WOUND CARE

- skin is the body’s first line of defense protecting the underlying structures
from invasions by organisms
- intact skin surface is important, because a break or disruption is potentially
dangerous and possibly life
threatening
- nurses play a major role in maintaining skin integrity by identifying risk
factors that predispose a patient’s
risk for impaired skin integrity, and in providing specific wound care
when breaks in integrity arise
- knowledgeable and skilled wound care is essential
- individualized plan of care is developed to asses, to identify and prevent, and
to provide physical and
emotional support

wounds – break or disruption in the normal integrity of the skin and tissues
- range from a small cut on the finger to a third-degree burn covering almost
all of the body
- result from mechanical forces (ex. surgical incisions) or physical injury

WOUND CLASSIFICATION
Intentional – result of planned invasive therapy or treatment
- wound edges are clean and bleeding is usually controlled, risk for
infection is decreased

Unintentional – occur from unexpected trauma, such as accidents, forcible

injury (ex. stabbing or gunshot),
and burns
- wound occur in an unsterile environment, contamination is likely
- edges are usually jagged, multiple trauma is common and bleeding is
uncontrolled
- high risk for infection and longer healing time

Open – occurs from intentional or unintentional trauma

- skin surface is broken with bleeding, tissue damage
- increased risk for infection with the possibility of delayed healing

Closed – results from a blow, force, or strain caused by trauma such as a fall,
an assault, or a motor vehicle
crash
- skin surface is not broken, but soft tissue is damaged, internal injury
and hemorrhage may occur

Acute – ex. surgical incisions, usually heal within days to weeks

- wound edges are well approximated, risk for infection is lessened

Chronic – do not progress through the normal sequence of repair

- edges are often not approximated, risk of infection is increased
- normal healing time is delayed
 - include deep pressure ulcers and peripheral vascular arterial or venous
ulcers

Partial-thickness – all or portion of the dermis is intact

Full-thickness – dermis and underlying subcutaneous fat tissue is also
damaged or destroyed

WOUND HEALING
- injured tissues are repaired by physiologic mechanisms that regenerate
functioning cells and replace
connective tissue cells with scar tissue
- fills the gap caused by tissue destruction, restoring the structural integrity of
the damaged tissue through
the orderly release of growth factors and chemical mediators
- chemical substances help to increase the blood supply to the damaged area,
wall off and remove cellular
and foreign debris and initiate cellular development
PHASES OF WOUND HEALING
Epithelialization – fill in, cover or seal a wound

- intentional wounds with minimal tissue loss, such as those made by a

surgical incision with sutured
approximated edges, usually heal by primary intention
- large or open wounds, such as from burns or major trauma, which require
more tissue replacement and are
often contaminated, commonly heal by secondary intention
- if healing by first intention becomes infected, it will heal by secondary
intention
- connective tissue healing and repair have differences that include the length
of time required for each
phase and the extent of granulation tissue formed

Inflammatory Phase – begins at the time of injury and prepare the wound
for healing
- activities include hemostasis (blood clotting) and vascular and cellular
phase of inflammation
- blood vessels dilate and capillary permeability increases to allow
plasma and blood components to
leak out into the area that is injured, forming a liquid called
exudate
- exudate causes swelling and pain
- increased perfusion results in heat and redness
- if wound is small, the clot loses fluid and a hard scab forms to
protect the injury
- macrophages are essential to the healing process
- not ingest debris but also release growth factors that are
necessary for the growth of
epithelial cells and new blood vessels and for attracting
fibroblasts that help to fill in
 the wound
- generalized body response, including a mildly elevated temperature,
leukocytosis, and generalized
malaise

Proliferative Phase – begins within 2 to 3 days of injury

- new tissue (granulation tissue) forms the foundation for scar tissue
development
- highly vascular, red, and bleed easily
- adequate nutrition and oxygenation, as well as prevention of strain on
the suture line, are important
patient care considerations

Remodeling Phase – final stage that begins about 3 wks. after the injury,
possibly continuing for as long as
6 months
- collagen is haphazardly deposited in the wound, making the healed
wound stronger and more like
adjacent tissue

scar – avascular collagen tissue that does not sweat, grow hair, or tan
in sunlight

FACTORS AFFECTING WOUND HEALING

Age – children and healthy adults heal more rapidly than older adults
- older adults are more likely to have one or more chronic illnesses, with
pathologic changes that
impede the healing process

