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Wound Care
Chapter 13
| Question | Answer |
|---|---|
| Phases of wound healing Inflammatory Response | >Vascular response >Cellular response > Formation of Exudate > Healing |
| Inflammatory phase Vascular Response | Transient Vasoconstriction-> Histamine Release -> Vasodilation (Increased blood flow which raises filtration pressure) --> Increased capillary permeability (facilitate movement from capillaries into tissue spaces)-> Fibrin-> Growth Factors |
| What is Fibrin | fibrous, non-glabular protein involved in clotting of blood |
| Vasodilation and Increased capillary permeability responsible for: | redness, heat, and swelling |
| What is Exudates | any fluid that filters from the circulatory system into lesions or areas of inflammation |
| Cellular Response | >Neutrophils >Monocytes and Macrophages >Lymphocytes and other WBCs |
| Neutrophils in Cellular Response | >First to arrive (6-12 hours)--> Engulf bacteria, other foreign material & damaged cells --> short life span (24-48 hours) --> dead neutrophils accumulate w/digested bacteria & other cell debris = creamy substance (pus) |
| Monocytes and Macrophages in Cellular Response | second to migrate from circulating blood. >arrive (3-7 days) after onset of inflammation >on entering tissue space monocytes transform int macrophages --> engulf inflammatory debris >the role--> cleaning area before healing can occur > long life span |
| Lymphocytes and other WBCs in Cellular Response | arrive later at injury |
| Types of inflammatory exudate Serous | Results from outpouring of fluid; seen in early stages of inflammation or when injury is mild. Examples: skin blisters, pleural effusion |
| Types of inflammatory exudate Serosanguineous | Found during the midpoint in healing after surgery or tissue injury. Composed of RBCs and serous fluid. This fluid is semiclear pink and may have red streaks. Examples: Surgical drain fluid |
| Types of inflammatory exudate Fibrinous | Occurs with increasing vascular permeability and fibrinogen leakage into interstitial spaces. Excessive amounts of fibrin that coats tissue surfaces may cause them to adhere. Examples: Adhesions, gelatinous ribbons seen in surgical drain tubing |
| Types of inflammatory exudate Hemorrhagic | Results from rupture or necrosis of blood vessel walls Examples: Hematoma, bleeding after surgery or tissue trauma |
| Types of inflammatory exudate Purulent (pus) | Consists of WBCs, microorganisms (dead and alive) liquefied dead cells, and other debris. Examples: Furuncle (boil), abscess, cellulitis (diffuse inflammation in connective tissue). |
| Types of inflammatory exudate Catarrhal | Found in tissues where cells produce mucus. Mucus production is accelerated by inflammatory response. Examples: runny nose associated with upper respiratory tract infection |
| Healing Process Regeneration | replacement of lost cells and tissues with cells of same type |
| Healing process Repair | healing as a result of lost cells being replaced by connective tissue (most common results in scar formation) |
| Healing process Regeneration Labile Cells | >Labile cells->divide constantly -> rapid regeneration (ex: skin, mucous membranes of GI, bone marrow) |
| Healing process Regeneration Stable Cells | >Stable cells (retain their ability to regenerate but do so only if organ is injured) (ex: liver, pancreas, kidney) |
| Healing process Regeneration Permanent Cells | Permanent Cells (do not divide) (ex: CNS, Cardiac, and skeletal muscle cells) -permanent loss if damaged - CNS neurons destroyed replaced by glial cells -Cardiac & skeletal replace by scar tissue |
| Healing process Repair Primary Intention | Surgical incision or papercut 1. Initial 2. Granulation 3. Scar Contracture |
| Healing process Repair Primary Intention Initial Phase | 1. Initial: (3-5 days) approximation of incision edges; migration of epithelial cells; clot serving as meshwork for starting capillary growth |
| Healing process Repair Primary Intention Granulation Phase | 2. Granulation (5 days to 4 weeks) Migration of fibroblasts; secretion of collagen; abundance of capillary buds, fragility of wounds |
| Healing process Repair Primary Intention Scar Contracture | 7 days to several months. Remodeling of collagen; strengthening of scar |
| Healing Process Repair Secondary Intention | wounds that occur from trauma, ulceration, or infection have large amounts of exudate & wide irregular wound margins with tissue loss -edges that can be brought together -clean debris before healing |
| Healing process Repair Tertiary Intention | Delayed primary intention -contaminated wound is left open & sutured closed after infection is controlled -larger scar than primary and secondary |
| Clinical Manifestations of Wounds | Local reactions -Redness -Heat -Pain -Swelling -Loss of Function Systemic -Leukocytosis -Fever |
| Clinical Manifestation Redness | hyperemia from vasodilation |
| Clinical Manifestation Heat | increased metabolism at inflammatory site |
| Clinical Manifestation Pain | Change in pH, nerve stimulation by chemicals (histamine, prostaglandins) pressure from fluid exudate |
