Wounds and Wound Healing

Fistulas

Abnormal passage from internal organ to body surface or between two internal organs/ Rupture or drainage from abscess (tunnel)

Advantages of Wound Dressings

Absorbs drainage to help promote wound healing Protect the wound from mechanical injury When used as a pressure dressing or with elastic bandages, promote hemostasis, help prevent hemorrhage, & approximation

Laceration

Accidental trauma Tissues are torn Wound edges are ragged Depth of wound varies, & affects risk of complications Often caused b unclean object, Increasing risk for infection Ex. Cut with broken glass

Factors Affecting Wound Healing

Age Circulation and Oxygenation Condition of the wound Overall wellness of the client

Inflammatory Phase

Begins with incision for surgery Last through 4-6 post-op day Hemostasis Phagocytosis Immediate, prepares tissue for healing

Classification by Color

Black necrotic dead tissue- also called eschar tissue black leathery scab or dry crust (debridement removal + wet-to-dry dressing) Yellow exudate or fibrous debris Red pink granulation tissue

Open Wound

Break in skin. Ex.) incision, gunshot, abrasions. Portal of injury, risk for infection Occurs from intentional or unintentional trauma (can heal in acute phase) Skin surface is broken May be accompanied by bleeding, tissues damage, and increased risk for infection. Delayed healing

Disadvantages of wound dressings

Can rub or stick to the wound, causing further superficial injury Can create a warm, damp, environment- conductive to the growth of bacteria, with resultant infection

RYB Wound Classification

R= Red- Protect (Keep clean & moist) Tellfa/ Red- Pink Granulation Tissue Y= Yellow- Cleanse (wound cleanser/irrigating) Yellow exudate or fibrous debris B= Black- Debride (doctor) after/treat as yellow, as healing progresses, a red wound Black nectrotic dead tissue- also called eschar black/leathery Page 939****

More Advantages

Splint or Immobolize the wound, facilitating healing & prevention further trauma Prevent contamination from the external environment Provide physical, physiologic, & aesthetic comfort

Pressure Ulcer Classification

Stage 1- Non-blanchable erythema over a bony prominence Stage 2- partial thickness (dry shallow w/o slough/bruising) Stage 3- full thickness skin loss (subcutaneous/shallow) Stage 4- full thickness tissue loss with exposed muscle, bone, or tendon Unstagable- Full thickness or tissue loss- depth unknown, completley obsecured by slough/eschar Page: 933

Secondary Intention

4-6 Weeks minimum Large wound with considerable tissue loss Natural healing by formation of granulation tissue Healing takes longer & results in more scarring Wound healing using primary intention that gets infected goes automatically to secondary intention Ex. Burns, Major Trauma

Wound

A break or disruption in the normal integrity of the skin and tissues.

Drainage

Amount, color, odor & consistency are assessed Amount & Color depend on the wound location & size, larger wounds have more drainage Drainage can be assessed on the wound, on the dressings, in drainage bottles or resevoirs, and under the client Amount- Scant, Small, Moderate, Large

Assessing the surgical wound

Apperance Drainage Pain Sutures & Staples Drains & Tubes Signs of possible complications

Apperance

Approximation of wound edges Should be clean & well approximated with a crust along the wound edges Color of the wound & surrounding area The wound's edges initally are reddened & slightly swollen, but by the end ofabout a week, the skin should be closer to normal in apperance & the wound edges

Pain

Assess q 2 hrs Incision pain most severe 2-3 days Pain, when accompanied by an increased prulent drainage, indicates delayed healing or the presence of infection

Documenting Wound Care

Assessments/Interventions each time wound care is given, describing the wound's apperance. If drainage is present, the kind & amount are described If the client has a complicated dressing, details for caring for the wound should be in the patient's care plan * Shadowing or Active bleeding

Proliferation Phase

Begins on 4-6 day & last till day 21 (last 3 weeks) Granulation tissue Adequate nutrition & oxygenation are important Avoid strain on suture line (Dehiscence) * " I think I just heard something pop"

Serous Drainage

Composed primary of the clear, serous portion of the blood and from serous membranes Clear and watery

Sanguineous Drainage(hemorrhagic)

Consists of large numbers of red blood cells and looks like blood Bright red sanguineous drainage is indicative of fresh bleeding Darker drainage indicates older bleeding * Should not see after 4 days

