Wound Care: Definitions, Phases, and Healing

Wound Care: Definitions and Terminology

• A wound is damaged skin or soft tissue from trauma, classified as open or closed.
• Open wounds involve a break in the skin or mucous membrane, caused by cuts, lacerations, or punctures.
• Closed wounds do not have a skin break and often result from blunt trauma causing contusions or bruises.
• Phagocytosis is the process by which cells engulf and digest cellular debris and pathogens.
• Granulation tissue is new connective tissue and microscopic blood vessels that form on wound surfaces.

Phases of Wound Repair

• The inflammation phase lasts 2-5 days, with redness, warmth, swelling, pain, and decreased function.
• The proliferation phase includes granulation tissue formation, re-epithelialization, and wound contraction, typically from days 3 to 21 post-injury.
• The remodeling phase can last months to years, involving collagen remodeling and scar formation.

Types of Wounds and Healing Intentions

• First-intention healing occurs in clean, surgical wounds with approximated edges, leading to minimal scarring.
• Second-intention healing involves open wounds healing by granulation, contraction, and epithelialization, causing more scarring.
• Third-intention healing involves delayed closure of a wound, left open for a period before surgical closure.

Wound Healing Complications and Interventions: Common Wound Complications

• Infection can cause increased redness, warmth, swelling, and purulent drainage, potentially leading to sepsis if untreated.
• Dehiscence is the partial or total separation of wound layers, often due to infection or excessive tension.
• Evisceration involves the protrusion of internal organs through an open wound, requiring immediate medical intervention.

Nursing Interventions for Wound Care

• Debridement involves removing nonliving tissue from a wound to promote healing, surgically or with methods like maggot therapy.
• Dressing changes should occur regularly to maintain a moist environment, prevent infection, and absorb exudate.
• Binders and bandages secure dressings and provide support to the wound area, reducing movement and tension.

Gerontologic Considerations in Wound Healing: Age-Related Changes Affecting Healing

• Delayed healing can occur in older adults, possibly taking twice as long due to diminished collagen and blood supply.
• Older adults have increased susceptibility to infection due to conditions like diabetes and reduced immune response.
• Declining skin integrity increases the risk of pressure ulcers and shearing injuries due to thinning skin and decreased subcutaneous tissue.

Preventive Measures for Older Adults

• Positioning frequent repositioning (every 60-90 minutes) reduces pressure ulcers, especially in vulnerable areas.
• Nutritional support requires collaboration with dietitians to ensure adequate nutrition for wound healing.
• Skin care should involve aggressive routines with protective devices and monitoring for signs of skin breakdown.

The Inflammatory Response and Wound Repair: The Inflammatory Process

• The physiological response includes inflammation as the body's immediate reaction to injury, with increased blood flow and immune cell activity.
• Signs of inflammation include redness, warmth, swelling, pain, and loss of function.
• The cellular response involves leukocytes migrating to the injury site to clear debris and pathogens.

Inflammatory Response and Phagocytosis: Characteristic Signs of Inflammation

• Local response to injury include swelling, redness, warmth, pain, and decreased function.
• These signs indicate the body's initial defense against injury or infection.
• Swelling results from increased blood flow and fluid accumulation in the affected area.
• Redness and warmth result from vasodilation and increased blood flow to the site.
• Pain is mediated by chemical signals that sensitize nerve endings.
• Decreased function is a protective mechanism to prevent further injury.

Role of White Blood Cells in Inflammation

• Polymorphonuclear leukocytes and macrophages are crucial in the inflammatory response.
• These cells migrate to the injury site to engulf pathogens and debris through phagocytosis.
• Leukocytosis indicates increased white blood cell production, shown in a white blood cell count.
• Neutrophils are the first responders.
• Monocytes arrive later and differentiate into macrophages.
• Phagocytosis involves engulfing pathogens, which are digested by lysosomal enzymes for wound cleansing.

