WOUND HEALING

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nikkiknak
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39480
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WOUND HEALING
Updated:
2010-10-04 16:27:58
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wound healing
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NURSING LEVEL 1 TEST 3 wound healing
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  1. CLASSIFICATION of WOUNDS
    • OPEN
    • involves disriuption or break in the skin
    • CLOSED
    • no break in skin (bruise)
    • INTENTIONAL
    • occurs during treatment (i.e. surgery, radiation burn, venipuncture, drawing blood)
    • UNINTENTIONAL
    • accidental (i.e. fracture caused by a fall, stabwound)
  2. WOUNDS: DESCRIBED BY HOW ACQUIRED
    • INCISION
    • caused by sharp instrument (surgical)
    • CONTUSION
    • blow from blunt force (bruise)
    • ABRASION
    • surface scrape (intentional or accidental)
    • PUNCTURE
    • penetration of skin & possibly underlying tissues from sharp instrument
    • LACERATION
    • open wound with jagged edges
    • PENETRATING
    • goes through skin, into body cavity or organ
    • PRESSURE ULCER
    • related to excessive pressure on body site
  3. WOUNDS ARE DESCRIBED BY DEGREE OF WOUND CONTAMINATION
    • CLEAN
    • free of infectious organisms
    • CONTAMINATED
    • containing microorganisms and includes:
    • -open, fresh accidental wound
    • -surgical wound involving major break in sterile technique
    • -surgical wound where there is spillage from GI tract
    • DIRTY OR INFECTED
    • -old, accidental wound containing dead tissue
    • -wound with evidence of infection (i.e. purulent drainage)
  4. PHYSIOLOGY OF WOUND HEALING: PHASES
    • INFLAMMATORY PHASE
    • time of injury - day 3 or 4
    • PROLIFERATIVE OR RECONSTRUCTIVE PHASE
    • day 4-21
    • MATURATION OR REMODELING PHASE
    • day 21-2 years
  5. PHYSIOLOGY OF WOUND HEALING: INFLAMMATORY PHASE
    • first 3-4 days of injury
    • -blood supply to wound increases, bringing nutrients and substances necessary for healing process
    • -area appears red and edematous (signs of infection, but normal in this phase)
    • PAIN is experienced
  6. PHYSIOLOGY OF WOUND HEALING: INFLAMMATORY PHASE
    2 major processes
    • HEMOSTASIS (clotting)
    • -vasoconstriction for control of bleeding
    • -platelet accumulation
    • -deposition of fibrin and formation of blood clots to provide a fibrin matrix
    • -scab formation on surface of wound aids hemostasis & inhibits wound contamination

    • PHAGOCYTOSIS
    • -leukocytes (neutrophils) move in
    • -macrophages engulf, digest microorganisms to clean debris from wound bed
    • -shedding of dead tissue occurs
  7. PHYSIOLOGY OF WOUND HEALING: PROLIFERATIVE PHASE
    • GRANULATION
    • -new capillaries grow across wound, increasing blood supply
    • -tissue becomes translucent red, fragile, bleeds easily
    • EPITHELIALIZATION
    • -when granulation tissue matures, epithelial cells migrate to it to fill wound bed.
    • SCAR FORMATION
    • -if wound has greater tissue loss, healing occurs from inside out.
    • -fibroblasts migrate to wound & initiate collagen synthesis (protein substance that adds strength)
    • -progressive accumulation of collagen forms basic structure of scar.
  8. PHYSIOLOGY OF WOUND HEALING: MATURATION OR REMODELING PHASE
    • -fibroblasts continue to synthesize collagen
    • -maturation of scar occurs

