Fundamental Fundamental NursingNursing

Chapter 28Chapter 28

Wound CareWound Care

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Body tissues have a remarkable ability to Body tissues have a remarkable ability to recover when injuredrecover when injured. . This chapter discusses This chapter discusses several types of tissue injury, including those several types of tissue injury, including those caused by surgical incisions and prolonged caused by surgical incisions and prolonged pressurepressure. . It also addresses nursing It also addresses nursing interventions to support the healing process interventions to support the healing process and actions to prevent tissue injury. and actions to prevent tissue injury.

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WoundsWounds

A A woundwound (damaged skin or soft tissue) results (damaged skin or soft tissue) results from from traumatrauma (general term referring to (general term referring to injury). Examples of tissue trauma include injury). Examples of tissue trauma include cuts, blows, poor circulation, strong chemicals, cuts, blows, poor circulation, strong chemicals, and excessive heat or cold. Such trauma and excessive heat or cold. Such trauma produces two basic types of wounds: open and produces two basic types of wounds: open and closed (closed (Table 28-1Table 28-1).).

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An An open woundopen wound is one in which the surface of is one in which the surface of the skin or mucous membrane is no longer the skin or mucous membrane is no longer intact intact

In a In a closed woundclosed wound, there is no opening in the , there is no opening in the skin or mucous membrane. Closed wounds skin or mucous membrane. Closed wounds occur more often from blunt trauma or occur more often from blunt trauma or pressure. pressure.

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Wound RepairWound Repair

The process of wound repair proceeds in three The process of wound repair proceeds in three sequential phasessequential phases: : inflammation, proliferation, inflammation, proliferation, and remodelingand remodeling..

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InflammationInflammation

InflammationInflammation, the physiologic defense , the physiologic defense immediately after tissue injury, lasts approximately immediately after tissue injury, lasts approximately 2 to 5 days. It’s purposes are to 2 to 5 days. It’s purposes are to

limit the local damage, limit the local damage, remove injured cells and debris, and remove injured cells and debris, and prepare the wound for healing. prepare the wound for healing.

Inflammation progresses through several stages (Inflammation progresses through several stages (Fig. 28-1Fig. 28-1).).

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Figure 28-1 • The inflammatory response. The words in red are the five classic signs and symptoms of inflammation.

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During the first stage, local changes occurDuring the first stage, local changes occur. . Immediately following an injury, blood vessels Immediately following an injury, blood vessels constrict to control blood loss and confine the constrict to control blood loss and confine the damagedamage. . Shortly thereafter, the blood vessels dilate to Shortly thereafter, the blood vessels dilate to deliver platelets that form a loose clotdeliver platelets that form a loose clot. . The The membranes of the damaged cells become more membranes of the damaged cells become more permeable, causing release of plasma and chemical permeable, causing release of plasma and chemical substances that transmit a sensation of discomfortsubstances that transmit a sensation of discomfort. . The local response produces the characteristic signs The local response produces the characteristic signs and symptoms of inflammationand symptoms of inflammation: : swelling, redness, swelling, redness, warmth, pain warmth, pain , and , and decreased function.decreased function.

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A second wave of defense follows the local A second wave of defense follows the local changes when changes when leukocytesleukocytes and and macrophagesmacrophages (types of white blood cells) migrate to the site (types of white blood cells) migrate to the site of injury, and the body produces more and of injury, and the body produces more and more white blood cells to take their place. more white blood cells to take their place.

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ProliferationProliferation

ProliferationProliferation (period during which new cells (period during which new cells fill and seal a wound) occurs from 2 days to 3 fill and seal a wound) occurs from 2 days to 3 weeks after the inflammatory phase. It is weeks after the inflammatory phase. It is characterized by the appearance of characterized by the appearance of granulation tissuegranulation tissue (combination of new blood (combination of new blood vessels, fibroblasts, and epithelial cells), which vessels, fibroblasts, and epithelial cells), which is bright pink to red because of the extensive is bright pink to red because of the extensive projections of capillaries in the area.projections of capillaries in the area.

