WOUND HEALING & PREVENTION OF INFECTION

signs of normal healing: partial thickness wounds

inflammatory response for first 24 hours including redness swelling heat and serous exudate. epithelial proliferation and migration resurfacing of wound bed open to air resurface and six to seven days moist environment resurfaced in four days we establish of epidermal layers developing normal thickness and dried pink tissue

factors related to pressure ulcer development

1. Pressure Intensity (16-32 mmHG needed) 2. Pressure Duration 3. Tissue Tolerance -immobility -previous pressure ulcer -Diabetics can't feel; High blood sugar--> damage of small vessels--> nerve damage

Nosocomial Infection

HAI acquired while receiving health care in health care facility

How might wound care in the home setting differ from the hospital setting?

clean vs sterile technique

tertiary intention healing

2 + 1 = 3 Delayed primary closure Wound left open until no sign of infection then sutured closed Sutured after granulation begins Wider and deeper scar

Pressure ulcer 6 stages

*Stage I* "intact skin, no blanching" may have temp/color/hardness difference *Stage 2* "partial thickness (or serum filled blister)" -loss of dermis *Stage 3* "full thickness, no muscle, tendon, or bone" *Stage 4* "muscle tendon or bone" *Unstageable* "can't see the bottom" *Suspected Deep Tissue Injury* "oooh, that looks bad" & "blood filled blister"

hydrogel

-Clear, viscous gels that protect the wound from drying out. -Contraindicated when the wound is producing moderate to heavy exudate because would contribute to wound maceration. -Not beneficial for infection; does not contain an antimicrobial agent

alginate: when to use

-Excellent for wounds with heavy exudate (can absorb up to 20 x its weight)and keeps wound moist -Once wet with exudate, forms a gel-like plug in the wound -Facilitates autolytic debridement -Does not adhere to the wound bed surface and therefore do not mechanically debride the wound when removed. -Can be left in wound: Does not cause increased inflammation or irritation, or infection and will dissolve in tunnels or undermined area

Full Thickness Wound Repair (4 stages)

1 Hemostasis 2 Inflammatory 3 Proliferative 4 Maturation

Partial-Thickness Wound Repair (3 stages)

1 Inflammatory 2 Epithelial proliferation & migration 3 Reestablishment of epidermal layers

nursing care plan on p. 1200 (Mrs Stein) outcomes.

1. Mrs. Stein has intact skin integrity in the area of nonblanching erythema. Mrs. Stein's sacral ulcer shows signs of healing. Mrs. Stein maintains intact skin over other pressure points. 2. Left hip wound demonstrates signs of healing. 3. Hyperemia is not present at any pressure points. Hyperemia in sacral region has a decrease in nonblanchable pressure areas.

STAGE IV

3 plus: ●● Perform nonadherent dressing changes every 12 hr. ●● Treatment can include skin grafts or specialized therapy such as hyperbaric oxygen. ●● Provide nutritional supplements. ●● Administer analgesics. ●● Administer antimicrobials (topical and/or systemic)

What is proper technique for irrigating/ cleaning a wound?

A 35 mL syringe and a 19 gauge needle for appropriate amount of pressure to remove bacteria and exudates -Wound irrigation does not always require sterile technique. In the case of a chronic wound, you can delegate cleansing using clean technique. -Wounds should be irrigated in the direction of least contamination to most contamination. -Wounds should be irrigated using slow, continuous pressure.

transparent film tegaderm

A temporary "second skin" ideal for small, superficial wounds -Waterproof and semi-permeable to oxygen and water vapor -Prevent wound drying and contamination by bacteria. (don't stretch - will open pores and make permeable to bacteria) -promotes autolytic debridement. -Good as secondary dressings over bony prominences to prevent shearing -May be left in place for several days in non infected, little exudate wounds -especially good for securing primary dressings such as alginates

secondary intention healing

Heals from inside out gaping, irregular edges can't suture Fills in with granulation tissue Prone to infection longer to heal, larger scar

Describe nursing interventions to prevent infections.