Circulation and Oxygenation – adequate blood flow to deliver nutrients and

oxygen and to remove local
toxins, bacteria, and other debris is essential for wound healing
- large amounts of subcutaneous and tissue fat (which has fewer blood
vessels) may slow healing
because fatty tissue is more difficult to suture, more prone to
infection, and takes longer to heal
- oxygenation of tissue is decreased in people with anemia or chronic
respiratory disorders and in
those who smoke

Nutritional Status – healing requires adequate proteins, carbohydrates, fats,

vitamins, and minerals to
rebuild cells and tissues
- healing is slowed or inadequate in the patient with poor nutritional
status and fluid balance

Wound Condition – infected wounds or wounds that retain foreign bodies

heal slowly
 Health Status – corticosteroids decrease the inflammatory process, delaying
healing
- radiation depresses bone marrow function, resulting in decreased
leukocytes and an increased risk
of infection
- chronic illness (ex. cardiovascular disease) or impaired immune
function can impair healing

WOUND COMPLICATIONS
Infection – bacteria can invade a wound at the time of trauma, during
surgery, or at any time after the initial
wound occurs
- symptoms of infection usually become apparent within 2 to 7 days
after the injury or surgery
- symptoms include purulent drainage, increased drainage, pain,
redness, and swelling in
and around the wound, increased body temperature, and
increased white blood cell count

Hemorrhage – may occur from a slipped suture, a dislodged clot from stress
at the suture line or operative
site, infection, or the erosion of a blood vessel by a foreign body (such
as a drain)
- dressing (and wound) must be checked frequently during the first 48
hours after surgery and no
less than every 8 hours thereafter

Dehiscence – partial or total disruption of wound layers

Evisceration – protrusion of viscera through the incisional area
- the most serious postoperative wound complications
- patients at greater risk for these complications are those who are
obese or malnourished, have
infected wounds, or experience excessive coughing, vomiting, or
straining
- if either complication occurs, cover the wound area with sterile towels
soaked in sterile 0.9%
sodium chloride solution and notify the physician immediately
- emergencies that require prompt surgical repair

Fistula Formation – abnormal passage from an internal organ to the skin or

from one internal organ to
another
- postoperative fistula formation is most often the result of delayed
healing, commonly manifested by
drainage from an opening in the skin or surgical site

PSYCHOLOGICAL EFFECTS OF WOUNDS

Pain – often increased by activities such as ambulating, coughing, moving in
bed, and dressing changes
 Anxiety and Fear – apprehension about the possibility of the wound opening,
how much privacy will be lost
as the wound is being cared for, and how they and others will react to
the appearance and smell of
the wound

Changes in Body Image – when the skin and tissues are traumatized, that
image is changed, requiring the
person to adapt and reformulate the concept of self
- wounds and scars that are visible can result in feelings of
conspicuousness, ugliness, and
diminished self-worth
- large scars, such as from removal of a breast or from creation of
colostomy opening, can seriously
affect the person’s sexuality, social relationships, and self-concept

NURSING PROCESS FOR WOUND CARE

Assessing – involves inspection (sight and smell) and palpation for
appearance, drainage, and pain
- includes sutures, any drains or tubes, and manifestations of
complications

Appearance – approximation of wound edges, color of the wound and

surrounding area, drains or
tubes, staples or sutures, and signs of dehiscence or evisceration
- healthy healing surgical wound appears clean and well
approximated
- initially edges are reddened and slightly swollen
- after approx. 1 wk, the skin is closer to normal in
appearance with wound edges
healing together
- may at first be bruised but this too returns to normal as
blood is restored
- when infection is present, the wound is swollen and deep red
- feels hot on palpation and drainage is increased and
possibly purulent
- foul odor may also be noted
- if dehiscence is impending or present, the wound edges
are separated

Drainage – inflammatory response resulting in the formation of exudate,

which then drains from the
wound
- exudate is described as:
serous = primarily clear, serous portion of the blood and from
serous membranes
- clear and watery

sanguineous = large numbers of red blood cells and looks like

blood
 - bright red drainage is indicative of fresh bleeding
- darker drainage indicates older bleeding
- surgical wounds most commonly have a mixture of serum
and red blood cells
(serosanguineous)

purulent – made up of white blood cells, liquefied dead tissue

debris, and both dead and
live bacteria
- drainage is thick, often has a musty or foul odor, and
varies in color (such as dark
yellow or green), depending on the causative
organism

