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Wound Care:

Part I

Jassin M. Jouria, MD

Dr. Jassin M. Jouria is a medical doctor,

professor of academic medicine, and medical

author. He graduated from Ross University

School of Medicine and has completed his

clinical clerkship training in various teaching

hospitals throughout New York, including King’s County Hospital Center and Brookdale

Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and

has served as a test prep tutor and instructor for Kaplan. He has developed several medical

courses and curricula for a variety of educational institutions. Dr. Jouria has also served on

multiple levels in the academic field including faculty member and Department Chair. Dr.

Jouria continues to serves as a Subject Matter Expert for several continuing education

organizations covering multiple basic medical sciences. He has also developed several

continuing medical education courses covering various topics in clinical medicine. Recently,

Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s

Department of Surgery to develop an e-module training series for trauma patient

management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy &

Physiology.

Abstract

Although many types of wounds are easily treated, some require specialized

expertise in order to resolve or treat the primary cause and to prevent

additional wounds. Clinicians who opt to specialize in wound care provide an

important skillset to patients suffering from chronic or acute injury, disease,

or medical treatment. Often, a holistic approach is adopted, with

coordination of health team efforts to ensure that all aspects of a patient's

health are considered during the course of initial and ongoing wound care

management. Wound care clinicians also serve as a resource to prepare the

patient to continue care at home.

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Policy Statement

This activity has been planned and implemented in accordance with the

policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's Commission on

Accreditation for registered nurses. It is the policy of NurseCe4Less.com to

ensure objectivity, transparency, and best practice in clinical education for

all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 3.5 hours. Nurses may only claim

credit commensurate with the credit awarded for completion of this course

activity.

Statement of Learning Need

As wound care is a rapidly advancing field, continuing education is necessary

to ensure that clinicians caring for patients with wounds stay on top of the

latest treatment techniques and strategies to achieve wound healing.

Certification in the field of wound care is available for clinicians wanting to

specialize in their area of practice to best; causes of skin breakdown, types

of wounds, treatment of acute and chronic wounds and, importantly, wound

prevention, are all key areas for clinicians to commit to continuous learning

and practice improvement.

Course Purpose

To provide clinicians with knowledge of wound risk, and phases of wound

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development and healing.

Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and

Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,

Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.

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1. Tertiary intention involves the process of:

a. wound closure done by applying physical measures to close a wound.

b. initially leaving the wound open to partial healing. c. leaving a wound open to heal through production of new granulation

tissue to fill in the wound base. d. None of the above.

2. A nurse must continue to monitor a surgical wound

a. regardless of the type of surgical wound.

b. when a wound is closed with sutures. c. only if there is an open wound

d. Answers a and b.

3. True or False: venous insufficiency is a condition that develops when the veins are unable to return blood to the heart at a

normal rate and the blood collects in the lower extremities.

a. True.

b. False.

4. Surgical wound drains

a. must be emptied on a regular basis to ensure that they work properly. b. may cause damage to wound tissues.

c. prevent wound infections caused by drainage accumulation. d. All of the above.

5. When a nurse must administer medications intravenously, he or

she should be aware that

a. medications known as vesicants are safe because they do not cause

tissue damage to the skin. b. it is preferable to administer medications intravenously because they

cannot accidentally infiltrate into the skin tissues. c. some medications, when administered intravenously, can cause

significant wounds if accidentally infiltrated into the skin and tissues. d. extravasation does not develop if medications are administered

intravenously.

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Introduction

Wound care is a specialized form of nursing that requires thorough

knowledge of the skin and its potential for breakdown and ulceration. A

nurse who provides wound care on a regular basis must have the skills to

perform various procedures and to provide treatment to patients of different

backgrounds. Wounds can develop through a number of sources, including

chronic disease, injury or trauma, cancer, or through surgical procedures.

Appropriate care and treatment of wounds requires experience and

understanding of the complex needs of the diverse patient populations who

develop wounds, as well as those methods that will support the best

outcomes for these patients.

Causes Of Wounds

The skin is the largest organ of the body and provides a significant amount

of protection for internal structures from damaging pathogens and

environmental factors that can cause internal injuries. There are times,

though, when the skin breaks down and its damaged areas are unable to

perform their normal functions. When a skin wound develops, the skin

requires time and extra care for healing, particularly when the wound is

deep or extensive. There are multiple causes of wounds, which can occur on

any area of the body covered by skin.

Injury

An injury is an event that causes damage to the body. Injuries may cause

various types of wounds, from small and minor tears in the skin to large

openings that expose underlying tissue and organs. The type of wound that

results from an injury depends on the mechanism of injury that incurred the

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trauma. Wounds caused by injuries may include incisions, lacerations,

abrasions, bites, penetrating wounds, and burns.

A nurse may care for a wound caused by an injury at different stages of its

healing. A trauma nurse may care for a patient who is being seen in the

emergency department just after a gunshot wound and the nurse must work

to stabilize the patient and the wound to prevent hemorrhage. Alternatively,

a nurse who works in a rehabilitation unit may care for a patient who is

slowly recovering from a significant burn wound, providing debridement and

dressing changes on a regular basis. Both types of wounds occurred because

of injuries, but they are cared for in different stages.

Management of wounds caused by injuries involves assessment of the size

and depth of the wound, understanding the mechanism of injury, ensuring

there are no other factors involved that would complicate the wound, such

as the presence of foreign objects or other injuries around the wound,

managing the patient’s pain, and preventing other complications associated

with the wound, such as bleeding or infection.

Disease

Chronic disease can impair skin and tissue integrity, causing wounds that

may be slow to heal. Certain diseases impact the circulatory system, which

causes skin breakdown when the peripheral tissues do not receive enough

oxygen. Examples of diseases that can cause wounds include venous

insufficiency and diabetes.

Other types of wounds may occur from diseases that cause skin breakdown

after exposure to substances or environmental stimuli. Some diseases cause

wounds when they impact patient mobility and activity levels, increasing the

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risk of skin breakdown from pressure sores and poor circulation. Finally,

some diseases cause growths within the body that ultimately lead to

external wounds. An example of this situation might be a cancerous tumor

that grows under the skin and then causes a wound on the skin surface,

known as a fungating wound.

In addition to treating the wound caused by a disease process, a significant

part of the nurse’s work when caring for a wound patient is to also manage

the underlying disease. This includes administration of medications,

providing treatment or therapy for the disease, and educating the client

about his or her condition. When a wound has developed as a result of a

disease, the nurse must work to help the patient control the disease

symptoms to prevent the wound from occurring again in the future.

Medical Treatment

Medical treatments and procedures can cause wounds. The wound may heal

rapidly or it may need more time to heal. Surgical incisions are one of the

most common types of wounds that occur because of medical treatments,

although other procedures, such as radiation therapy or the administration

of certain kinds of medications, can also cause sores or burns on the skin

that must be monitored and treated.

The process of wound healing may vary depending on the method of

intention used to close the wound. Wounds are healed by intention, which is

categorized into three different stages and is based on the type of wound,

the amount of debris present or if the wound is contaminated, and the

mechanisms of the cause of the wound.

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Primary intention is a method of wound closure that is done by applying

physical measures to close a wound. A wound may be closed by primary

intention by applying sutures, staples, or medical-grade glue to approximate

the wound edges and bring them together for healing. Primary intention is

most often used with linear wounds, such as when closing a surgical incision.

As the wound edges grow together to form a scar, the resulting tissue is

typically as strong as the surrounding, undamaged tissue.

Secondary intention involves leaving a wound open to heal through

production of new granulation tissue to fill in the wound base. Eventually,

the wound edges will heal and result in a scar, although this process

typically takes months longer than a wound healed by primary intention.

When the wound has completely healed, the scar tissue covering the wound

is not as strong as the surrounding tissue; it is thought that it reaches

approximately 80 percent of its previous strength as that of surrounding,

undamaged tissue once a wound has healed by secondary intention.21

Examples of wounds that may heal by secondary intention include wounds

that develop from pressure ulcers, venous ulcers, and diabetic ulcers.

Tertiary intention involves the process of initially leaving the wound open to

partial healing. The application of sutures, staples, or glue, to bring the

edges together, closes the wound after a period of time. These types of

wounds initially develop some scar tissue as they heal. After the wound

edges are brought together, the scar may become stronger than when the

wound was healing through secondary intention.21 Tertiary intention may be

performed in a case when there is an extensive wound that is contaminated

and needs to be cleaned and debrided for a period before surgically closing

the wound.

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As a wound heals, it goes through a series of stages in which the tissue that

was broken down comes back together to form a scar. A wound that is small

may heal relatively quickly and without complications. Alternatively, a very

deep wound, one that is contaminated, or a wound in a patient who has an

underlying chronic disease that is poorly controlled, may take much longer

to heal. The stages of wound healing include the following.

Inflammatory phase

Bleeding that may be present initially stops when the blood starts to clot. As

the blood clots dry, they form a scab, which is a combination of old blood

and wound exudate. The body’s immune system responds to the wound by

causing inflammation. In the first hours or days after the wound has

developed, it may become red, swollen, and tender to the touch. White

blood cells are sent to the wound site and there is increased blood flow to

provide oxygen. There may be exudate production at this stage.

Proliferative phase

Granulation tissue begins to form in the wound bed and angiogenesis, the

process of creating new blood vessels, takes place under the skin. The

wound edges begin to come together as the cells migrate during

epithelialization. This stage lasts anywhere from a few days to several weeks

after the wound has developed.

Remodeling phase

Collagen formation builds strength in the wound bed; the wound has “filled

in” with epithelial tissue, although it is not as strong as the surrounding

tissue. The remodeling phase may occur for months or years after a wound

has developed.102

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Wound Types

Wounds are typically classified as being either chronic or acute wounds,

depending on how the wound has formed and the mechanism of injury

causing the wound. Chronic wounds are those that develop after tissue

damage has been ongoing. Examples of chronic wounds include wounds that

develop due to arterial insufficiency, diabetic ulcers, pressure sores, and

wounds that occur from venous insufficiency. The period of time that it takes

to develop a chronic wound may be weeks to months, but the point that

differentiates chronic wounds from acute wounds is that chronic wounds

develop over some period of time.

Alternatively, acute wounds are those that occur after injury to the skin

leads to damage and bleeding. Examples of types of acute wounds include

wounds from burns or trauma, and surgical wounds in which an incision is

made and the surgeon closes the wound with sutures or staples. The type of

wound that occurs, whether it is acute or chronic, typically affects one or

more layers of the skin, and may extend enough to impact the subcutaneous

fat, underlying tendons and ligaments, or may even affect the bones and

organs under the skin.

The outermost layer of skin, the epidermis, consists of layers of cells that

are continuously pushed upward toward the skin surface where they are

eventually sloughed from the body. The lowest layer of the epidermis is a

row of cells known as germinative cells; these cells divide continuously to

form keratinocytes, which are the cells that make up a majority of the

epidermis. Keratinocytes form from the germinative layer of cells and then

slowly proceed toward the outside edge of the epidermis. As they move,

they become filled with keratin, which is a fibrous protein that provides

structure. Once the keratinocytes reach the outermost layer of the

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epidermis, they die. They are not removed immediately, but instead remain

as the surface of the skin where they provide protection against

environmental components that could otherwise invade the body.

