WOUND CAREBy 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

▫ 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.

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?

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

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

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

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

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

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

Stage 1

•Reddened boggy heel

Stage 2

•Partial thickness loss•Or blister

Stage 3

•Down to but not through the facia

Stage 4

•To muscle, bone, tendons, etc.

Unstageable Pressure Ulcers

•Purple, yellow, black

Other Ulcers

•Arterial

•Venous

Other ulcers

•Neuropathic

•Diabetic

Stay open-minded

•Remain alert to all possibilities.