Lecture 7: Wound Assessment and Management Flashcards
5 main functions of the skin
-protection
-storage
-absorption
-heat regulation
-sensation/perception
3 part structure of skin…
skin
1. epidermis
2. Dermis
3.Subcutaneous tissue
muscle
wound classifications (5)
- Cause (surgical vs non surgical)
- Duration (acute vs chronic)
- Level contamination
- Depth of tissue affected
- Colour of wound
L CD CD
Acute wound
Any surgical wound that heals by primary intentions or secondary intention (normal healing phases)
Chronic wound
Wound that fails to progress through normal healing phases. Stuck in inflammatory phase.
Level of contamination of wounds (4):
clean wound: no inflammation, operative incision
Clean/contaminated no inflammation but has resp, GI, urinary tract as been entered.
contaminated wound: open traumatic wounds or surgical wound, beak in sterile field, shows signs of inflammation.
Infected wound: Old, traumatic, dead tissue and wound evidence of infection
Types of tissue colour
-Red
-yellow
-black
Red: Granulation tissue (clean, superficial or deep)
Yellow: Slough tissue (ideal for bacterial growth)
Black: Eschar or necrotic tissue
(gangrenous ulcers)
what are 3 types of wound debridement
- Conservative sharp wound debridement: Use an instrument to remove wound tissue
- Surgical debridement
- Non-surgical debridement:
-autolytic
-enzymatic
-Mechanical
-Maggot therapy
Serous drainage
Clear or straw coloured
-Protein and fluid
Sanguineous
Red,thin,watery
-blood drainage
Serosanguinous
-Pink,thin,watery
-blood cells mixed with serous drainage
-expected drainage few hours post surgery
Purulent
yellow, grey,green
Hemorrhage
Thick!!!
-leaking blood vessel
most wounds heal by_____
tissue repair
wounds usually result in what
Scar tissue
What’s the wound healing process…
- Initial hemostasis/inflammatory
3-5 days
2.Granulation proliferative) phase
5 days-3 weeks
3.Maturation
remodeling
several months or years
Homeostasis inflammation
-lasts several days
-occurs immediately after injury
-platelet aggregation
-edema
-macrophage engulf and remove debris
-release of cytokines
clinical manifestations of inflammation:
-local response
-systemic response
-exudate formation
local: redness, heat,swelling, loss function
systemic response: leukocytosis,nausea,anorexia,fever
exudate formation: fluid and leukocytes move from the circulation to the site of injury
major events of granulation phase of wound healing
1.Epithelization
2.Collagen formation
3. Granulation tissue formation
4. Contraction
maturation phase
- can last up to 2 yrs
- collagen reorganization
- increased tensile strength of the scar
- colour of scar changes from red to white
methods of wound closure
primary - 1st intention
secondary - 2nd intention
tertiary - 3rd intention
1st intention
- closing the wound by mechanical means i.e: sutures staples, tape, skin glue
indicated:
- minimal tissue loss
- skin edges are well approx
- clean lacerations
most surgical incisions closed using primary intention: 3 phases of healing occur quickly w minimal scarring
2nd intention
the wounds usually are large w either:
- significant tissue loss/damage
- bacterial concentration
take more time to heal - uses same phases of healing
3rd intention - delayed primary intention
- is a method of wound closure that uses a combo of primary and secondary intention
- the wound is left open for short period (usually a few days) to allow edema and infected exudate (pus) to resolve, then closed by primary intention or secondary intention
complications of wound healing
- infection
- hypertrophic scars/keloid formation
- contracture
- dehiscence
- adhesions
infection
- ranges from superficial cases of cellulitis to deep-seated abscesses
- staphylococcus and pseudomonas species are common organisms causing wound infections
hypertrophic scars and keloids
hypertrophic scar: inappropriately large, red, raised and hard. it remains confined to the wound edges and may regress in time.
keloid: is an even greater production of scare tissue that extends beyond the wound edges and may form tumor-like masses
- overproduction of collagen
contractures
excessive wound contraction may result in deformity or contracture, especially if wound is near a joint.
dehiscence
- separation and disruption of previously joined wound edges
3 contributing causes:
- infection causing inflammatory process
- granulation tissue not strong enough to withstand external forces
- obesity
evisceration
occurs when wound edges separate to the extent that intestines protrude through the wound
what to do when evisceration occurs
- call for help but stay pt
- notify surgeon immediately
- lower bed so its flat no higher than 20 degrees
- bend knees to reduce abdominal muscle tension
- sterile towels and soak w sterile saline
- remove soiled dressing, don w sterile glove, place moistened towels over loops of bowel
adhesions
- filmy bands of scar tissue that may form btwn or around organs
- most adhesions cause no sympt at all
- serious complication is intestinal obstruction
principles of wound care
“measures”
- minimize trauma to wound bed
- eliminate dead space
- assess and manage the amount of drainage/exudate
- support the body’s tissue defense sys
- use nontoxic wound cleansers
- remove infection, debris, and necrotic tissue
- environment maintenance; moist wound bed
- surrounding tissue, protect from injury and bacterial invasion
cleansing - normal saline
0.9% NaCl
most used solution - intentional wound
gauze dressing
- provides absorption of exudates supports debridement (mechanical) if applied and kept moist
- used to maintain moist wound surface or as a filler dressing
non-adherent gauze
- minimally absorbent
- mainly used on minor wounds or as 2ndary dressing
- woven or non-woven: may be impregnated with saline, petrolatum or antimicrobials ex: adaptic w vaseline gauze
transparent dressings
- no drainage/exudate
- indications: superficial wound
- pros: wound inspections
- disadvantages: not for draining wounds, not absorptive
hydrocolloids
light to moderate drainage
- indication: partial and full thickness wound. Ex: pressure injury 2 and 3; 1st and 2nd degree burn
- pros: promote autolytic debridement
- cons: not recommended for heavy (++) drainage wounds
hydrogels
light drainage and black tissue
- indication: partial and full thickness wounds; pressure injury 2 to 4; 1st and 2nd degree burn, necrotic wounds
- pros: promote autolytic debridement
- disadvantages: some requires secondary dressing to secure, may macerate periwound, not recommended for heavy draining
aliginates
- heavy drainage/exudate: highly absorbent dressing made from seaweed material
- pros: can be used w tunneling and undermining
- cons: requires a 2nd dressing
replaces gauze packing in a very wet wound
foam dressing
heavy drainage/exudate
- highly absorbent
- indications: partial and full thickness wounds, PI stage 2 to 4
- pros: comfortable, easy to apply and remove
- cons: not recommended for non-drainage wounds, not easily able to pack into wounds, may macerate peri-wound area if not changed appropriately
antimicrobials
broad spectrum against bacteria
-‘ve pressure wound therapy or vacuum assisted wound closure (VAC)
moderate to heavy drainage/exudate
- indication: partial to full thickness wounds, dehisced wounds, surgical wounds, acute traumatic wounds
- pros: decrease edema and bacterial colonization. increase blood supply and granulation
- cons: need training to apply; can be long/difficult to apply correctly
Betadine and hydrogen peroxide
- must be used as antiseptic only
- indicated for intact skin only
- not best practice: do not apply on open skin
surgical drains
- penrose drains
- jackson-pratt drain
- hemovac drain
