Wound assessment and healing Flashcards
Acute inflammatory phase
Healing occurs in 2 to 3 weeks, usually leaving no residual damage
Neutrophils are predominant cell type at site of inflammation
Sub-acute inflammatory phase
Has same features as acute inflammation but persists longer
Chronic inflammatory phase
May last for years
Injurious agent persists or repeats injury to site
Predominant cell types involved are lymphocytes and macrophages
May result from changes in immune system (e.g., autoimmune disease)
Inflammatory Response
Final phase of inflammatory response is HEALING
Healing has 2 major components
Regeneration
Repair
Wound Healing: Regeneration
Replacement of lost cells and tissues with cells of same type
Stable cells regenerate in response to injury
Liver, bone, kidney & pancreas
Constantly dividing cells that rapidly regenerate
Skin, bone marrow, lymphoid organs, mucous membrane cells of urinary, reproductive, and GI tracts
Permanent cells do not divide
Neurons replaced by glial cells or stem cells
Skeletal & cardiac muscle are repaired with scar tissue
Wound Healing: Regeneration
Replacement of lost cells and tissues with cells of same type
Stable cells regenerate in response to injury
Liver, bone, kidney & pancreas
Constantly dividing cells that rapidly regenerate
Skin, bone marrow, lymphoid organs, mucous membrane cells of urinary, reproductive, and GI tracts
Permanent cells do not divide
Neurons replaced by glial cells or stem cells
Skeletal & cardiac muscle are repaired with scar tissue
Wound Healing: Repair
Repair
Healing as a result of lost cells being replaced with connective tissue
More common than regeneration
More complex than regeneration
Occurs by primary, secondary, or tertiary intention
Primary Intention
Initial phase
Lasts 3 to 5 days
Edges of incision are aligned
Blood fills the incision area, which forms matrix for WBC formation
Acute inflammatory reaction occurs
May initially be covered with dry dressing
Granulation phase
Lasts 5 days to 3 weeks
Fibroblasts migrate to site
Wound pink and vascular
Surface epithelium begins to regenerate
Maturation phase & scar contraction
Begins 7-days after injury & continues for several months/years
Fibroblasts disappear as wound becomes stronger
Mature scar forms
Secondary Intention
Wounds occurring from trauma, ulceration & infection
Large amounts of exudate
Wide, irregular margins
Extensive tissue loss
Edges cannot be approximated
Results in more debris, cells, exudate
Wound care depends on etiology & type of tissue in wound
Tertiary Intention
Delayed primary intention due to delayed suturing of the wound
Example: A contaminated wound left open & sutured closed after infection is controlled
Tertiary Intention
Delayed primary intention due to delayed suturing of the wound
Example: A contaminated wound left open & sutured closed after infection is controlled
Risks Factors for Delayed Healing
Nutritional deficiencies
Inadequate blood supply
Corticosteroid drugs
Infection
Smoking
Mechanical friction on wound
Advanced age
Obesity
Diabetes mellitus
Poor general health
Anemia
Complications:
Adhesions
Contractures
Dehiscence
Evisceration
Excess granulation tissue
Fistula formation
Infection
Hemorrhage
Hypertrophic scars
Keloid formation
Pressure Ulcers
Graded or “Staged” according to deepest level of tissue damage:
Stage I (minor) to Stage IV (severe)
Un-stageable
Slough and/or eschar must be removed for accurate staging
EXCEPTION:
Stable (dry, adherent, intact) eschar on the heels serves as “the body’s natural (biologic) cover” & should not be removed
Stage I pressure ulcers
Intact skin
Areas of non-blanchable redness (in lighter skin individuals)
In dark-skinned patients after applying light pressure, look for an area that’s darker than the surrounding skin or that’s taut, shiny, or indurated (hardened)
If you suspect a skin area is becoming damaged, use the light from a camera flash system to enhance your visualization of dark skin; with the patient’s permission, take a series of digital images each day to document changes in wound color, size, and depth. Check for localized changes in skin texture and temperature.
Stage I – Dark Skin
Early signs of skin damage include induration, bogginess (less-than-normal stiffness), and increased warmth at the injury site compared to nearby areas. Over time, as tissues become more damaged, the area becomes cooler to the touch.
