Alterations in Physical Alterations in Physical IntegrityIntegrity

Types of WoundsTypes of Wounds

Wound: disruption of normal anatomical Wound: disruption of normal anatomical structure and FX that results from structure and FX that results from pathological processes beginning pathological processes beginning internally or externally to the involved internally or externally to the involved organ(s). (p. 1551)organ(s). (p. 1551)

Classification of WoundsClassification of Wounds

Intentional vs. UnintentionalIntentional vs. Unintentional

Intentional:Intentional:

Usually the result of Usually the result of therapy. Occur under therapy. Occur under aseptic conditions.aseptic conditions.

Wound edges: usually Wound edges: usually smooth/cleansmooth/clean

Unintentional:Unintentional:

Occurs unexpectedly. Occurs unexpectedly. Occurs under unsterile Occurs under unsterile conditions.conditions.

Wound edges: Wound edges: sometimes jagged.sometimes jagged.

Open vs. ClosedOpen vs. Closed

Open:Open:

Involves a break in the Involves a break in the skin or mucous skin or mucous membranes. membranes.

Wound edges are not Wound edges are not closed. closed.

If drainage system in If drainage system in place, it is an open place, it is an open system.system.

ClosedClosed

Involves no break in skin Involves no break in skin integrity.integrity.

Wound edges are Wound edges are closed. closed.

If drainage system is in If drainage system is in place, it is a closed place, it is a closed system.system.

AcquisitionAcquisitionIncision: Incision: Wound made with a Wound made with a sharp instrument.sharp instrument.

Puncture/Puncture/PerforatingPerforating::

Penetrating wound in which Penetrating wound in which a foreign object enters/exits a foreign object enters/exits an internal organ.an internal organ.

Contusion:Contusion:

Closed wound caused by a Closed wound caused by a blow to the body by blunt blow to the body by blunt object.object.

Laceration: Laceration: Tearing apart of Tearing apart of tissues. Wound has irregular tissues. Wound has irregular edges.edges.

Abrasion: Abrasion:

Superficial wound. Superficial wound.

Scraping, rubbing of skin’s Scraping, rubbing of skin’s surface.surface.

Penetrating:Penetrating:

Wound involving a break in Wound involving a break in epidermal skin layer, as well epidermal skin layer, as well as dermis and deeper as dermis and deeper tissues or organs.tissues or organs.

ContaminationContaminationClean wounds: Clean wounds: Closed Closed surgical wound not entering surgical wound not entering GI, respiratory, genital, GI, respiratory, genital, uninfected urinary tract, or uninfected urinary tract, or oropharyngeal cavity.oropharyngeal cavity.

Contaminated woundsContaminated wounds

Open, traumatic, accidental Open, traumatic, accidental wound.wound.

Surgical wound involving a Surgical wound involving a break in aseptic technique. break in aseptic technique.

Clean-contaminated Clean-contaminated wounds:wounds:

Surgical wound entering GI, Surgical wound entering GI, respiratory, genital, respiratory, genital, uninfected urinary tract, or uninfected urinary tract, or oropharyngeal cavity under oropharyngeal cavity under controlled conditions. controlled conditions.

DirtyDirty or infected wounds: or infected wounds:

Any wound that does not Any wound that does not properly heal and grows properly heal and grows organisms.organisms.

Old traumatic wound, Old traumatic wound, surgical incision into a area surgical incision into a area infected. infected.

AcuteAcute: Wound that proceeds through an : Wound that proceeds through an orderly and timely reparative process.orderly and timely reparative process.

ChronicChronic: Wound that fails to proceed : Wound that fails to proceed through an orderly and timely reparative through an orderly and timely reparative process.process.

SuperficialSuperficial: Wound that involves only : Wound that involves only epidermal layer of skin.epidermal layer of skin.

Stages of Wound HealingStages of Wound HealingRegeneration:Regeneration: The process of tissue The process of tissue

renewalrenewal

Defensive stage (Defensive stage (Inflammatory Inflammatory Phase/Reaction) Phase/Reaction) (hemostasis, (hemostasis, inflammation, cell migration & inflammation, cell migration & epithelializationepithelialization) )

Reconstructive stage Reconstructive stage

((Proliferative Phase/Regeneration) Proliferative Phase/Regeneration)

Filling in of the wound with new connective Filling in of the wound with new connective or granulation tissue or granulation tissue

the closing of the top of the wound by the closing of the top of the wound by epitheliazation.epitheliazation.

Maturative stage Maturative stage (Maturation Phase /Remodeling)(Maturation Phase /Remodeling)

May take more than a year. May take more than a year.

Collagen scar continues to reorganize and Collagen scar continues to reorganize and gain strength for several months. gain strength for several months.

Usu. scar tissue has fewer pigmented cells Usu. scar tissue has fewer pigmented cells and has a lighter color than normal skin.and has a lighter color than normal skin.

