Chapter 3 Advanced Wound Care Skills

1. Chapter 3Advanced Wound Care Skills

2. Ways of Describing Wounds • Open wounds: breaks in the skin and possibly the underlying tissue • Closed wounds: a result of damage to tissues underneath intact skin • Intentional wounds: planned surgical or medical interventions

3. Ways of Describing Wounds (cont.) • Unintentional wounds: the result of accidents • Acute wounds: expected to heal completely within a few days or weeks • Chronic wounds: delayed in healing or may never heal completely

4. Intentional and Unintentional Wounds

5. Three Common Pressure Ulcers • Late-stage pressure ulcers • Venous (stasis) ulcers • Arterial ulcers

6. To Help Prevent a Pressure Ulcer From Forming • Avoid allowing a person to remain in one position for a long period of time. • Use your observation skills (look for red, hot, or painful areas over pressure points or previously reddened areas that have turned white, pale, or shiny). • Provide good skin care. • Anticipate toileting needs and provide good perineal care.

7. To Help Prevent a Pressure Ulcer From Forming (cont) • Encourage exercise. • Use lift devices and lift sheets when moving or repositioning people to minimize skin injury caused by friction or shearing. • Encourage good nutrition and hydration. • Use pressure-relieving devices.

8. Question A gunshot wound is a(n): • Intentional Wound • Closed Wound • Chronic Wound • Unintentional Wound

9. Answer • Unintentional Wound Unintentional wounds are the result of an accident. Examples of unintentional wounds are those resulting from falls, motor vehicle crashes, and gun and knife violence.

10. Phases of Wound Healing • Inflammatory phase: Begins immediately; during this phase the area is hot, red, swollen and painful. • Proliferative phase: Begins 2–3 days after injury and can last 2–3 weeks; scar tissue replaces the tissue that is normally found in this area. • Remodeling phase: This is the final stage of healing, in which more collagen is secreted and the wound is strengthened; this phase can last as long as 6 months.

11. Three Types of Wound Healing • First-intention wound healing: an open wound is closed surgically with sutures or staples as soon as possible • Second-intention wound healing: a wound is kept clean but otherwise left alone to let the tissue repair itself, allowing the wound to close on its own • Third-intention wound healing: the wound is left open for a period of time to make sure no infection will occur, then closed surgically with sutures or staples

12. Factors That Affect Wound Healing 1. Nutrition and hydration 2. Overall health status 3. Age 4. Wound condition

13. Question Wound healing increases the body’s need for ___________ and _____________. A. fat and carbohydrates B. minerals and water C. calories and protein D. vitamins and supplements

14. Answer • calories and protein The body requires more protein and calories to assist with cell repair and healing.

15. Complications of Wound Healing • Infection • Hemorrhage • Hematoma • Dehiscence and evisceration

16. Infection

17. The First Sign of Hemorrhage

18. Dehiscence and Evisceration

19. Question Blood collected under the skin is known as: A. Pus B. Evisceration C. Hematoma D. Hemorrhage

20. Answer • Hematoma Hematoma is better known as a bruise. Blood collects under the tissue and can interfere with healing.

21. Interventions to Support Wound Healing 1. Sutures and staples 2. Dressings and bandages 3. Drains (open and closed)

22. Sutures and Staples • Subcuticular sutures: placed underneath the dermis • Retention sutures: threaded through a rubber tube over a plastic bridge

23. Keep the wound clean Help prevent infection Maintain a moist environment that assists with wound healing Absorb wound drainage Treat infection Apply pressure to the wound (to prevent or control hemorrhage, bruising, or swelling) Remove necrotic (dead) tissue Protect the wound from further injury Protect the patient from becoming upset at the sight of the wound Dressings

24. Dressings and Bandages Layers of dressings • Contact layer • Secondary layer Bandages • Abdominal binder • Montgomery straps/ties

25. Transparent Dressing

26. Question Tell whether the following statement is true or false. When applying a dressing, the contact layer is applied directly to the wound. • True • False

27. Answer A. True The contact layer is against the wound and generally made of non-stick material or gel.

28. Abdominal Binder

29. Drains • Penrose drain • Closed drainage systems • Jackson-Pratt drain • Hemovac drain

30. Penrose Drain

31. Closed Drainage Systems

32. Wound Care • Proper cleansing of a wound • Removal of sutures and staples • Débridement: the removal of necrotic tissue

33. Cleaning an Incision Site Report it to the nurse immediately if: • Edges of the wound are gaping open between the sutures or staples • Sutures or staples have ripped out or broken • Excessive swelling along the incision line is seen • Excessive redness along the incision line is seen • Incision line is hot to the touch

34. Cleaning an Incision Site (cont) • Purulent drainage or pus is seen along the incision line • Wound drainage has a foul odor • Patient complains of increased pain at wound site 2 to 3 days after the injury or surgery took place • Fever occurs 24 hours or more after the injury or surgery took place • Increased amount of bloody drainage is seen on the wound dressing or in the wound drainage system

35. Different Types of Wound Drainage • Serous: clear and watery-looking • Sanguineous: bloody-looking • Serosanguineous: pink and watery-looking • Purulent: thick and ranging in color from dark yellow or green to creamy white

36. Removing Sutures and Staples

37. Pin Care

38. Débridement • Sharp (surgical) • Mechanical • Autolytic • Enzymatic (chemical) • Biological • Vacuum-assisted closure (VAC) therapy

39. Vacuum-assisted (VAC) therapy