Proliferative Phase of Wound Healing: Granulation Tissue Formation

• Granulation tissue appears 2 days to 3 weeks post-injury.
• It is characterized by new blood vessels, fibroblasts, and epithelial cells appearing bright pink to red due to capillaries.
• It is fragile and easily disrupted, needing careful handling.
• Fibroblasts produce collagen, which strengthens the wound; growth occurs from the wound margins toward the center.
• Color changes as blood vessels regress.

Mechanisms of Healing

• Healing occurs through resolution, regeneration, or scar formation.
• Resolution involves damaged cells recovering to restore normal function.
• Regeneration duplicates cells to replace lost tissue.
• Scar formation occurs when fibrous tissue replaces damaged cells, leading to nonfunctional patches.
• The remodeling phase follows, lasting from 6 months to 2 years, impacting the extent of scar tissue formation.

Types of Wound Healing: First-Intention Healing

• First-intention healing occurs when wound edges are closely approximated, minimizing scar formation typical for surgical wounds.
• The process is rapid, requiring less granulation tissue with efficient healing and a lower infection risk.

Second-Intention Healing

• Second-intention healing occurs when wound edges are not in direct contact, needing more time and granulation tissue.
• The process is more complex and can result in a noticeable scar.
• It is prolonged if the wound contains fluid or debris, needing careful wound care.
• The granulation tissue must bridge the larger gap, taking longer than first-intention healing.

Third-Intention Healing

• Third-intention healing leaves wound edges widely separated, brought together later with closure materials.
• It is used for deep wounds with significant drainage and debris.
• The resulting scar is broad and deep; requires drainage devices.
• It is often seen in surgical wounds that become infected or complicated.

Complications in Wound Healing: Factors Affecting Healing

• Adequate blood flow is crucial for effective wound healing.
• Compromised circulation, infection, and fluid accumulation hinder the healing process.
• Nutritional status significantly impacts healing.
• Excessive tension on wound edges can disrupt healing and cause delays.
• The nurse’s assessment includes assessing infection and unusual swelling.

Assessment of Wound Healing

• Assessment checking for undermining, slough, and necrotic tissue.
• Undermining= tissue erosion beneath intact skin
• Slough = moist, stringy dead tissue needing removal for healing.
• Necrotic = dry, devitalized tissue; requiring debridement for recovery.
• Proper assessment determines appropriate care and intervention strategies.

Understanding Wound Evisceration: Causes of Wound Evisceration

• Insufficient intake of protein and vitamin C weakens tissue integrity.
• Premature removal of suture or staples causes inadequate closure of the wound.
• Unusual strain on the wound disrupts healing ie coughing, sneezing, or vomiting.
• Weak muscular support to incision causes evisceration.
• Abdominal distention from gas leads to evisceration.
• Previous surgeries may compromise tissue integrity.

Signs and Symptoms of Evisceration

• The client may report "something given way" indicating potential evisceration.
• Signs include pinkish drainage and impaired blood flow.
• Immediate action involves sterile dressing, normal saline, minimizing strain and positioning.
• Physician notification is essential for further intervention.

Nursing Interventions for Evisceration

• Position client to reduce strain on the wound; apply sterile dressings moistened with normal saline to exposed organs.
• Monitor infection or impaired blood flow.
• Document findings and interventions to ensure continuity of care.
• Educate the client on signs of complications needed post discharge.
• Collaborate with healthcare team to develop plan of care.

Wound Management Techniques: Goals of Wound Management

• The goal is to reapproximate tissues.
• Techniques include changing dressings, caring for drains and wound irrigations.
• Proper wound care prevents infection and delays healing.
• Client education is essential
• Regular assessment is critical to make changes to plan.

Types of Dressings and Their Purposes

• The common dressing types include gauze, transparent and hydrocolloid.
• Dressings helps to keep wounds clean, bleed control, absorb drainage, and protect injury.
• Gauze- highly absorptive can obscure wound complicates assessment.
• Transparent allows easy access as it does not require removal but not absorbent.
• Hydrocolloid and hydrogel maintains faster and moist environment to promote healing.
• Alginate used to absorb wound exudates

Dressing Change Protocols

• Dressings require changing when it becomes loose or saturated with wound damage.
• Nurse reinforces is to prevent wicking of micro organism.
• MD perform initial dressing change if complex wound.
• Proper technique is crucial to avoid disrupting the introduction of infection.
• Documentation and client education is critical.