When a wound occurs, part of the healing process involves producing new

skin cells from the germinative cells of the epidermis that are near the

wound edges. The epidermis is a very thin outer layer and covers the lower

dermal layer. Because it is so thin, the epidermis does not contain hair

follicles, blood vessels, or sweat glands, although hairs will protrude from

where they are formed in the dermis and extend through the epidermis to

the skin surface. When a wound occurs that is very superficial and only

affects the epidermis, the wound typically heals quickly and with little

scarring, as the body is able to produce new skin cells from nearby

germinative cells.

Deeper wounds may affect the dermis, the skin layer that lies below the

epidermis. The dermis is thicker than the epidermis and it mostly consists of

connective tissue. The dermal layer contains many structures, including

blood vessels, hair follicles and nerve endings, as well as other cells that

take part in inflammatory processes when a wound occurs. The dermis is

much tougher than the epidermis because of its composition. The lower

levels of this layer contain collagen fibers that provide strength for the skin

and that take part in wound healing and scar formation.

Below the dermis is the subcutaneous tissue, which consists of fat and other

components, including blood vessels, nerves, and lymph channels. The

subcutaneous tissue is covered by fascia, a membrane of connective tissue

that provides protection. The subcutaneous tissue covers underlying

structures such as bone and muscle, however, the thickness of

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subcutaneous tissue layers varies between locations. Some areas, such as

those of the abdomen or upper thigh, naturally contain more fat tissue when

compared to other areas. The organs and muscles underneath the

subcutaneous tissue also have their own protective membranes. Depending

on the wound and the mechanism of injury, the wound can extend down into

the subcutaneous tissue and can expose underlying muscles or bone. There

are many different mechanisms that can produce wounds, whether by

disease processes, through acute injury to the tissue, or through ongoing

factors that contribute to skin breakdown over time.

Pressure Ulcers

A pressure ulcer develops in an area that becomes ischemic because

increased pressure on the skin and underlying tissues prevents adequate

blood flow to the area. Pressure ulcers can develop almost anywhere on the

body where excessive pressure impairs blood flow, but they are most

common on areas that cover bony prominences. The most likely areas where

pressure ulcers develop include the sacrum, the heels, the ear, and the

coccyx.3 Pressure ulcers used to be referred to as decubitus ulcers or

bedsores; however, these terms do not necessarily reflect a comprehensive

mechanism of injury. For instance, a person who is not confined to bed may

still develop a pressure ulcer. The term “pressure ulcer” is more consistent in

defining the means of injury that occurs with this type of wound.

Increased pressure over an area of skin causes compression of the blood

vessels that normally supply oxygenated blood to the skin, subcutaneous

tissue, and underlying fascia. When the blood vessels are constricted in this

manner, blood flow to these sites slows and the distal areas do not receive

adequate oxygen or nutrients that are so needed to maintain healthy skin.

Further, venous return is also slowed, and blood is unable to adequately flow

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away from these areas and back toward the heart because of vessel

compression. As a result, metabolic wastes, which are normally carried away

from the area as part of venous return, instead accumulate in the affected

area. This causes a negative cycle as the increased build up of metabolic

wastes causes vasodilation of surrounding blood vessels, followed by edema,

and further compression of the blood vessels supplying the area.

After a period of time in which blood flow is restricted, tissue ischemia

develops whereby the tissues fed by the compressed blood vessels no longer

have enough oxygen to survive and cell death occurs. This cell death then

contributes to skin breakdown and the affected person develops a pressure

ulcer.

Regular wound assessment is required to determine the depth and extent of

the wound, as well as whether treatment measures are being effective in

healing the wound. The nurse should note the location, size, and appearance

of the wound to better determine the degree of damage. The National

Pressure Ulcer Advisory Panel (NPUAP) has defined several classifications of

pressure ulcers according to the depth of tissue involvement and the extent

of damage. By understanding the stages of pressure ulcers, the nurse can

assess a wound and better understand how it is staged. By staging the

wound, the provider then has a guide for the best form of wound

management.

Stage I

In stage I the skin is still intact but does not blanch when pressed. The skin

appears red, which does not resolve with time or position changes. It may

more likely appear over a bony prominence. In a person with dark skin, the

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area may not be red or even noticeable except that the affected skin

appears as a different color when compared to the surrounding skin.

Normally, an area of skin may turn red after a short period of pressure; this

situation is known as reactive hyperemia. The process occurs when the body

increases blood flow to the compressed area to make up for temporary

oxygen deprivation.8 With reactive hyperemia, the skin becomes red and

appears flushed. However, this typically resolves quickly with position

changes and as blood flow resumes to its normal pattern.3 An area of

redness can be considered a stage I ulcer if the redness does not resolve

and the area does not blanch.

Stage II

The skin is broken in Stage II but the wound is typically confined to the

epidermis. The skin appears red and blisters filled with serous fluid may be

present; blisters may have broken, resulting in shallow wounds that ooze.

The base of the wound may appear pink or red and slough may or may not

be present.

Stage III

In state III the wound is deep enough that it extends through the epidermis

and into the dermis. A stage III pressure wound is considered a full-

thickness wound; however, this stage of wound does not affect the

underlying muscle, tendons, or bone. The subcutaneous fat under the dermis

may be seen in some areas where there are greater amounts of fat. Slough

may or may not be present at the base of the wound, which may make it

difficult to determine depth. Stage III wounds can have tunneling, in which a

hole or tunnel progresses deeper into surrounding tissue. If a second wound

is nearby, tunneling may connect the two wounds.8

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Undermining may also be present at this stage, which occurs when the

edges of the wound at the surface cover more of the wound than is present

at the base. When undermining is present, the wound is actually larger than

it appears at the surface.

Stage IV

Stage IV pressure ulcer is a full-thickness wound that extends from the

epidermis into the dermis and subcutaneous tissue and exposes underlying

bones, muscles, or tendons. In areas where there is less subcutaneous fat

and cartilage is present instead, such as on the nose or the ear, the

exposure of underlying cartilage classifies the wound as a stage IV pressure

ulcer.3 Tunneling and undermining may also be present with this stage of

wound.

In addition to the standard categories of wounds based on the depth of the

affected tissue and the exposure of underlying structures, there are other

classifications of pressure wounds that consider those injuries whose

measurements or depth are not obvious and apparent.

Deep Tissue Injury

In a deep tissue injury (DTI) the skin may or may not be broken but there is

significant bruising that appears as blue or purplish skin with bruising that

extends down into lower layers of skin. The appearance of the wound may

also look like that of a blood-filled blister. The texture of the skin with a deep

tissue injury can vary; some patients have skin that feels warmer than

surrounding tissue, while others have cooler skin. The skin texture may feel

firm or it may be mushy. Some patients have intense pain while others do

not.

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Deep tissue injury occurs in an area that has been injured by shear forces. It

can be difficult to determine how deep the injury is and if it extends down

past the dermal layer. A DTI can be difficult to assess in a patient with dark

skin. As the injury heals, it may become an ulcer with open skin on the

surface or it may resolve under the skin.

Kennedy Terminal Ulcer

Another type of ulcer, termed the Kennedy Terminal Ulcer, is a specific type

of skin breakdown that may occur hours, weeks, or months before death in a

terminal patient. This type of terminal ulcer typically develops among

patients who are nearing death and who are cared for in long-term care

situations. The skin takes on a purple, red, or yellow appearance and the

wound may be shaped like a pear or a butterfly.3,4 The most common

location where the ulcer develops is on the sacrum, although it can show up

on any part of the skin. This type of ulcer may be more commonly seen by

caregivers who work in long-term care facilities or among those who work in

critical care units who receive patient transfers from long-term care facilities.

A Kennedy terminal ulcer may develop rapidly through the process of skin

breakdown as the patient nears death. As Margaret Falconio-West of Medline

best explained, when a person nears death, organ failure becomes an issue

and is often a cause of death. It stands to reason, then, that the skin, the

largest organ of the body, may also fail, leading to skin breakdown

associated with a Kennedy terminal ulcer.4

Unstageable Wound

The unstageable type of wound is not obvious as far as its depth is

concerned. The clinician may not be able to classify the wound based on its

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appearance and further measurements are often required. The base of the

wound is usually covered with slough or eschar, which makes the depth of

the wound difficult to determine.

Several other terms that describe wound tissue may be identified as

characteristics of wounds; these elements may be present in pressure ulcers

or in wounds that have developed as a result of other reasons. Eschar is

used to describe necrotic tissue that has developed within a wound. Eschar

is dead skin that is often tough and thick; it may have a similar appearance

to a scab but it is not the same. Eschar is what must be removed with

debridement. Without removal of eschar, would healing can be significantly

delayed.

Slough is another component of the wound that may develop alongside

eschar, but it has an appearance that is different. Slough is also a collection

of necrotic tissue, but unlike eschar, it is typically moist, crusty, or crumbly.

It is typically white, yellow, or cream colored and it is thought to contain

dead leukocytes, bacteria, dead skin, fibrin, and wound exudate.22 Slough

must be removed during debridement in order to promote wound healing, as

the body typically cannot get rid of slough on its own and it may accumulate,

harboring bacteria and preventing growth of normal, new skin tissue.

Factors contributing to pressure ulcers

Other factors may contribute to development of pressure ulcers, putting

some populations of patients at higher risk. Immobility is a prime cause of

development, as the inability to move or change positions to relieve pressure

on an affected area results in sustained periods of time in which affected

blood vessels are compressed. Patients who have excess moisture on their

skin, whether from such factors as sweating or poor hygiene, are at

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increased risk, particularly when the skin has become ischemic from too

much pressure. The excess moisture on the skin causes the surface skin to

become softer and more prone to breakdown.

Older adults are a population at high risk, not only because of their

increased instances of immobility, but also because of body changes

associated with aging. Many older adults have less subcutaneous fat under

the surface of the skin, which results in less protection from epidermal

injury. Older adults also have thinner skin as a result of aging, which often

becomes dry and less elastic due to decreased action of collagen and elastin

within the skin’s structure. These effects of aging cause the skin to heal

much more slowly when a wound occurs. Further, some older adults suffer

from sensory changes that result in diminished sensation in the extremities

and distal tissues. These older adults may be less likely to perceive when

tissue damage is happening because they cannot feel it immediately.

Obese patients are also at higher risk of skin breakdown due to pressure

ulcers and tissue ischemia. Patients who are obese have more weight

applied to certain areas when lying in different positions. A person who is

obese may have extra skin folds that can retain moisture and can be difficult

to clean. The skin in these folds may break down more easily when moisture

remains between the folds or skin folds rub on bed sheets or linens, causing

small abrasions on the surface of the skin.