- amount and color depend on the wound location and size

- drainage can be assessed on the wound, on the dressings, in
drainage bottles or
reservoirs, or possibly under the patient

Pain – increased or constant pain from the wound require further

assessment
- pain may indicate delayed healing or an infection

Sutures and Staples

skin sutures – may be black silk, synthetic material, fine wire,
metal skin clips, or metal
stapes to hold tissue and skin together
- typically removed in 6 to 8 days
retention sutures are used to provide extra support for obese
patients or wounds with an
increased risk of dehiscence

- removed when the wound has developed enough tensile

strength to hold the wound edges
together during healing
- this stage varies from patient to patient, depending on
age, nutritional status, and
wound location
- small adhesive wound closure strips (Steri-strips) may be applied
directly to the wound to
help hold it together

Related Assessments – evaluate the patient’s general condition and

laboratory test results
- be alert for signs and symptoms of infection which may cause
generalized malaise,
increased pain, anorexia, and an elevated body temperature
and pulse rate

Diagnosing
 Impaired Skin Integrity – state in which an individual has altered
epidermis or dermis

Outcome Identification and Planning - plan of care is directed toward

facilitating the patient’s return to
health by providing interventions that facilitate wound healing, reduce
the risk for complications, and
promote psychosocial adaptation

Implementing - nursing interventions focus on preventing infection and

promoting would healing; preventing
further injury or alteration in skin integrity; promoting physical and
emotional comfort; facilitating
coping

Changing Dressings
- goal of wound care is to promote tissue repair and regeneration
so that skin integrity is
restored
- moist environment is best for wound healing

dressing – protective cover over a wound

- closed method uses a dressing
- open method does not use a dressing
- most dressings, especially those used for surgical wounds,
consist of three layers

contact layer – dressing applied directly over the wound,

allows drainage to pass
into the middle layer
- this layer should be able to be removed without
causing further tissue
damage
middle layer – absorbs the drainage
outer layer – keeps the two inner layers in place

Purposes: * provide physical, psychological, and aesthetic

comfort
* remove necrotic tissue * prevent,
eliminate, or control infection
* absorb drainage * maintain a moist wound
environment
* protect the wound from further injury
* protect the skin surrounding the wound

Supplies – items needed vary with the type, location and amount
of wound drainage
cleaning agents – sterile 0.9% sodium chloride solution is usually
the agent of choice
 - any agent other then o.9% sodium chloride may have
possible caustic effects on
the skin, tissues, and granulation tissue
dressing materials – number and types used depend on the
location and size of the wound
as well as the amount and type of drainage
- incision line is often covered with sterile petrolatum gauze
or a special gauze
called Telfa (shiny outer surface is applied to the
wound and allows
drainage to pass through)
- protective dressings prevent outer dressings from adhering
to the wound and
causing further injury when removed
- gauze dressings are commonly used to cover wounds
- special gauze dressings are precut halfway to fit
around drains or tubes
- larger dressings are placed over the smaller gauze
and absorb drainage
and protect the wound
- transparent dressings are applied directly over small
wounds or tubes
- occlusive, decreasing the possibility of
contamination while
allowing visualization of the wound
- used over intravenous sites, subclavian
catheter insertion sites,
and noninfected healing wounds
tape - materials used to secure the dressing and support the
wound
- come in wide varieties of sizes and types

Cleaning a Wound and Applying Clean Dressing

- prepare the patient for the dressing change before starting the
procedure by explaining what will be
done
- help the patient into a position that is comfortable and also convenient
for changing the dressing
- expose only the area necessary to perform the wound care while
maintaining proper draping
- use appropriate aseptic techniques
- be especially vigilant in performing hand hygiene before and
after changing dressings
- no standard frequency for how often dressings should be changed
- depends on the amount of drainage, physician’s preference, and
nature of the wound
- physician to perform the first dressing change, usually within 24
to 48 hrs after surgery,
with nurses doing the needed or daily changings
 - frequency of dressing changes is noted on the patient’s plan of
care
- remember, wound contamination occurs through a moist medium
- always replace dressings with fresh dressings or reinforce the
dressing with additional
dressings before drainage causes saturation

