Wound Care Flashcards
Types of Healing
- Primary intention healing
- Secondary intention healing
- Tertiary intention healing
Primary intention healing
- tissue surfaces approximated (brought together)
- minimal or no tissue loss
- minimal granulation tissue and scar
- surgical incision as an example
Secondary intention healing
- Edges cannot or should not be approximated (brought together)
- repair time longer, more scarring and risk for infection
Tertiary intention healing
“delated primary intention”
- left open for 3-5 days and then closed
- allows edema to resolve exudate to drain
- closed with sutures, staples, or adhesive skin closures
Phases of Wound Healing
- Hemostasis Phase
- Inflammatory Phase
- Proliferative Phase
- Maturation Phase (Remodeling)
Hemostasis Phase
- cessation of bleeding
- vasoconstriction and formation of clot
- scab inhibits infection
- epithelial cells migrate into wound to prevent entry of microorganisms
Inflammatory Phase
Blood supply increases
- erythema and edema
- exudate cleanses wound
- neutrophils first 24 hrs
- replaced by macrophages
- phagocytosis
- crucial healing
Proliferation Phase
Day 3-4 to 21 days
- Fibroblasts synthesize collagen that adds strength to wound
- Capillaries grow across wound, bring fibrin
- Granulation tissue forms
- Light red or pink
Maturation Phase
- Remodeling*
- From day 21 to 1-2 yrs
- fibroblasts continue to synthesize collagen
- wound site is remodeled and contracted
- scar becomes stronger
- too much collagen?
Complications
- Hemorrhage
- Infection
- Dehiscence
- Evisceration
Hemorrhage
- May bleed uncontrollably
- apply pressure
- surgery may be needed
- Hematoma under wound, may obstruct blood flow to area
Infection
- microbes compete for oxygen and nutrition (impairs wound healing)
- change in wound color, pain, drainage
- may occur druing injury, surgery, post-op
- confirmed by culture
- may have fever, increase WBCs
- immunosuppressed increase risk
Dehiscence
- Partial or total rupture of sutured wound
- cover with sterile saline gauze
- patient to bed with knees bent
- notify doctor
Evisceration
- protrusion of internal viscera through an incision
- usually occurs 4-5 days post-op
- cover with large sterile dressing
- patient in bed with knees bent
- notify surgeon immediately
Risk factors for evisceration
- obesity
- poor nutrition
- trauma
- failure to suture
- coughing
- vomiting
- straining
Prevention
- protein
- CHOs
- Lipids
- Vit A and C
- Iron
- Zinc
- Copper
Lifestyle Preventative measures
- regular exercise leads to better circulation
- smokers at risk for delayed healing
Medications not good for wound healing
- anti-inflammatory (need inflammatory response for wound healing)
- antineoplastic (cancer drugs, same thing)
- prolonged antibiotics (prone to infection from resistant bacteria)
Exudate
- serous (clear, light yellow)
- serosanguineous (light pink)
- sanguineous (bloody red)
- purulent (yellow green, puss)
Elderly patients Considerations
-at risk for imparied wound healing due to:
- impaired liver fx
- nutritional deficiencies
- chronic illness
- vascular changes
- delayed inflammatory response
- slowed collagen synthesis
Diagnostic Tests
wound culture and sensitivity
Surgery
- Emergency: life threatening/ repair tissue or vessels
- Non-emergency: ineffective healing/debridement for infected or necrotic tissue
- necrotic tissue removed
- wound flushed with saline
- abscess (incision and drain)
- Escharotomy to remove eschar
What is the difference between necrotic tissue and eschar?
?
Pharmacologic Therapy
- Antibiotics
- Topical gels or injectable meds with growth factors
- opioids and NSAIDs
Non-Pharm Therapy
- nutrition
- compression
- vacuum-assisted closure
- hyperbaric oxygen therapy
- stem cells
- maggots
- alternative
Nursing Care
- Assessment
- Maintain moist wound healing
- promote optimal nutrition and hydration
- prevent infection
- position to minimize pressure on the wound
EBP
- Hydrocolloid dressings best for dry wounds
- impermeable to oxygen, moisture, and bacteria
- Maintain moist environment
- Support autolytic debridement
- dry wound with no drainage - transparent film
- exudative wound - absorptive dressings
Drain purpose
allow excessive fluid, purulent drainage to drain; assists with granulation tissue formation
Drain labels
- type of drain
- date
- initials
nursing care of drains
maintain suction as needed, assess and document drainage
Wound V.A.C.
Vacuum Assisted Closure
- continuous or intermittent negative pressure
- removes fluid and exudate
- prepares the wound for healing and closure
Wound V.A.C. complications
- hemorrhage from suction with anticoagulant therapy
- wound infection from dressing pieces left in wound
Wound V.A.C. Care
- eval pts for risk of bleeding
- stop VAC if bright red blood seen - apply pressure and notify MD
- Perform proper dressing change