    **scar tissue never exceeds 80% of pre-injury strength**
  9. TYPES OF WOUND HEALING
    • PRIMARY INTENTION
    • -occurs when tissue surfaces are approximated (brought together or closed)
    • -minimal or no tissue loss
    • -heals with minimal granulation tissue and scarring (scar is thin, flat)
    • --->examples: minor clean cut; surgical incision with surgical closure
    • SECONDARY INTENTION
    • -wound edges cannot be approximated due to tissue loss and type of wound
    • -repair time is longer
    • -epithelialization occurs from wound margins
    • -scarring is greater
    • -allowed to heal and close on own
    • -greater susceptibility to infection (i.e. pressure ulcer; large, irregular, or infected wounds)
    • TERTIARY INTENTION
    • delayed closure
    • -occurs in wounds which may be contaminated, infected, or draining excessive exudate
    • -wound is intentionally left open to permit drainage of contaminated material
    • -wound is surgically closed when infection has cleared & initial granulation has taken place
    • i.e. contaminated abdominal wound
  10. FACTORS AFFECTING WOUND HEALING
    • HYGIENE
    • NUTRITIONAL/FLUID STATUS
    • AGE
    • OXYGEN STATUS
    • IMMUNE STATUS
    • NEUROLOGICAL STATUS
    • MEDICATIONS
  11. FACTORS AFFECTING WOUND HEALING:
    in detail
    • HYGIENE
    • risks for wound infection
    • -Poor personal hygiene
    • -diaphoresis, incontinence
    • NUTRITIONAL/FLUID STATUS
    • -Protein, Zinc, Vitamins A & C necessary (vital) for tissue repair
    • -Obesity--adipose tissue has poor blood supply (diabetes)
    • -Emaciation (wasted condition of body; thin)--O2 transport is deficient
    • -Metabolic demand--increases for wound healing
    • -Hydration--promotes cellular function
    • AGE
    • -Degenerative changes in blood vessels, immune system and respiratory system slow healing time
    • -Inflammatory response is delayed in elderly
    • OXYGEN STATUS
    • -impaired blood flow to wound or tissues delays wound healing
    • -smoking constricts blood vessels, reduces tissue oxygenation; also impairs clotting (hemostasis)
    • IMMUNE STATUS
    • immunosuppressed patients have:
    • ---slower inflammatory response,
    • ---slower wound epithelialization,
    • ---decrease in leukocytes
    • NEUROLOGICAL STATUS
    • -Impaired sensation or sensory awareness (LOC) increase risk for skin breakdown
    • MEDICATIONS
    • meds which inhibit inflammation can alter cell growth and inflammatory phase of healing
    • i.e. steroids, NSAIDS, chemotherapy drugs
  12. WOUND DRAINAGE
    • EXUDATE
    • SEROUS DRAINAGE
    • SANGUINOUS (HEMORRHAGIC) DRAINAGE
    • SEROSANGUINOUS
    • PURULENT DRAINAGE
    • SLOUGH
    • ESCHAR
  13. PRESSURE ULCERS
    aka DECUBITOUS ULCERS
    • A CHALLENGE TO NURSING CARE
    • AREA of LOCALIZED ISCHEMIA
    • -deficiency of blood to tissues results in deprivation of oxygen and nutrients (ischemia)
    • -tissue death (necrosis) may occur
    • TYPICALLY LOCATED OVER BONY PROMINENCE
    • -caused by constant pressure and moisture
    • SHEARING AND FRICTION OFTEN ACT IN CONJUNCTION WITH PRESSURE TO PRODUCE AN ULCER
    • -can put powder on bedpan rim to prevent rubbing
  14. STAGES OF ULCER FORMATION (NPUAP 2/07)
    • STAGE I
    • localized, non-blanchable redness of intact skin
    • in dark-skinned persons--area may be warm, cool, discolored or bluish
    • STAGE II
    • partial-thickness skin loss of dermis and epidermis (involves first 2 layers of skin)
    • appears as shallow, open ulcer with red pink wound bed
    • does not have slough or bruising
    • may also present as an intact or open/ruptured serum-filled blister
    • STAGE III
    • full thickness tissue loss
    • subcutaneous fat may be visible (3 layers of skin)
    • slough may be present, but does not obscure the depth of tissue loss
    • may include undermining or tunneling
    • STAGE IV
    • full thickness tissue loss with exposed bone, tendon, or muscle (4 layers of skin)
    • slough or eschar may be present on some parts of the wound bed
    • often includes undermining, tunneling, or sinus tracts may form
    • UNSTAGEABLE
    • full thickness tissue loss
    • base of ulcer is covered by slough (yellow, tan, gray, green, brown) and/or eschar (tan brown, black) in the wound bed
    • SUSPECTED DEEP TISSUE INJURY
    • -purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying tissue from pressure and/or shear
    • -may be preceded by tissue which is painful, mushy, boggy, warmer, or cooler in comparison to adjacent tissue.
  15. VALIDATED RISK ASSESSMENT TOOLS
    • NORTON SCALE
    • 5 categories of risk:
    • -general physical condition
    • --mental state
    • ---activity
    • ----mobility
