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WOUND CARE
Presentation for ACC Lab
March 22, 2006By Herlinda M. Burks, RN, BA, CWCN, CCCN
Risk Assessments
Report: focus on Hx of diseases, surgeries, how recent, present wounds, incisions. Read the H&P.
10 minute assessmentWhat do you see? Tubes, drains, obesity, weakness, skin
damage in patterns?, etc.Braden Scale Pressure Risk
Assessment
Wound Treatments
Never leave a wet open wound open to air (OTA) and unprotected.
Only leave ischemic black dry wounds on the feet and toes OTA or dressed lightly with gauze.
Wound Healing Processes
Types of Wound Closures Primary Intention
Sutures, staples, skin bonds, etc.
Secondary Intention Partial thickness
Regenerate specific cells Epithelialize
Full thickness Regranulate Epithelialize Remodel
Tertiary Intention
Processes Involved in Wound healing Acute phase
Hemostasis Inflammation Proliferation Remodeling
Chronic phase Stalls for 2 weeks Change Tx Reassess full body,
meds, labs.
Wound Assessments
Etiology - watch those with ischemia Size – consistent measure from nurse to nurse
L x W x D in centimeters (head to toe, 9 to 3 o’clock) Locations of tunnels & undermining by the clock
Drainage – type (color, amount, consistency, odor) Wound bed % of red, yellow, black tissues
Granulation, Slough, Eschar or tan crust or blister Wound edges – rolled (epiboly), macerated
Peripheral tissues – discoloration, stains, scars? Edema, induration, scaling (peeling), plaques?
Wound Culturing
Cleanse the wound with saline Irrigate till clear if it is a deep wound.
Use culturette that has 2 swabsWipe tissue in 1 cm2 area
Infection causing Bacteria is in the tissue Do not get just a sample of the drainageMultiple bacteria from peripheral tissues can
be in the drainageSubmit to lab
Nutrition for Wound Healing
Assessment of Nutrition - labs Serum Albumin 18 to 20 days half-life
Affected by hydration (> if dehydrated, < if overhydrated) Transferrin – 8 to 10 days half-life easily affected by
other factors. Prealbumin – 2 days half-life – best predictor
Nutrients needed for Wound healing Calories –enough to support healing and other
present disease processes Protein Vitamins
Nutrients
Protein – fibroplasia, neogenesis, collagen formation, remodeling
Carbohydrates – energy and protein sparing
Fat - cell wallsVitamins – A, B, C, D, E, KCopper, Iron, Magnesium, Zinc
Types of Wounds
Open wounds Incisions, dehisced or
delayed closure Pressure ulcers Arterial ulcers Venous stasis ulcers Neuropathic ulcers Diabetic ulcers Abcesses Fistulas Ostomies Trauma, Burns
Closed Wounds Incisions
Stitched, Stapled, Steri-stripped or Skin bonded
Pressure ulcers Hematomas Abcesses, nodules,
various dermatologic types.
http://www.medicaledu.com/pictures.htm
Pressure Ulcers
Braden Scale – 16 points or below is considered a risk Sensory Perception 4pts
Completely, very, slightly, not impaired Moisture (4pts)
Constantly, very, occasionally, rarely moist Activity (4pts) – bedfast, chairfast, walks occ, freq. Mobility (4pts)
Completely, very, slightly immobile, no limitation Nutrition (4pts)
Very poor, probably Inadequate, adequate, excellent Friction & Shear (3pts)
Problem, potential problem, no apparent problem
Pressure Ulcers
Stages 1 intact, persistent
redness 2 partial thickness
loss or blister 3 full thickness loss to
but not through fascia 4 full thickness loss to
muscle, bone, etc. Unstageable –purple,
yellow or black Never back stage.
Prevention and treatment Turn every 2 hours
when in bed Move every 15 minutes
or at least every hour in wheel chair or chair
Apply appropriate dressing to manage drainage
Educate patient and family on reasons for treatment and causes of pressure ulcers.
Monitor q shift
Stage 1
Reddened boggy heel
Stage 2
Partial thickness lossOr blister
Stage 3
Down to but not through the facia
Stage 4
To muscle, bone, tendons, etc.
Unstageable Pressure Ulcers
Purple, yellow, black
Other Ulcers
Arterial
Venous
Other ulcers
Neuropathic
Diabetic
Stay open-minded
Remain alert to all possibilities.