Transcript Wounds - lwthspn

Wounds
2 categories:
- surgical
- traumatic
Wound examples
•Closed surgical
•Open surgical
•Closed traumatic
•Open traumatic
Infection
Any incision or wound
increases the risk of
infection!!
Wound Healing
•First Intention
•Second Intention
•Third Intention
First Intention
Healing
•Wounds with minimal
tissue loss
•edges approximated
•most surgical wounds
•dec. infection/scar risk
Second Intention
Healing
•Occurs with tissue loss
•edges not approximate
•left open to heal
•opening fills with
granulation tissue
Granulation tissue
•Soft, pink
•capillary projections
•once begins, usually
stop packing wound
Second Intention
(cont.)
•Later, epithelial cells
grow over
granulation tissue
•inc. risk for scarring
and infection
Third Intention
Healing
•Wound intentionally
kept open for time
•Closed surgically later
•Scarring common
Wound Healing
Process
•Increased wbc’s during
inflammation
Neutrophils (wbc type)
- engulf bacteria
- release enzyme
Wound Healing
(cont.)
Monocytes (wbc type)
- engulf bacteria, debris
- live longer
Fibroblast (cell type)
- produce collagen
Wound problems
Dehiscence:
•wound edges separate
Evisceration:
•separation of wound
with contents expelled
Factors affecting
healing:
•Extent of injury
•Blood supply to area
•Type of injured area
- epithelial tissue heal
fastest
Factors affecting
healing (cont.)
•Presence of infection
•Presence of debris
•Health of patient
How should primary
intention look?
•Color
•Edges
•Sutures
•Bleeding / Drainage
•Vital signs
Nursing
assessment
•Anatomic location
•Duration of wound
•Size of wound in cm.
- width, length, depth
•Color of wound bed
Nursing
Assessment (cont.)
•Presence of tunneling
•Presence of exudate
•Warm, cold, hard?
•C/O pain?
•Any foreign bodies?
Nursing
Assessment (cont.)
•May draw diagram in
notes if irregular
•Other objective
assessments
- body temp, Bl. tests
Care of closed
wounds
•Follow hospital policy
and MD orders
•Change dsg and do not
disturb suture line
Care of open
wounds
•Check MD order
•Must be kept moist
•Cleanse at each dsg
change with ordered
solution or sterile NSS
Wet-to-Dry Dsg.
•Debride wound
•Cleanse inside > out
•Surgical asepsis
•Volume of force impt.
•Damp - don’t saturate
Packing the wound
•Must be used for deep
wound
•Dead space is deadly
•NSS on gauze OK
•Tissue up gauze
Pressure Sores
•Decubitis ulcers
•Bedsores
•Pressure ulcers
Causes:
•Prolonged pressure
•Shear
•Friction
•Stripping
•Urine or stool
More causes!!
•Perspiration
•Arterial insufficiency
•Wrinkles or debris in
bedding
Nursing
responsibility
Early prevention and
recognition is the key!!
Early appearance
•Pallor over pressure
area
•Reddened skin
•Cellular death and
skin breakdown
Stages of
pressure sores
Stage 1
- inflamm and erythema
- no blanching
- lasts for 30 min after
pressure relieved
Stage 2
•Loss of epidermis
•Damage to dermis
•Shallow crater or
blister
•Swollen and painful
Stage 3
•Subcutaneous involved
•Not painful
•May have foul drainage
Stage 4
•Extensive damage to
underlying structures
•Tendons, muscle,
bone
Prevention
•ID individuals at risk
•Use preventative
measures
•Adequate blood supply
•Nutrition
REMEMBER:
•Check MD order
•Check protocol
•Closed wounds dry
•Open wounds moist
•Cleanse inside to out
More to remember!
•NSS appropriate
•Irrigation is best for
open wound cleansing
•Obliterate dead space
•Draining wound care