Classification of Wound HealingClassification of Wound Healing

Primary IntentionPrimary Intention

Wounds that heal with little tissue loss. Wounds that heal with little tissue loss. The skin wedges are approximated.The skin wedges are approximated. Risk of infection is low.Risk of infection is low. Healing occurs quickly: Healing occurs quickly:

drainage stops by day 3 of closure,drainage stops by day 3 of closure, wound is epitheliazed by day 4, wound is epitheliazed by day 4, inflammation is present up to day 5,inflammation is present up to day 5,healing edge is present by day 9.healing edge is present by day 9.

Classification of Wound HealingClassification of Wound Healing

Secondary IntentionSecondary Intention

Wound edges do not approximate.Wound edges do not approximate.Wound is left open until it becomes filled by scar Wound is left open until it becomes filled by scar

tissue.tissue.Chance of infection is greater.Inflammatory phase Chance of infection is greater.Inflammatory phase

is often chronicis often chronicWound filled with granulation tissue (a form of Wound filled with granulation tissue (a form of

connective tissue that has a more abundant connective tissue that has a more abundant blood supply than collagen.blood supply than collagen.

Scarring is greater.Scarring is greater.

Classification of Wound HealingClassification of Wound Healing

Tertiary IntentionTertiary Intention

There is a time delay between the time of the There is a time delay between the time of the injury and the approximation of the wound injury and the approximation of the wound edges.edges.

Attempt by surgeon to allow for effective drainage Attempt by surgeon to allow for effective drainage and cleansing of a clean-contaminated or and cleansing of a clean-contaminated or contaminated wound.contaminated wound.

Not closed until all evidence of edema and wound Not closed until all evidence of edema and wound debris has been removed.debris has been removed.

Dressing is used to protect.Dressing is used to protect.

Wound DrainageWound Drainage

Serous: Clear, waterySerous: Clear, watery

Sanguineous: Hemorrhagic. Specify color.Sanguineous: Hemorrhagic. Specify color.

Serosanguinous: pink to light red in color. Thinner Serosanguinous: pink to light red in color. Thinner than sanguineous.than sanguineous.

Purulent: thick drainage that is often yellow-green Purulent: thick drainage that is often yellow-green in color.in color.

Factors affecting Wound HealingFactors affecting Wound Healing

Compromised hostCompromised host StressStress

NutritionNutrition Patient teachingPatient teaching

ObesityObesity Hospital in-patient “time”Hospital in-patient “time”

Medications Medications (immunosuppressants)(immunosuppressants)

Blood sugarBlood sugar

Factors Inhibiting Wound Healing: ElderlyFactors Inhibiting Wound Healing: Elderly

Diminished epidermal cell Diminished epidermal cell activityactivity

After age of 50 cell renewal After age of 50 cell renewal time is increased by one time is increased by one third. Epithelial cell renewal third. Epithelial cell renewal takes 30 or more days for takes 30 or more days for the elderly. SLOWS the elderly. SLOWS Healing…Healing…

Atrophy and Thinning of Atrophy and Thinning of both skin layersboth skin layers

Both layers are thinner and Both layers are thinner and flatter. The thinning of the flatter. The thinning of the epidermis reduces the skin’s epidermis reduces the skin’s natural barriers.natural barriers.

Weakening in the Weakening in the epidermis and dermis epidermis and dermis attachment. attachment.

The epidermis can slide – The epidermis can slide – precipitates skin tears.precipitates skin tears.

Factors Inhibiting Wound Healing: ElderlyFactors Inhibiting Wound Healing: Elderly

Impaired immune Impaired immune function of skin cellsfunction of skin cells

Increases the risk of Increases the risk of infection infection

Hypodermics is Hypodermics is decreased (insulator of decreased (insulator of the skin)the skin)

Little subcutaneous padding Little subcutaneous padding over bony prominences. over bony prominences. More at risk for More at risk for skin skin breakdownbreakdown and and heat heat strokestroke..

Loss in the amt. of Loss in the amt. of collagencollagen

Decreased skin turgor Decreased skin turgor Greater risk for shearing and Greater risk for shearing and tearing injuries.tearing injuries.

Complications of Wound HealingComplications of Wound Healing

HemorrhageHemorrhage

DehiscenceDehiscence

EviscerationEvisceration

InfectionInfection

FistulasFistulas

Nursing Process for Wound Nursing Process for Wound ManagementManagement

Untreated Wounds – basic first aideUntreated Wounds – basic first aide

Treated Wounds – prescribed per M.D. or Treated Wounds – prescribed per M.D. or wound care nurse.wound care nurse.

Wound Care ProtocolWound Care Protocol

Wound AssessmentWound Assessment

AppearanceAppearance

Drainage (penrose, J-P drain, Hemovac)Drainage (penrose, J-P drain, Hemovac)

Swelling & IndurationSwelling & Induration

PainPain

TemperatureTemperature

Sequential signs of primary wound Sequential signs of primary wound healing:healing:

Absence of bleedingAbsence of bleeding InflammationInflammation Granulation tissueGranulation tissue Scar formationScar formation Reduction in scar sizeReduction in scar size

Lab DataLab Data

WBCWBC

Hgb, HctHgb, Hct

BUN, AlbuminBUN, Albumin

Wound culturesWound cultures

MD promotes wound healingMD promotes wound healing

RN provides:RN provides: Ongoing wound assessmentOngoing wound assessment Aseptic wound care according to MD Aseptic wound care according to MD

specificationsspecifications Documentation of wound statusDocumentation of wound status Keeps MD apprised of wound status as Keeps MD apprised of wound status as

appro.appro.