Possible indicators
Skin temperature
Tissue consistency
Pain
May appear red, blue, or purple in patients with darker skin tones
Stage II
Partial-thickness loss of dermis
Shallow open ulcer with red pink wound bed
Presents as an intact or ruptured serum-filled blister
May also present as a blood-filled blister
Stage III
Full-thickness skin loss
Damage or necrosis of subcutaneous tissue
May extend to, but not through underlying fascia
Presents as a deep crater with possible undermining
Depth varies by anatomic location
Stage IV
Full-thickness loss extending to muscle, bone, or supporting structures
Bone, tendon, or muscle may be visible or palpable
Undermining & tunneling may occur
Slough or eschar may be present on some parts of the wound bed.
Stage IV
Full-thickness loss extending to muscle, bone, or supporting structures
Bone, tendon, or muscle may be visible or palpable
Undermining & tunneling may occur
Slough or eschar may be present on some parts of the wound bed.
Wound Assessment
Admission skin assessment
On admission from PACU
At regular intervals
Identify factors that may delay healing
Nursing Diagnosis
Impaired skin integrity
Impaired tissue integrity
Risk for infection
Wound Assessment
Admission skin assessment
On admission from PACU
At regular intervals
Identify factors that may delay healing
Nursing Diagnosis
Impaired skin integrity
Impaired tissue integrity
Risk for infection
Wound Classification
Cause
Surgical or nonsurgical
Acute or chronic
Depth of tissue affected
Superficial, partial thickness, full thickness
Color
Red
Yellow
Black
May have two or more colors
Wound Measurement
Made in centimeters
Head to toe
Side to side
Depth (if any)
Tunneling?
Undermining?
Tunneling
Movement when cotton-tipped applicator is placed in wound
Undermining
Presence of “lip” when cotton-tipped applicator is placed in wound
Charted in respect to a clock with 12 o’clock being toward the patient’s head
Wound Documentation
Location
Type
Stage if pressure ulcer
Measurements (Height, width, depth)
Undermining?
Tunneling?
% granulation tissue, slough, eschar?
Drainage (amount, color, quality, odor?)
Dressing / treatment
Patient tolerance, pain?
Method of Wound Care Depends On:
Causative agent
Degree of injury
Patient’s condition
Purposes of wound management
Cleansing
Treating infection
Protecting clean wound from trauma
Sutures / fibrin sealant help closure
Drains may be inserted
Topical antimicrobials / antibacterials should be used with caution
Nursing Implementation
Red Wounds
Protection
Gentle cleaning PRN
Yellow wounds
Absorb exudate
Cleanse wound surface
Hydrocolloid dressings
Black Wounds
Debridement of nonviable tissue (“Eschar”)
Types of Debridement
Surgical
Mechanical
Wet-to-dry (moist) dressings
Irrigation
Whirlpool
Autolytic
Semi-occlusive
Occlusive
Transparent films
Hydrocolloids (Duoderm)
Enzymatic
Topical application of enzyme ointments / creams
Covered with moist dressing
Collagenase (Santyl)
Papain / Urea (Panafil)
Types of Debridement
Surgical
Mechanical
Wet-to-dry (moist) dressings
Irrigation
Whirlpool
Autolytic
Semi-occlusive
Occlusive
Transparent films
Hydrocolloids (Duoderm)
Enzymatic
Topical application of enzyme ointments / creams
Covered with moist dressing
Collagenase (Santyl)
Papain / Urea (Panafil)
Negative Pressure Wound Therapy
Vacuum-assisted closure
“Wound VAC” (K.C.I.)
Suction removes drainage and speeds healing
Monitor:
Serum protein
Fluid & electrolytes
Coagulation studies
Negative Pressure Wound Therapy
Vacuum-assisted closure
“Wound VAC” (K.C.I.)
Suction removes drainage and speeds healing
Monitor:
Serum protein
Fluid & electrolytes
Coagulation studies
Hyperbaric Oxygen Therapy
Delivery of 100% oxygen
1.5 to 3 times normal atmospheric pressure
10 to 60 treatments (90 to 120 minutes)
Allows O2 to diffuse into serum
Stimulates angiogenesis
Kills anaerobic bacteria
Increases killing power of WBCs & certain antibiotics
Accelerates formation of granulation tissue
Nutritional Therapy
High protein
High carb
High vitamin
Moderate fat
Psychological Implications
Fear of scar / disfigurement
Concern about drainage or odor
Infection Prevention/Control
Don’t touch recently injured areas
Keep environment free of possibly contaminated items
Prophylactic antibiotics?
Wound cultures - Concurrent swab specimens obtained from wound exudate
Z-technique
Rotate swab as wound is swabbed margin to margin in a 10-point zigzag
Levine’s technique
Rotate swab over a 1cm² area with sufficient pressure to express fluid