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Granulation tissue grows from the wound Granulation tissue grows from the wound margin toward the centermargin toward the center. . It is fragile and It is fragile and easily disrupted by physical or chemical easily disrupted by physical or chemical meansmeans. . As more and more fibroblasts produce As more and more fibroblasts produce collagencollagen (a tough and inelastic protein (a tough and inelastic protein substance), the adhesive strength of the wound substance), the adhesive strength of the wound increases. increases.

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Generally, the integrity of skin and damaged Generally, the integrity of skin and damaged tissue is restored by: tissue is restored by:

((11)) resolutionresolution (process by which damaged cells (process by which damaged cells

recover and re-establish their normal function), recover and re-establish their normal function), (2)(2) regenerationregeneration (cell duplication), (cell duplication), or or (3)(3) scar formationscar formation (replacement of damaged cells (replacement of damaged cells

with fibrous scar tissue).with fibrous scar tissue).

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Remodeling

RemodelingRemodeling (period during which the wound (period during which the wound undergoes changes and maturation) follows undergoes changes and maturation) follows the proliferative phase and may last 6 months the proliferative phase and may last 6 months to 2 years. During this time, the wound to 2 years. During this time, the wound contracts, and the scar shrinks.contracts, and the scar shrinks.

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Wound HealingWound Healing

Several factors affect wound healing:Several factors affect wound healing:

Type of wound injuryType of wound injury Expanse or depth of woundExpanse or depth of wound Quality of circulationQuality of circulation Amount of wound debrisAmount of wound debris Presence of infectionPresence of infection Status of the client's healthStatus of the client's health

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Wound Healing Wound Healing ComplicationsComplications

Factors that may interfere include Factors that may interfere include compromised circulation; infection; purulent, compromised circulation; infection; purulent, bloody, or serous fluid accumulation that bloody, or serous fluid accumulation that prevent skin and tissue approximation, and prevent skin and tissue approximation, and drugs like corticosteroids, and obesity.drugs like corticosteroids, and obesity.

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The nurse assesses the wound to determine The nurse assesses the wound to determine whether it is intact or shows evidence of whether it is intact or shows evidence of unusual swelling, redness, warmth, drainage, unusual swelling, redness, warmth, drainage, and increasing discomfort.and increasing discomfort.

Two potential surgical wound complications Two potential surgical wound complications include include dehiscencedehiscence (separation of wound (separation of wound edges) and edges) and eviscerationevisceration (wound separation (wound separation with protrusion of organs) (with protrusion of organs) (Fig. 28-4Fig. 28-4). ).

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Figure (28-4 • (A ) Wound dehiscence (B ) Wound evisceration).

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Wound management involves changing Wound management involves changing dressings, caring for drains, removing sutures dressings, caring for drains, removing sutures or staples when directed by the surgeon, or staples when directed by the surgeon, applying bandages and binders, and applying bandages and binders, and administering irrigationsadministering irrigations..

Wound ManagementWound Management

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DressingsDressings

A A dressingdressing purposes: purposes: Keeping the wound cleanKeeping the wound clean Absorbing drainageAbsorbing drainage Controlling bleedingControlling bleeding Protecting the wound from further injuryProtecting the wound from further injury Holding medication in placeHolding medication in place Maintaining a moist environmentMaintaining a moist environment

The most common wound coverings are gauze, The most common wound coverings are gauze, transparent, and hydrocolloid dressings. transparent, and hydrocolloid dressings.

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Gauze DressingsGauze Dressings

Gauze dressings are made of woven cloth Gauze dressings are made of woven cloth fibers. Their highly absorbent nature makes fibers. Their highly absorbent nature makes them ideal for covering fresh wounds that are them ideal for covering fresh wounds that are likely to bleed or wounds that exude drainage.likely to bleed or wounds that exude drainage.

Unfortunately, gauze dressings obscure the Unfortunately, gauze dressings obscure the

wound and interfere with wound assessment. wound and interfere with wound assessment.

