Wound Care: The Basics, Study notes of Nursing

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Wound Care:

The Basics

Suzann Williams-Rosenthal, RN, MSN, WOC, GNP

Norma Branham, RN, MSN, WOC, GNP

University of Virginia

May, 2010

What Type of Wound is it?How long has it been there?  Acute -generally heal in a couple weeks, but can become chronic:

Surgical  Trauma  Chronic -do not heal by normal repair process-takes weeks to months:

Vascular-venous stasis, arterial ulcers  Pressure ulcers  Diabetic foot ulcers (neuropathic)

Pressure Ulcer Staging

Where is it?  Where is it located?

Use anatomical location-heel, ankle, sacrum,coccyx, etc.  Measurements-in centimeters

Length X Width X Depth

Length = greatest length (head to toe)

Width = greatest width (side to side)

Depth = measure by marking the depth with a Q-Tip and then hold to a ruler

Wound Characteristics :

Describe by percentage of each typeof tissue:

Granulation tissue:

red, cobblestone appearance (healing,filling in)

Necrotic:

Slough-yellow, tan dead tissue(devitalized) - Eschar-black/brown necrotic tissue, canbe hard or soft

Evaluating additionaltissue damage:  Undermining

Separation of tissue from the surface underthe edge of the wound

Describe by clock face with patients head at 12(“undermining is 1 cm from 12 to 4 o’clock”)

Tunneling

Channel that runs from the wound edgethrough to other tissue

“tunneling at 9 o’clock, measuring 3 cm long”

Condition of Periwound  Consider use of Skin Prep or equivalentproduct to protect periwound tissue  Periwound-tissue around wound

Viable, macerated, inflamed

Color-erythema (purple appearance on dark skin),pale

Texture-dry, moist, boggy (soft), macerated (white,soggy appearance), edema

Temperature-cool, warm

Skin integrity-lesions, excoriation, maceration,denuded (loss of epidermis)

Is the wound infected? 

All wounds are contaminated, but not necessarilyinfected:



Contamination-microorganisms on wound surface



Colonization-bacteria growing in wound bed withoutsigns or symptoms of infection



Critical colonization-bacterial growth causes delayedwound healing, but has not invaded the tissue



Infection-bacteria invades soft tissue, causessystemic response

Inflammation, pus, increase/change in exudate, fever,pain, delirium in elderly

Other factors that contributeto wound healing:  Nutrition/hydration

Protein

Circulation

Pressure relief

Oxygenation

No tobacco

Edema

Glucose control - Diabetics

PUP-the highpoints  Minimize friction, sheer, and pressure 

Repositioning every 1-2 hours

Necessary even when using specialty beds, in chair 

HOB <30 degrees



Elevate heels

 Incontinence 

Scheduled toileting



Frequent changing, skin barrier

 Nutrition 

R.D. assessment



Calories, protein, supplements

 Education 

Staff, resident, families

Dressing selection  Determined by condition of the wound bed  Determine dressing according to amount ofexudate (drainage)  Consider cost and availability of dressingsat your institution $$$$  Assess wound at least every 2 weeks and change treatment if not improved  If not healing or questions about dressingselection, consult WOC nurse

Cleansing the wound bed:  Be gentle!

Saline or wound cleanser

Management of devitalizedtissue

Eschar-black necrotic tissue

Slough-soft, moist, avascular tissue

Firm, dry, stable eschar should not be debrided from heels

May not have adequate circulation toheal wound

Dressings:  Manage drainage while maintaining a moistenvironment

Maceration  Excoriation  Basically 5 categories:

Films  Hydrogel  Hydrocolloids  Alginates  Foam