Various other factors, both extrinsic and intrinsic, can impact the risk of

developing pressure ulcers. Extrinsic factors include such elements as:

Friction and shear

Level of moisture

Irritating substances on the skin

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The environment that prevents movement or turning to relieve

pressure

Alternatively, intrinsic factors are part of the patient; some intrinsic factors

can be changed, while others cannot. Intrinsic factors that affect wound

development include:

Age

Circulation status

Personal habits that affect skin integrity (smoking, diet, alcohol

consumption)

Body temperature

Use of some medications (steroids, vasoactive drugs)

Weight

History of injury or disability

Assessment tools and rating scales

Multiple rating scales are available to assess patient risk for development of

pressure ulcers. In the United States, the Braden scale is one of the most

common tools used to assess whether particular patients are at risk of skin

breakdown or if the skin is no longer intact. The nurse may use the Braden

scale when performing a patient assessment. The results are given scores

based on factors such as the patient’s levels of sensory perception, moisture

content of the skin, nutrition levels, and mobility. The lower the score, given

with the Braden scale, the higher the risk for skin breakdown.

Assessment tools may be used on any patient who may be at risk of

pressure ulcers; although, not all patients may need intervention for

pressure ulcer prevention, it is always better to provide more care to prevent

ulcers than to avoid interventions because a patient is believed to be at low

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risk. Increased nursing care and interventions for prevention of pressure

ulcers has been shown to decrease pressure ulcer development, regardless

of the patient’s level of risk.3

Arterial Insufficiency

Arterial insufficiency refers to decreased and inadequate blood flow to

tissues and organs. When a patient has arterial insufficiency, he or she is at

increased risk of developing ulcers when the skin and underlying tissues

become ischemic from lack of blood flow. Arterial insufficiency ulcers most

commonly affect the lower extremities, including the legs and feet. As blood

flow diminishes, the cells are starved for oxygen and tissue ischemia

develops. Without correction of adequate blood flow, the skin becomes

necrotic and starts to break down, forming a wound.

Arterial insufficiency can develop through various causes and it may occur

suddenly or it can develop gradually. A sudden cause of arterial insufficiency

may result from trauma or injury to a part of the body that disrupts blood

flow to the extremities. Alternatively, chronic arterial insufficiency may

develop over time due to atherosclerosis.9

According to Hess, author of an arterial ulcer checklist in the journal

Advances in Skin and Wound Care, several conditions are associated with

arterial insufficiency and patients with these illnesses are more likely to

suffer from blood flow abnormalities and wounds that develop from arterial

insufficiency. Examples include thrombosis of any cause, vasculitis,

rheumatoid arthritis, systemic lupus erythematosus, sickle cell disease,

polycythemia, and Raynaud’s phenomenon. These conditions affect blood

circulation through such factors as abnormalities in blood vessel structure or

anomalies within blood cells, resulting in decreased circulation to peripheral

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tissues. Despite underlying abnormalities in blood flow associated with

certain diseases, the most common cause of arterial insufficiency is

atherosclerosis.9

Frequent sites of ulcers in the lower extremity include the lateral malleolus

of the ankle, the foot, and the toes. Wounds that develop from arterial

insufficiency are often small and round without granulation tissue in the

wound base. They often cause significant pain for the affected patient.

Arterial insufficiency causes symptoms similar to that of peripheral arterial

disease (PAD) and is often affiliated with the condition. PAD develops as a

result of atherosclerosis in the large vessels that supply blood to the lower

extremities; the plaques found in the walls of the blood vessels disrupt blood

flow and decrease circulation. Older adults are at increased risk of PAD and,

ultimately, an increased risk of arterial insufficiency wounds. Older adults

are more likely to develop atherosclerosis, as the incidence increases with

advancing age. The Clinical Guide to Skin and Wound Care states that the

incidence of arterial ulcers is 2.2 percent in patients of the ages 50 to 59

years and 7.7 percent among patients ages 70 to 74 years.10

When a wound does develop as a result of decreased blood flow, the healing

process can be slow and difficult. Because oxygen is needed not only to

prevent wounds from forming, but also for wounds to heal properly,

decreased oxygenation from arterial insufficiency results in wounds that heal

poorly and that do not close properly. When a wound develops because of

trauma, the wound is more likely to close slowly and have difficulties with

healing in a person with arterial insufficiency when compared to someone

with normal circulation. For example, a person with PAD if injured by

stepping on a sharp object, may have a wound at the site of injury.

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Decreased circulation to the site may further potentiate spreading of the

wound or it may limit the pace at which the wound heals.

Arterial insufficiency often is paired with other illnesses that all contribute to

ulcers and wounds as a result of impaired circulation. A patient may not only

have arterial insufficiency due to peripheral artery disease or vasculitis, but

may also have other conditions that contribute to wound development, such

as diabetes. The risk of ulceration and tissue necrosis is often increased

when more than one condition affecting circulation is present.

Diabetic Ulcers

Diabetes is becoming a global epidemic, affecting more than 150 million

people throughout the world, over 5 percent of the world’s population.

Approximately 16 million people in the United States alone suffer from

diabetes, of which, over 33 percent are not even aware that they have the

disease.13 Based on these statistics, the implications for treatment and

management of diabetes, as well as prevention of its complications, are of

immense proportions.

Ulcers of the foot and lower leg are a complication of diabetes, with

approximately 5 percent of diabetic patients developing foot ulcers each year

and 1 percent requiring amputation.12 A diabetic ulcer occurs when a wound

develops in a person who has diabetes; the wound is typically on one of the

lower extremities, such as the foot. The wound may initially be superficial

and affect only the upper layers of skin, but without treatment, it can spread

to the underlying soft tissue structures below the skin and cause further

tissue breakdown in the tendons, muscles, and bones.

23

Diabetic ulcers commonly occur as a result of atherosclerosis, peripheral

vascular disease, or neuropathy in the diabetic patient. Persons with

diabetes are at higher risk of developing atherosclerosis because of an

increased production of free radicals that affect the ability of the blood

vessels to relax. Diabetes also increases chronic inflammation and slows

blood flow through the vessels, which significantly contributes to

atherosclerosis.18 Additionally, people with diabetes are at increased risk of

other factors that contribute to atherosclerosis, including increased levels of

low-density lipoproteins and increased platelet adhesiveness.12

Peripheral vascular disease develops in conjunction with diabetes when

poorly controlled blood glucose levels cause changes in the vascular system

that result in narrowing of the blood vessels. With narrowing, the blood

vessels become smaller in diameter, which limits blood flow to less than

normal levels and reduces the amount of oxygenated blood that reaches the

peripheral tissues. Decreased blood flow, in particular to peripheral tissues

such as the extremities, can result in tissue ischemia followed by skin

breakdown when the tissue becomes necrotic.

Diabetic peripheral neuropathy develops as a result of nerve damage to the

peripheral sensory nerves because of elevated glucose levels in the

bloodstream. It may also be related to other factors, such as nerve injury,

chronic inflammation, and reduced blood flow due to peripheral vascular

disease.12 The patient with diabetic peripheral neuropathy typically has

reduced sensation to the peripheral extremities — most often the lower legs

and feet — which affects how well he or she is able to determine if an injury

has occurred or to feel if a wound is developing. For instance, a diabetic

patient with neuropathy may have such diminished feeling in the feet that he

or she is unaware when shoes do not fit normally and consequently rub the

24

skin off in one area. This can cause further skin breakdown and infection

because of blood flow abnormalities as a result of the diabetes. If a wound

does develop and grow larger on the foot, it may become extensive before

the affected person notices it, particularly if he or she does not perform

routine foot self-exams.

Diabetic peripheral neuropathy may be present to some extent in up to 60

percent of patients who have diabetes.12 It is one of the most common

causes of diabetic ulcers in this population. A structural complication that

can develop as a result of diabetic peripheral neuropathy and that

contributes to wound development is the Charcot foot. Rogers, et al., in the

journal Diabetes Care, describe this condition as an inflammatory syndrome

that results in changes to the bones and connective tissue of the feet,

altering the structure and causing a “rocker bottom” appearance, in which

the sole of the foot is rounded.19 The muscles of the foot are weakened and

small fractures may occur in the bones of the foot. The patient with Charcot

foot can develop a significant foot deformity. When this occurs, the foot is

more likely to also develop skin breakdown when walking places undue

repetitive stress and pressure on certain areas.

In addition to systemic diseases that contribute to wound development,

people with diabetes are at higher risk of developing foot problems that can

eventually lead to skin breakdown and wounds. Some of the most common

foot problems seen in patients with diabetes include corns and calluses,

fungal infections, skin changes and cracking, ingrown toenails, and bunions.

The reasons why diabetic patients tend to develop more foot problems are

related to circulatory changes and the presence of diabetic neuropathy.

Diabetes affects the nerves that reach the foot to control oil and sweat

secretions, affecting moisture content. As a result, a person with diabetes

25

may have very dry skin on the feet and lower legs, which can crack and

bleed, increasing the risk of wound development.

Calluses form as thickened areas of skin on the feet and toes; at times, a

person with diabetes may try to trim calluses, but any minor cut outside of

the calloused area can cause an increase in infection risk. Further, chemicals

applied to corns and calluses can also cause skin breakdown, skin burns, and

foot damage that can perpetuate wound development. Alternatively, calluses

can become quite thick and then the skin can break down when they are not

cared for, which can cause a diabetic ulcer.

A diabetic patient who does not care for his or her feet regularly may

develop an ulcer if unaware of the damage occurring. Poorly fitting shoes,

minor injuries from walking barefoot, and small objects in the shoe that rub

on the foot can all lead to skin breakdown. The most common locations of

diabetic ulcers are on the ball of the foot and on the great toe; however,

diabetic ulcers can develop anywhere on the feet, ankles, toes, and lower

legs.

There is not one particular classification system that has been universally

accepted for staging and grading diabetic wounds. Some of the most well

known systems include the Meggitt-Wagner staging system and the

University of Texas system. A thorough and straightforward staging system

can better help practitioners to discern effective treatment methods and to

evaluate the effectiveness of those methods on the diabetic wounds they are

used for.

The Meggitt-Wagner system classifies the diabetic wound on the foot based

on its depth and/or extent of tissue damage caused by gangrene, if the

26

wound is significant. According to the Meggitt-Wagner system, the stages of

the diabetic wound are classified as follows:

Stage 0: No external symptoms of the wound; the presence of pain

indicates that damage has occurred

Stage 1: Superficial skin wound affecting the uppermost layers of

skin

Stage 2: Deep ulcers

Stage 3: Wounds that affect the underlying bone

Stage 4: Gangrene present on a partial area of the foot

Stage 5: Gangrene present on the entire foot

The Journal of Diabetic Foot Complications performed a review of the

common types of diabetic wound classification systems and found several

limitations with this staging system. First, the system is used for classifying

the foot, and although it is the most common area of diabetic wound

development, there may be other areas where a wound can develop that has

been caused by complications of diabetes but that cannot be staged using

this system. Secondly, this system does not consider other problems

associated with wounds, such as the presence of infection, nor does it

quantify the significance of vascular disease as the cause of this type of

wound.15 However, when a patient presents with a diabetic wound on the

foot, the Meggitt-Wagner system can be implemented in many cases to

properly stage the wound according to its depth and the presence of necrotic

tissue.