Assess wound characteristics Protect wounds from infection (can't always prevent) Hand washing Dressing Changes Contaminated articles off floor/ room surfaces Handle exudate carefully Bottled solution care Contaminated needle care Warmth promotes healing

prevention techniques for pressure ulcers

Avoid: Friction, Shear, Moisture Turn & Position q 1.5 - 2 hours Teach to shift weight q 15 Keep skin clean, dry, and intact. bed firm, wrinkle‑free ●● Reposition the client in bed at least every 2 hr and every 1 hr in a chair. limit time in chair to 2 hours Document position changes. ●● Keep the head of the bed at or below a 30° angle (or flat), ●● Raise heels off of the bed to prevent pressure. ●● Ambulate clients as soon and as often as possible. ●● Keep clients from sliding down damage. Lift, rather than pull, clients up Use pressure reducing chair/ mattress keep clean with tepid water and mild agent dimethicone moisterizer proper hydration NO powder/cornstarch DO NOT use donut shaped cushions DO NOT use heat lamps NEVER massage reddened areas

Care for red wound (Traumatic & surgic)

Needs moisture & protection to heal.

Stage 2 Pressure Ulcer

An intact or open/ruptured (clear) serum-filled blister. shiny or dry shallow ulcer without slough or bruising. -should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. *Bruising indicates suspected deep tissue injury*

Normal Reactive Hyperemia

Normal vasodilation that blanches and redness goes away in an hour

Hydrocolloid is used for which stages?

Clean 1, 2, 3

nursing interventions to facilitate wound healing

Cover wound to keep moist ◯◯ Encourage 2,000 to 3,000 mL fluid/day, unless kidney/heart probs ◯◯ Note serum albumin levels below 3.5 g/dL ◯◯ Provide at least 1,500 kcal/day ◯◯ Use gentle friction, Isotonic solutions ◯◯ Do not use cotton balls (shed fibers). ◯◯ 5 to 8 psi of pressure. A 30 to 60 mL syringe with a 19‑gauge needle, normal saline, lactated Ringer's, or an antibiotic/ antimicrobial solution. Remove sutures and staples. ●● Administer analgesics and monitor pain . ●● Administer antimicrobials

nursing care plan on p. 1200 (Mrs Stein): goals

Goals: 1. Injury to Mrs. Stein's skin and underlying tissue resulting from pressure, friction, and shear over the bony prominence will be reduced within 2 to 4 weeks. 2. Red area around hip wound and tan-colored drainage will be absent within 5 days. 3. Mrs. Stein's ability to tolerate position changes and correctly change positions will improve within 2 to 4 weeks.

treatment of pressure ulcers; DO NOT

Don't rub, wet DO NOT use cytotoxic solutions on granulation tissue: Dakin's Solution (sodium hypochlorite) Acetic Acid Povodine-iodine Hydrogen peroxide

You are aware that the risk of hemorrhage particularly in surgical wounds is the greatest...

During the first 24 to 48 hours after surgery

The nurse caring for Rhonda is aware that an obese client is at risk for poor wound healing post-operatively because:

Fatty tissue has a poor blood supply and therefore cannot receive nutrients, clotting factors and other elements necessary for tissue repair. Impaired wound healing due to a thicker layer of fatty, poorly vascularized subcutaneous tissues can also lead to increased risk for post-op complications like dehiscence and evisceration in the obese patient

Describe signs and symptoms of a systemic infection.

Fever and chills (babies very high fever, elderly hypothermic and change in mental status) Swollen lymph nodes Increased WBC Malaise Weakness Anorexia N/V (nausea vomitting) Headache Confusion/ Altered LOC

Stage 4 Pressure Ulcer

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Stage IV ulcers can extend into muscle and/or supporting structures making osteomyelitis possible.

