Date post: | 24-Dec-2015 |
Category: |
Documents |
Upload: | justin-glenn |
View: | 220 times |
Download: | 0 times |
WOUND CAREBy Helen Harkreader, RN, PhD
Wound Healing Processes• Types of Wound Closures▫ Primary Intention
Sutures, staples, skin bonds, etc.
▫ Secondary Intention Partial thickness
Regenerate specific cells Epithelialize
Full thickness Regranulate Epithelialize Remodel
▫ Tertiary Intention
• Processes Involved in Wound healing▫ Acute phase
Hemostasis Inflammation Proliferation Remodeling
▫ Chronic phase Stalls for 2 weeks Change Tx Reassess full body,
meds, labs.
Wound Assessments• Etiology - watch those with ischemia• Size – consistent measure from nurse to nurse
▫ L x W x D in centimeters (head to toe, 9 to 3 o’clock)▫ Locations of tunnels & undermining by the clock
• Drainage – type (color, amount, consistency, odor)
• Wound bed % of red, yellow, black tissues▫ Granulation, Slough, Eschar or tan crust or blister▫ Wound edges – rolled (epiboly), macerated
• Peripheral tissues – discoloration, stains, scars?▫ Edema, induration, scaling (peeling), plaques?
• Contaminated or infected?
Wound Culturing•Cleanse the wound with saline
▫Irrigate till clear if it is a deep wound.•Use culturette that has 2 swabs•Wipe tissue in 1 cm2 area
▫Infection causing Bacteria is in the tissue ▫Do not get just a sample of the drainage▫Multiple bacteria from peripheral tissues
can be in the drainage•Submit to lab
Nutrition for Wound Healing•Assessment of Nutrition - labs
▫Serum Albumin 18 to 20 days half-life Affected by hydration (> if dehydrated, < if
overhydrated)▫Transferrin – 8 to 10 days half-life easily
affected by other factors.▫Prealbumin – 2 days half-life – best predictor
•Nutrients needed for Wound healing▫Calories –enough to support healing and other
present disease processes▫Protein▫Vitamins
Nutrients
•Protein – fibroplasia, neogenesis, collagen formation, remodeling
•Carbohydrates – energy and protein sparing
•Fat - cell walls•Vitamins – A, B, C, D, E, K•Copper, Iron, Magnesium, Zinc
Types of Wounds• Open wounds
▫ Incisions, dehisced or delayed closure
▫ Pressure ulcers▫ Arterial ulcers▫ Venous stasis ulcers▫ Neuropathic ulcers▫ Diabetic ulcers▫ Abcesses▫ Fistulas▫ Ostomies▫ Trauma, Burns
• Closed Wounds▫ Incisions
Stitched, Stapled, Steri-stripped or Skin bonded
▫ Pressure ulcers▫ Hematomas▫ Abcesses, nodules,
various dermatologic types.
http://www.medicaledu.com/pictures.htm
Pressure Ulcers• Braden Scale – 16 points or below is considered a
risk ▫ Sensory Perception 4pts
Completely, very, slightly, not impaired▫ Moisture (4pts)
Constantly, very, occasionally, rarely moist▫ Activity (4pts) – bedfast, chairfast, walks occ, freq.▫ Mobility (4pts)
Completely, very, slightly immobile, no limitation▫ Nutrition (4pts)
Very poor, probably Inadequate, adequate, excellent▫ Friction & Shear (3pts)
Problem, potential problem, no apparent problem
Pressure Ulcers• Stages
▫ 1 intact, persistent redness
▫ 2 partial thickness loss or blister
▫ 3 full thickness loss to but not through fascia
▫ 4 full thickness loss to muscle, bone, etc.
▫ Unstageable –purple, yellow or black-must be removed before staging
▫Never back stage.
• Prevention and treatment▫ Turn every 2 hours
when in bed▫ Move every 15
minutes or at least every hour in wheel chair or chair
▫ Apply appropriate dressing to manage drainage
▫ Educate patient and family on reasons for treatment and causes of pressure ulcers.
▫ Monitor q shift
Stage 1
•Reddened boggy heel
Stage 2
•Partial thickness loss•Or blister
Stage 3
•Down to but not through the facia
Stage 4
•To muscle, bone, tendons, etc.
Unstageable Pressure Ulcers
•Purple, yellow, black
Other Ulcers
•Arterial
•Venous
Other ulcers
•Neuropathic
•Diabetic
Stay open-minded
•Remain alert to all possibilities.