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Gauze dressings usually are secured with tapeGauze dressings usually are secured with tape. . If gauze dressings need frequent changing, If gauze dressings need frequent changing, Montgomery strapsMontgomery straps (strips of tape with (strips of tape with eyelets) may be used (eyelets) may be used (Fig. 28-5Fig. 28-5). ).

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Figure 28-5 • (

A) The adhesive outer edge of Montgomery straps are applied to either side of a wound.

B) The inner edges of Montgomery straps are tied to hold a dressing over a wound. They prevent skin breakdown and wound disruption from repeated tape removal when checking or changing a dressing.

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Transparent Dressings

Transparent dressings are clear wound Transparent dressings are clear wound coverings. One of their chief advantages is that coverings. One of their chief advantages is that they allow the nurse to assess a wound without they allow the nurse to assess a wound without removing the dressing removing the dressing ((Fig. 28-6Fig. 28-6). ).

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Figure 28-6 • Transparent dressing.

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Hydrocolloid DressingsHydrocolloid Dressings

Hydrocolloid dressings are self-adhesive, Hydrocolloid dressings are self-adhesive, opaque (opaque ( �ْو�ن ( الَّل �َم�ُد� ْك

� �ْو�ن ( َأ الَّل �َم�ُد� ْك� air- and water-occlusive , air- and water-occlusive ,َأ

wound coverings (wound coverings (Fig. 28-7Fig. 28-7). They keep ). They keep wounds moist. Moist wounds heal more wounds moist. Moist wounds heal more quickly because new cells grow more rapidly quickly because new cells grow more rapidly in a wet environment. If the hydrocolloid in a wet environment. If the hydrocolloid dressing remains intact, it can be left in place dressing remains intact, it can be left in place for up to 1 week. for up to 1 week.

27Figure 28-7 • A hydrocolloid dressing absorbs drainage into its matrix.

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Dressing Changes

Nurses change dressings when a wound Nurses change dressings when a wound requires assessment or care and when the requires assessment or care and when the dressing becomes loose or saturated with dressing becomes loose or saturated with drainage.drainage.

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Drains

DrainsDrains are tubes that provide a means for are tubes that provide a means for removing blood and drainage from a wound. removing blood and drainage from a wound. They promote wound healing by removing They promote wound healing by removing fluid and cellular debrisfluid and cellular debris

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Open Drains Open drains are flat, flexible tubes that provide a Open drains are flat, flexible tubes that provide a

pathway for drainage toward the dressing. pathway for drainage toward the dressing. Draining occurs passively by gravity and Draining occurs passively by gravity and capillary action.capillary action. Sometimes a safety pin or long Sometimes a safety pin or long clip is attached to the drain as it extends from the clip is attached to the drain as it extends from the woundwound. .

As the drainage decreases, the physician may As the drainage decreases, the physician may instruct the nurse to shorten the drain, instruct the nurse to shorten the drain, ((Fig. 28-8Fig. 28-8). ).

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Figure 28-8 • An open drain is pulled from the wound, and the excess portion is cut. A drain sponge is placed around the drain, and the wound is covered with a gauze dressing.

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Closed Drains

Closed drains are tubes that terminate in a Closed drains are tubes that terminate in a receptacle. Some examples of closed drainage receptacle. Some examples of closed drainage systems are a Hemovac.systems are a Hemovac.

Closed drains are more efficient than open Closed drains are more efficient than open drains because they pull fluid by creating a drains because they pull fluid by creating a vacuum or negative pressurevacuum or negative pressure. .

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Sutures and Staples

SuturesSutures, knotted ties that hold an incision , knotted ties that hold an incision together, generally are constructed from silk or together, generally are constructed from silk or synthetic materials such as nylon. synthetic materials such as nylon.

StaplesStaples (wide metal clips) perform a similar (wide metal clips) perform a similar function. Staples do not encircle a wound like function. Staples do not encircle a wound like sutures; instead, they form a bridge that holds sutures; instead, they form a bridge that holds the two wound margins together.the two wound margins together.