Stage 3 Pressure Ulcer

Full thickness tissue loss. No muscle, tendon or bone visible Slough may be present but does not obscure the depth

Unstagable Pressure Ulcer

Full thickness where base is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) Until enough slough and/or eschar is removed, stage cannot be determined. *Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed.*

Healing Process: Full Thickness Wound

Hemostasis Blood vessels constrict and Platelet clots form Inflammatory Phase 3 days Vascular and Cellular Responses clean wound Proliferative Phase 3-24 days (large range) Vascular bed reestablished: red & shiny. Wound filled with granulation and collagen and contraction pulls wound together surface is repaired by Epithelization from edges to center. Maturation say 21/months to > 1 yr Collagen fibers become more organized Fewer melanocytes, more pale less tensile strength

Abnormal Healing

Incision line poorly approximated Pale or fragile granulation tissue, granulation tissue bed excessively dry or moist Drainage present more than 3 days after closurePurulent exudate present Inflammation increased in first 3-5 days after injuryNecrotic or slough tissue present in wound baseNo epithelialization of wound edges by day 4Epithelialization not continuous Fruity, earthy, or putrid odor present Presence of fistula(s), tunneling, undermining

How to tell if a wound is infected vs. normal inflammation and healing

Infected: Yellow wound - slough, exudate Normal: Red wound, Dead: black, pus

Primary Acute Infection -

Infection develops rapidly, causes sx, comes to a climax & then fades fairly quickly.

Partial-Thickness Wound Repair- walk through

Inflammatory Response: First 24 hrs -Serous Exudate Proliferation & Migration: resurfacing takes 6-7 days air dried or 4 days moist Reestablishment of Epidermal Layers Developing Normal Thickness Dry Pink Tissue

The nurse applies a hydrogel dressing to a client with radiation-damaged skin. Why was the hydrogel dressing the best choice for this client?

It is soothing and reduces pain in the wound

Assessment of pressure ulcers, assigning proper stage and other descriptors. (USE RUBRIC FROM IN LECTURE ASSIGNMENT)

Location Stage Wound Dimensions Width (left to right/ hip to hip) Length (top to bottom/ head to toe) Depth (measured with q-tip) Undermining or Tunneling (Sinus Tracts) (measure in cm, direction by clock method, if more than one number each clockwise) Wound Base Description(base or wound bed by %) (Can only do if you have an open wound bed to see.) ex. Granulation tissue Drainage Amount (scant, moderate, copious, small, medium, heavy, # of dressings saturated, cm spot on dressing removed) Color/ Consistency (serous, serosanguineous, purulent, thick, thin) Odor (present or not) Wound Edges - up to 4 cm from edge of wound (color, thickness, character, measurement - e.g: light pink, deep red, purple, macerated, calloused) Surrounding Skin (temperature, thickness, color, blanching) Pain (pain associated with the wound and interventions) Progress (improved, no change, declined) (e.g.: Stage III Pressure ulcer on coccyx 3.5 cm wide, 2 cm high, .5 cm deep /s undermining or tunneling; wound base: 75% red granulation tissue, 20% yellow slough, 5% black eschar; /c thick yellow exudate saturating the 5 4x4 dressings that were removed, no drainage on abd cover dressing; foul odor; wound edges pink, blanchable and non-edematous tissue extending 2 cm beyond wound edge, surrounding skin warm, dry, intact, blanches; appears improved from last week, pain level at 3, throbbing.

heal by primary intention

Minimum tissue loss Uncomplicated and clean wound, approximated sutured, stapled, glued Very little scarring

There are three phases of wound healing. The nurse observes granulation tissue in a client 's pressure ulcer. What phase of wound healing is represented by granulation tissue?