Drain Management in Wound Care: Types of Drains

• Open drains allow passive drainage by gravity and capillary action.
• Closed drains create vacuum to effectively remove risk of infection.
• EX of closed drain includes Hemovac and Jackson- Pratt drains.
• Monitor drain for patency and specific protocol type.

Care and Maintenance of Drains

• Clean in circular motion to lower risk.
• Use precut sponge to observe drainage and change.
• Educate about drain care at all times to prevent accidental dislodgement.

Advanced Wound Healing Techniques: Vacuum-Assisted Closure (VAC) Therapy

• VAC uses for wounds with wide separated edges that are can not be approximated with stitches.
• Nurse is trained on how to apply the device and care for it and should be educated on the process.
• Regular assessment of wound is necessity.

Wound Care Techniques: Cleaning and Dressing Wounds

• Nurses clean the insertion site in a circular motion
• Apply precut or drain sponges around the site for absorption.
• Gauze used to manage area and keep clear.

Negative Pressure Wound Therapy (NPWT)

• Also refer VAC, for open wounds of staples or sutures.
• Promotes rapid wound healing by helping to draw fluid debris.
• Foam filter involves the wounds blood flow growth.

Types of Wound Closures

• Staples and sutures need to be cared for properly per the wound type.
• Liquid adhesives for low wounds.
• Suture an staples removed between few days and two week

Bandages and Binders: Purpose and Application of Bandages

• Bandages protect injuries.
• Binders add support or protection.
• Proper application requires wrapping using metal to adhere.

Roller Bandage Techniques

• Roller bandages required to anchored for movement.
• Nurse to assess circulation to prevent bandaging to tight

Wound Debridement Methods: Mechanical Debridement Techniques

• Sharp instruments involves surgical removal
• Irrigation is flushing of other area and ear.
• Wet to dry no longer common due to damaging new skin .

Nursing Guidelines for Eye Irrigation

• Client head tilled to promote drain and easy cleaning .
• Supply needs to be ready and available such as bulb syringe.
• Warm the temp and proper procedure crucial.

Wound Debridement Techniques : Overview of Wound Debridement

• Wound debridement = removal of dead tissue to promote healing and blood to the site
• Modern emphasize the importance of healthy damage tissue.

Advantages and Disadvantages of Debridement Methods

• Autolytic uses the body fluid to do the work but take some to do so.
• Mechanical can cause damage it tissue.
• Enzymatic id fast acting.

Wound and Eye Irrigation Techniques : Wound Irrigation

• Required proper tech sterile solution
• Proper wound tech and sterile solution
• Needed solution.

Eye Irrigation

• Eye irrigation used to flush substance
• Nurse to ensure effective patient and proper instruction .
• Proper documentation include eye detail and response.

Ear and Vaginal Irrigation Techniques: Ear Irrigation

• Ear should not be done perforation.
• Procedure requires direction and auditory canal to avoid buildup.

Vaginal Irrigation

• Use to cleanse but avoid due to infection
• Patient educated and time .
• Wound temperature during procedure can help and is vital.

Heat and Cold Applications in Wound Care: Therapeutic Uses of Heat and Cold

• Heat improve Circulation
• Cold reduces swelling and alleviate help.
• Technique requires different indications and precaution and temperature can effect the result.

Client and Family Teaching for Heat and Cold Applications

• Teaching include to use ice packs and cover to prevent skin damage.
• Chemical packs are one single used only for safety.
• Cover with appropriate temperature

Application of Compresses and Aquathermia Pads : Compress Application Techniques

• Requires soak and proper procedure to improve healing
• Wringed out for comfort for client.

Aquathermia Pad Usage

• K-pad is electrical device that can circulate water with hollow channels.
• Help with wound management.
• Assess skin to remove injury.

