Chapter 55 Wounds - Lecture notes 2 PDF

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Wound Lecture Notes for Buchanan...

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Chapter 55 Pressure Ulcers, Wounds & Wound Management Stages of Wound Healing Inflammatory Stage o Begins with the injury and lasts 3-6 days Effects to the wound o Controlling bleeding w/ vasoconstriction, retraction of blood vessels, fibrin accumulation, and clot formation. o Delivering oxygen, white blood cells, and nutrients to the area via the blood supple. Macrophages engulf microorganisms & cellular debris (phagocytosis). This phase is prolonged when there is too little inflammation (with debilitating disease), or when there is too much inflammation. Proliferative stage o Lasts the next 3-24 days Effects to the wound o Replacing loss tissue w/ connective or granulated tissue & collagen o Contracting the wound’s edges to reduce the area that requires healing o Resurfacing of new epithelial cells Maturation or remodeling stage o Occurs on day 21 o Involves strengthening of the collagen scar & the restoration of a more normal appearance. o Can take more than 1 year to complete, depending on the extend of the original wound Healing Processes Primary Intention o Little or no tissue loss o Edges approximated, as with surgical incision o Heals rapidly o Low risk of infection o No or minimal scarring Example: closed surgical incision w/ staples, sutures, or liquid glue to seal laceration

Secondary Intention o Loss of tissue o Wound edges widely separated, unapproximated (pressure injury, open burn areas) o Longer healing time o Increase risk of infection o Scarring o Heals by granulation Example: pressure injury left open to heal Tertiary intention o Widely separated o Deep o Spontaneous opening of a previously closed wound o Closure of wounds occurs when they are free of infection and edema o Risk of infection o Extensive drainage and tissue debris o Closed later o Long healing time Example: abdominal wound initially left open until infection is resolved and then closed ASSESSMENT/DATA COLLECTION Appearance o Note the color of open wounds o Red – healthy regeneration of tissue  COVER o Yellow – presence of purulent drainage and slough  CLEAN o Black – presence of eschar that hinders healing and requires removal  DEBRIDE, REMOVE NECROTIC TISSUE Drainage (Exudate) – a result of the healing process and accumulates during the inflammatory and proliferative phases of healing o Note the amount, odor, consistency, and color of drainage from a drain or on a dressing o Note the integrity of the surrounding skin o With each cleansing, observe the skin around a drain for irritation and breakdown

o For accurate measurement of drainage, weigh the dressing (1 g = 1 mL) o Note and document the # of dressings and frequency of dressing changes o Serous drainage – the portion of the blood (serum) that is watery and clear or slightly yellow in appearance (fluid in blisters) o Sanguineous drainage – contains both serum & blood. It is thick and appears reddish. Brighter drainage indicates active bleeding; darker drainage indicates older bleeding o Serosanguineous drainage – contains both serum and blood. It is watery and looks pale and pink due to a mixture of red and clear fluid. o Purulent drainage – the result of infection. It is thick and contains white blood cells, tissue debris, and bacteria. It may have a foul odor, and its color (yellow, tan, green, brown) reflects the type of organism present (green for a Pseudomonas aeruginosa infection). o Purosanguineous – a mixed drainage of pus and blood (newly infected wound) C – consistency O – odor C – color of drainage A – Amount NURSING INTERVENGTIONS  Provide adequate hydration and meet protein and calorie needs o Encourage 2,500 ml/day of fluid from food and beverage sources if no contraindications o Note if blood albumin levels are low (below 3.5 g/dL) because a lack of protein increases the risk for a delay in wound healing and infection

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Perform and wound cleansing and irrigation Administer analgesics and monitor for effective pain management Administer antimicrobials (topical, systemic) and monitor for effectiveness (reduced fever, increase in comfort, decreasing WBC count) Document the location and type of wound and incision, the status of the wound and type of dressing and materials, client teaching, and how the client tolerated the procedure

-----------------------------------------------------------------------1. A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type 1 diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (Select all that apply)  Chronic illness  Low hemoglobin  Malnutrition 2. A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (Select all that apply)  Increase in incisional pain  Fever and chills  Reddened wound edges 3. A nurse educator is reviewing the wound healing process w/ a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply)  Stage 3 pressure injury  Open burn area 4. A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation

and pain in their surgical incision. The nurse checks the surgical wound and finds it separate with viscera protruding. Which of the following actions should the nurse take? (Select all that apply).  Cover the area with saline-soaked sterile dressings  Position the client supine with the hips and knees bent 5. A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client’s skin? (Select all that apply)  Keep the head of the bed elevated 30 degree angle  Have the client sit on a gel cushion when in a chair...