Wound Care

Debridement removal of nacrotic tissue Sloughing shedding of dead tissue Wound irrigation & Packing Wet-to-dry/Debridement = same outcome (get nacrotic tissue out)

Dehiscence & Evisceration

Dehiscence- partial/total disruption of wound layers Evisceration- protrusion of viscera through incision area *avoid excessive coughing, straining, vomiting (hold something against it/splint it) Cover with warm moistened towels/call MD

Risk factors

Dehydration Incontinence Skin hygiene Diabetes Melitius Diminished Pain Awareness Fractures History of corticosteroid therapy Immunosuppresion Multisystem trauma Poor Circulation Previous pressure ulcers Significant obesity or thinness

Dressing Changes

Depends on the amount of drainage The physician's preference The nature of the wound Usually the physician will perform the 1st dressing change 24-48 hours after surgery, then the nurses change the dressing as order, usually as needed or on a dail basis Frequency- should be noted on the nursing care plan! Applying bandages & Binders****

Suspected deep tissue injury

Depth Unknown Blood- filled blister d/t damage of underlying soft tissue from pressure and/or shear. Mush/boggy- d/t fluid underneath Ex. Patient who has fallen taken blood thinners

Pressure ulcers

Development ischemia from the absence of blood flow or reduction of blood flow to tissue Risk factors- impaired motor/sensory functioning, LOC changes, age, orthopedic devices Pathogenesis intensity, duration, & tissue tolerance (bony prom.) Reactive hyperemia- Normal (redness goes away) Come back in 30 min. /Document pass on Nonblanchable- Erythema (redness stays) not normal

Chronic Wound

Healing process is impeded, remain in the inflammatory phase of healing. Ulcers d/t continued exposure to friction Takes 4-6 weeks to heal.

Primary Intention

Expected to heal in acute phase Wound is clean, in a straight line, with little loss of tissue All wound edges are well approximated with sutures Usually rapid healing with minimal scarring Ex. Surgical Incision

Maturation Phase

Final stage of healing Begins about day 21, can last up to 1-2 years after injury Scar is formed

Types of Dressing

Gauze Telfa Non-adherent Self-adhesive and transparent

Using dressings

Goal of wound care is to promote tissue repair & regeneration so that skin integrity is restored Two methods of caring for wounds: *Closed method- a dressing is used as a protective cover over the wound * Open method- No dressing is used

Preventing Ulcer Development/Page 936

Identification of patients at risk Braden's scale Hygiene & skin care Positioning (Fowler's most pressure on bony prominences) do not massage- they are already have ischemia Support & Therapeutic beds

Wound Complications

Infection Hemorrhage Dehiscence Evisceration Fistulas

General Principles of Tissue Healing

Influenced by extent of damage/person's general state of health more effective if proper nutrition has been maintained Response systemically to trauma in any of it's parts blood transports substance to & from injured tissue Intact skin/MM 1st line defense against microorganisms healing Promoted- free of foreign bodies/bacteria

Contusion (Bruise)

Injury to underlying soft tissue damage/ ruptured blood vessels/ overlying skin remains in tact. Caused by a blow from a hard object. Closed wound, results in soft tissue damage and ruptured blood vessels. Pallor, anxious, diaphoresis; low blood pressure, high heart rate (Vital Signs overall condition) Causes swelling and pain; possible resultant bruising/ hematoma. Serious effect is internal organs are involved

Drains & Tubes

Inserted into or near a wound when it is anticipated that a collection of fluid in a closed area will delay healing May or may not be sutured in place Important to know which type of drain was inserted in surgery Patency & placement are included in the wound assessment Pen-rose drain (open), Hemovac, Jackson-Pratt (closed) Page 951

Results from planned therapy or treatment that requires invasive measures.

