Today we're going to talk about wound healing and wound care. Let's talk wounds! With Cindi Bell RN, BSN
***=might show up on the NCLEX
Cindi:Hey there, this is Cindi from nursing clinical mastery. Today we're going to talk about wound healing and wound care. If you're preparing for the NCLEX, when you hear this sound(ding), you can expect to see this on the test. Let's talk wounds. There are two types of healing. The first is primary intention or first intention. This is when tissue surfaces are approximated, which means closed, and there is minimal or no tissue loss. An example of this would be a surgical incision. The second kind is called secondary intention healing. This is when a wound is allowed to heal on its own. When the tissue surfaces cannot be closed or should not be closed, and it results in extensive tissue loss. An example of this would be a pressure ulcer. Bite wounds are another example. There are three major differences between secondary intention and primary intention healing. The repair is longer for secondary intention. There is usually more scarring and those types of wounds are more susceptible to infection because they are usually open longer. So let's review the three phases of healing. The first phase is the inflammatory phase. This phase spans about three to six days after injury. The main thing that goes on during this stage is hemostasis, which is the cessation of bleeding and the formation of clots. The blood vessels retract away and a connective tissue matrix is deposited called fibrin. The vascular response to remove dead tissue begins and an increase in blood supply results in redness and edema. Another cellular response is called phagocytosis. Angiogenesis factor or AGF is secreted and it forms epithelial buds at the end of the blood vessels.***An important nursing tip is that clients taking steroids can have slow healing during this phase. Phase two begins at day four and can last 21 days. This is called the proliferative phase. During this phase, fibroblasts synthesize collagen, which is a whitish protein that adds strength. This is the phase when granulation tissue is forming and the capillary bed increases and becomes a translucent red color. If epithelialization does not occur. A black, dried plasma and dead tissue matrix can cover the wound. This is called eschar. The third and final phase is called the maturation phase. During this phase, more fibroblasts and collagen are organized. A thick gray scar becomes stronger. Scar tissue is never as strong as the original pre-wound tissue.***Some clients may develop what's called a keloid, which is a hypertrophic scar with an abnormal amount of collagen. So important factors for nurses to know about wound healing. The first major factor is development, meaning older adults have a harder time healing wounds. Peripheral vascular disease in older adults can impair blood flow. Decreased liver function impairs the synthesis of clotting factors. Any changes in the immune system due to age will affect wound healing and scar tissue and collagen are less elastic as adults get older.***Major factors that affect clients of all ages include nutrition, lifestyle, especially smoking, medications, including anti inflammatory medications, heparin, an antineoplastic, medications and contamination and infection prevention. Our major nursing priorities: now that we've discussed wound healing, let's cover some general guidelines about wound care. The skin and tissue of very young and very old clients is increasingly fragile and susceptible to injury. It's important to know that wounds heal more rapidly in children. As mentioned, corticosteroids caused the thinning of skin and an increased risk for injury. Wound types: there are two major categories of wounds. Intentional and unintentional. Intentional wounds are surgical wounds or vena puncture, for example, unintentional wounds or fractures or tissue injury. Wounds are further classified according to whether or not they are contaminated, open or closed. An open wound is a skin or mucus membrane surface that's broken. Clean wounds are considered closed wounds or draining with closed drainage. They do not involve respiratory, elementary, genital or urinary track wounds. Wounds in these areas are considered clean/contaminated wounds with no evidence of infection. Contaminated wounds are open, fresh, accidental, or surgical wounds that involve a major break in sterile technique or a large spillage of GI contents. There is often evidence of inflammation. A dirty or infected wound is an old wound containing dead tissue and purulent drainage.***This type of drainage is a clinical sign of infection. Wounds are then further classified by how they occurred and incision is made with a sharp instrument. A contusion results from a blow from a blunt instrument. An abrasion is a scraping of the skin surface. This could be intentional or unintentional. A puncture wound is the penetration of the skin or underlying tissue by a sharp object.***Puncture wounds are typically much deeper than they are longer. Because of this, they usually need to heal from the inside out by secondary intention. A laceration results from torn tissue and usually has jagged edges. A penetrating wound is a term used to describe a metal fragment or object, like a bullet, that damages underlying tissue. The last type of wound and most commonly seen by nurses are pressure ulcers. These used to be called decubitus ulcers. Decubitus means lying down. A pressure sore, a bedsore, a distortion sore are all terms used to describe pressure ulcers in the past. These are lesions caused by unrelieved pressure. It's important to understand how pressure ulcers occur and the forces that are involved.***The underlying cause is ischemia, which is localized. There's decreased blood to the tissues and the tissue begins to die and the blood vessels become damaged. The phases of healing cannot occur properly. Reactive hyperemia is a term for when pressure is relieved and the skin becomes a bright, flush red color. This results from vasodilation. It's the body's way of protecting the tissue.***Assessing for non-blanching skin is one way to test for the first phase of pressure ulcer development. There are two forces that are important to understand that contribute to the development of pressure tissue injury.***This is friction or a rubbing that is parallel to the skin and shearing force, which is a combination of friction and pressure. Usually this happens because of a certain position and the force of gravity on the body in that position. An example would be fowler's position. This position often contributes to the development of pressure sores on the sacrum where the body contacts the bed and gravity is pulling down. We will cover pressure tissue injury in more detail in another segment. I want to talk about what nurses can do to help with wound healing and then we'll move on to care of acute wounds and dressings.***Priorities for the nurse include nutrition and fluids, prevention of infection, and positioning. A goal of 2,500 ml's of intake of fluid per day is optimal unless contra indicated this assessed with hemostasis and the phases of wound healing, prevent infection, and the spread of infection between clients. This is accomplished with proper wound care and proper infection control.