To promote healing/prevent complications…To promote healing/prevent complications…

Adequate nutritionAdequate nutrition Prevent wound stress/traumaPrevent wound stress/trauma

vomitingvomiting

coughingcoughing

abdominal distentionabdominal distention Prevent wound infectionPrevent wound infection

Factors Affecting Wound CareFactors Affecting Wound Care

Type of woundType of wound SizeSize Drainage/exudateDrainage/exudate Open vs. closedOpen vs. closed Wound locationWound location MD ordersMD orders Presence of complicationsPresence of complications

Drain managementDrain management

Open vs. closedOpen vs. closed

Monitor drainageMonitor drainage

Universal precautions, aseptic techniqueUniversal precautions, aseptic technique

Penrose DrainPenrose Drain

Open Drainage System

Jackson Pratt DrainJackson Pratt Drain

Close Drainage system

HemovacsHemovacs

Close Drainage System

Drainage Drainage Collection Bag Collection Bag (T-tubes)(T-tubes)

Sutures….Sutures….

Staples….Staples….

Hot/cold applicationsHot/cold applications

Pressure ulcerPressure ulcerPressure sore, Decubitus UlcerPressure sore, Decubitus Ulcer

Epidermis:Epidermis:

Stratum corneumStratum corneum

stratum basalestratum basale

DermisDermis

Tissue Ischemia: local absence of blood Tissue Ischemia: local absence of blood flow/major reduction in blood flowflow/major reduction in blood flow

Blanching: Normal red tones of light-Blanching: Normal red tones of light-skinned client are absent. Does not occur skinned client are absent. Does not occur in clients with darkly pigmented skin.in clients with darkly pigmented skin.

Darkly pigmented skin: Skin that remains Darkly pigmented skin: Skin that remains unchanged (does not blanch) when unchanged (does not blanch) when pressure is applied over a boney pressure is applied over a boney prominence – prominence – irrespective of the client’s irrespective of the client’s race or ethnicity.race or ethnicity.

Normal Reactive Hyperemia: Visible effect Normal Reactive Hyperemia: Visible effect of localized vasodilatation, the body’s of localized vasodilatation, the body’s normal response to lack of blood flow to normal response to lack of blood flow to the underlying tissue. Area blanches with the underlying tissue. Area blanches with fingertip pressure. Lasts less than 1 hour.fingertip pressure. Lasts less than 1 hour.

Abnormal reactive hyperemia: Excessive Abnormal reactive hyperemia: Excessive vasodilatation and induration in response vasodilatation and induration in response to pressure. The skin appears bright pink to pressure. The skin appears bright pink to red. Lasts more than 1 hour to 2 weeks to red. Lasts more than 1 hour to 2 weeks after the removal of the pressure. Does after the removal of the pressure. Does not blanch.not blanch.

Characteristics of Intact Dark Skin that might Characteristics of Intact Dark Skin that might alert nurses to the potential for pressure alert nurses to the potential for pressure ulcers (p. 1546)ulcers (p. 1546)

Color Color

Temperature Temperature

Touch Touch

AppearanceAppearance

Risk Factors for Skin BreakdownRisk Factors for Skin Breakdown

Impaired Sensory inputImpaired Sensory input

Impaired motor fxImpaired motor fx

Alteration in LOCAlteration in LOC

Orthopedic devicesOrthopedic devices

Any equipmentAny equipment

Contributing FactorsContributing Factors

Shearing ForceShearing Force

FrictionFriction

EdemaEdema

AnemiaAnemia

CachexiaCachexia

ObesityObesity

InfectionInfection

Impaired peripheral Impaired peripheral circulationcirculation

Age (elderly)Age (elderly)

NutritionNutrition

Evaluation ToolsEvaluation Tools

Classification of Pressure UlcersClassification of Pressure Ulcers

II Nonblanchable erythema of the intact skinNonblanchable erythema of the intact skin. .

IIII Partial-thickness skin loss involving Partial-thickness skin loss involving epidermis and /or dermis. epidermis and /or dermis.

IIIIII Full-thickness skin loss involving damage Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that or necrosis of subcutaneous tissue that may extend down to but not through may extend down to but not through underlying fasciaunderlying fascia..

IVIV Full-thickness skin loss with extensive Full-thickness skin loss with extensive destruction; tissue necrosis; or damage to destruction; tissue necrosis; or damage to muscle, bone, or supporting structures. muscle, bone, or supporting structures.

Stage I(no skin loss)

Stage I(no skin loss)

Stage II(Shallow crater – involves epidermis and/or dermis)

Stage IIShallow crater – involves epidermis and/or dermis)

Stage III(Full thickness involving damage/necrosis of subc. Tissue.

Does not extend down through underlying fascia)

Stage III or IVStage III or IV

Four Stages of UlcersFour Stages of Ulcers