Soaks, Moist Packs, and Therapeutic Baths: Soaks and Moist Packs

• Requires solution to warmth usually 15 to 20 min with appropriate temp control.
• Need to monitor assess client
• Therapeutic done to reduce fever

Understand Pressure Ulcers

• Pressure Ulcer cause and factor are usually from pressure.
• Common due to other immobilization can cause issue
• Primary Goal is Prevention with skin care treatment

States pf Pressure Ulcer

• Stage base don the extent of injury
• Stage 1- Intact skin not blanchable
• Stage 2 Redness with Blistering
• Stage 3- Skin Crator extension
• Stage IV Deep Ulcerate with most exposure and risk systemic Infection

Definition and Causes of Pressure Ulcers

• Pressure results in localized injury
• Cause by restricting blood and necrotic area

Risk Factors for Developing Pressure Ulcers

• Age with 70 year are susceptible to infection.
• Obesity and Chronic are a risk.
• Mobility and inactivity and malnutrition are a risk.

Prevention of Pressure Ulcers: Nursing Guidelines for Prevention

• Change rotation for patients.
• Change and shift location that can minimize friction damage
• Pillow placement in skin

Prevention Strategies for Pressure Ulcers: Positioning and Mobility

• Positioning with pillow and devices to prevent skin damage
• Laterally rotation

Skin Care and Hygiene

• Maintaining skin , moisturizer routine help bacteria.
• Clean for reduction leads to skin Breakdown

Nutritional Considerations for Wound Healing: Essential Nutrients for Healing

• Increase nutrients such Protein, VIT A, C and E
• Supplements can reduce occurrence of pressure Ulcers by 25%
• Vit and and Copper are vital for wounds

Recommended Dietary Intake

• Diet intake is 1.25 to 1.5 g/ kg per day
• Intake assist Hydration

Nursing Implications and Care Plans

• Skin inspection help to prevent skin damage.
• Wrenching dressing in prevention to infection

Understanding Wound Types and Healing Processes: Types of Wounds

• Open-Mucous no longer in tank exposes underlying to EX lacerations.
• Close is Skin remaining in tract can be damaging to the skin.
• Pressure Ulcer with prolong pressure.

.Phases of Wound Healing.

• Remodeling where wound becomes strength
• Wound require wound type infection and pressure effect healing.

Factors Affecting Wound Healing

• Circulating can improve healing
• Assess presence

Pressure Ulcer Staging and Management: Staging of Pressure Ulcers

• State one Skin in touch.
• Stage 2 partial thickness
• state 3 thickness layer
• Stage IV Thickness damage with neurotic
• Risk factor tool to assess.

Positioning.

• Prevention reduce pressure in the system
• Wound treatment should be base on.

Wound Care Techniques and Best Practices: Dressing Changes and Wound Management

• Hydrogel dressing
• Negative Pressure
• Debritdement can be done with various forms.
• Assesment ensure document heal factor with education and risk.

1: Changing a Gauze Dressing: Overview of Dressing Change

• Pain meds prior with correct and necessary to assess clean to do.
• Standard to follow

Step-by-Step Procedure

• Proper location setup for assessment and correct
• Assess sterile saline to assist removal.

Rationale for Actions

• Technique with correct and necessary to prevent
• Collab ensure client feel comfort

Documentation and Evaluation

• Ensure to detail date for procedure

Skill 28-2: Irrigating a Wound: Assessment and Planning

• Verify medical order for understanding
• Ensure to gathered equip

Implementation Steps

• Assess antiseptic for gloves
• Help solution decrease infec

Rationale for Actions

• Assess and perform clean.
• Proper position and infection
• Assist clean environment to prevent solution.

Skill 28-3: Providing a Sitz Bath : Assessment and Preparation

• Confirm order pain level.
• bath , towel , help comfort
• Implement steps

Rationale for Actions

• Assist pain and help assist in correct wound
• Temperature for ensure saf

Evaluation and Documentation

• Client pain and level assessment
• Procedure follow up and documet