The University of Texas has also provided a staging system for classifying

diabetic wounds. This system classifies wounds from Grade 0 to Grade 3,

and then further breaks each stage down into stages that range from Stage

27

A to Stage D, which represent the presence of infection, ischemia, or both as

part of the wound. A Grade 0 wound may represent very little tissue damage

when classified at Grade 0, Stage A of the system; alternatively, a wound

classified as Grade 3, Stage D of the system is the most extensive with

infection and ischemia present.15 The classification system is demonstrated

as follows:

Grade 0 Grade 1 Grade 2 Grade 3

Stage

A

Pre-ulcerative

lesion with no

obvious skin

breakdown

Superficial wound Wound that

penetrates to

underlying tendons

Wound

penetrating to

bone or joint

Stage

B

Infection Infection Infection Infection

Stage

C

Ischemia Ischemia Ischemia Ischemia

Stage

D

Infection and

ischemia

Infection and

ischemia

Infection and

ischemia

Infection and

ischemia

Jain, A. K. C. (2012). A new classification of diabetic foot complications: A simple

and effective teaching tool. The Journal of Diabetic Foot Complications 4(1): 1-5.

Retrieved from http://jdfc.org/2012/volume-4-issue-1/a-new-classification-of-

diabetic-foot-complications-a-simple-and-effective-teaching-tool/#hide

Diabetes affects both the development of wounds and their ability to heal

properly. When a patient does not control diabetes well, he or she may be

more likely to suffer nerve damage from neuropathy; decreased sensation,

particularly in the extremities, decreased immune function, poor circulation,

and an increased risk of infections.2 When an infection is present, the

condition requires strict management and prevention of complications, as

the diabetic patient may have delayed wound healing that could cause an

28

infection to spread to surrounding tissues or to the underlying bone. If a

patient has neuropathy, he or she may not notice the skin breakdown right

away and may not feel significant pain. It is still important for the patient to

seek care and to manage the diabetic wound before it worsens or becomes

infected. All diabetic patients should be taught of the importance of caring

for their feet and the possible consequences of untreated diabetic wounds.

Venous Insufficiency

Formerly called venous stasis, venous insufficiency is a condition that

develops when the veins are unable to return blood to the heart at a normal

rate. For various reasons, the valves inside the veins do not propel blood

toward the heart, leading to changes in the lower extremities, including the

appearance of the skin and the increased risk of skin breakdown that causes

wounds. Approximately 500,000 people develop wounds from venous

insufficiency each year.

The arteries deliver blood throughout the circulatory system at relatively

high pressures; the amount of this pressure is measured when taking a

patient’s blood pressure. Once the blood has been sent to pertinent organs

and tissues and has been filtered through the capillary system, the pressure

at which the veins return the blood to the heart is comparatively much

lower.57 Veins are classified as being superficial, deep, or communicating

veins. An example of a superficial vein is one of the saphenous veins in the

legs, while the popliteal or iliac veins would be considered deep veins.58

When a person is standing up, the veins must return blood to the heart at a

force that works against hydrostatic pressure, which is the pressure of

gravity that pushes the blood down toward the feet. In order to get the

blood to return to the heart and to push against the hydrostatic pressure,

29

the internal lumens of the veins contain valves, which support blood flow in

the proper direction and prevent the backflow of blood toward the feet.

Venous insufficiency develops when the veins are unable to effectively pump

blood toward the heart and the blood collects in the lower extremities. The

backup of blood in the veins may cause them to become larger and

distorted; the condition also leads to venous hypertension, which is

increased blood pressure inside the veins. Venous hypertension causes the

skin changes associated with venous insufficiency, as well as edema and

pain in the lower extremities.

The calf muscle pump, found in the lower leg and consisting of the calf

muscle and the veins that run through it, is important for promoting blood

return to the heart. When the calf muscle contracts, it pushes blood against

hydrostatic pressure to promote venous return and prevent blood pooling.

Some patients with venous insufficiency have calf muscle pump dysfunction,

in which blood does not always flow in the proper direction and instead pools

in the lower extremities.57 Calf muscle pump dysfunction may be more prone

to develop when a patient sits with the legs in the dependent position for

long periods of time. This position does not require use of the pump as often

and the blood tends to pool in the lower legs.

Deep vein thrombosis (DVT) develops as a blood clot in one of the deep

veins that feeds into the vena cava. A patient with venous insufficiency is at

higher risk of developing DVT when blood flow is poor or blood pools in the

lower extremities. DVT can lead to other complications, such as a pulmonary

embolism; it is dangerous because almost 50 percent of cases do not

demonstrate any symptoms.62 When DVT does cause symptoms, the patient

may experience pain in the legs while walking. DVT symptoms also include

swelling and warm, tender skin.

30

Patients with immobility and those with a history of varicose veins are at

higher risk of developing a DVT, as well as patients who are obese, those

who have had major surgery, and people with blood clotting disorders. Once

inflammation develops as a result of DVT, the patient is at increased risk of

developing more blood clots again in the future.

Up to one-half of patients who develop DVT will have post-thrombotic

syndrome, a condition that causes chronic pain, a feeling of heaviness in the

legs, swelling, and skin ulcers.62 When DVT develops, it causes damage to

the vein and its valves, further perpetuating poor venous return. The risk of

post-thrombotic syndrome (PTS) is increased if the patient has had more

than one blood clot. Other signs and symptoms of PTS are similar to venous

insufficiency and may cause changes in skin appearance and texture, as well

as swelling and eczema in the lower extremities.

A patient with post-thrombotic syndrome after DVT is more likely to develop

a venous ulcer, which will then require assessment and management of the

condition as long as the wound is healing. Further prevention of PTS is

required to prevent future blood clots and skin wounds. Prevention of PTS is

similar to management of venous insufficiency and venous ulcers; the

patient should use compression therapy to promote blood flow and

medications such as anticoagulants may be necessary to reduce the chance

of further blood clots.

Venous insufficiency tends to develop more commonly among people who

live sedentary lifestyles and those who are overweight or obese. It is also

more common among women and its incidence increases with pregnancy.

Other populations who are at higher risk of venous insufficiency include men

who smoke, and people who must stand for long periods of time, such as

31

required standing to perform a job. In addition to those who have calf

muscle pump dysfunction or a history of DVT, some people are born with

incompetent valves in some of the veins of the lower extremities, and a

small population of people who are born with Klippel-Trénaunay-Weber

(KTW) syndrome will also have venous insufficiency. KTW syndrome causes

skin changes such as port-wine stains and an increased incidence of varicose

veins; both conditions have been shown to cause an increase in skin

breakdown and ulceration among affected patients.58

The skin changes that occur as a result of venous insufficiency develop when

blood leaks out of the capillaries and the veins and is deposited in the

surrounding tissues. The tissue becomes edematous and the skin may turn a

patchy brown color. This occurs from the creation of hemosiderin, a yellow-

brown skin pigment that is formed by the breakdown of hemoglobin.

Eventually, the skin increasingly becomes more fibrous in appearance and

the texture is firm and thickened.59 The fibrous, thickened skin condition is

known as lipodermatosclerosis. The patient may also develop skin eczema,

known as stasis dermatitis.

As blood leaks from the capillaries into the tissues, the inflammatory process

is activated and cell damage ensues. This sets off a series of events that

includes release of leukocytes, platelet aggregation, and cellular edema that

contribute to tissue breakdown and wound development.61 If a patient has

an ulcer that may be caused by venous insufficiency, diagnostic tests should

be performed to confirm that venous problems are the cause of the ulcer

and that it is not caused by other factors, such as diabetic neuropathy or

arterial insufficiency. Diagnostic tests such as the ankle-brachial index or

venous ultrasonography may be used to pinpoint the cause. Identifying the

32

cause as venous insufficiency is important because the treatment modalities

will differ for this type of ulcer when compared to some other causes.

The most common location of venous ulcers is just above the lateral

malleolus of the ankle.59 Venous ulcers also tend to develop over other bony

prominences. They are usually shallow wounds with irregular borders. It

may take months to years for an ulcer of this type to heal; many patients

who originally develop one venous ulcer as a result of venous insufficiency

will have recurring ulcers form. The patient most commonly has pain, edema

that is reduced when the affected extremity is elevated, and itching and

signs of eczema around the ulcerated site.

When a venous ulcer develops, a major component of managing the wound

is the correction or management of venous insufficiency as well. Although

venous insufficiency does not need to be corrected completely for a wound

to heal, management of the condition and reduction of symptoms is

necessary to prevent further wound development. Most patients who have

skin thickening and staining of the skin from lipodermatosclerosis do not

achieve normal, healthy skin in the area again. In other words, once the skin

changes have occurred as a result of venous insufficiency, they are

permanent, even if the resulting wounds can be healed.

The patient often experiences severe pain at the location of the ulcer. The

pain may be worse when the leg is in the dependent position, such as when

the patient is sitting with the legs dangling or lowered below the rest of the

body.

Compression therapy is the treatment of choice for venous insufficiency to

both manage and prevent development of venous ulcers. Compression

33

therapy may consist of several different measures that support the return of

blood flow to the heart through the veins. The patient with an ulcer also

requires consistent and thorough wound care to help the wound to heal,

despite poor venous circulation. Collins and Seraj reported in American

Family Physician that continuous compression therapy is successful in

healing venous ulcers in up to 85 percent of cases after one year of

treatment.61

In some severe cases of venous insufficiency, in which ulcers continue to

develop and heal poorly, surgery may be necessary to correct venous blood

flow and to prevent future skin breakdown. Whether or not surgery is

performed depends on the affected veins; and, whether they are superficial

or deep veins. Surgical procedures that may help to correct venous

insufficiency, typically performed on superficial veins, include valvuloplasty

and venous ablation, among others, which can correct some of the work of

the valves and restore some proper blood flow.

Anticoagulant medications may be used for a patient who has developed a

DVT and has an increased risk of developing more blood clots. However,

other medications, such as antibiotics, are not useful for treating venous

insufficiency and are not typically prescribed unless the resulting ulcer

becomes infected.

Surgical Wounds

A surgical wound is one that is created by a surgical intervention, rather

than developing as a result of an injury or disease process. Most surgical

wounds are made when a surgeon cuts the skin with a scalpel as part of a

surgical process. The wound may also be closed with sutures or staples —

through primary intention — but the creation of a surgical wound does not

34

necessarily mean that it will be closed in this method. Some surgical wounds

are left open for healing by secondary intention. Surgical wounds, regardless

of how they are closed, are at risk of infection and complications such as

dehiscence.

According to the World Health Organization (WHO), there are several basic

types of surgical wounds that are classified according to their levels of

contamination:63

1. Clean wounds that show no sign of infection or inflammation and are

free of debris.

2. Clean contaminated wounds that have normal tissue that is colonized

with chronic bacterial colonization.

3. Contaminated wounds that contain debris or foreign materials that can

cause an infection.

4. Infected wounds that demonstrate signs of infection and where pus is

present.

The classification of wound contamination helps the provider to understand

how best to close the wound, whether by primary or secondary intention or

by delayed closure. Wounds that are clean should be closed by primary

intention, with the wound site monitored regularly; this includes checking for

signs of redness or drainage and ensuring that the sutures or staples are

intact. An example would be when a patient has a surgical procedure, such

as an appendectomy, and the surgeon opens the skin for the purpose of

removing tissue. There is no infection present and the skin is not inflamed,

so the surgeon uses sutures to close the wound. The nurse checks the

incision during the patient assessment to ensure that it is healing well.