Wound Drains, Tubes, and Catheters

- variety of drains, catheters, or tubes may be inserted into or near a
wound when it is anticipated
that a collection of fluid in a closed area would delay healing
- ex. Penrose drain – open drainage system consisting of a hollow open-
ended tube - sometimes physician orders for Penrose drain
to be shortened daily
- closed drainage systems are used more often than incisional
drains
- cuts infection rate in half when placed through a stab wound (separate
opening) rather than the
incision
- consists of a drainage tube that may be connected to an
electrical suction device or have a
portable built-in reservoir to maintain constant low suction
- prevents microorganisms from entering the wound from
saturated dressings
- allow accurate measurement of drainage
- ex. Jackson Pratt drainage tube or Hemovac

Collecting a Wound Culture – if assessment of the wound indicates a

possible infection, obtain a
specimen of the drainage and send it to the lab for culture and
sensitivity
- explain the procedure to the patient
- gather equipment, don clean gloves, remove dressing, use
aseptic technique to don sterile
gloves and clean wound, remove sterile gloves, use sterile
cotton tipped swab to
collect specimen (carefully insert swab into wound and roll
gently - - use another
swab if collecting from more than one site) , place inside
uncontaminated culturette
tube without touching outside of container, label specimen
container, attach lab
requisition and send to lab within 20 minutes, record
collection of specimen,
appearance of wound and description of drainage in chart

Irrigating and Packing a Wound - irrigation – directed flow of solution

over tissues
 - purposes include cleaning the area of pathogens and other
debris and applying local heat
or an antiseptic to the area
- nonsterile solutions are used of wound is closed
- sterile equipment and solutions (0.9% sodium chloride, sterile
water, antiseptic, antibiotic
solution) are used for open wounds
- sterile, large volume syringe is used to direct the flow

Caring for Draining Wounds - similar to that of wounds with little or no

drainage
- if wound care is uncomfortable, administer a prescribed
analgesic 30 – 45 minutes before
changing the dressing
- also plan to change the dressing midway between meals
so that the patient’s
appetite and mealtimes are not disturbed
- use an ointment or paste on the surrounding clean skin to act as
a protective barrier to
prevent skin irritation and excoriation from wound drainage
- remove ointment or paste daily, cleaning the skin
thoroughly after removal using
as little rubbing as possible
- first layer of dressing material is often nonabsorbent or
hydrophilic (carries moisture)
applied directly to the draining wound and is less likely to
stick to patient
- this allows drainage from the wound to move into overlying
absorbent layers,
helping to prevent maceration and reinfection
- material to absorb and collect drainage is then placed over the
first layer of nonabsorbent
material
- material acts as a wick, pulling drainage out by capillary
action
- cotton-lined gauze sponges soak up more liquid than
unlined sponges
- number of gauzes used in the dressing depends on the
amount of drainage
- fluffy and loosely packed dressings are more absorbent
than tightly packed
- top of dressing may be further protected by surgical or
abdominal pads, which are thick,
absorbent pads that help to absorb profuse drainage
- draining wounds often require more frequent dressing changes
than those without

Caring for Open Wounds - because cellular migration needed for tissue
repair and healing is
 enhanced by a moist surface, a moist (rather than wet) packing
for open wounds is
recommended
- apply packing loosely and only to the edges of the wound
- cover the wound with a secondary dressing to absorb drainage
- if packing dries, soak with 0.9% sodium chloride solution
before removal to prevent
it from sticking to the healing tissue and causing injury

Classifications – based on assessment of wound color

- wounds that have all three colors are categorized as mixed
wounds
- when all colors are present, treat first for the most serious
color (black), followed
by yellow and finally red

Red – proliferative stage of healing and reflect the color of normal

granulation tissue
- protection is provided with nursing interventions that
include gentle cleansing, use
of moist dressings, application of a transparent or
hydrocolloid dressing,
and changing of the dressing only when necessary

Yellow – characterized by oozing from the tissue covering the

wound, often accompanied by
purulent drainage
- nursing interventions include irrigating the wound; using
wet-to-moist dressings;
using nonadherent, hydrogel, or other absorptive
dressings; and consulting
with the physician about using a topical antimicrobial
med.