| Clinical Manifestation Swelling | Fluid shifts to interstitial spaces, fluid exudation accumulation |
| Clinical Manifestation Loss of function | Caused by pain and swelling |
| Clinical Manifestation Leukocytosis | increase release of leukocytes from bone marrow (nausea, malaise, anorexia, fatigue) |
| Phases of healing | >New capillary networks >Granulation Tissue >Epithelialization >Action of fibroblasts |
| Description/Characteristics of Red Wound | -superficial or deep if clean and pink in appearance -serosanguineous drainage -pink to bright/dark red healing, or granulating tissue |
| Examples of red wound | Skin tears, pressure ulcers (stage II), partial thickness, or second degree burns |
| Purpose of treatment for red wound | protection and gentle atraumatic cleaning |
| Dressings and therapy of red wound | Transparent film dressing (ex: tegaderm, opsite, duoderm, hydrogels (tegagel), gauze dressing with antimicrobial ointment or solution, telfa dressing with antibiotic ointment |
| Description/Characteristics of Yellow wound | -slough or soft necrotic tissue -liquid to semiliquid slough with exudate ranging from creamy ivory to yellow green |
| Example of Yellow Wound | Wounds with nonviable necrotic tissue, which creates an ideal situation for bacterial growth and therefore must be removed |
| Purpose of treatment for Yellow Wound | Wound cleansing to remove nonviable tissue and absorb excess drainage |
| Dressing and therapy for Yellow Wound | Absorptive dressing, hydrocolloidal dressing, hydrogel covered with gauze, wound irrigations, hydrotherapy, moist gauze dressing with or without antibiotic or antimicrobial agent |
| Description/Characteristics of Black Wound | -Black, gray, or brown adherent necrotic tissue called eschar, possible presence of purulent drainage -risk of wound infection increases in proportion to amount of necrotic tissue present |
| Example of Black Wound | Full-thickness or third-degree burns, pressure ulcers (stage III and IV) and gangrenous ulcers |
| Purpose of treatment of Black Wound | Debridement of eschar and nonviable tissue |
| Dressing and therapy For Black Wound | Topical debridement (enzyme, surgical, chemical) hydrotherapy, moist gauze dressing, hydrogel covered with gauze, absorptive dressing covered with gauze |
| What factors delay wound healing | -Nutritional Deficiencies -Inadequate blood supply -Corticosteroid drugs -Infection -Mechanical friction -Advanced age -Obesity -Diabetes Mellitus -Anemia -Poor general health |
| delay wound healing -Nutritional deficiency | -Vit. C (delays formation of collagen fibers and capillary development) -Protein (Decreases supply of amino acids for tissue repair) -Zinc (impairs epithelialization) |
| Delay Wound Healing -Inadequate blood supply | -Decreases supply of nutrients to injured area -decreases removal of exudative debris -inhibits inflammatory response |
| Delay Wound Healing -Corticosteroid Drugs | -Impair phagocytosis by WBCs -Inhibit fibroblast proliferation and function -Depress formation of granulation tissue -Inhibit wound contraction |
| Delay Wound Healing -Infection | Increases inflammatory response and tissue destruction |
| Delay Wound Healing -Smoking | Nicotine is a potent vasoconstrictor and impedes blood flow to healing area |
| Delay Wound Healing -Mechanical Friction | -Destroys granulation tissue -Prevents apposition of wound edges |
| Delay Wound Healing -Advanced age | -Slows collagen synthesis by fibroblast -Impairs Circulation -requires longer time for epithelialization of skin -alters phagocytic and immune responses |
| Delay Wound Healing -Obesity | Decreases bloody supply in fatty tissue |
| Delay Wound Healing -Diabetes Mellitus | -Decreases collagen synthesis -Retards early capillary growth -impairs phagocytosis (result of hyperglycemia) -reduces supply of O2 and nutrients secondary to vascular disease |
| Delay Wound Healing -Poor general health | Causes generalized absence of factors necessary to promote wound healing |
| Delay Wound Healing -Anemia | Supplies less oxygen at tissue level |
| Complication of Healing | -Hypertrophic Scars -Contracture -Dehiscence -Evisceration -Excess granulation tissue -Adhesions |
| Complication of Healing -Adhesions | -Bands of scar tissue that form between or around organs -Adhesions may occur in abdominal cavity or between lungs and pleura -Adhesions in abdomen may cause an intestinal obstruction |
| Complication of Healing -Hypertrophic Scars | -Occur when an overabundance of collagen is produced during healing -Forms an inappropriately large, raised red and hard scar that is non-life threatening |
| Complication of Healing -Contracture | -Wound contraction is a normal part of healing -Complications occur when there is excessive contraction resulting in deformity -muscle or scar tissue shortening; esp. over joints, from fibrous tissue formation |
| Complication of Healing -Dehiscence | -separation/disruption of previously joined wound edges -Occurs when healing site burst open -Caused by- infection causing inflammation-granulation tissue weak-obesity bc less blood supply in adipose fluid develop preventing wound edges coming together |