35

Depending on the patient’s health and nutrition status, the wound is likely to

heal and leave a minor scar.

When a surgical wound is closed by primary intention, the physician may use

sutures, staples, adhesive skin tape, glue, or a combination thereof. Sutures

are available in different materials. Some sutures are absorbable and will be

broken down by enzymes in the skin.66 Alternatively, non-absorbable sutures

will later need to be removed. Non-absorbable sutures may remain in place

in the skin for varied periods of time; the physician will prescribe removal of

sutures based on the strength of the surgical wound and the process of

healing. Sutures are removed at the right time that demonstrates that the

wound has approximated enough that it will hold together without the

sutures in place. Alternatively, keeping sutures in place too long can lead to

infection at the incision site.

A wound that is contaminated or infected should not be closed by primary

intention. Instead, it should be left open to heal by secondary intention,

which involves regular wound maintenance and monitoring for signs of

delayed healing or of the wound infection spreading to nearby tissues. For

example, a patient with a lymph node infection that has developed into a

seroma under the skin may need surgery to remove the tissue. Based on the

infection, the surgeon leaves the wound open to heal by secondary intention.

The nurse checks the wound on a regular basis, controls exudate and keeps

a moist wound bed, performs dressing changes, and provides antibiotics.

Delayed primary closure involves leaving a wound open for a period of time

and then closing the wound later with sutures or staples. Delayed primary

closure is often done on surgical wounds that are contaminated or those that

are clean but that are more than 6 hours old. The surgeon may delay closing

36

the wound by primary intention in order to give the wound time to heal, and

to prevent infection. When debris is contaminating the wound bed, the

surgeon will not close the wound over the debris, as this process would most

likely lead to infection. Delayed closure gives time for the debris to be

removed and the wound to partially heal from the base before it is closed.

Regardless of the type of surgical wound, the nurse must continue to

monitor the wound frequently for signs and symptoms of infection. When a

wound is closed with sutures, the nurse assesses for red skin around the

incision, wound edges that are not well approximated, drainage, swelling,

tenderness, and skin that is hot to the touch. Because a surgical wound

involves a break in the skin, there is always the potential for microorganisms

to enter the space and multiply to cause an infection.

In some situations, a surgeon may place a surgical wound drain, which

allows excess fluid and blood to drain from the wound instead of building up

within the tissue. The surgical drain may be sutured in place to prevent

being pulled out. Some drains are passive drains, in which fluid leaks directly

out of the opening. An example of a passive drain that may be placed in a

wound is the Penrose drain. Alternatively, some wound drains are active in

that their structure is compressed and then slowly regains its previous shape

while pulling drainage from the wound and collecting it. An example of this

type of active drain is a Jackson-Pratt wound drain.

Wound drains are useful in that they work to prevent wound infections that

can be caused by drainage accumulation. They must be monitored carefully

and/or emptied on a regular basis to ensure that they work properly. A

surgical drain may cause damage to wound tissues, particularly if the tubing

is compressed against the skin. The body may also recognize the drain as a

37

foreign object, which can lead to inflammation around the site of the

wound.66

The nurse should utilize aseptic technique when handling the drain. In some

cases, the drain may have a dressing placed over the insertion site, which

should be changed on a regular basis, particularly if it becomes wet with

drainage. The amount of time a surgical drain is left in place after surgery

varies, but it is typically removed when drainage has stopped. If the wound

is infected and the drain is in place to clear an abscess, the length of time

the drain is in place may be longer when compared to drainage from a clean,

surgical wound.

Surgical site infections (SSIs) are the most common wound complication

that occurs after a surgical procedure.64 Surgical site infections have been

shown to occur in between 3 and 11 percent of postoperative surgical

incisions; the variation exists depending on the type of surgery performed.65

The severity of an SSI can range from purulent drainage, redness, and

incisional swelling to full-blown septicemia that rapidly develops into a life-

threatening situation.

Milne, et al., in an article found in Wounds UK, described an approach that

can reduce the risk of surgical site infection by performing assessments

before, during, and after the operative session. Prior to surgery, during the

preoperative phase, the nurse must assess for those patient factors that will

increase the risk of skin breakdown and wound formation, such as advancing

age, obesity, immobility, or malnutrition. During the surgical procedure, the

healthcare team provides care using aseptic technique to reduce the risk of

infection. This includes cleansing the operative site appropriately; ensuring

sterile technique throughout the procedure, and ensuring instruments have

38

been properly sterilized before use. Postoperatively, the nurse must continue

to use aseptic technique when caring for the wound, clean the wound with

saline and perform dressing changes as ordered, and monitor for signs of

skin breakdown.64

The risk of surgical site infection is increased with advancing age, longer

length of time of the surgical operation, a longer stay in the hospital prior to

the surgical procedure, inadequate bathing or showering before the

procedure, lack of appropriate removal of body hair in the operative area;

and, other patient factors, including a history of smoking, increased BMI,

and a history of certain chronic diseases, such as chronic obstructive

pulmonary disease, diabetes, and malnutrition.66 Antibiotics that are ordered

prophylactically must be given at the appropriate time surrounding the

surgery. Antibiotics are effective when given on time and not too far before

the procedure or well after the surgery has started.

The initial process of inflammation that develops at the beginning of the

healing process may be confused with a surgical site infection.

Administration of antibiotics occurs after confirmation of infection through a

wound culture, as well as other physical manifestations of wound infection,

such as increased pain, patient fever, surrounding skin maceration, and

purulent drainage.

Wound dehiscence is another potential complication of a surgical wound.

Dehiscence occurs when the edges of the surgically closed wound come

apart. It may occur as partial or complete separation of the wound edges.

The most common area of wound dehiscence is a surgical wound on the

abdomen; however, the condition has also developed with surgical wounds

in other locations, such as cesarean section wounds, episiotomies, and

39

sternotomy wounds.66 Normally, the healing surgical wound develops a ridge

of tissue along the incision line. When this ridge is missing or has never

developed, dehiscence is more likely to occur.

When wound dehiscence occurs, the nurse should cover the wound and get

help. If evisceration has also occurred with dehiscence, a condition in which

the organs behind the wound spill out through the wound opening, the nurse

should quickly place a saline-soaked gauze over the organs for protection

and prepare for surgical intervention. Depending on the extent of

dehiscence, surgery may be necessary to clean out debris and anything that

is contaminating the wound, as well as infected materials that may have

collected within the wound. The wound should stay covered with gauze

soaked in normal saline until the patient goes back to surgery.

Similar to management of wounds caused by other factors, such as venous

insufficiency or diabetic neuropathy, surgical wounds require an appropriate

healing environment that promotes tissue growth and prevention of

infection. Surgical wounds may have complications that are specific to this

type of opening, particularly when affected tissues under the incision

become infected or develop other problems because of underlying medical

issues, such as chronic disease. The nurse should frequently monitor the

surgical wound and perform routine care measures to promote healing,

support nutrition and health, and to educate the patient about his or her

condition.

Fungating Cancer or Malignant Wound

A wound that develops as a result of a tumor, sometimes called a fungating

cancer wound or malignant wound, occurs when a tumor that is growing

under the skin reaches the skin surface and breaks through to create a

40

wound. This type of wound can be very difficult to manage, through physical

or psychological patient care, as the wound can be painful and debilitating,

but the patient may also need emotional support to handle a potential

malignant diagnosis associated with the wound.

As it grows, a fungating tumor wound may cause damage under the skin

when it presses toward the skin surface. The affected tissues may become

deprived of oxygen after capillary damage from the growing tumor, leading

to ischemia and tissue necrosis. The wound may have an odor and typically

it may release fluid, blood, or other discharge that must be managed. The

patient may also experience severe pain or itching at the site.

The most common types of cancer that cause tumor wounds are breast

cancer, melanoma, and head and neck cancer. Approximately 62 percent of

fungating wounds develop on the breast, with another 24 percent occurring

as lesions on the head or neck.67,68 The wound may grow through the skin at

the site of the cancer or it may appear in an area where the cancer has

metastasized. A fungating wound typically develops within the last few

months of a patient’s life. Confirmation that the wound has actually

developed from metastatic disease and not from another infectious process

or chronic illness is important to guide treatment measures for the wound.

The initial appearance of the tumor may look like a hard nodule that is the

same color as the outer skin or it may be blue, violet, or black in color. The

nodule(s) that develop are typically not painful at first, but as they grow,

they become more prominent and the ulceration can also lead to formation

of sinus tracts or tunneling around the wound.68 When the tissue becomes

necrotic as a result of the wound, anaerobic organisms collect in the area,

since it has been deprived of oxygen. Because of this, the fungating wound

41

is more likely to have a strong odor that is usually embarrassing and

unpleasant for the affected patient.

The nurse who cares for a patient with a fungating wound must not only

provide wound care and management, but also should assess and provide

treatments for the patient’s malignant condition. This may involve

administering medications for cancer treatment or drugs to increase the

patient’s comfort levels and reduce distress associated with cancer

symptoms. An additional aspect of care is continually assessing the patient’s

psychological and emotional health as the wound and the cancer diagnosis

relates to care. Other factors, such as the patient’s nutritional status,

presence of other chronic conditions, mobility, and ability to perform

activities of daily living should also be incorporated as part of wound care

management in these situations.

Management of wound odor is one of the most prominent concerns when

working with a patient who has a fungating wound. The patient may suffer

much embarrassment because of the smell of the wound, which is attributed

to growth of anaerobic bacteria in the wound bed. Administration of

antibiotics may be necessary, but systemic antibiotics are typically not

administered on a long-term basis in order to avoid the potential for

development of resistant organisms. Topical metronidazole, an antifungal

medication, has been shown to reduce wound odor after 2 to 3 days of

application.68 The nurse may also consider other measures that can help

with wound odor, such as by applying dressings infused with charcoal, which

absorb some of the wound odor, controlling exudate, and performing regular

debridement.

42

A fungating wound often causes pain for the patient, which is controlled

through medications given for pain management, including both opioids and

non-opioid analgesics, as well as other adjuvant medications. Other

considerations that the nurse must give for management of a tumor wound

include control of exudate and bleeding, as this type of wound tends to

produce greater amounts of fluid and/or is more likely to bleed. These

aspects are controlled by appropriate dressings and regular wound care and

dressing changes.

Depending on the patient’s condition, the nurse may need to provide

palliative treatment as part of wound care, particularly if the wound has

developed at the end of the patient’s life. When this occurs, comfort

measures and psychosocial support are essential, in addition to regular

wound care to minimize discomfort from a spreading infection or skin

breakdown from a poorly managed wound. Alternatively, some patients with

fungating wounds may choose more aggressive treatments and may opt for

surgical removal or treatment with other elements, such as chemotherapy or

hormone therapy. The nurse must provide support and help for the patient

with a wound caused by a tumor regardless of the treatment decision that is

made. Each situation is different and depending on the choice for treatment

or wound management, the nurse continues to provide gentle and

compassionate care that is therapeutic for this very difficult situation.