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Sutures and staples are left in place until the Sutures and staples are left in place until the wound has healed sufficiently to prevent wound has healed sufficiently to prevent reopeningreopening. . Depending on the location of the Depending on the location of the incision, this may be a few days to as long as 2 incision, this may be a few days to as long as 2 weeksweeks..

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Figure 28-10 • (A ) Technique for suture removal. (B ) Technique for staple removal.

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Bandages and Binders

A A bandagebandage is a strip or roll of cloth wrapped is a strip or roll of cloth wrapped around a body part. One example is Crib around a body part. One example is Crib bandage. bandage.

A A binderbinder is a type of bandage generally is a type of bandage generally applied to a particular body part such as the applied to a particular body part such as the abdomen or breast.abdomen or breast.

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DébridementDébridement

Some wounds require Some wounds require débridementdébridement (removal (removal of dead tissue) to promote healing. The four of dead tissue) to promote healing. The four methods for débriding a wound are sharp, methods for débriding a wound are sharp, enzymatic, autolytic, and mechanical. enzymatic, autolytic, and mechanical.

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Sharp Débridement

Sharp débridement is the removal of Sharp débridement is the removal of necrotic necrotic tissuetissue (nonliving tissue) from the healthy areas (nonliving tissue) from the healthy areas of a wound with sterile scissors, forceps, or of a wound with sterile scissors, forceps, or other instruments.other instruments.

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Enzymatic Débridement

Enzymatic débridement involves the use of Enzymatic débridement involves the use of topically applied chemical substances that topically applied chemical substances that break down and liquefy wound debris.break down and liquefy wound debris.

This form of débridement is appropriate for This form of débridement is appropriate for uninfected wounds or for clients who cannot uninfected wounds or for clients who cannot tolerate sharp débridementtolerate sharp débridement..

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Wound Irrigation

Wound irrigation generally is carried out just Wound irrigation generally is carried out just before applying a new dressing. This before applying a new dressing. This technique is best used when granulation tissue technique is best used when granulation tissue has formed. Surface debris should be removed has formed. Surface debris should be removed gently without disturbing the healthy gently without disturbing the healthy proliferating cells.proliferating cells.

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Heat and Cold Applications

Heat and cold have various therapeutic uses (Heat and cold have various therapeutic uses (Box 28-1Box 28-1).).

The terms hot and cold are subject to wide The terms hot and cold are subject to wide

interpretation interpretation Table 28-2Table 28-2

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Therapeutic Baths

Therapeutic bathsTherapeutic baths (those performed for other (those performed for other than hygiene purposes) help to reduce a high than hygiene purposes) help to reduce a high fever or apply medicated substances to the fever or apply medicated substances to the skin to treat skin disorders or discomfort.skin to treat skin disorders or discomfort.

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The most common type of therapeutic bath is a The most common type of therapeutic bath is a sitz bathsitz bath (soak of the perianal area). Sitz baths (soak of the perianal area). Sitz baths reduce swelling and inflammation and reduce swelling and inflammation and promote healing of wounds after a promote healing of wounds after a hemorrhoidectomyhemorrhoidectomy (surgical removal of (surgical removal of engorged veins inside and outside the anal engorged veins inside and outside the anal sphincter) or an sphincter) or an episiotomyepisiotomy (incision that (incision that facilitates vaginal birth). facilitates vaginal birth).

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A A pressure ulcerpressure ulcer is a wound caused by is a wound caused by prolonged capillary compression that is prolonged capillary compression that is sufficient to impair circulation to the skin and sufficient to impair circulation to the skin and underlying tissue. The primary goal in underlying tissue. The primary goal in managing pressure ulcers is prevention. Once managing pressure ulcers is prevention. Once a pressure ulcer forms, however, the nurse a pressure ulcer forms, however, the nurse implements measures to reduce its size and to implements measures to reduce its size and to restore skin and tissue integrityrestore skin and tissue integrity

Pressure Ulcers

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Pressure ulcers or sores, also referred to as Pressure ulcers or sores, also referred to as decubitus ulcersdecubitus ulcers, most often appear over bony , most often appear over bony prominences of the sacrum, hips, and heels. prominences of the sacrum, hips, and heels. They also can develop in other locations such They also can develop in other locations such as the elbows, shoulder blades, back of the as the elbows, shoulder blades, back of the head, and places where pressure is unrelieved head, and places where pressure is unrelieved because of infrequent movement (because of infrequent movement (Fig. 28-17Fig. 28-17). ).

