)

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Prevention Techniques

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Braden Scale measures risk (1-4: 1 highest risk, 4 no/minimal risk)

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Sensory perception Moisture Activity Mobility

More at risk

How to Prevent? Be Knowlegeable 

Eliminating Pressure    

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Special mattresses/beds 

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Turning Positioning Elevating Pads (eg. Heel protectors)

Low air-flow

Keep clean/dry Pay attention to details 

Eg. Tubing, folds

V. Wound Care and Treatments 

Nursing Care Plan (1512-1513)  

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Assessment (1503-1509) 

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Bates-Jensen Wound Assessment Form (1522-1525)

Postop Assessment (1633)   

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Management of wounds (1518-1521, 1526) Critical Thinking (1500-1501)

Suture Care (1543-1547) Dressings Changes Drains (1508, 1547)

Cleansing of Wounds (1527, 1542)

Wound Care/Rx continued … 

Irrigation (1544-1546)

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Wound Packing (1536)

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Dressings/Bandages/Bi nders (1527-1536, 1547-1553)

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Specimen Collection (800, 1508-1509)

More Care/Rx …. 

Other Treatments 

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Heat/Cold Rx (1549, 1554-1560)

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Debridement   

Chemical Sharp Other  Maggots/Leeches  Wet to Dry Dressings

Wound Vac Systems (1538-1541)

Surgical Wound Treatment

VI. Complications (1493-1494)    

Evisceration (1637) Dehiscence (1637) Impairment (1498-1499) Infection (1400, 1620)  

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Nosocomial (780) Postop Infections (1637)

Wound Stress (1499) Scarring, Keloid Formation, Adhesions

Dehiscence & Evisceration 

Dehiscence    

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Separation of wound edges at suture line Usually occurs 6-8 days after surgery S&S: > drainage, can see underlying tissues *Can occur in nonsurgical clients

Evisceration   

Protrusion of internal organs/tissues through incision Usually occurs 6-8 days after surgery can occur in nonsurgical clients

Infections (780, 1499, 1620, 1637) 

How to tell? (assessment)

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What to do about it? (planning/intervention)

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Is it improving or worsening? (evaluation)

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Now what to do? (revise plan/intervention)