Black – wounds covered with thick eschar (necrotic tissue) which

is usually black but may
also be brown, gray, or tan
- requires debridement (removal) before wound can heal
sharp debridement (using a scalpel or scissors to
cut away the dead
tissue)
mechanical debridement (scrubbing the wound or
applying a wet to-moist dressing)
chemical debridement (using collagenase enzyme
agents)
autolytic debridement (using a dressing that
contains wound moisture to
help the body produce enzymes to break down
the eschar)
 Caring for Chronic Wounds – follow the same general procedures for any
other wounds
- moisture-retentive materials, and different treatments, such as
vacuum-assisted closure
therapy, many be used
- vacuum-assisted closure therapy is the application of
negative pressure to pull the
cells closer together
- allows epithelial cells to multiply rapidly and form
granulation tissue
- increases cell proliferation, stimulates blood flow to
wounds, and stimulates the
growth of new blood vessels

HEAT ANDCOLD THERAPY

- heat / cold applied to bring about local or systemic change in body
temperature for various therapeutic
purposes
- physiologic responses are modified by method & duration of app., degree of
heat & cold applied, patient’s
age & physical condition, and amount of body surface covered by app.
- initially, heat and cold skin receptors are strongly stimulated by sudden
changes in temperature
- inform patients that increasing the temperature or lengthening the time of
application can seriously damage
tissues

EFFECTS OF APPLYING HEAT

- dilates peripheral blood vessels, increases tissue metabolism, reduces blood
viscosity and increases
capillary permeability
- vasodilation increases local blood flow → oxygen and nutrients to area is
increased → venous
congestion is decreased → viscosity of blood is reduced and capillary
permeability improves
delivery of leukocytes and nutrients → removal of wastes increases →
prolonged clotting time (all
together accelerate inflammatory response to promote healing)
- reduces muscle tension to promote relaxation and helps to relieve muscle
spasms and joint stiffness
- helps relieve pain by stimulating specific nerve fibers, closing the gate that
allows the transmission of pain
stimuli
- used to treat infections, surgical wounds, inflamed tissue, arthritis, joint and
muscle pain, dysmenorrheal,
and chronic pain
- systemic effects include increased cardiac output, sweating, increased pulse
rate, and decreased blood
pressure
 - produces vasodilation in 20 – 30 minutes, if continued beyond that time,
tissue congestion and
vasoconstriction occur

EFFECTS OF APPLYING COLD

- application constricts peripheral blood vessels: reduces blood flow to tissues
and decreases the local
release of pain-producing substances such as histamine, serotonin, and
bradykinin which in turn
reduces the formation of edema and inflammation
- reduces muscle spasms, alters sensitivity (producing numbness), and
promotes comfort by slowing the
transmission of pain stimuli
- used after direct trauma, for dental pain, for muscle spasms, after sprains,
and to treat some chronic pain
syndromes
- maximum vasoconstriction occurs when the skin reaches 15°C
(60°prolongedF) then vasodilation begins
- exposure produces systemic effects of increased blood pressure,
shivering and goose bumps

NURSING PROCESS FOR APPLYING HEAT / COLD

Assessing – carefully evaluate factors influencing the patient’s ability to
tolerate heat and cold apps.
* How long will the application be? * What body part is involved?
* Is the skin intact? * How large is the area?
* What’s the patient’s age? * What is the patient’s physical
condition?

Before initiating heat or cold therapy, assess:

a. patient’s physical and mental status – include obtaining health
history and completing a physical
exam
- cardiovascular or peripheral vascular impairment, sensory
impairment, and alterations in
mental status (confusion or decreased level of
consciousness) indicates the need
for caution when using heat or cold because of danger of
tissue damage
- assessments include response to stimuli (sharp and dull), color
and appearance of body
tissues, circulation (pulses, blanching sign, temperature, and
color), level of
consciousness, and orientation
- heat should not be applied to an open wound immediately after
trauma; during hemorrhage; over noninflammatory
edema; to an acutely inflamed area, a localized
malignant tumor, the testes, or the abdomen of a pregnant
woman; or over metallic
implants
 - cold should not be used for open wounds or for patients with
impaired peripheral circulation
or allergy to cold