    • -----incontinence
    • maximum score = 20
    • score 5 of 12 or < indicates R/F development of ulcer
    • BRADEN SCALE
    • consists of 6 subscales
    • maximum score = 23
    • score of 16 or < indicates risk
  16. PREVENTION OF PRESSURE ULCERS
    • Perform risk assessment on admission and daily
    • --lift folds of skin: breasts, wrinkles, fat excess skin...
    • Provide adequate nutrition
    • Maintain skin hygiene: use mild cleansing agents; minimize friction and force when cleaning; don't use same washcloth for opposite folds; pat dry
    • Do not massage over bony prominences
    • Reduce friction by use of cornstarch or powder
    • Pad bony prominences esp. heels and elbows
    • Provide smooth, firm, wrinkle-free foundation
    • Provide special mattress/specialty bed per risk assessment score and facility protocol
    • Reposition, turn q 2 hours or more; consider use of trapeze bar.
  17. COMPLICATIONS OF WOUND HEALING
    • THE CHRONIC WOUND
    • non-healing/slow-healing
    • does not progress from Inflammatory Phase
    • causes: repetitive chemical and/or mechanical trauma
    • Signs/Symptoms:
    • --Delayed healing despite intervention
    • --change in color of wound bed
    • --friable (dry, crumbly) granulation tissue
    • --new or increased pain, drainage, or odor
    • INFECTION
    • wound may be infected at time of injury, during surgery, or post-op
    • signs/symptoms (post-op on day 2-7)
    • --fever, elevated WBC's
    • --Purulent drainage
    • --swelling, tenderness
    • --erythema at wound edges
    • --general malaise
    • HEMORRHAGE
    • possible causes:
    • dislodged clot
    • slipped ligature during surgery
    • erosion or cut of blood vessel
    • internal hemorrhage
    • --may occur without evidence of external bleeding
    • --Signs/Symptoms:
    • swelling in wound area
    • change in general condition of pt
    • --Hematoma = localized collection of blood inside tissues; forms in early post-op period
    • External Hemorrhage
    • greatest risk = first 48 hours
    • ID'd by bloody drainage at site or on surgical dressing
    • --mark with date, time, initials and check back with patient to view progression of strikethrough.
    • FISTULA FORMATION
    • fistula = abnormal passage between 2 internal organs or between an organ and the external skin surface.
    • May result from:
    • Abscess or infection
    • Injury, inflammation
    • Disease such as cancer
    • DEHISCENCE
    • partial or total rupture of wound
    • may occur post-op day 4-5
    • factors include:
    • --obesity
    • --poor nutrition; dehydration
    • --excessive coughing; vomiting
    • --suture failure; multiple trauma
    • Evisceration = dehiscence with protrusion of internal viscera
    • Interventions:
    • --support wound with large sterile dressing soaked in sterile normal saline
    • --notify M.D. STAT!
  18. ASSESSMENT OF WOUNDS
    LSD SD STP WDD
    • LOCATION
    • document anatomical size
    • SIZE
    • measure in cm: length, width, depth
    • COLOR
    • of wound bed (red, yellow, black)
    • SURROUNDING SKIN
    • color of wound edges
    • erythema of wound edge
    • DRAINAGE
    • amount, color, consistency, odor
    • degree of saturation of dressing (i.e. how many gauzes)
    • SWELLING
    • use gloves; palpate for tenseness around wound
    • minimal to moderate swelling normal in early stages of healing process
    • TEMPERATURE
    • palpate wound and surrounding tissues
    • cold = hypoxia, possible tissue necrosis (not enough O2 to tissues
    • increased warmth = infection
    • PAIN
    • expect severe-moderate pain for 3-5 days post-op
    • suddens onset of severe pain = possible hemorrhage or infection
    • WOUND CLOSURE
    • describe type of closure (staples, suture...)
    • note if intact
    • well-approximated?
    • DRAINS
    • type of drain used
    • inspect placement
    • note/measure amount, character of drainage (purulent, sanguinous, serosanguinous...)
    • DIAGNOSTICS/LAB TESTS USED IN ASSESSMENT
  19. DIAGNOSTIC/ LAB TESTS USED IN WOUND ASSESSMENT
    • WBCS
    • increase = infection
    • decrease = delayed wound healing
    • Hgb
    • low = impaired O2 transport to tissues
    • Erythrocyte Sed. Rate (ESR)
    • high = general indication of inflammation/infection
    • ALBUMIN
    • overall nutritional status; indicates body's reserves for rebuilding cells
    • low = hemodilution (increase in plasma volume = reduced RBC concentration) (i.e. with blood loss)
    • Wound Culture
    • r/o (rule out) or confirm presence of infectious organism
    • Diagnostic Imaging
    • to rule out or diagnose infection of bone
    • --X-Ray
    • --Bone Scan
  20. COMMON NURSING DIAGNOSIS
    Impaired Skin Integrity