Proliferative phase (Maturation is the final stage of wound healing. Tissue granulation occurs in the proliferative phase. Hemostasis occurs during the inflammatory phase)

Suspected Deep Tissue Injury

Purple or maroon discolored intact skin or blood-filled blister Often -Boggy -Nonblanchable -Painful -Mirror Image -Blistered (blood blister) may appear as thin blister over a dark wound bed. may further evolve/become covered by thin eschar. May rapidly expose more layers of tissue

Stage 1 TTT

Relieve pressure. ●● frequent repositioning. ●● Pressure‑relieving devices ●● Keep the client dry, clean, well‑nourished, and hydrated

During the skin assessment of an older adult client who had a stroke, the nurse noted a reddened area over the coccyx. The next actions of the nurse for this client should include:

Repositioning the client off the coccyx area and reassessing the area in an hour

There are several instruments for assessing clients who are at high risk for developing a pressure ulcer. The Braden Scale is the most commonly used. What risk factors are assessed using the Braden Scale?

Sensory perception, moisture, activity, mobility, nutrition, friction and shear A loss of 5% of usual weight, weight less than 90% of ideal body weight, and a decrease of 10 lbs in a brief period are all signs of actual or potential nutritional problems

Exudate described as

Serous: clear, watery like plasma Sanguineous: bright red containing RBC's Seroanguineous: pale red, combination of above Purulent: infected, thick, yellow, green, tan or brown

where may stage 3 and 4 pressure ulcers be shallow?

The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow.

How often to turn and position? How long in chair?

Turn & Position q 1.5 - 2 hours in bed shift weight q 15 min in chair

Iatrogenic Infection -

a type of nosocomial infection resulting from a diagnostic or therapeutic procedure

alterations that make a patient at risk for infection

a. Skin damage b. Immune weakened c. Age d. Nutrition e. Hydration f. low BP or high bp g. Disease (diabetes)

types of wounds

abrasion is superficial with little bleeding and is considered a partial-thickness wound. "weepy" plasma leakage A laceration bleeds more based on depth and location . Lacerations greater than 5 cm (2 inches) long or 2.5 cm (1 inch) deep cause serious bleeding. Puncture wounds bleed in relation to the depth, size, and location of the wound (e.g., a nail puncture does not cause as much bleeding as a knife wound). The primary dangers of puncture wounds are internal bleeding and infection.

How would you pack a deep wound?

alginate, not too tight

What is important in removing an old dressing?

allow removal of slough, bacteria, irrigate, allow growth, prevent ischemia

Abnormal Hyperemia

blanches and redness not gone in an hour

Care for yellow wound

cleaning to remove pus.

The nurse is to collect a specimen for culture after assessing the client's wound drainage. The best technique for obtaining the culture is:

cleansing the wound first and swabbing the granulation tissue, the culture should show a more accurate picture of any causative organisms of wound infection.

what you would do if you removed the dressing and saw increased drainage and that the sutures were open and a small piece of bowel was protruding out of the previously closed peritoneum. You respond that you would...

cover the area with sterile saline-soaked towels or dressing pads and immediately notify the surgical team; this is a wound evisceration. Wound evisceration is the protrusion of internal organs through an incision. If either of these occurs, the physician is notified immediately. The client is placed in low Fowlers position, kept quiet and instructed not to cough.

Care for black wound

debridement to remove necrotic tissue to shorten inflammatory phase, speed healing and activate platelets which release growth factor—promotes proliferative phase of wound healing Decreases infection potential Easier assessment

Secondary Infection -

develops from a second organism after a primary infection has resolved. Includes: Suprainfection - or Opportunistic Infection that occurs with antibiotic therapy

If the wound is covered by a dressing and the health care provider has not ordered it changed, should you inspect it?

do not inspect it directly unless you suspect serious complications such as a large volume of bright red bleeding, excessive odor, or severe pain under the dressing. In such a situation inspect only the dressing and any external drains.

abrasions, minor lacerations, and small puncture wounds,

first rinse the wound with normal saline and lightly cover the area with a dressing

