Tissue Healing and Wound Management

skin torn apart, has irregular edges

Blow from a sharp object

In tact skin with damage underneath

Small wound produced by a stab with a sharp pointed object

A crater like wound formed from erosion of the skin/and or mucous membrane and underlying structures

Cut with a sharp object...knife, scalpel.

Smooth edges

Propelled object enters skin and leaves a well defined hole

Bullet

Death of one or more cells or a portion of tissue or organ

painful, pale, crater like lesion.

Found on Big toe, between toes or on upper aspect of a foot.

Is usally cold with a weak or absent pulse

Necrotic, superficial, crater like lesion with minimal pain on ankles or lower legs.

Usually caused by chronic venous congestion.

Produces Copious Exudate

Any lesion caused by unrelieved pressure resulting in damage of underlying tissue.

Ulcers that develope on the plantar surface of the foot, heel or anywhere pressure is exerted or an area where a person can have vascular or neurological complications from Diabetes

scraping or wearing away of skin

• Advanced age
• Malnutrition
• Infection
• Immunosuppression
• Chemo
• Decreased blood supply

• Ischemia
• Venous Stasis
• SMOKING!!!

Nicotine causes vasoconstriction of the vessels, increasing platelet adhesiveness, RBC proliferation is reduced (diminishing oxygen transport).  Carbon monoxide diminishes oxygen transport and metabolism...less oxygen to tissues

• Redness (color)
• Edema
• Approximation
• Drainage
• Size

For length and width use the face of a clock.

• Length use 12 and 6
• Width measure from 3 to 9...is there tunneling?

Depth-insert a sterile cotton tipped swab in to deepest part of wound.

Record all measurements in cm

Tell what % of the wound  has yellow slough

Do the edges of the wound come together?  Or is it partially separated?

Is it present in or around it?

If it is black...necrotic and dead

If it is dark pink to beefy red and moist...it is revascularized and is HEALTHY

it is necrotic tissue which is ideal for bacterial growth.

Purulent or green and sticky, smelly= INFECTION

Must remove slough for wound to heel

Most severe must be removed first...

Black, yellow...want red

When the skin heals with a thin scar tissue formed at the closure site.  Wound edges approximate closely.

Achieved by sutures or staples

Large amount= Jackson Pratt or Hemovac. 

The device is kept compressed and negative pressure will withdraw fluid from the wound.

To get infectious debris away from the wound

The wound is left open to heal, permitting drainage of infectious material and debris from non sterile body cavity.

Example:  pressure ulcer, infected abscess, dehisced surgical wound

BIG SCAR

from the edges inward and from the base upward until it is all filled in.

Surgically debrided by doctor who then  leaves the wound open for 3-5 days allowing for drainage and a decreased chance of infection. 

Wound is closed by 1st intention, leaving a smaller scar.

• Absorbent
• Will absorb moisture and collect exudate

Purpose is to collect newly grown tissue, absorb excessive drainage away from the wound and keep the wound free of contamination

• Non absorbent
• Clear, transparent...acts like a second skin, but retains moisture too.

• It is left on until they begin to leak or the protective seal is broken
• Duoderm

• Hydrogels
• Alginates
• Foams

Sutures, staples, steri strips and fibrin sealers

• Normal Saline and Kara Klenz
• Neosporin
• Acetic Acid
• Dakins and Betadine

Per physicians orders

Allows for autolysis....mechanical debridement while allowing the bodies own natural process to debride the wound

keep it moist and surrounding INTACT skin DRY

• Immobilize and rest injured tissue-control bleeding
• Protect from futher injury/infection
• Convert to a clean wound by irrigation, packing and debridement
• Preserve blood supply to injured tissue
• Administer steroids with CAUTION
• Reduce swelling by elevating injured part
• GOOD NUTRITION
• Relieve pain
• Monitor for infection
• Document wound care given!!!

• First treatment of choice
• Cover or pack wound with dressing to keep it moist and surrounding skin dry and in tact.
• Allows the bodies natural defenses to clean the necrotic wound of debris.

INFLAMMATORY process in action

using medications or topical enzymes to break down necrotic tissue and liquefy slough

Using "wet to moist" gauze allowing for moisture to help the epithelization across the wound.  Will debride necrotic tissue, but with less trauma to the wound.

NEVER "wet to dry" any more!!  tears away newly generating tissue

• CSM checks
• Warm packs
• Hydrotherapy/whirlpool
• Compression dressings or wraps to promote circulation in extremeties with poor venous return

Delays it

Adequate NUTRITION

READS!!!

• Initial phase of inflammation
• Proliferative phase of granulation
• Remodeling phase of maturation

•  HIGH PROTEIN & Calorie diet
• With adequate carbs, fats, vitamins, minerals and rest.

POSITIVE nitrogen balance

• B-blood cell formation
• A-epithelization & collagen synthesis
• C-collagen formation & tissue synthesis
• K-coagulation

• Copper & iron-RBC's Hgb and collagen synthesis
• Zinc- protein synthesis and cell proliferation

• Nutrition supp. like Boost or Ensure
• Provide small meals & nutrient dense snacks
• Find something they like that is good for them and let them eat it all of the time if they want
• Give them ample eating time
• Encourage breakfast
• Monitor protein and serum albumin levels
• Monitor caloric intake....keep at 95% or must adjust

• Partial thickness (dermal and epidermal damage)
• Full thickness (tissue damage)

• Dont want to leave it open...will get infected
• Dont want to put an antacid on it, it has sugar in it and will promote bacterial growth
• Dont put heat on it...will dry it out
• Spend $$ on good treatments...worth it
• Topical lotions and creams need to be administered with double gloves or you will get the affects of the ointment yourself.

• Include:
• amount and type of dressings
• how to obtain supplies
• how often to change dressings
• how to change the dressing

WASH HANDS!!!

Dehiscence-partial or complete separation of upper layers of a wound

Evisceration-total separation of layers and extrusion of internal organs or viscera thru the open wound

• Dont panic
• If dehisced-cover with non adherent dressing.
• If eviscerated-cover wound with STERILE dressing moistened or saturated with normal saline
• Call MD STAT and stay with pt
• If eviscerated DONT re insert organs`

Penrose

Hydrogel

Alginates

Foams

All types of wounds

One that you suspect is infected....need a doctors order

One that is positive for pseudomonas

One that needs a broad spectrum antimicrobial