Intentional wounds- (Less risk for infection) made under sterile conditions. Wound edges are clean Bleeding is usually controlled Risk of infection is decreased Healing is facilitated Unintentional wounds- accidental, jagged wound edges Occurs from unexpected trauma (accidents, gunshots, burns) Contamination is likely- occurs in an unsterile environment High risk for infection- burns-lots of issues with pain Longer healing time

Infection

Invasion of the wound by bacteria can occur at the time of trauma, during surgery, or at any time after the initial wound Contaminated wound more likely to become infected Surgical wound resulting from a procedure that involves the intestines(bowel prep)

Tertiary Intention

Left open to heal (to allow edema or infection to resolve/exudate to drain/then they are closed) * Prevent Sepsis Time delay before wound is sutured Greater granulation, greater risk of infection, greater inflammatory reaction than primary intention Late suturing & more scarring Ex. Ruptured Appendix

Puncture

Made by sharp instrument/object that penetrates the skin & underlying tissue May be intentional or unintentional Ex. stabbed with ice pick, IV site

Purulent Drainage

Made up of white blood cells, liquefied dead tissue debris, and both dead and alive bacteria Thick yellow mucus Often has a musty or foul order Varies in color, depending on the causative organism

Infection may cause

Malaise, Increased pain, anorexia, usually 2-7 days after Prulent/Increased drainage Redness & swelling in & around the wound Increased body temperature, Increased Pulse Increased WBC count

Hemmorhage

May indicate: Slipped Suture Dislodged clot from stress @ suture line Infection Erosion of blood vessel by foreign body (hardware from surgery)

Serosanguineous Drainage

Most commonly found in surgical wounds Mixture of serum and red blood cells * Most common/mixture of the two Serous- outside Sanguineous- Center

Closed Wound

No break in skin, but there is soft tissue damage. Ex.) blunt force, fracture, strain, MVA, fall Can't see the damage; caused by blow, force, or trauma, such as a fall, an assault, MVA, etc. Internal injury and hemorrhage may occur.

Open Wounds

Occurs from intentional or nonintentional trauma skin surface is broken may be accompanied by bleeding, tissue damage, & increased risk of infection

Avulsion

Open wound, always unintentional, partial ripping of multiple tissue layers (multiple layers, chronic wound). Unintentional wound Open wound

Status of Skin Integrity

Open- Bleeding, tissue damage Closed- Soft tissue is damage, & internal injury& hemorrhage may occur. Acute- wound proceeds through orderly and timely reparative process with restoration of anatomy and function; trauma from sharp object. Chronic- wound fails to proceed as in acute phase; ulcers due to continued exposure to friction. Intentional wounds- planned- heal acute (surgical incisions, etc.) IV therapy.

Physiological Effects of Wounds

Pain Anxiety & Fear- answer ? keep family informed Alterations in Self-Concept-listen/consult other disciplines if nec

Abrasion

Painful open wound Only involves top layer of skin, nerves are still in tact (Ex. road rash/skinned knee). Superficial scraping epidermal layer Accidental injury or fall that scrapes or rubs off the skin surface. An intentional dermatologic procedure (micro abrasion)

Purposes of Dressing

Remove necrotic tissue Prevent, Eliminate, or Control Infection Absorb drainage Maintain a moist wound environment Protect the wound from further injury Protect the skin surrounding the wound

Hemorrhage may cause

Restlessness, Anxiety (d/t lack of oxygen) Decrease in systolic BP Increased Pulse/RR Decreased Urinary Output (measure, not characteristics) Decreased HGB & HCT HGB: 12-18 HCT: 37-42 7-27 Blood Transfusion

Closed Wounds

Results from a blow, force, or strain, fall, assault, or MVA skin surface is NOT broken but there is soft tissue damage Internal injury & hemorrhage may occur

Wound Drainage (Exudate)

Serous Sanguineous Serosanguineous Prulent

Factors influencing Ulcer formation & Healing

Shearing force & friction Moisture Nutrition Infection Age Others Norton Scale for Pressure Ulcer Risk

Sutures & Staples

Skin sutures are used to hold the skin together Must get staple remover Retention sutures are used to provide an extra support for obese clients & for wounds with increased risk for dehiscence Steri-strips- do not have to be removed/may be applied to hold the wound together or give additional support

Effects of cold application

Vasoconstriction Local anesthesia Reduced cell metablism decreased muscle tension

Effects of Heat application

Vasodilation Reduced viscosity Reduced muscle tension Increased tissue metabloism Increased capillary permeability **** Moist heat more dangerous- burns*****

Acute Wound

Wound proceeds through orderly and timely repetitive process with respiration of anatomy & function; trauma from sharp object

Skin Tears

d/t fragile granulation tissue

Debridement

to clean away, remove bad/damaged tissue

Symptoms of infection

usually become apparent w/in 2-7 days after injury/surgery prulent drainage, increased drainage, redness/swelling in & around wound increased temperature & WBC count