    Risk For Impaired Skin Integrity

    Risk for Infection

    Acute Pain

    Body Image Disturbance

    Imbalanced Nutrition

    Impaired Mobility

    Anxiety, Hopelessness

    Fear
  21. GOALS/OUTCOMES FOR WOUNDS
  22. Goals must be realistic: for example:
    Can a serious, infected, chronic wound heal completely by client’s discharge from acute care?
  23. INTERVENTIONS TO PROMOTE WOUND HEALING
    • IN ORDER TO EFFECTIVELY TREAT A WOUND, THE NURSE MUST TREAT
    • “THE WHOLE PERSON.”

    Referral to wound care specialist is necessary for all complicated or chronic wounds, including Stage 3-4 pressure ulcers.

    Medications:

    • o Treat systemic or local infection:
    • antibiotics, topical antiinfectives

    • o Treat pain:
    • analgesics, topical local anesthetics

    o Nutritional supplements

    Dietary Interventions

    o Provide adequate Nutrition/Calories

    Vitamin C (citrus, green vegs.)

    Vitamin A (green/yellow fruits & vegs. dairy, fish-liver oil, egg yolk)

    Protein (meat, fish, eggs, dairy, legumes)

    Zinc (dairy, eggs, legumes, liver, whole grains)

    Hygiene

    o Keep skin clean and dry

    Clean the Wound With Cleaning Agents

    o Removes bacteria, slough and necrotic tissue
  24. DEBRIDEMENT OF A WOUND
    • DEBRIS IN A WOUND PREVENTS THE WOUND FROM HEALING
    • Wound Debridement
    • – Removal of dirt, foreign matter or necrotic tissue (e.g. eschar) from a wound that cannot be removed via normal cleaning.
    • Allows thorough examination of the extent of wound

    • o Types of Debridement
    • Sharp – use of a scalpel, scissors, or laser
    • Mechanical – use of mechanical force, (e.g. whirlpool, scrubbing, or wet-to-moist dressing)
    • Enzymatic – chemical breakdown of necrosis
    • Autolytic – moisture-retentive dressing with occlusive seal allows body’s own macrophages and neutrophils to destroy necrotic tissue
  25. WOUND DRESSINGS: PURPOSE
    Purposes of Dressings

    Protect wound from mechanical injury

    Protect wound from microbial contamination

    • Provide high humidity
    • a moist wound bed promotes re-epithelialization of the wound

    Absorb drainage and/or debride a wound

    Prevent hemorrhage (when applied as a pressure dressing)
  26. WOUND DRAINS: PURPOSES
    • Permit drainage of excessive fluid from surgical
    • incisions

    Drain purulent material from infected wounds

    Promote healing

    Assist in wound closure/approximation
  27. OTHER INTERVENTIONS FOR WOUND HEALING
    Hyperbaric therapy

    Light therapy

    Ultrasound, Electrotherapy
  28. CLIENT TEACHING
    • Self-care includes
    • maintaining hygiene (handwashing)
    • understanding correct wound care supplies and techniques
    • signs of infection
    • Family teaching includes:
    • positioning
    • protective devices
    • hygiene and nutrition
  29. EVALUATION OF INTERVENTIONS may include
    Does wound show signs of healing?

    Does wound remain free from signs of infection?

    Does skin of Stage 1 pressure ulcer remain intact?

    Is client verbalizing adaptation to changes in body image?

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