Chapter 33 Wound Care Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Chapter 33Chapter 33

Wound CareWound Care

Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

A wound is a break in the skin or mucous A wound is a break in the skin or mucous membrane.membrane. Common causes are:Common causes are:

• SurgerySurgery• TraumaTrauma• Unrelieved pressure or frictionUnrelieved pressure or friction• Decreased blood flow through the arteries or veinsDecreased blood flow through the arteries or veins• Nerve damageNerve damage

Infection is a major threat.Infection is a major threat. Wound care involves preventing:Wound care involves preventing:

• Infection and further injury to the wound and nearby Infection and further injury to the wound and nearby tissuestissues

• Blood loss and painBlood loss and pain

Slide 2Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Wound CareWound Care

Skin TearsSkin Tears

A skin tear is a break or rip in the outer A skin tear is a break or rip in the outer layers of the skin.layers of the skin. The epidermis (top skin layer) separates from the The epidermis (top skin layer) separates from the

underlying tissues.underlying tissues. The skin is “peeled back.”The skin is “peeled back.” The hands, arms, and lower legs are common The hands, arms, and lower legs are common

sites for skin tears.sites for skin tears.


Skin Tears (cont’d)Skin Tears (cont’d)

Skin tears are caused by:Skin tears are caused by: Friction, shearing, pulling or pressure on the skinFriction, shearing, pulling or pressure on the skin Falls or bumping a hand, arm, or leg on any hard Falls or bumping a hand, arm, or leg on any hard

surface surface Holding the person’s arm or leg too tightHolding the person’s arm or leg too tight Removing tape or adhesivesRemoving tape or adhesives Bathing, dressing, and other tasksBathing, dressing, and other tasks Pulling buttons and zippers across fragile skinPulling buttons and zippers across fragile skin Jewelry—yours or the person’sJewelry—yours or the person’s Long or jagged fingernails (yours or the person’s) Long or jagged fingernails (yours or the person’s)

and long or jagged toenailsand long or jagged toenails


Persons at risk for skin tears:Persons at risk for skin tears: Need help moving.Need help moving. Have poor nutrition.Have poor nutrition. Have poor hydration.Have poor hydration. Have altered mental awareness.Have altered mental awareness. Are very thin.Are very thin.

Careful and safe care helps prevent skin Careful and safe care helps prevent skin tears and further injury.tears and further injury.


Skin Tears (cont’d)Skin Tears (cont’d)

Circulatory UlcersCirculatory Ulcers

Circulatory ulcers (vascular ulcers) are open Circulatory ulcers (vascular ulcers) are open sores on the lower legs or feet.sores on the lower legs or feet. They are caused by decreased blood flow They are caused by decreased blood flow

through the arteries or veins.through the arteries or veins. Persons with diseases affecting the blood Persons with diseases affecting the blood

vessels are at risk.vessels are at risk. These wounds are painful and hard to heal.These wounds are painful and hard to heal.

You must help prevent skin breakdown on You must help prevent skin breakdown on the legs and feet.the legs and feet.


Circulatory Ulcers (cont’d)Circulatory Ulcers (cont’d)

Venous ulcers (stasis ulcers) are open sores on Venous ulcers (stasis ulcers) are open sores on lower legs or feet caused by poor blood flow.lower legs or feet caused by poor blood flow. These ulcers can develop when valves in the legs do These ulcers can develop when valves in the legs do

not close well.not close well.• The veins do not pump blood back to the heart in a normal The veins do not pump blood back to the heart in a normal

way.way.• Blood and fluid collect in the legs and feet.Blood and fluid collect in the legs and feet.• The heels and inner aspect of the ankles are common sites The heels and inner aspect of the ankles are common sites

for venous ulcers.for venous ulcers.• They can occur from skin injury.They can occur from skin injury.• They can occur without trauma.They can occur without trauma.• Venous ulcers are painful and walking is difficult.Venous ulcers are painful and walking is difficult.• Infection is a risk.Infection is a risk.


Risk factors for venous ulcers include:Risk factors for venous ulcers include:• History of blood clotsHistory of blood clots

• History of varicose veinsHistory of varicose veins

• Decreased mobilityDecreased mobility

• ObesityObesity

• Leg or foot surgeryLeg or foot surgery

• Advanced ageAdvanced age

• Surgery on the bones and jointsSurgery on the bones and joints

• Phlebitis (inflammation of a vein)Phlebitis (inflammation of a vein)



To prevent venous ulcers:To prevent venous ulcers:• Follow the care plan to prevent skin breakdown.Follow the care plan to prevent skin breakdown.• Prevent injury.Prevent injury.• Move and transfer the person carefully and gently.Move and transfer the person carefully and gently.

