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NUR 204 Health and Wellness Exam 2 Study Guide.pdf - Wound Care.
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Health and Wellness Exam 2 Study Guide.pdf - Wound Care..Wound Care
Factors/ Conditions that may affect Wound Healing:
- Vascular Disease
- Diabetes
- Nutrition (increase in protein is needed for the formation of collagen also increase Vitamin A,C
and E
- Medications
- Excessive Moisture
- External Forces (pressure, shear, and friction)
- Age
Wound Classification Based on:
The Cause (pressure ulcer, diabetic ulcer)
Skin Integrity (open or closed wound)
Wound Depth (partial thickness, superficial)
Amount of Contamination (clean, contaminated, infected)
Healing Process (acute, chronic)
A wound can heal through either primary intention or secondary intention, in secondary intention the
wound must heal from the bottom and sides of the wound until it’s filled with new tissue.
Phases of Wound Healing
Inflammatory: lasts up to 3 days coagulation occurs and the wound is cleaned by the body
Proliferative: usually lasts a couple weeks, formulation of the granulation tissue forms new skin
Maturation: takes up to 1 year scar tissue may develop giving strength to the wound
*scar tissue is not as strong as regular skin
Complications of Wound Healing Include:
- Dehiscence
- Evisceration
- Fistula formation
*if a wound is healing properly, a 1 cm wide range area next to the incision should be able to be palpated
also known as “the healing ridge”
*symptoms of dehiscence and evisceration include a popping sensation and increase in drainage, nurse
should encourage the patient to use a splint or binder to prevent this when coughing or during movement
*fistulas puts patient at risk for fluid loss and electrolyte imbalance
Pressure Injuries can be caused by:
- Intensity of pressure
- Duration of pressure
- Mechanical devices (nose cannula that may irritate the skin behind the ears or under the nose)
, Health and Wellness Exam 2 Study Guide.pdf - Wound Care..
- Friction/ shearing
- Sensory loss
- Moisture/ Nutrition
Stages of Pressure Injuries
Stage 1: skin is still intact but the skin is erythematous and non blanchable, for a dark skinned patient, the
site may be painful and differ in firmness or temperature
Stage 2: partial thickness is lost with an exposed dermis, blisters may form
Stage 3: full thickness of skin is lost but there is no bone present, there may be tunneling or undermining
present
Stage 4: Exposure of bone, tendon, or connective tissue is present osteomyelitis may occur and sloughing
Unstageable: obscured full thickness and tissue loss but it can’t be measured due to necrotic tissue
Deep Tissue Pressure Injury: Nonblanchable deep injury that may cause discoloration under intact skin
*wounds don’t heal backwards, a healed wound would be considered a healed Stage 4
*wound measurement is the best way to assess a healing wound
Blood tests can identify chronic diseases that may be leading to the delay of wound healing
Biopsy of the wound helps rule out infection
A score lower than 18 on the braden scale puts the patient at risk for a pressure injury
Wound Assessment Includes Noting:
Location of the wound
Size and Color
Presence of Drainage
Condition of the Wound edge
Characteristics of the Wound bed
Patient’s response to the wound
*a sterile cotton tipped applicator is used to measure a wound then measure the width and length of the
edges of the wound
*wound should be “beefy red” and the area should be moist
Wound Interventions:
1. Wound Cleansing/Irrigation
0.9% normal saline solution is commonly used, tap water can also be used if its drinkable
Irrigation solution should be room temp or warmed
Irrigation is used to remove debris or bacteria and apply heat and medication
2. Debridement
Removal of necrotic tissue
3. Dressings
Keep the wound free from contamination
Absorb drainage and prevent infection
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