Post on 18-Dec-2015
transcript
First Intention Healing
•Wounds with minimal tissue loss
•edges approximated•most surgical wounds•dec. infection/scar risk
Second Intention Healing
•Occurs with tissue loss•edges not approximate•left open to heal•opening fills with granulation tissue
Second Intention (cont.)
•Later, epithelial cells grow over granulation tissue
•inc. risk for scarring and infection
Third Intention Healing
•Wound intentionally kept open for time
•Closed surgically later•Scarring common
Wound Healing Process
•Increased wbc’s during inflammation
Neutrophils (wbc type) - engulf bacteria - release enzyme
Wound Healing (cont.)
Monocytes (wbc type)- engulf bacteria, debris- live longer Fibroblast (cell type)- produce collagen
Wound problems
Dehiscence:•wound edges separateEvisceration:•separation of wound with contents expelled
Factors affecting healing:
•Extent of injury•Blood supply to area•Type of injured area - epithelial tissue heal fastest
Nursing assessment
•Anatomic location•Duration of wound•Size of wound in cm. - width, length, depth•Color of wound bed
Nursing Assessment (cont.)
•Presence of tunneling•Presence of exudate•Warm, cold, hard?•C/O pain?•Any foreign bodies?
Nursing Assessment (cont.)
•May draw diagram in notes if irregular
•Other objective assessments
- body temp, Bl. tests
Care of closed wounds
•Follow hospital policy and MD orders
•Change dsg and do not disturb suture line
Care of open wounds
•Check MD order•Must be kept moist•Cleanse at each dsg change with ordered solution or sterile NSS
Wet-to-Dry Dsg.
•Debride wound•Cleanse inside > out•Surgical asepsis•Volume of force impt.•Damp - don’t saturate
Packing the wound
•Must be used for deep wound
•Dead space is deadly•NSS on gauze OK•Tissue up gauze
Stages of pressure sores
Stage 1 - inflamm and erythema - no blanching - lasts for 30 min after pressure relieved
More to remember!
•NSS appropriate•Irrigation is best for open wound cleansing
•Obliterate dead space•Draining wound care