Wound Risk Factors

Although there are various causes of wounds that result from differing states

of health or disease, there are some risk factors that are more common to

wound development in general. By and large, a poor state of health, whether

because of chronic disease, malnutrition, lack of activity, or poor self-care,

43

typically contributes to an increased risk of wound development and poor

wound healing when a wound does happen.

Insufficient Oxygen

Poor oxygen perfusion contributes to wound development when the tissues

do not receive enough oxygenated blood. This may more likely occur in a

condition in which blood flow is reduced or blocked due to an occlusion, such

as in the case of arterial insufficiency or peripheral arterial occlusive disease.

The skin and underlying tissues need oxygen from the blood in order to stay

healthy and to prevent the growth of anaerobic bacteria, which are

microorganisms that can grow in the absence of oxygen. When the skin and

peripheral tissues do not have enough oxygen, the skin is more likely to

break down, causing a wound, and the resultant wound could become

infected more easily.

Malnutrition

Malnutrition impacts wound healing due to changes in protein sufficiency and

lack of vitamins that normally act as healing factors in the body. Malnutrition

can develop in some people because of a lack of intake due to a number of

situations, including socioeconomic factors that affect accessibility of food,

stressful events or periods of severe illness, difficulties with feeding,

chewing, or swallowing food, malabsorption syndromes that affect how the

body digests and absorbs nutrients, or mental health diagnoses of eating

disorders, such as anorexia. Alternatively, malnutrition can also occur among

some patients who are overweight or obese. An obese patient may have

malnutrition even when food intake is excessive because he or she may only

44

be eating certain types of foods that add to weight gain but that do not

provide important nutrients.

When a person is malnourished, he or she may use protein for energy

instead of glucose. To get this protein, the body breaks down its own

sources, such as protein found within skeletal muscle tissue. Because wound

healing requires protein to form a healing matrix through collagen, wounds

may heal slower when the body is focusing its protein sources instead on

gaining energy.

Malnutrition also contributes to wound development through other methods.

Poor nutrition depletes lean body mass and the patient has less muscle

tissue for activities of daily living; he or she may be more likely to develop

greater degrees of immobility, which can further impair other body

processes and contribute to skin breakdown. Further, decreased protein

intake impairs the immune system and can increase the risk of infection if a

wound develops.20

A patient who develops an illness or goes through a surgical procedure loses

a certain amount of protein each day. This protein loss then contributes to

further effects that can lead to wound development. Additionally, certain

procedures, periods of hospitalization, or general lack of intake can affect

how well a wound heals when it does develop. Malnutrition has been shown

to impact function of both B and T lymphocytes and prevents proper

functioning of leukocytes in the body, increasing the risk of infection.

Further, if a wound starts to develop, skin breakdown may be perpetuated

by loss of protein and malnutrition; as a malnourished state also increases

the length of the inflammation stage of wound healing, it decreases collagen

synthesis and decreases overall strength of the skin.53

45

A patient who is malnourished may also be underweight and may have less

fat tissue to protect bony prominences. Consequently, more bony

prominences increase the risk of pressure ulcers without the extra padding

under the skin. A patient who has decreased muscle mass and more bony

prominences as a result of malnutrition may have less activity when

compared to another person who is not malnourished. The increase in

immobility, decrease in muscle mass, and greater number of pressure points

can all contribute to skin breakdown associated with pressure ulcers.

Diabetes mellitus can cause a form of malnutrition because the patient has

abnormal carbohydrate metabolism and is therefore unable to adequately

use this type of macronutrient in a normal manner needed for the body.

Diabetes, or even a severe state of stress or illness that leads to changes in

blood glucose concentrations, can disrupt the functions of the cells of the

immune system, thereby increasing the risk of infection. Hyperglycemia has

also been shown to reduce the body’s ability to absorb vitamin C into

leukocytes and fibroblasts in the skin cells.20

Several vitamins are also necessary to help the body with wound healing.

Vitamin C, or ascorbic acid, is needed for synthesis of collagen, which

provides a structural framework in the growth of new tissue in the wound

bed. Vitamin C also supports the body’s immune response, and lack of

vitamin C may contribute to increased inflammation when a wound has

developed.53

Vitamin A deficiency leads to a decrease in the function of certain types of

immune cells, including macrophages and monocytes. Vitamin D depletion

also leads to decreased strength in the healed wound if one does develop.

Another fat-soluble vitamin, vitamin E, is associated with health of the skin.

46

Deficiencies in vitamin E are uncommon, but they can cause problems with

the body’s defenses because of its antioxidant properties. Further, vitamin E

deficiency may lead to uncontrolled inflammation in and around the

wound.20

Fluid volume deficit also has an impact on wound healing. A patient may

have adequate intake of food and may gain enough vitamins, minerals, and

nutrients through eating, but lack of fluid can lead to dehydration, which can

stunt the wound healing process. Dehydration causes a decrease in overall

circulation; in addition to causing other problems such as electrolyte

imbalance, decreased blood volume from dehydration prevents adequate

blood flow from reaching the wound site. The body is less able to send blood

cells to the site of injury for their part in maintaining immunity, stimulating

wound healing, and preventing infection.

Immobility

Immobility is one of the most common factors associated with pressure ulcer

development, but it also plays a contributing role in wound development for

patients with other chronic diseases, such as venous insufficiency and

diabetes. Lack of movement from immobility decreases overall circulation

and can cause wounds related to incontinence or an inability to perform self-

care measures.

When a patient is immobile and must rely on caregivers for movement or

repositioning, he or she is at greater risk of skin breakdown because of an

inability to shift positions to take pressure off of certain areas of the skin.

Wounds may be more likely to occur in an immobile patient who must spend

a significant amount of time in bed or sitting in a chair, and who otherwise

47

can do little to increase circulation in the extremities and support or

maintain proper blood flow.

Many immobile patients have difficulties with getting up to use the bathroom

and are often forced to rely on bedpans, catheters, and/or bedside

commodes for elimination. Immobile patients may be at increased risk of

incontinence if they are unable to access these devices quickly enough or if

they must rely on a caregiver for help. Urinary and fecal incontinence

contribute to skin breakdown because of the components of these wastes.

Urine is a fluid that, when left on the skin, increases moisture content and

causes skin softening and maceration. The enzymes found in stool, as well

as its pH content can also cause skin breakdown, particularly after times

when fecal matter is left on the skin without being cleaned in a timely

manner.

Many people think of immobility as affecting older adults who are living in

long-term care facilities and who are dependent on caregivers for help with

turning or with getting out of bed. While this is true in many cases, another

population of patients are at risk of skin breakdown because of immobility in

the healthcare environment are those who receive care in the intensive care

unit.

Patients in intensive care environments are at risk of wound development,

often because of the increased amounts of medical equipment used because

of their fragile medical states.3 A patient in the intensive care unit may be at

higher risk of pressure ulcers because he or she is typically immobile

because of illness, rather than a chronic disability or advanced age, as is

seen among some other immobile patients. The patient in the intensive care

unit often also needs more medical equipment as part of his or her care,

48

which may include a ventilator, urinary catheter, sequential compression

device, intravenous line or central catheter, and hemodynamic monitoring

systems. Some of the medications administered to a patient may also

increase the risk for skin breakdown.

Based on the amount of equipment required and the clinical status of acute

illness, the intensive care unit patient is actually quite immobile. Depending

on the level of care required, he or she may not be able to get up or move

out of bed in any way, whether because of illness and level of consciousness

or because of the presence of so many pieces of medical equipment needed

to provide care. For example, a patient who requires mechanical ventilation

typically requires sedation, which places him or her in an altered state of

consciousness and, most likely, restricted to bed rest rather than chair

activity to facilitate position changes. Prevention of pressure ulcers,

therefore, is centered on turning and repositioning the patient frequently and

preventing medical equipment from applying too much pressure at a

particular site.

In addition to limiting how much a patient in the intensive care unit is able

to get up or move, medical equipment also places pressure on certain parts

of the skin, which can lead to skin breakdown. An endotracheal tube that is

positioned in the same area or that presses against the lip for too long can

cause tissue breakdown in that area. A patient who is turned and who is

accidentally positioned so that the catheter hub of the central line is under

the body can suffer from skin breakdown in a short time due to the

intravenous tubing continuously pressing into the skin until such time the

patient is moved again. The administration of some vesicant solutions as

part of treatment for complex medical conditions often seen in the intensive

care unit can cause significant skin and tissue damage if extravasation

49

occurs. For instance, administration of cisplatin can cause tissue damage and

necrosis if it leaks from the intravenous site into the surrounding tissue.

Comorbidities

Certain factors impact wound development and affect healing when a wound

does develop. Comorbidities are diseases that are present in the patient that

may directly cause wound development or may result in a wound becoming

chronic and difficult to heal. Some patients have several comorbidities,

making their risks for wound development much higher than the general

population.

As a wound goes through the phases of healing, a comorbid condition that is

already present in the patient may interrupt the process and either slow or

stop wound healing altogether or cause complications that require further

intervention. For example, a patient who has diabetes and has developed a

foot wound may be on track with wound healing through proper care and

wound management. However, time spent with uncontrolled blood glucose

levels and improper foot care — both of which are factors associated with

diabetes as a comorbidity in this case — can lead to a wound infection and

skin breakdown on the wound periphery, further complicating the healing

process.

There are a number of comorbid conditions that can impair and delay wound

healing. These factors may contribute to the cause of the wound or they

may be elements that affect the wound’s healing progress. Examples of

comorbid conditions that can impact wound development and healing include

chronic conditions such as diabetes, vasculitis, systemic lupus

erythematosus, renal failure, various forms of cancer, rheumatoid arthritis,

and scleroderma.

50

When comorbidities are present in the wound care patient, the nurse

performs more than one role. Part of wound care management is controlling

the health of the wound, providing supportive care and treatment through

dressing changes and medication administration, and ensuring that the

patient knows how to care for the wound. Additionally, the nurse must

provide interventions that deal with the comorbid conditions that are present

in the patient in order to prevent these conditions from harming the wound

care process. As part of comprehensive care, the nurse provides medications

and patient education, performs or assists with certain procedures designed

to improve the patient’s health, and provides psychosocial support for the

patient’s condition.

As an example, a patient who has renal failure and who has a lower leg ulcer

not only needs ongoing wound care through assessment and treatment, but

also needs supportive treatment for renal disease. The nurse is often also

responsible for providing other care measures that may seem unrelated to

the wound because they do not directly affect the wounded area. However,

care of comorbid conditions will impact wound healing and is a necessary

part of treatment. In this example, in addition to providing wound care, the

nurse might also administer medications, arrange a referral for a dietary

consult, and/or assist with the patient’s dialysis.

Any patient who has a chronic disease and a healing wound must be

educated about how the condition affects wound repair and healing. Because

the patient should be an active participant in the wound care process, he or

she needs to know what factors could possibly delay wound healing. The

patient may or may not understand the correlation between a chronic

disease and a wound involving the skin. It is the nurse’s responsibility to

educate the patient about how each condition is related to the other. By

51

educating the patient about the factors that affect wound healing, the

patient can become more involved in his or her treatment regimens and may

take steps to assist not only with wound care, but with care of his or her

chronic disease as well.

