WOUND CARE

Presentation for ACC Lab

March 22, 2006By Herlinda M. Burks, RN, BA, CWCN, CCCN

Risk Assessments

Report: focus on Hx of diseases, surgeries, how recent, present wounds, incisions. Read the H&P.

10 minute assessmentWhat do you see? Tubes, drains, obesity, weakness, skin

damage in patterns?, etc.Braden Scale Pressure Risk

Assessment

Wound Treatments

Never leave a wet open wound open to air (OTA) and unprotected.

Only leave ischemic black dry wounds on the feet and toes OTA or dressed lightly with gauze.

Wound Healing Processes

Types of Wound Closures Primary Intention

Sutures, staples, skin bonds, etc.

Secondary Intention Partial thickness

Regenerate specific cells Epithelialize

Full thickness Regranulate Epithelialize Remodel

Tertiary Intention

Processes Involved in 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?

Wound Culturing

Cleanse the wound with saline Irrigate till clear if it is a deep wound.

Use culturette that has 2 swabsWipe tissue in 1 cm2 area

Infection causing Bacteria is in the tissue Do not get just a sample of the drainageMultiple bacteria from peripheral tissues can

be in the drainageSubmit 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 wallsVitamins – A, B, C, D, E, KCopper, 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, Steri-stripped 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 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 lossOr 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.