Wounds and Wound

Care

Reference:
Perry & Potter

Mary J. Aigner RN, MSN, FNPC

I. Different Types of Wound –
by Cause
 Ulcers: considered chronic wounds …
hard to heal

 Diabetic
 Venous
 Arterial
 Pressure

Prevention is easier than healing!

Traumatic or Unintentional
“acute” wounds
 Minor Wounds (1526-
27) - Handout
 Skin Tears
 Abrasions
 Bruises
 Cuts

 Major Traumatic
Wounds
 Hemorrhage 1493
Surgical or Intentional
II. Classification Systems
& Terminology
 Staging System (1488)
 1, 2, 3, 4, or unable to stage

 Classification by Color (1491)

 Red, yellow, black, mixed colors

 Skin Integrity
 Is it Open or Closed?

 Severity
 Penetrating?

 Perforated?
Staging System:
What stages are these?
Color System:
What colors are these?
More on Wound Terminology

 Cleanliness (1490)

 Descriptives

 Laceration
 Abrasion
 Contusion

 Drainage Types (1494)

Cleanliness of Wound (1490)
 Clean
 Contains no pathogenic organisms
 Clean – Contaminated
 Wound made under aseptic conditions but in body cavity that
normally harbors microorganisms
 Contaminated
 Presence of microorganisms likely
 Infected
 Bacterial organisms usually > 100,000/gm tissue
 Colonized
 Contains microorganisms – usually multiple (types)
 Drainage (1494)
 Serous
 Clear, watery plasma

 Purulent
 Thick
 Yellow, green, tan, or brown

 Sanguinous
 Bright red (active bleeding)

 Serosanguinous
 Pale, red, watery
 Mixture of serous and
sanguinous
III. Healing

 Barriers to healing
(1498-1499)

 Nutrition
(1496-1497, 1499)

 Physiology of Healing
(1492-1493, 1640)
Barriers to Healing (1498-1499)
 Age
 Malnutrition
 Obesity
 Impaired Oxygenation
 Smoking
 Drugs
 Diabetes
 Radiation
 Wound Stress
 * Poor Care
 Smoking & Healing
 Decreases functional Hgb in
blood
 Hbg needed to bring O2 to
cells

 Thought to increase platelet

aggregation,
hypercoagulability (clotting)

 Interferes with release of O2

to tissues

 *also vasoconstriction
Drugs & Healing
 Steroids

 Antiinflammatory

 Prolonged ATB use

 Risk of superinfection

 Chemotherapeutic
 Immunosuppressants

 Others
IV. Who’s at Risk?
 Risk Factors for Pressure
Ulcers
(1496-1497)

 Prevention Techniques

 Braden Scale measures

risk
 (1-4: 1 highest risk, 4
no/minimal risk)
 Sensory perception
 Moisture
 Activity
 Mobility
More at risk
How to Prevent?
Be Knowlegeable
 Eliminating Pressure
 Turning
 Positioning
 Elevating
 Pads (eg. Heel
protectors)
 Special
mattresses/beds
 Low air-flow
 Keep clean/dry
 Pay attention to details
 Eg. Tubing, folds
 V. Wound Care and Treatments
 Nursing Care Plan (1512-1513)
 Management of wounds (1518-1521,
1526)
 Critical Thinking (1500-1501)

 Assessment (1503-1509)
 Bates-Jensen Wound Assessment Form
(1522-1525)

 Postop Assessment (1633)

 Suture Care (1543-1547)
 Dressings Changes
 Drains (1508, 1547)

 Cleansing of Wounds (1527, 1542)

Wound Care/Rx continued …
 Irrigation (1544-1546)

 Wound Packing (1536)

 Dressings/Bandages/Bi
nders (1527-1536,
1547-1553)

 Specimen Collection
(800, 1508-1509)
More Care/Rx ….
 Other Treatments
 Wound Vac Systems
 Heat/Cold Rx (1549, (1538-1541)
1554-1560)

 Debridement
 Chemical
 Sharp
 Other
 Maggots/Leeches

 Wet to Dry Dressings

Surgical Wound Treatment
VI. Complications (1493-1494)

 Evisceration (1637)
 Dehiscence (1637)
 Impairment (1498-1499)
 Infection (1400, 1620)
 Nosocomial (780)
 Postop Infections (1637)
 Wound Stress (1499)
 Scarring, Keloid Formation,
Adhesions
Dehiscence & Evisceration
 Dehiscence
 Separation of wound edges at suture line
 Usually occurs 6-8 days after surgery
 S&S: > drainage, can see underlying tissues
 *Can occur in nonsurgical clients

 Evisceration
 Protrusion of internal organs/tissues through incision
 Usually occurs 6-8 days after surgery
 can occur in nonsurgical clients
Infections
(780, 1499, 1620, 1637)
 How to tell? (assessment)

 What to do about it?

(planning/intervention)

 Is it improving or worsening?
(evaluation)

 Now what to do? (revise

plan/intervention)