To treat venous ulcers:To treat venous ulcers:• Persons at risk need professional foot care.Persons at risk need professional foot care.• The doctor may order drugs for infection and to decrease The doctor may order drugs for infection and to decrease

swelling.swelling.• Medicated bandages and other wound care products are Medicated bandages and other wound care products are

often ordered.often ordered.• Devices used for pressure ulcers are often ordered.Devices used for pressure ulcers are often ordered.• The doctor may order elastic stockings or elastic bandages.The doctor may order elastic stockings or elastic bandages.



Arterial ulcers are open wounds on the lower Arterial ulcers are open wounds on the lower legs or feet caused by poor arterial blood flow.legs or feet caused by poor arterial blood flow. They are found between the toes, on top of the toes, They are found between the toes, on top of the toes,

and on the outer side of the ankle.and on the outer side of the ankle. They are caused by diseases or injuries that They are caused by diseases or injuries that

decrease arterial blood flow to the legs and feet.decrease arterial blood flow to the legs and feet.• High blood pressureHigh blood pressure• DiabetesDiabetes• Narrowed arteries from agingNarrowed arteries from aging• Smoking is a risk factor.Smoking is a risk factor.

The doctor treats the disease causing the ulcer.The doctor treats the disease causing the ulcer.• Drugs, wound care, and a walking and exercise program Drugs, wound care, and a walking and exercise program

are ordered.are ordered. Professional foot care is important.Professional foot care is important.



Diabetic foot ulcers are open wounds on the feet Diabetic foot ulcers are open wounds on the feet caused by complications from diabetes.caused by complications from diabetes. Some diabetics have nerve and blood vessel Some diabetics have nerve and blood vessel

damage.damage.• Both problems can lead to diabetic foot ulcers.Both problems can lead to diabetic foot ulcers.

• Infection and gangrene are risks.Infection and gangrene are risks.

• The affected part may need to be amputated to prevent The affected part may need to be amputated to prevent the spread of gangrene.the spread of gangrene.

You need to:You need to:• Check the person’s feet every day.Check the person’s feet every day.

• Report any signs of a foot problem to the nurse at once.Report any signs of a foot problem to the nurse at once.

• Follow the care plan.Follow the care plan.



Wound HealingWound Healing

The healing process has three phases.The healing process has three phases. Inflammatory phase (3 days)Inflammatory phase (3 days)

• Bleeding stops.Bleeding stops.

• A scab forms.A scab forms.

Proliferative phase (day 3 to day 21)Proliferative phase (day 3 to day 21)• Cells multiply to repair the wound.Cells multiply to repair the wound.

Maturation phase (day 21 to 2 years)Maturation phase (day 21 to 2 years)• The scar gains strength.The scar gains strength.


Wound Healing (cont’d)Wound Healing (cont’d)

Healing occurs in three ways.Healing occurs in three ways. First intention (primary intention, primary closure)First intention (primary intention, primary closure)

• The wound is closed.The wound is closed.

Second intention (secondary intention)Second intention (secondary intention)• Wounds are cleaned and dead tissue removed.Wounds are cleaned and dead tissue removed.

• Wound edges are not brought together.Wound edges are not brought together.

• Infection is a great risk.Infection is a great risk.

Third intention (delayed intention, tertiary Third intention (delayed intention, tertiary intention)intention)• The wound is left open and closed later.The wound is left open and closed later.

• Infection and poor circulation are common reasons.Infection and poor circulation are common reasons.


Many factors affect healing and the risk for Many factors affect healing and the risk for complications.complications. Wound typeWound type The person’s age, health, nutrition, and life-styleThe person’s age, health, nutrition, and life-style CirculationCirculation Certain drugsCertain drugs Immune system changesImmune system changes Persons taking antibioticsPersons taking antibiotics

• Specific antibiotics kill specific pathogens. In doing so, Specific antibiotics kill specific pathogens. In doing so, other pathogens may grow and multiply.other pathogens may grow and multiply.



Complications include:Complications include: Hemorrhage and shockHemorrhage and shock

• You cannot see internal hemorrhage. Shock, vomiting blood, You cannot see internal hemorrhage. Shock, vomiting blood, coughing up blood, and loss of consciousness signal internal coughing up blood, and loss of consciousness signal internal hemorrhage.hemorrhage.