| Complication of Healing -Evisceration | Occurs when wound edges separate & intestines protrude thru wound |
| Complication of Healing -Excess Granulation tissue (proud flesh) | -protrudes above healing wound surface -if cauterized/cut off healing in normal manner |
| What are pressure ulcers? | localized injury to the skin and/or underlying tissue->bony area result of pressure or pressure in combo with shear or friction |
| What are contributors to pressure ulcers? | -Shearing force->pressure on skin when adheres to bed & skin slide in direct of body movement -Friction -> 2 surfaces rubbing - excessive moisture |
| Characteristics of Stage I pressure ulcer? | intact skin w/ nonblanchable redness. |
| Characteristics of Stage II pressure ulcer? | Partial thickness loss of dermis ->shallow open ulcer w/ red-pink wound bed or blister |
| Characteristics of Stage III pressure ulcer? | full thickness tissue loss->subcutaneous fat may be visible->no bone, tendon, muscle visible |
| Characteristics of Stage IV pressure ulcer? | Full thickness tissue loss w/ exposed bone, tendon, muscle |
| What are the focused assessment of pressure ulcers? | >location >Size >Color >Surrounding skin >Drainage >Temperature >Pain >Wound Closures |
| Characteristics of unstageable pressure ulcer? | full thickness tissue loss->base of ulcer covered by slough (yellow, tan, gray, green, brown) &/or eschar (tan, brown, black) in wound bed |
| Diagnostic test for pressure ulcers | >CBC -Leukocytosis -hemoglobin >Sedimentation rate >C reactive protein >Albumin |
| What are nursing interventions? | >Fever >Rest and immobilization >elevation >heat/cold >oxygenation |
| Wound management for secondary intention? | >cleansing >keeping the wound moist >filling dead space |
| Sharp Debridement | -quick method of debridement to prevent, control, remove infection -Used when large amounts of nonviable tissue are present -prepares wound bed for healing, skin grafting, or flaps |
| Mechanical debridement 3 methods | 1. wet to dry dressing-open mesh gauze moistening w/saline->pack on or in wound, and drys. Removing dressing removes debris. 2. Wound irrigation-make sure bacteria is not driven in wound with high pressure 3. Whirlpool-used-minimal debris present |
| Autolytic debridement | -Semiocclusive or occlusive dressing used to soften dry eschar by autolysis. -Area around wound must be assessed for maceration when these dressings are used |
| Enzymatic debridement | -Drugs applied topically to dissolve necrotic tissue and then covered with moist dressing (ex: saline moistened gauzed) -Ex. of drugs include collagenase, papain, urea -Process can be slow and thick eschar may need to be scored with scalpel |
| Dressings: Gauzes and nonwovens | -Exudate absorption -Debridement if applied and kept moist -Maintain moist wound surface -Cleansing, packing, covering wound variety ex: Curity, Kling, kerlix |
| Dressings: Nonadherent | -woven or nonwoven -impregnated with saline, petrolatum, anitmicrobials -minimally absorbent -Mainly used on minor wounds or second dressing ex: adaptic, vaseline gauze, xeroform |
| Dressings: Transparent films | -semipermeable membrane permits gaseous exchange between wound & environment -allows wound visualization -minimally absorbent -Used for dry non infected wounds or wounds with minimal drainage ex:tegaderm, bioclusive, blisterfilm, carrafilm, omniderm |
| Dressings: Hydrocolloids | -Wafers, powders, pastes made of gelatin, pectin, or carboxymethylcellulose. -occlusive dressing not allow O2 to wound -supports debridement & secondary infection prevention -Superficial & partial thickness wounds/infected wounds ex: Duoderm, Exuderm |
| Dressings: Foams | -Sheets & other shapes of foamed polymer solutions with small, open cells capable of holding fluids -Absorbing of moderate to heavy amounts of exudate -Easy removal -Partial/full-thickness wounds ex: allevyn, curafoam, flexzan, hydrasorb, lyofoam |
| Dressings: Absorptive dressing | -Absorbing exudates -Maintain moist surface -Place in wounds to destroy dead space -Partial/full-thickness wounds ex: ABD combine pads, Covaderm, Curity abdominal pads, multipad |
| Dressings: Hydrogel | -Sheet, gel, gauze designed to donate moisture to a dry wound and maintain moist healing environment -Rehydrate wound tissue ->debridement partial or full thickness wounds, deep wounds w/minimal drainage, necrotic wounds ex: Aquasite, carrasyn gel |
| Dressings: Alginates | -nonwoven, nonadhesive pads and ribbons made of polysaccharide fibers or xerogel derived from seaweed. -Contact with exudate, form a moist gel -Easy over irregular shape -Moderate to heavy exudates (pressure ulcer) ex: Algicell, Algisite, Carrasorb, |
| Dressings: Antimicrobials | -Deliver iodine, silver, polyheamethylene biguanide->antibacterial properties -No resistance -Partial/Full thickness wounds (surgical incisions) ex: Acticoat, Biopatch, Curity AMD, Island wound dressing with microban |
| Additional therapies | -Negative pressure wound therapy -Hyperbaric oxygen therapy -Positioning >HOB as low as tolerated >Support surfaces-pressure reduction > Turn q 2 hours |
Created by:
ygwallace
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