Medications

Certain medications can cause skin breakdown when they cause changes in

the skin because of side effects or when they are inadvertently administered

in a method that the medication interacts with the skin when it is not

supposed to. There are a number of medications that cause rash or eczema

as side effects. While this may not initially cause skin breakdown, the skin

can become more sensitive when a patient takes medications with these

effects. The patient may also scratch the skin in an attempt to soothe the

itching; excessive scratching can eventually lead to skin breakdown, sores,

or lesions.

Some medications, when administered intravenously, can cause significant

wounds if their solutions are accidentally infiltrated into the skin and tissues.

This can happen when, upon administration of the medication into the

intravenous catheter, the medication leaks out into the tissues and causes

damage. Medications known as vesicants can cause tissue damage and

necrosis of the skin when extravasation occurs during administration.

Extravasation can lead to such a significant wound that the patient requires

debridement and regular dressing changes while the wound heals,

sometimes over a period of weeks or months.

When a nurse must administer medications intravenously, he or she should

be aware of the potential affects on the skin. When giving vesicant

medications, the nurse must routinely check the intravenous catheter and

52

monitor the intravenous site and the tubing for changes to ensure that

extravasation does not develop and cause severe tissue damage to the skin.

Summary

Management of wounds involves a number of considerations, which include

the mechanism of injury and the assessment of the wound. Assessment of

the wound involves the wound size and depth. Additionally, its important to

consider other complicating factors, such as the presence of foreign objects

or other injuries around the wound, pain management, and the prevention

of bleeding or infection.

The process of wound healing may vary depending on the method of

intention used to close the wound. Wounds are healed by intention, which is

categorized into three different stages, primary, secondary and tertiary;

and, is based on the type of wound, the amount of debris present or if the

wound is contaminated, and the mechanisms of the cause of the wound.

Wounds are typically classified as being either chronic or acute wounds.

Chronic wounds are those that develop after tissue damage has been

ongoing, such as, wounds due to arterial insufficiency, diabetic ulcers,

pressure sores, and venous insufficiency. The point that differentiates

chronic wounds from acute wounds is that chronic wounds develop over

some period of time.

Risk factors more common to wound development generally include a poor

state of health due to chronic disease or poor self-care. Immobility, the most

common factors associated with pressure ulcer development, also plays a

contributing role in wound development for patients with chronic diseases,

such as venous insufficiency and diabetes. A decrease in overall circulation

due to immobilization can cause wounds related to incontinence or poor self-

53

care performance. Patients at risk of skin breakdown rely on caregivers to

help with mobility and position change to prevent skin pressure areas.

Wound assessment, the first step in the management of a wound, is

discussed in Wound Care Part II and is important throughout the entire

diagnostic and treatment process. In this study, wound care risks and stages

of development have been discussed. The next level of care involves

evaluation of wound healing and treatment efficacy.

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment

of Knowledge Questions after reading the article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course requirement.

54

1. Tertiary intention involves the process of:

a. wound closure done by applying physical measures to close a

wound. b. *initially leaving the wound open to partial healing.

c. leaving a wound open to heal through production of new granulation tissue to fill in the wound base.

d. None of the above

2. A nurse must continue to monitor a surgical wound

a. regardless of the type of surgical wound. b. when a wound is closed with sutures.

c. only if there is an open wound d. *Answers a., and b., are correct

3. True or False: venous insufficiency is a condition that develops when the veins are unable to return blood to the heart at a

normal rate and the blood collects in the lower extremities.

a. *True b. False

4. Surgical wound drains

a. must be emptied on a regular basis to ensure that they work

properly. b. may cause damage to wound tissues.

c. prevent wound infections caused by drainage accumulation. d. *All of the above

5. When a nurse must administer medications intravenously, he or she should be aware that

a. medications known as vesicants are safe because they do not cause

tissue damage to the skin. b. it is preferable to administer medications intravenously because

they cannot accidentally infiltrate into the skin tissues. c. *some medications, when administered intravenously, can cause

significant wounds if accidentally infiltrated into the skin and tissues.

d. extravasation does not develop if medications are administered intravenously.

55

6. The National Pressure Ulcer Advisory Panel (NPUAP) has

defined several classifications of pressure ulcers according to the

a. length of tissue involvement and presence of exudate.

b. *depth of tissue involvement and the extent of damage. c. circumference of tissue involvement and level of pain.

d. world health criteria.

7. The dermis is thicker than the epidermis and

a. mostly consists of connective tissue. b. contains many structures, including blood vessels, hair follicles and

nerve endings. c. is much tougher than the epidermis because of its composition.

d. *All of the above

8. A patient in the intensive care unit is vulnerable to pressure

areas or skin break down because of

a. medical equipment placing pressure on certain parts of the skin. b. vesicant solutions, such as cisplatin, leaking from the IV site into

the surrounding tissue. c. language barriers.

d. *Answers a., and b., are correct

9. A fungating wound

a. often is NOT painful for the patient. b. involves management of a burned area.

c. *requires control of exudate and bleeding.

d. is controlled by staying out of the sun.

10. Malnutrition impacts wound healing due to

a. *changes in protein sufficiency and lack of vitamins. b. high phosphorus levels.

c. age factors. d. autoimmune factors.

56

11. True or False: The most common location of venous ulcers is

just above the lateral malleolus of the ankle.

a. *True b. False

12. Venous ulcers tend to develop over other bony prominences and

are usually

a. deep wounds with irregular borders. b. *shallow wounds with irregular borders.

c. superficial, hence painless because. d. should not be elevated because it reduces circulation to the area.

13. A patient with a chronic disease and immobility is prone to

wound development due to

a. decreased overall circulation.

b. incontinence. c. inability to perform self-care measures.

d. *All of the above

14. Without oxygen presence to the skin and underlying tissue there is growth of ______________ bacteria, causing increased

risk of wound formation and infection.

a. aerobic b. *anaerobic

c. spores and d. Answers a., and c., are correct

15. Classification of wound contamination helps the provider to understand how best to close the wound, whether by

a. acute or delayed closure.

b. use of a device or surgical closure. c. *primary or secondary intention or by delayed closure.

d. primary or delayed closure.

57

16. Hyperglycemia has also been shown to reduce the body’s ability

to absorb ____________ into leukocytes and fibroblasts in the skin cells.

a. *Vitamin C

b. Vitamin E c. Vitamin B complexes

d. Vitamin A

17. What medication can cause tissue damage and necrosis of the skin when extravasation occurs during administration?

a. Evacuante

b. *Vesicant c. Esicant

d. Vesic

18. Fluid volume deficit can stunt the wound healing process

because of a

a. decrease in overall circulation. b. electrolyte imbalance.

c. decreased blood volume (to send blood cells to site of injury). d. *All of the above

19. Wounds are healed by intention, which is categorized in stages

of

a. *primary, secondary and tertiary b. principal and complicating

c. initial trauma and secondary infectious

d. non-infected and infected

20. Chronic wounds are those that develop

a. *due to arterial and venous insufficiency. b. at the time of injury.

c. as a category of wound occurring after 3 days. d. Both a., and c., are correct

58

21. The most common types of cancer that cause tumor wounds are

a. breast.

b. melanoma. c. head and neck.

d. *All of the above.

22. Approximately ____ percent of fungating wounds develop on the breast.

a. 20

b. 32 c. *62

d. 75

23. Twenty-four percent fungating wounds occur as lesions on the

a. breast.

b. *head or neck. c. skin.

d. mouth.

24. _______________ has been shown to impact function of both B and T lymphocytes and prevents proper functioning of

leukocytes in the body, increasing the risk of infection.

a. *Malnutrition b. Dehydration

c. Acute blood loss d. Blunt trauma

25. Deficiencies in vitamin E

a. are common, and may lead to uncontrolled wound inflammation. b. *are uncommon but they may lead to uncontrolled wound

inflammation. c. are not known to impair the body’s defenses.

d. lead to coagulopathy and blood loss.

59

26. True or False: A severe state of stress or illness that leads to

changes in blood glucose concentrations can disrupt the functions of the cells of the immune system, thereby increasing

the risk of infection.

a. *True b. False

27. Malnutrition may occur with

a. anorexia but not obesity.

b. wound inflammation. c. *anorexia and obesity.

d. dehydration.

28. _________________ wounds can have tunneling.

a. Stage I

b. Stage II c. *Stage III

d. Answers a., and b., are correct

29. True or False: If a second wound is nearby, tunneling may connect the two wounds to each other.

a. *True

b. False

30. People born with Klippel-Trénaunay-Weber (KTW) syndrome may also have

a. arterial insufficiency b. *venous insufficiency

c. abnormally dry skin d. flattened, abnormally small veins

31. ________________ foot ulcer would include ischemia and

infection, regardless of the Grade.

a. Stage A b. Stage B

c. Stage C d. *Stage D

60

Correct Answers:

1. Tertiary intention involves the process of:

b. initially leaving the wound open to partial healing.

“Tertiary intention involves the process of initially leaving the wound

open to partial healing.”

2. A nurse must continue to monitor a surgical wound

a. regardless of the type of surgical wound. b. when a wound is closed with sutures.

c. only if there is an open wound

d. Answers a., and b., are correct [correct answer]

“Regardless of the type of surgical wound, the nurse must continue to

monitor the wound frequently for signs and symptoms of infection. When a wound is closed with sutures, the nurse assesses for red skin

around the incision, wound edges that are not well approximated, drainage, swelling, tenderness, and skin that is hot to the touch.”

3. True or False: Venous insufficiency is a condition that develops when the veins are unable to return blood to the heart at a

normal rate and the blood collects in the lower extremities.

a. True

“… venous insufficiency is a condition that develops when the veins are unable to return blood to the heart at a normal rate. For various

reasons, the valves inside the veins do not propel blood toward the heart, leading to changes in the lower extremities, including the

appearance of the skin and the increased risk of skin breakdown that causes wounds.”

61

4. Surgical wound drains

a. must be emptied on a regular basis to ensure that they work

properly. b. may cause damage to wound tissues.

c. prevent wound infections caused by drainage accumulation. d. All of the above [correct answer]

“Wound drains are useful in that they work to prevent wound infections

that can be caused by drainage accumulation. They must be monitored carefully and/or emptied on a regular basis to ensure that they work

properly. A surgical drain may cause damage to wound tissues, particularly if the tubing is compressed against the skin. The body may

also recognize the drain as a foreign object, which can lead to inflammation around the site of the wound.”

5. When a nurse must administer medications intravenously, he or she should be aware that

c. some medications, when administered intravenously, can cause

significant wounds if accidentally infiltrated into the skin and tissues.

“Certain medications can cause skin breakdown when they cause changes in the skin because of side effects or when they are

inadvertently administered in a method that the medication interacts with the skin when it is not supposed to… When a nurse must

administer medications intravenously, he or she should be aware of the potential affects on the skin. When giving vesicant medications, the

nurse must routinely check the intravenous catheter and monitor the intravenous site and the tubing for changes to ensure that

extravasation does not develop and cause severe tissue damage to the

skin.”