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Figure 28-17 • Locations where pressure ulcers commonly form. (A ) Supine position. (B ) Side-lying position. (C ) Sitting position.

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The tissue in these areas is particularly The tissue in these areas is particularly vulnerable because body fat, which acts as a vulnerable because body fat, which acts as a pressurepressure--absorbing cushion, is minimalabsorbing cushion, is minimal. . Consequently, the tissue is compressed Consequently, the tissue is compressed between the bony mass and a rigid surface between the bony mass and a rigid surface such as a chair seat or bed mattresssuch as a chair seat or bed mattress. . If the If the compression on local capillaries continues compression on local capillaries continues without intermittent relief, the cells die from without intermittent relief, the cells die from lack of oxygen and nutritionlack of oxygen and nutrition..

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Stages of Pressure Ulcers

Pressure ulcers are grouped into four stages Pressure ulcers are grouped into four stages according to the extent of tissue injury (Fig. according to the extent of tissue injury (Fig. 28-18). 28-18).

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Figure 28-18 • Pressure sore stages. (A ) Stage I. (B ) Stage II. (C ) Stage III. (D ) Stage IV.

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Stage I is characterized by intact but reddened is characterized by intact but reddened skinskin. . The hallmark of cellular damage is skin The hallmark of cellular damage is skin that remains red and fails to resume its normal that remains red and fails to resume its normal color when pressure is relievedcolor when pressure is relieved..

A stage II pressure ulcer is red and pressure ulcer is red and accompanied by blistering or a accompanied by blistering or a skin tearskin tear (shallow break in the skin). Impairment of the (shallow break in the skin). Impairment of the skin may lead to colonization and infection of skin may lead to colonization and infection of the wound.the wound.

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A stage III pressure ulcer has a shallow skin crater pressure ulcer has a shallow skin crater that extends to the subcutaneous tissuethat extends to the subcutaneous tissue. . It may be It may be accompanied by accompanied by serous drainageserous drainage (leaking plasma) or (leaking plasma) or purulent drainagepurulent drainage (white or greenish fluid) caused (white or greenish fluid) caused by a wound infection. The area is relatively painless by a wound infection. The area is relatively painless despite the severity of the ulcer.despite the severity of the ulcer.

Stage IV pressure ulcers are life threatening. The pressure ulcers are life threatening. The tissue is deeply ulcerated, exposing muscle and bone tissue is deeply ulcerated, exposing muscle and bone (Fig. 28-19). The dead or infected tissue may produce (Fig. 28-19). The dead or infected tissue may produce a foul odor. The infection easily spreads throughout a foul odor. The infection easily spreads throughout the body, causing the body, causing sepsissepsis (potentially fatal systemic (potentially fatal systemic infection).infection).

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Figure 28-19 • Example of stage IV pressure sore.

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Prevention of Pressure Ulcers

The first step in prevention is to identify The first step in prevention is to identify clients with risk factors for pressure ulcers clients with risk factors for pressure ulcers (Box 28-2). The second step is to implement (Box 28-2). The second step is to implement measures that reduce conditions under which measures that reduce conditions under which pressure ulcers are likely to form. See Nursing pressure ulcers are likely to form. See Nursing Guidelines 28-2. Guidelines 28-2.

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Nursing ImplicationsNursing Implications

Acute PainAcute Pain Impaired Skin IntegrityImpaired Skin Integrity Ineffective Tissue PerfusionIneffective Tissue Perfusion Impaired Tissue IntegrityImpaired Tissue Integrity Risk for InfectionRisk for Infection