b. area of application – risk for damage to tissues is increased if the

area is traumatized or has
altered integrity
- assess for open lesions, blisters, wounds, edema, bleeding, or
drainage or evidence of
altered circulation, such as changes in color, temperature,
pulses, and sensation
- tissues with decreased or absent pulses, those that appear pale
or cyanotic, and those that
feel cold to the touch indicate a decrease in circulation
- ongoing assessments are made to ensure patient safety and
comfort
- when heat is used, assess for undesired responses,
including localized redness,
blistering, and pain (symptoms of burning), with
possible systemic
responses, such as hypotension and changes in
consciousness
- when cold is used, assess for localized responses, including
pallor, cyanosis, numbness,
and pain

c. condition of equipment – nurse is responsible for checking the

equipment used and for
maintaining patient safety
- condition of cords, plugs, and heating or cooling elements should
be checked
- DO NOT USE FAULTY EQUIPMENT

Diagnosing – possible nursing diagnoses including Ineffective

Thermoregulation, Ineffective Tissue
Perfusion, Acute Pain, Risk for Injury

Outcome Identification and Planning – when applications of heat or cold

are part of a plan of care, the
following outcomes are appropriate:
* verbalize increased comfort
* demonstrate evidence of wound healing, decreased muscle spasms,
decreased edema, and
increased comfort
* verbalize and demonstrate safe hot or cold application

Implementing – heat and cold applications may be moist or dry, using many
forms and methods
- prescription should include type of application, body area to be
treated, and frequency & length of
 time for application
- explain the purpose and steps of the application and sensations that
will be experienced

Applying Heat – dry and moist methods include:

hot water bags or bottles – relatively easy and inexpensive to use
disadvantages = may leak, often the weight of the bag or
bottle on the patient’s
body part can be uncomfortable, and the danger of
burns from improper use
electric heating pads – easy to apply, relatively safe to use and
provides constant and even
heat (improper use can result in injury)
- avoid using pins to secure a heating pad
- place a cover over the pad
- do not cover the heating pad with anything that might be
heavy
- place heating pad anteriorly or laterally to, not under, the
body part
- use heating pad with selector switch that cannot be turned
up beyond a safe temp.
- assess the skin at regular intervals for the effects of
excessive exposure to heat
hot compresses or packs, sitz baths, or soaks provide moist heat
by conduction

Applying Cold
ice bags – relatively easy and inexpensive
disadvantages = may leak, often the weight of the bag or
bottle on the
patient’s body part can be uncomfortable, and the
danger of burns from
improper use
- fill bag with small pieces of ice to about 2/3 full, then
remove air
- test for leaks and wipe off excess moisture
- place cover on ice bag to provide comfort and to absorb
moisture
- apply ice bag for 30 minutes, remove for about 1 hour
before reapplying
- in home setting, a bag of frozen vegetables makes a good
substitute
cold packs – sealed containers filled with a chemical or nontoxic
substance
- frozen in freezer or (if not frozen) squeezed to activate
chemical that produces cold
- frozen solution remains pliable and can be easily molded to
fit body part
- covered with ribbed cotton sleeve so that bag can be
slipped onto extremity or
 placed on body part
- skin beneath the pack should be assessed periodically for
symptoms of numbness
and pain
hypothermia blankets – apparatus has coils through which a
refrigerated solution circulates
- place hypothermia blanket on bed and cover with a sheet
- connect cooling blanket to machine and select
temperature setting
- insert probe into patient’s anus to monitor body temp
every 15 min.
- monitor all vitals every 30 min.
- set temp. control at 98.6°F (37°C), decreasing it 2° to 3°
every 15 min. until
ordered temp is reached
- when treatment is discontinued, turn off the machine and
continue to monitor temp
every 2 hrs for 24 hrs
- assess patient for shivering, fluid status, edema, and
altered skin integrity
moist cold – used for injured eye, headache, tooth extraction, and
sometimes hemorrhoids
- texture and thickness of material used depend on area
treated
- change compress frequently, continuing application for 20
min.
- repeat application every 2 – 3 hrs as ordered

Evaluating – expected outcomes included as part of plan of care used to

evaluate effectiveness of planned
interventions
- nursing care considered effective if patient is able to:
* verbalize increased comfort and ability to rest and sleep
* demonstrate evidence of wound healing
* demonstrate decrease in symptoms of muscle spasms,
inflammation and edema
* verbalize and demonstrate safe hot and cold applications