Stressors that Affect Skin Integrity

Wound Care

NUR101 Fall 2008

LECTURE # 8
K. Burger MSEd, MSN, RN, CNE

PPP By: Sharon Niggemeier RN MSN

Revised kburger906,907
Factors that Impair Wound Healing
Age
Malnutrition
Obesity/Emaciation
Poor circulation and oxygenation
Immunosuppression
Smoking
Incontinence
Medications ( Steroids )
Co-morbidities ( Diabetes)
Wound Stress
Radiation
Wounds - Classification
Intentional results from planned treatment
Unintentional wounds- results from
unexpected traumaaccident/ burns/ shooting
Open -skin broken, portal of entry
Closed trauma from force, skin intact, soft
tissue damage, internal injury, possible bleeding
Acute goes through normal/timely healing
process
Chronic fails to go through normal stages of
healing; no timely progress in healing
Wounds Classification
Superficial Clean
Penetrating Contaminated
Perforating Infected
Colonized
Laceration
Pressure Ulcers
Puncture Stage I
Abrasion Stage II
Contusion Stage III
Stage IV
Wound Assessment
Appearance: granulation tissue, eschar, slough,
edema, tunneling, undermining, sinus tracts, color
Drainage: serous, serosanguineous,
sanguineous, purulent and amount
Pain
Size & location on body
Presence of sutures/staples
Presence of drains/tubes
Wound edges
 ??Other Factors to Assess??

ODOR
LAB VALUES
WHAT CAUSED THE WOUND?
NEED FOR TETANUS?
WHEN DID WOUND OCCUR?
WHAT (IF ANY) TREATMENTS HAVE
BEEN TRIED?
Wound - Healing

Healthy body has the ability to restore

itself, it depends on the amount of
damage and state of health of the
individual.
Referred to as regeneration (renewal)
of tissue.
There are (3) phases of regeneration
Phase I Wound Healing
Inflammatory phase- begins immediately
after injury.
Includes Hemostasis (cessation of bleeding) due
to vasoconstriction and platelet aggregation
Release of histamine, increasing capillary
permeability (plasma leaking) and vasodilation
Also phagocytosis ( process when
macrophages engulf microbes and secrete
growth factors that promote angiogenesis)
stimulates epithelial buds at the end of injured
tissue resulting in increased circulation which
sustains the healing process
Phase ICONTINUED Wound Healing
Inflammatory Response
4 Cardinal S/S
Pain
Redness
Heat
Edema
 Phase I Inflammatory Response
SYSTEMIC RESPONSE

Elevated temperature
Elevated WBC ( norms 5000-10000 )
Malaise
Phase II Wound Healing
Proliferation (Fibroplasia) Phase -
second phase , fibroblasts synthesize
collagens which add strength to the
wound. Begins 2-3 days after injury.

Thin layer of epithelial cells forms, blood

flow is reinstituted. Tissue forms - known
as granulation tissue. Translucent red
color/fragile/bleeds easily.
Phase III Wound Healing
Maturation (Remodeling) Phase-
final phase begins about 3 weeks after the
injury.
Collagen originally in haphazard order
remodels and reorganizes into a a more
orderly structure.
Scar (cicatrix) forms - avascular tissue ,
doesnt sweat, grow hair, or tan.
Keloid- abnormal amount of collagen laid
down, hypertrophic scar. ( common in dark
skin).
Types of Wound Healing
Primary Intention: clean, straight line, edges
well approximated with sutures, rapid healing

Secondary Intention: larger wounds with tissue

loss, edges not approximated, heals from the
inside out, granulation tissue fills in the wound,
longer healing time, larger scars

Tertiary Intention: delay 3-5 days before injury

is sutured, greater access for pathogens to
invade, greater inflammation, more granulation,
larger scars .
Wound Complications
Infection- S/S purulent drainage, pain, redness around
wound, edema, increased temp, elevated WBC

Hemorrhage S/S large amts sanquineous drainage +

other symptoms of hypovolemic shock. Check UNDER
clients

Dehiscence- S/S wound edges pulling away; not well-

approximated. Early sign = increasing serosanquineous
drainage

Evisceration- S/S wound opens revealing internal organs.

Emergency rx = sterile NS gauze to cover; prepare for OR

Psychosocial impact Encourage verbalization of

feelings; encourage self-care as tolerated by client
Promotion of Wound Healing
Dressings: keep wound covered &
clean
Wound bed moist / Surrounding skin
dry
Debridement when necessary
Remove exudate:
Drains, Wound VAC, Irrigation
Pack wounds loosely
Nutritional interventions
 Debridement Methods

Surgical
Mechanical
Enzymatic ( proteolytic enzymes)
Autolytic
Maggots
 Wound Dressing
Principles
If exudate is present - Select one that
absorbs exudate.
Keep wound bed moist but surrounding
skin dry
Pack wounds loosely to avoid pressure on
new granulation tissue
Fasten securely using tape, binders etc
OR self-adhesive type dressing materials.
Dressings for DRY wounds
Transparent: gas exchanged between wound &
environment but bacteria prevented from
entering. Creates moist healing environment
Example: Tegaderm

Hydrogels: High water content enhances

epithelialization and autolytic debridment.
Needs cover dressing and wound edge barrier
Example: Carrasyn

Wet to- Moist Gauze dressings: keeps

wound bed moist. Minimizes trauma to
granulation tissues
Dressings for DRY wounds

Wet to Moist Gauze

Dressings for MOIST wounds
Hydrocolloid: hydrophilic particles mix with water to
from a gel... wound stays moist. DO NOT use in infected
wounds.
Example: Duoderm

Absorption Materials: beads, powders, rope or sheets

that absorb large amount of exudate
Example: Calcium Alginate

Foam: Made of hydrophilic material. Highly absorbent.

Example: Allevyn

Dry Gauze: Can absorb wound drainage. Can be

impregnated with agents to promote healing
Dressings for MOIST wounds
Irrigations
Cleanses a wound using pressure
Sterile Normal Saline = usually prescribed
Avoid caustic agents ie: peroxide, iodine
etc.
Pressure between 4-15 pounds per
square inch (psi) i.e. 60ml syringe with
catheter tip
Other Therapies
Wound V.A.C. negative pressure
vacuum assisted closure system.
Removes drainage and helps wounds
close.
Hydrotherapy Pulse lavage, Whirlpool
Aids in debridement and cleansing, warm
water vasodilation.
Hyperbaric Oxygen
Electrical Stimulation
Other Therapies

Electrical Stimulation:
- electrical signals direct
cell migration in wound
healing
Bandages & Binders

Secures dressings in place

Determine size needed

Outer covering must cover entire wound

Tape to secure (initial,date time)

Heat & Cold Therapy
Heat- reduces pain & promotes healing
through vasodilation
Increases oxygen and nutrients to aid in
inflammatory response
Reduces edema by promoting removal of
excessive interstitial fluid
Promotes muscle relaxation
Heat & Cold Therapy
Cold- decreases pain by vasoconstriction
Decreased blood flow to the area
decreases inflammation and edema
Raises the threshold of pain receptors
thereby decreasing pain
Decreases muscle tension
 Safety Precautions
Heat & Cold Therapy
Need physicians order
Very young and very old
Peripheral vascular disease
Decreased LOC
Spinal cord injury
Presence of edema and/or scar tissue
NO LONGER than 20-30minutes at a time.
Rebound phenomena