Understanding Wound Care and Repair

• Wound care involves the management and treatment of damaged skin or soft tissue resulting from trauma.

Types of Wounds

• Open wounds occur when the skin or mucous membrane is no longer intact.
• Closed wounds are those with no opening in the skin or mucous membrane.

Wound Repair

• Inflammation is a physiologic defense that occurs immediately after tissue injury and lasts 2 to 5 days
• The purpose of inflammation is to limit local damage, remove injured cells and debris, and prepare the wound for healing.
• Signs and symptoms of inflammation include swelling, redness, warmth, pain, and decreased function.
• Neutrophils and monocytes are primarily responsible for phagocytosis
  • Phagocytosis is a process in which cells emigrate from blood vessels to consume pathogens, coagulated blood, and cellular debris.
• Proliferation is the period during which new cells fill and seal a wound, occurring 2 days to 3 weeks after the inflammatory phase.
• The integrity of skin and damaged tissue is restored by resolution, regeneration, and scar formation.
• Remodeling involves changes and maturation to the wound
  • Remodeling lasts 6 months to 2 years
  • During remodeling, the wound contracts and the scar shrinks.

Wound Healing

• First-intention healing occurs when wound edges are directly next to each other.
• Second-intention healing occurs when wound edges are widely separated.
  • Second intention healing is more time-consuming and complex.
• Third-intention healing occurs when deep wound edges are brought together with some type of closure material.
  • Third-intention healing results in a broad, deep scar.

Factors affecting Wound Healing

• Type of wound injury
• Expanse or depth of wound
• Quality of circulation
• Amount of wound debris
• Presence of infection
• Status of the client’s health

Wound Healing Complications

• Adequate blood flow to the injured tissue is key.
• Nursing assessments should look for undermining, slough, and/or necrotic tissue.
• Dehiscence is a complication of wound healing.
• Evisceration is a complication of wound healing.

Wound Management

• Dressings keep wounds clean, absorb drainage, control bleeding, protect from further injury, hold medication, and maintain a moist environment
• Gauze dressings are ideal for covering fresh wounds that are likely to bleed or wounds that exude drainage.
• Transparent dressings are used to cover peripheral and central IV insertion sites.
• Hydrocolloid, hydrogel, alginate, and collagen dressings keep wounds moist, which helps them heal more quickly.
• Dressing changes are done when a wound requires assessment or care or when the dressing becomes loose or saturated with drainage.
• Open and closed drains may be needed.
• Vacuum-assisted closure (negative pressure wound therapy) may be necessary.
• Sutures, staples, and adhesives can aid in wound closure.
• Steri-Strips can be used to close superficial lacerations instead of sutures or staples.
• Bandages and binders hold dressings in place, especially if tape cannot be used or the dressing is extremely large.
• Bandages and binders support the area around the wound or injury to reduce pain.
• Bandages and binders limit movement in the wound area to promote healing
• Breast, single T-binder and double T-binder bandages are available.
• Debridement involves the removal of dead tissue
  • Sharp debridement utilizes sterile scissors and forceps.
  • Enzymatic debridement utilizes chemical substances.
  • Autolytic debridement uses the natural physiologic process.
  • Mechanical debridement is the physical removal of debris from a wound.
  • Wounds, eyes, ears, and the Vagina are commonly irrigated structures.
• Enzymatic debridement breaks down and liquefies wound debris, involving use of topically applied chemical substances.
• Autolytic debridement allows the body’s enzymes to soften, liquefy, and release devitalized tissue.
• Sharp debridement involves the removal of necrotic tissue with sterile scissors, forceps, or other instruments.
• Mechanical debridement involves physical removal of debris.
• Cold applications reduce fevers, prevent swelling, control bleeding, relieve pain and numb sensation
• Heat applications provide warmth, promote circulation, speed healing, relieve muscle spasms, and reduce pain.
• Heat and cold applications include ice bags, ice collars, chemical packs, compresses, aquathermia pads, soaks, moist packs and therapeutic baths.

Pressure Ulcers

• Pressure ulcers, also known as decubitus ulcers, appear over bony prominences of the sacrum, hips, heels, and places where pressure is unrelieved.
• Risk factors for pressure ulcers include inactivity, immobility, malnutrition, emaciation, diaphoresis, incontinence, sedation, vascular disease, localized edema, and dehydration.

Stages of Pressure Ulcers

• Stage I presents as intact but reddened skin.
• Stage II presents as reddened skin accompanied by blistering or a skin tear.
• Stage III presents as a shallow skin crater that extends to the subcutaneous tissue.
• Stage IV presents as deeply ulcerated tissue extending to muscle and bone and is life-threatening.

Prevention of Pressure Ulcers

• Change client’s position frequently.
• Lift during repositioning instead of dragging.
• Avoid using plastic-covered pillows.
• Use positioning devices.
• Use the lateral oblique position for side-lying.
• Massage bony prominences to promote circulation.
• Keep the skin clean and dry.
• Use a moisturizing skin cleanser rather than soap, if possible.
• Use pressure-relieving devices.
• Pad vulnerable body areas.
• Keep head of the bed elevated less than 30 degrees.
• Provide a balanced diet and adequate fluid intake for cellular health.