• Common signs of external hemorrhage are bloody drainage and Common signs of external hemorrhage are bloody drainage and dressings soaked with blood.dressings soaked with blood.

• Hemorrhage and shock are emergencies. Alert the nurse at once.Hemorrhage and shock are emergencies. Alert the nurse at once. InfectionInfection Dehiscence and evisceration are surgical emergencies.Dehiscence and evisceration are surgical emergencies.

• Dehiscence is the separation of wound layers.Dehiscence is the separation of wound layers.

• Evisceration is the separation of the wound along with the protrusion Evisceration is the separation of the wound along with the protrusion of abdominal organs.of abdominal organs.

• The person often describes the sensation of the wound “popping The person often describes the sensation of the wound “popping open.”open.”



Wound appearanceWound appearance Doctors and nurses observe the wound and its Doctors and nurses observe the wound and its

drainage.drainage. You need to make certain observations when You need to make certain observations when

assisting with wound care.assisting with wound care. Report and record your observations according Report and record your observations according

to agency policy.to agency policy. Wound drainageWound drainage

Amount and type of drainage depend on:Amount and type of drainage depend on:• Wound size and siteWound size and site• Bleeding and infectionBleeding and infection



Wound drainage is observed and measured.Wound drainage is observed and measured. Serous drainage—clear, watery fluidSerous drainage—clear, watery fluid Sanguineous drainage—bloody drainageSanguineous drainage—bloody drainage Serosanguineous drainage—thin, watery Serosanguineous drainage—thin, watery

drainage that is blood-tingeddrainage that is blood-tinged Purulent drainage—thick green, yellow, or brownPurulent drainage—thick green, yellow, or brown



Drainage must leave the wound for healing.Drainage must leave the wound for healing. When large amounts of drainage are expected, When large amounts of drainage are expected,

the doctor inserts a drain.the doctor inserts a drain. A Penrose drain is a rubber tube that drains onto A Penrose drain is a rubber tube that drains onto

a dressing.a dressing.• It is an open drain.It is an open drain.• Microbes can enter the drain and wound.Microbes can enter the drain and wound.

Closed drainage systems prevent microbes from Closed drainage systems prevent microbes from entering the wound.entering the wound.• A drain is attached to suction.A drain is attached to suction.



Drainage is measured in three ways.Drainage is measured in three ways. Weigh dressings before applying them.Weigh dressings before applying them.

• The weight of each new dressing is noted.The weight of each new dressing is noted.• Dressings are weighed after removal.Dressings are weighed after removal.• Dry dressing weight is subtracted from the wet Dry dressing weight is subtracted from the wet

dressing weight.dressing weight. Note the number and size of dressings with Note the number and size of dressings with

drainage.drainage.• The amount and kind of drainage on each dressing is The amount and kind of drainage on each dressing is

noted.noted. Measure the amount of drainage in the collection Measure the amount of drainage in the collection

container if closed drainage is used.container if closed drainage is used.



DressingsDressings

Wound dressings have many functions.Wound dressings have many functions. Protect wounds from injury and microbesProtect wounds from injury and microbes Absorb drainageAbsorb drainage Remove dead tissueRemove dead tissue Promote comfortPromote comfort Cover unsightly woundsCover unsightly wounds Provide a moist environment for wound healingProvide a moist environment for wound healing Apply pressure (pressure dressings) to help Apply pressure (pressure dressings) to help

control bleedingcontrol bleeding


Dressings (cont’d)Dressings (cont’d)

Dressing type and size depend on many Dressing type and size depend on many factors.factors. The type of woundThe type of wound Wound size and siteWound size and site Amount of drainageAmount of drainage InfectionInfection The dressing’s functionThe dressing’s function The frequency of dressing changes The frequency of dressing changes

The doctor and nurse choose the dressing The doctor and nurse choose the dressing for each wound.for each wound.


Dressings are described by the material used Dressings are described by the material used and how applied.and how applied. The following are common:The following are common:

• Gauze—absorbs drainage and moistureGauze—absorbs drainage and moisture

• Non-adherent gauze—gauze dressing with non-stick surfaceNon-adherent gauze—gauze dressing with non-stick surface

• Transparent adhesive film—allows wound observationTransparent adhesive film—allows wound observation

Some dressings contain special agents to promote Some dressings contain special agents to promote wound healing.wound healing.

