WOUND CARE

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WOUND CARE

• By Helen Harkreader, RN, PhD

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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.

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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
  oclock)
• 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?

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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

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Nutrition for Wound Healing

• Assessment of Nutrition - labs
• Serum Albumin 18 to 20 days half-life
• Affected by hydration (gt if dehydrated, lt 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

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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

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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
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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

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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

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Stage 1

• Reddened boggy heel

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Stage 2

• Partial thickness loss
• Or blister

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Stage 3

• Down to but not through the facia

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Stage 4

• To muscle, bone, tendons, etc.

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Unstageable Pressure Ulcers

• Purple, yellow, black

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Other Ulcers

• Arterial
• Venous

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Other ulcers

• Neuropathic
• Diabetic

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Stay open-minded

• Remain alert to all possibilities.