Transcript WOUND CARE
WOUND CARE By Helen Harkreader, RN, PhD Wound Processes • Processes Involved in • Types of Healing Wound Closures ▫ Primary Intention Sutures, staples, skin bonds, etc. ▫ Secondary Intention Partial thickness Regenerate specific cells Epithelialize Full thickness Regranulate Epithelialize Remodel ▫ Tertiary Intention Wound healing ▫ Acute phase Hemostasis Inflammation Proliferation Remodeling ▫ Chronic phase Stalls for 2 weeks Change Tx Reassess full body, meds, labs. Wound Assessments • Etiology - watch those with ischemia • Size – consistent measure from nurse to nurse ▫ L x W x D in centimeters (head to toe, 9 to 3 o’clock) ▫ Locations of tunnels & undermining by the clock • Drainage – type (color, amount, consistency, odor) • Wound bed % of red, yellow, black tissues ▫ Granulation, Slough, Eschar or tan crust or blister ▫ Wound edges – rolled (epiboly), macerated • Peripheral tissues – discoloration, stains, scars? ▫ Edema, induration, scaling (peeling), plaques? • Contaminated or infected? Wound Culturing • Cleanse the wound with saline ▫ Irrigate till clear if it is a deep wound. • Use culturette that has 2 swabs • Wipe tissue in 1 cm2 area ▫ Infection causing Bacteria is in the tissue ▫ Do not get just a sample of the drainage ▫ Multiple bacteria from peripheral tissues can be in the drainage • Submit to lab Nutrition for Wound Healing • Assessment of Nutrition - labs ▫ Serum Albumin 18 to 20 days half-life Affected by hydration (> if dehydrated, < if overhydrated) ▫ Transferrin – 8 to 10 days half-life easily affected by other factors. ▫ Prealbumin – 2 days half-life – best predictor • Nutrients needed for Wound healing ▫ Calories –enough to support healing and other present disease processes ▫ Protein ▫ Vitamins Nutrients • Protein – fibroplasia, neogenesis, collagen formation, remodeling • Carbohydrates – energy and protein sparing • Fat - cell walls • Vitamins – A, B, C, D, E, K • Copper, Iron, Magnesium, Zinc Types of Wounds • Open wounds ▫ Incisions, dehisced or delayed closure ▫ Pressure ulcers ▫ Arterial ulcers ▫ Venous stasis ulcers ▫ Neuropathic ulcers ▫ Diabetic ulcers ▫ Abcesses ▫ Fistulas ▫ Ostomies ▫ Trauma, Burns • Closed Wounds ▫ Incisions Stitched, Stapled, Steristripped or Skin bonded ▫ Pressure ulcers ▫ Hematomas ▫ Abcesses, nodules, various dermatologic types. http://www.medicaledu.com/pictures.htm Pressure Ulcers • Braden Scale – 16 points or below is considered a risk ▫ Sensory Perception 4pts Completely, very, slightly, not impaired ▫ Moisture (4pts) Constantly, very, occasionally, rarely moist ▫ Activity (4pts) – bedfast, chairfast, walks occ, freq. ▫ Mobility (4pts) Completely, very, slightly immobile, no limitation ▫ Nutrition (4pts) Very poor, probably Inadequate, adequate, excellent ▫ Friction & Shear (3pts) Problem, potential problem, no apparent problem Pressure Ulcers • Stages ▫ 1 intact, persistent redness ▫ 2 partial thickness loss or blister ▫ 3 full thickness loss to but not through fascia ▫ 4 full thickness loss to muscle, bone, etc. ▫ Unstageable –purple, yellow or black-must be removed before staging ▫ Never back stage. • Prevention and treatment ▫ Turn every 2 hours when in bed ▫ Move every 15 minutes or at least every hour in wheel chair or chair ▫ Apply appropriate dressing to manage drainage ▫ Educate patient and family on reasons for treatment and causes of pressure ulcers. ▫ Monitor q shift Stage 1 • Reddened boggy heel Stage 2 • Partial thickness loss • Or blister Stage 3 • Down to but not through the facia Stage 4 • To muscle, bone, tendons, etc. Unstageable Pressure Ulcers • Purple, yellow, black Other Ulcers • Arterial • Venous Other ulcers • Neuropathic • Diabetic Stay open-minded • Remain alert to all possibilities.