Dressings are wet or dry.Dressings are wet or dry.• Dry dressing Dry dressing

• Wet-to-damp dressingWet-to-damp dressing

• Wet-to-wet dressingWet-to-wet dressingSlide 22Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.


Dressings must be secured over wounds or Dressings must be secured over wounds or microbes can enter the wound, and drainage microbes can enter the wound, and drainage can escape if the dressing is dislodged.can escape if the dressing is dislodged. Tape and Montgomery ties are used to secure Tape and Montgomery ties are used to secure

dressings.dressings.• Binders hold dressings in place.Binders hold dressings in place.• Adhesive tape sticks well to the skin.Adhesive tape sticks well to the skin.• Paper, plastic, and cloth tapes usually do not cause Paper, plastic, and cloth tapes usually do not cause

allergic reactions.allergic reactions.• Elastic tape allows movement of the body part.Elastic tape allows movement of the body part.



• Montgomery ties are used for large dressings and frequent Montgomery ties are used for large dressings and frequent dressing changes.dressing changes. A wound may need 2 or 3 Montgomery ties on each side.A wound may need 2 or 3 Montgomery ties on each side. They have adhesive strips and cloth ties.They have adhesive strips and cloth ties. When in place, the strips are placed on both sides of the When in place, the strips are placed on both sides of the

dressing and the ties are secured over the dressing.dressing and the ties are secured over the dressing. They protect the skin from frequent tape application and They protect the skin from frequent tape application and

removal.removal.

You may assist the nurse with dressing changes.You may assist the nurse with dressing changes. Some agencies let you apply simple, dry, non-sterile Some agencies let you apply simple, dry, non-sterile

dressings to simple wounds.dressings to simple wounds.



Binders andBinders andCompression GarmentsCompression Garments

Binders are applied to the abdomen, chest, Binders are applied to the abdomen, chest, or perineal areas. or perineal areas.

Binders promote healing by:Binders promote healing by: Supporting woundsSupporting wounds Holding dressings in placeHolding dressings in place Preventing or reducing swellingPreventing or reducing swelling Promoting comfortPromoting comfort Preventing injuryPreventing injury


Binders and Binders and Compression Garments (cont’d)Compression Garments (cont’d)

Common binders include:Common binders include: Abdominal binder—provides abdominal support and Abdominal binder—provides abdominal support and

holds dressings in placeholds dressings in place Breast binder—supports the breasts after surgeryBreast binder—supports the breasts after surgery

Compression garments are commonly worn Compression garments are commonly worn after plastic surgery. They help:after plastic surgery. They help: Reduce swellingReduce swelling Prevent fluid build-up at the surgical sitePrevent fluid build-up at the surgical site Hold skin against the bodyHold skin against the body Achieve the desired shapeAchieve the desired shape


Heat and Cold ApplicationsHeat and Cold Applications

Heat and cold applicationsHeat and cold applications Promote healingPromote healing Promote comfortPromote comfort Reduce tissue swellingReduce tissue swelling


The wound causes pain and discomfort.The wound causes pain and discomfort. Allow pain drugs to take effect before giving care.Allow pain drugs to take effect before giving care.

Good nutrition is needed for healing.Good nutrition is needed for healing. Pain and discomfort and also odors from wound Pain and discomfort and also odors from wound

drainage can affect appetite.drainage can affect appetite. Infection is always a threat.Infection is always a threat. Delayed healing and infection are risks for Delayed healing and infection are risks for

persons who:persons who: Are older or obese Are older or obese Have poor nutritionHave poor nutrition Have poor circulation or diabetesHave poor circulation or diabetes


Meeting Basic NeedsMeeting Basic Needs

Many factors affect safety and security needs.Many factors affect safety and security needs. The person fears scarring, disfigurement, delayed The person fears scarring, disfigurement, delayed

healing, and infection.healing, and infection. Medical bills are other concerns.Medical bills are other concerns.

Victims of violence have many other concerns.Victims of violence have many other concerns. Future attacks, finding and convicting the attacker, Future attacks, finding and convicting the attacker,

and fear for family members are common concerns.and fear for family members are common concerns. Whatever the wound site or size, it affects Whatever the wound site or size, it affects

function and body image.function and body image. Love and belonging and self-esteem needs are Love and belonging and self-esteem needs are

affected.affected. Adjustment may be hard and rehabilitation necessary.Adjustment may be hard and rehabilitation necessary.


Meeting Basic Needs (cont’d)Meeting Basic Needs (cont’d)

Chapter 33 Wound Care Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

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Transcript of Chapter 33 Wound Care Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.