When hyperemia is noted assess

for blanching Palpate for induration (firmness) Outline affected area with a marker if abnormal reactive hyperemia suspected. Document: location, size, color, blanching, induration, temperature Move patient off pressure point Reassesses the area after 1 hour

full thickness wound healing process

hemostasis blood vessels constrict and platelet clots form inflammatory phase: 3 days blood vessels dilate causing redness edema warmth and throbbing as well as vascular and cellular responses cleaning the wound bed for healing proliferative phase: 3 - 24 days large range vascular bed reestablished granulation tissue fragile shiny red room filled with granulation and collagen synthesized, wound contraction pulls and margins together. surface of wound is repaired by epithelialization epithelial cells proliferate and migrate from edges to Center maturation can go on several months two more than a year collagen fibers become more organized strengthen England Scar Tissue contains fewer melanocytes does not regain previous tensile strength

Foams

highly absorbent keep wound moist good for packing cavitating moons during inflammatory phase of healing can remain for three to four days secured by bio occlusive dressing some have adhesive backing which are just used for wounds smaller than their diameter

What are important factors to consider in choosing a dressing?

how long in place, amount of exudate, size

Pressure Ulcer practice

http://www.slideboom.com/presentations/82699/Test-your-Pressure-Ulcer-

factors that promote healing

hydration nutrition vitamin C A and E protein intake zinc copper good circulation, oxygenation aseptic technique, normal flora

duoderm

hydrocolloid absorbs exudate and creates jail promotes autolytic debridement impermeable to water vapor oxygen and bacteria easily removable without tearing best for light to medium exudate can remain in place for 3 to 4 days if not too wet can you play some wet wounds and wet surrounding skin and remain intact not used for infected wounds or heavy exudate can develop a foul odor after two to four days

Chronic Infection -

long term infection that is hard to cure.

What factors impede wound healing? Why do they impede healing?

low blood pressure Advanced age malnutrition anemia smoking obesity wound stress infection deep open wound foreign body steroids anti-inflammatories chemotherapy diabetes radiation dehiscence evisceration fistulas abscesses h. SLOUGH i. Eschar (except on heel)

treatment of pressure ulcers; DO

move. duoderm hrydrate nutrition

How do you remove tape, sutures, staples, steri strips?

parallel to skin and between knot and skin

Chuck comes to your floor post-operatively with a wound drain in place. Which action would you avoid in the care of the drain?

post-operative drain should not be curled tightly or obstructed in anyway. This could prevent the drain from functioning properly

What causes pressure ulcers?

pressure and ischemia soft tissue is compressed between a bony prominence and an external surface for prolonged time

What type of positioning devices? Pressure reducing devices?

pressure reducing chair/ mattress

Describe signs and symptoms of a localized infection.

purulent material necrotic tissue All chronic dermal wounds > 100,000 (105) organisms per gram of tissue A contaminated or traumatic wound may show signs of infection early, within 2-3 days. A surgical wound, fourth or fifth post-op day

Why would you irrigate/ clean a wound?

remove exudate, promote healing, collect specimen

natural barriers to infection

skin natural flora mucous antibodies

Briefly outline a nursing care plan for wound healing and/or prevention of infection, using the nursing process.

●● Prevent infection by using aseptic technique when performing dressing changes. ●● Provide optimal nutrition to promote the immune response. ●● Provide for adequate rest to promote healing. ●● Administer antibiotic therapy after collecting specimens for culture and sensitivity testing.

STAGE III

●● Clean and/or debride the following. ◯◯ Prescribed dressing ◯◯ Surgical intervention ◯◯ Proteolytic enzymes ●● Provide nutritional supplements. ●● Administer analgesics. ●● Administer antimicrobials (topical and/or systemic).

STAGE II TTT

●● Maintain a moist healing environment (saline or occlusive dressing). Apply hydrocolloid dressing ●● Promote natural healing while preventing the formation of scar tissue. ●● Provide nutritional supplements. ●● Administer analgesics.