***If the client cannot move independently, implement a range of motion. Schedule twice a day and turn every two hours. Okay. Before the nurse assesses the wound, the nurse needs to remove the old dressing. A tip, when removing an old dressing to reduce pain is to pull in the direction of the hair growth on the skin. Another trick is to wet the dressing with saline. This helps loosen up any crusting drainage that has dried. Okay, let's talk about wound assessment. So untreated wounds should be assessed for size and severity, whether or not there's any bleeding and if it's internal or external, whether or not there are any foreign bodies or material, whether or not there are any associated injuries such as fractures,***and the need for tetanus immunization. Even for pressure ulcers, the nurse should assess the tetanus status of the client. When assessing a treated or sutured wound, if the wound cannot be inspected, inspect the dressing and assess for pain. Assess and observe the appearance and size of the wound and whether or not the tissue is approximated at the incision site. Assess for drainage and the status of the drain tubes. Detect whether there is any swelling or any pain. Redness surrounding the wound that is warm could indicate infection,***but the most prominent indicator of infection is purulent drainage. The nurse should also know whether or not there are any odors coming from the wound. Treating acute wounds is according to priorities.***The first is to control bleeding. Applying pressure and elevating an extremity if you're able to is the first priority. The second is infection prevention. Initial measures to prevent infection include flushing and cleaning abrasions and lacerations with water. The nurse should also cover the wound to protect it and apply pressure and approximate edges if this is possible by supporting the tissue around it. It's important not to remove clots, but to apply layers of dressings. Applying ice nearby can decrease swelling. Lastly, the nurse should assess the client for signs of shock.***Look for a thready pulse, low blood pressure, or cold and clammy skin. Now that the wound is stabilized, the nurse can move on to wound care. Once the nurse has assessed the wound, the nurse may need to cleanse the wound. Here's some tips for cleaning wounds.***Clean the surrounding skin first and direct the cleaning away from the wound. Then clean the wound from the innermost part to the outermost part. This prevents the nurse from contaminating the wound further. Use isotonic saline or lactated ringers rather than peroxide or betadine. These agents can interrupt tissue healing. Using warm solutions close to body temperature can increase comfort and can speed healing. If a wound has a lot of bacteria, slough or foreign bodies, expect to clean it at every dressing change. Avoid cleaning, really red wounds that have a lot of granulation tissue. Clean, superficial, noninfected wounds with normal saline and pressure. We'll go over wound irrigation in just a moment. Avoid using cotton balls which can stick to the wound and avoid drawing the wound after you clean it. Here's some tips for wound irrigation, also called wound lovage. This involves washing or flushing the area using sterile technique.***Before you begin, you can clean with swabs or cotton, first in circular strokes, inside to outside, discarding each swab. Effective irrigation requires four to 15 pounds per square inch of pressure. This can be accomplished by using a 30 to 50 ml syringe with an 18 to 19 gauge catheter tip. Some syringes are available specifically designed for irrigation. When flushing a wound, the nurse should continue until the solution is clear. Again, room temperature fluid can increase client comfort.***If splashing is anticipated, the nurse should wear eye protection once the wound has been cleaned. The nurse can apply a bandage. We will cover complex bandages in another segment. The function of bandages are either to support, immobilize, apply pressure, secure dressings, or retain warmth. There are many different kinds of dressings depending on the cause of the wound and the status of the wound bed. Here's some general guidelines for applying bandages, always bandage the part of the body and the normal anatomical position. Try to pad between skin surfaces.***Wrap from distal to proximal to aid in venous return. A little bit about wound drainage, and then we'll cover the complications of wound healing. Exudate is fluid and cells that escape from blood vessels during inflammatory response processes. It's deposited in or on tissue and the amount varies. There are two different kinds of exudate, serous exudate and purulent exudate. Serous exudate consists of serum. It is clear body fluid. Purulent exudate is viscous and contains pus. Pus is a collection of leukocytes, dead tissue debris, and dead and living bacteria. Sanguineous or hemorrhagic exudate indicates bleeding. These are red blood cells that have escaped from plasma. It indicates damage to blood vessels. Oftentimes the wound drainage is mixed exudate. A combination of serous and sanguineous exudate called serosanguineous. This is clear and bloody drainage combined and it's common postsurgery purosanguineous discharge. Is pus mixed with blood. There are some complications of wound healing that the nurse should be aware of. The first is hemorrhage. This is described as persistent bleeding and is a medical emergency. It results from a dislodged clot, a slipped ligature, or erosion of blood vessels. The greatest risk for hemorrhage is in the first 48 hours after surgery or an injury. The nurse should apply extra sterile pressure dressings and monitor vital signs for signs of shock. A hematoma is another complication and is a localized collection of blood underneath the skin. This can obstruct blood flow. Infection is another possible complication of wound healing. It is most apparent from day 2 to day 11 postsurgery. Dehiscence or partial or total rupture of sutured wounds. It indicates something has given way. This is a major complication. This tends to occur four or five days post-op. Increased flow of serosanguineous drainage will tip the nurse off that something is wrong. This may be proceeded by a sudden strain or a cough that disrupts the wound.***The risk is increased for dehiscence for clients who are obese, have poor nutrition when there's multiple trauma, when the suture has failed, when there is excessive coughing, vomiting, or dehydration. Another major complication is evisceration. This is the protrusion of internal viscera through the incision line. Things to do right away when this happens is quickly support the wound with a large sterile dressing soaked in normal saline. Then the nurse should place the client in bed with the knees bent. Notify the surgeon immediately. That's all for this review of acute wounds and wound care for more tips to master the NCLEX and more podcasts go to nclexmastery.com.