6. The National Pressure Ulcer Advisory Panel (NPUAP) has defined several classifications of pressure ulcers according to the

b. depth of tissue involvement and the extent of damage.

“The National Pressure Ulcer Advisory Panel (NPUAP) has defined

several classifications of pressure ulcers according to the depth of tissue involvement and the extent of damage.”

62

7. The dermis is thicker than the epidermis and

a. mostly consists of connective tissue.

b. contains many structures, including blood vessels, hair follicles and nerve endings.

c. is much tougher than the epidermis because of its composition. d. All of the above [correct answer]

“The dermis is thicker than the epidermis and it mostly consists of

connective tissue. The dermal layer contains many structures, including blood vessels, hair follicles and nerve endings, as well as other cells that

take part in inflammatory processes when a wound occurs. The dermis is much tougher than the epidermis because of its composition.”

8. A patient in the intensive care unit is vulnerable to pressure

areas or skin break down because of

a. medical equipment placing pressure on certain parts of the skin.

b. vesicant solutions, such as cisplatin, leaking from the IV site into the surrounding tissue.

c. language barriers. d. Answers a., and b., are correct [correct answer]

“A patient who is turned and who is accidentally positioned so that the

catheter hub of the central line is under the body can suffer from skin breakdown in a short time due to the intravenous tubing continuously

pressing into the skin until such time the patient is moved again. The administration of some vesicant solutions as part of treatment for

complex medical conditions often seen in the intensive care unit can cause significant skin and tissue damage if extravasation occurs. For

instance, administration of cisplatin can cause tissue damage and

necrosis if it leaks from the intravenous site into the surrounding tissue.”

9. A fungating wound

c. requires control of exudate and bleeding.

“A fungating wound often causes pain for the patient, which is

controlled through medications given for pain management, including both opioids and non-opioid analgesics, as well as other adjuvant

medications. Other considerations that the nurse must give for management of a tumor wound include control of exudate and bleeding,

63

as this type of wound tends to produce greater amounts of fluid and/or

is more likely to bleed.”

10. Malnutrition impacts wound healing due to

a. changes in protein sufficiency and lack of vitamins.

“Malnutrition impacts wound healing due to changes in protein sufficiency and lack of vitamins that normally act as healing factors in

the body.”

11. True or False: The most common location of venous ulcers is just above the lateral malleolus of the ankle.

a. True

“The most common location of venous ulcers is just above the lateral malleolus of the ankle.”

12. Venous ulcers tend to develop over other bony prominences and

are usually

b. shallow wounds with irregular borders.

“Venous ulcers also tend to develop over other bony prominences. They are usually shallow wounds with irregular borders.”

13. A patient with a chronic disease and immobility is prone to

wound development due to

a. decreased overall circulation.

b. incontinence. c. inability to perform self-care measures.

d. All of the above [correct answer]

“Immobility is one of the most common factors associated with pressure ulcer development, but it also plays a contributing role in wound

development for patients with other chronic diseases, such as venous insufficiency and diabetes. Lack of movement from immobility

decreases overall circulation and can cause wounds related to incontinence or an inability to perform self-care measures.”

64

14. Without oxygen presence to the skin and underlying tissue there

is growth of ______________ bacteria, causing increased risk of wound formation and infection.

b. anaerobic

“The skin and underlying tissues need oxygen from the blood in order to stay healthy and to prevent the growth of anaerobic bacteria, which are

microorganisms that can grow in the absence of oxygen. When the skin and peripheral tissues do not have enough oxygen, the skin is more

likely to break down, causing a wound, and the resultant wound could become infected more easily.”

15. Classification of wound contamination helps the provider to

understand how best to close the wound, whether by

c. primary or secondary intention or by delayed closure.

“The classification of wound contamination helps the provider to

understand how best to close the wound, whether by primary or secondary intention or by delayed closure.”

16. Hyperglycemia has also been shown to reduce the body’s ability

to absorb ____________ into leukocytes and fibroblasts in the skin cells.

a. Vitamin C

“Hyperglycemia has also been shown to reduce the body’s ability to

absorb vitamin C into leukocytes and fibroblasts in the skin cells.”

17. What medication can cause tissue damage and necrosis of the

skin when extravasation occurs during administration?

b. Vesicant

“Medications known as vesicants can cause tissue damage and necrosis of the skin when extravasation occurs during administration.”

65

18. Fluid volume deficit can stunt the wound healing process

because of a

a. decrease in overall circulation. b. electrolyte imbalance.

c. decreased blood volume (to send blood cells to site of injury). d. All of the above [correct answer]

“Fluid volume deficit also has an impact on wound healing. A patient

may have adequate intake of food and may gain enough vitamins, minerals, and nutrients through eating, but lack of fluid can lead to

dehydration, which can stunt the wound healing process. Dehydration causes a decrease in overall circulation; in addition to causing other

problems such as electrolyte imbalance, decreased blood volume from dehydration prevents adequate blood flow from reaching the wound

site. The body is less able to send blood cells to the site of injury for

their part in maintaining immunity, stimulating wound healing, and preventing infection.”

19. Wounds are healed by intention, which is categorized in stages

of

a. primary, secondary and tertiary

“The process of wound healing may vary depending on the method of intention used to close the wound. Wounds are healed by intention,

which is categorized into three different stages and is based on the type of wound, the amount of debris present or if the wound is

contaminated, and the mechanisms of the cause of the wound: [primary, secondary and tertiary].”

20. Chronic wounds are those that develop

a. due to arterial and venous insufficiency.

“Chronic wounds are those that develop after tissue damage has been ongoing. Examples of chronic wounds include wounds that develop due

to arterial insufficiency, diabetic ulcers, pressure sores, and wounds that occur from venous insufficiency.”

66

21. The most common types of cancer that cause tumor wounds are

a. breast.

b. melanoma. c. head and neck.

d. *All of the above.

“The most common types of cancer that cause tumor wounds are breast cancer, melanoma, and head and neck cancer.”

22. Approximately _____ percent of fungating wounds develop on

the breast.

c. 62

“Approximately 62 percent of fungating wounds develop on the breast,

with another 24 percent occurring as lesions on the head or neck.”

23. Twenty-four percent fungating wounds occur as lesions on the

b. head or neck.

“Approximately 62 percent of fungating wounds develop on the breast, with another 24 percent occurring as lesions on the head or neck.”

24. _______________ has been shown to impact function of both B

and T lymphocytes and prevents proper functioning of leukocytes in the body, increasing the risk of infection.

a. Malnutrition

“Malnutrition has been shown to impact function of both B and T lymphocytes and prevents proper functioning of leukocytes in the body,

increasing the risk of infection.”

25. Deficiencies in vitamin E

b. are uncommon but they may lead to uncontrolled wound inflammation.

“Deficiencies in vitamin E are uncommon, but they can cause problems

with the body’s defenses because of its antioxidant properties.”

67

26. True or False: A severe state of stress or illness that leads to

changes in blood glucose concentrations can disrupt the functions of the cells of the immune system, thereby increasing

the risk of infection.

a. True

“Diabetes, or even a severe state of stress or illness that leads to changes in blood glucose concentrations, can disrupt the functions of

the cells of the immune system, thereby increasing the risk of infection.”

27. Malnutrition may occur with

c. anorexia and obesity.

“Malnutrition impacts wound healing due to changes in protein sufficiency and lack of vitamins that normally act as healing factors in

the body. Malnutrition can develop in some people because of a lack of intake due to a number of situations, including socioeconomic factors

that affect accessibility of food, stressful events or periods of severe illness, difficulties with feeding, chewing, or swallowing food,

malabsorption syndromes that affect how the body digests and absorbs nutrients, or mental health diagnoses of eating disorders, such as

anorexia. Alternatively, malnutrition can also occur among some patients who are overweight or obese. An obese patient may have

malnutrition even when food intake is excessive because he or she may only be eating certain types of foods that add to weight gain but that do

not provide important nutrients.”

28. _________________ wounds can have tunneling.

c. Stage III

“Stage III wounds can have tunneling, in which a hole or tunnel

progresses deeper into surrounding tissue.”

29. True or False: If a second wound is nearby, tunneling may connect the two wounds to each other.

a. True

“If a second wound is nearby, tunneling may connect the two wounds.”

68

30. People born with Klippel-Trénaunay-Weber (KTW) syndrome

may also have

b. venous insufficiency

“… a small population of people who are born with Klippel-Trénaunay-Weber (KTW) syndrome will also have venous insufficiency.”

31. ________________ foot ulcer would include ischemia and

infection, regardless of the Grade.

d. Stage D

“The classification system is demonstrated as follows:

Grade 0 Grade 1 Grade 2 Grade 3

Stage

A

Pre-ulcerative

lesion with no

obvious skin

breakdown

Superficial

wound

Wound that

penetrates to

underlying

tendons

Wound

penetrating to

bone or joint

Stage

B

Infection Infection Infection Infection

Stage

C

Ischemia Ischemia Ischemia Ischemia

Stage

D

Infection and

ischemia

Infection and

ischemia

Infection and

ischemia

Infection and

ischemia

69

References Section

The References below include published works and in-text citations of

published works that are intended as helpful material for your further reading.

1. Katz, M. J., Kirr, C. A. (2012). Wound care. Retrieved from

http://www.nursingceu.com/courses/395/index_nceu.html 2. Kifer, Z. A. (2012). Fast facts for wound care nursing: Practical wound

management in a nutshell. New York, NY: Springer Publishing Company, LLC

3. Cooper, K. L. (2013, Dec.). Evidence-based prevention of pressure ulcers the intensive care unit. Critical Care Nurse 33(6): 57-66.

Retrieved from http://www.aacn.org/wd/Cetests/media/C1363.pdf

4. Falconio-West, M. (2013, Sep.). Kennedy Terminal Ulcer (KTU) is now recognized by CMS for long-term acute care hospitals (LTAC or LTCH).

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long-term-acute-care-hospitals-ltac-or-ltch/ 5. Covidien AG. (2008, Jan.). Support services and the prevention of

pressure ulcers. Retrieved from http://www.patientcare-edu.com/imageServer.aspx?contentID=20368&contenttype=application

/pdf 6. Brunner, M., Droegemueller, C., Rivers, S., Deuser, W. E. (2012).

Prevention of incontinence-related skin breakdown for acute and critical care patients. Urology Nurse 32(4): 214-219. Retrieved from

http://www.medscape.com/viewarticle/769850_2 7. DeMarco, S. (n.d.). Wound and pressure ulcer management. Retrieved

from http://www.hopkinsmedicine.org/gec/series/wound_care.html

8. Lippincott Nursing Center.com. (2009). Wound watch: Assessing pressure ulcers. LPN2009 5(1): 20-23. Retrieved from

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Wound Care 23(9): 432. Retrieved from http://journals.lww.com/aswcjournal/Fulltext/2010/09000/Arterial_Ulce

r_Checklist.11.aspx 10. Hess, C. (2012). Clinical guide to skin and wound care (7th ed.). Ambler,

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0358;year=2012;volume=45;issue=2;spage=316;epage=324;aulast=B

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40. Alumia, R. (2013, Sep.). Improving outcomes with non-contact low-

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