Study Notes
10/13/2008
Chapter 42
Wound Care
Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Wound Care
The skin is the body’s first line of defense.
It protects the body from microbes that cause
infection.
You must prevent skin injury and give good
skin care to help prevent skin breakdown.
Older and disabled persons are at great risk.
Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
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Wound Care (Cont’d)
A wound is a break in the skin or mucous
membrane.
Common causes are:
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Surgery
Trauma
Pressure ulcers from unrelieved pressure
Decreased blood flow through the arteries or veins
Nerve damage
When injury does occur, infection is a major
threat.
Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
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Study Notes
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Wound Care (Cont’d)
Wound care involves:
Preventing infection
Preventing further injury to the wound and nearby
tissues
Preventing blood loss
Preventing pain
Your role in wound care depends on:
Your job description
The client’s condition
Provincial or territorial laws
Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
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Types of Wounds
Wounds are described in the following ways:
Intentional wounds and unintentional wounds
Open and closed wounds
Clean wounds
Clean--contaminated wounds
Clean
Contaminated wounds (dirty wounds)
Infected wounds
Chronic wounds
Partial-- and fullPartial
full-thickness wounds
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Description of Wound
Wounds also are described by their cause.
Abrasion
Contusion
Incision
Laceration
Penetrating wound
Puncture wound
• Scraping away or rubbing of the skin
• Blow to the body (bruise)
• Clean, intentionally cut into the skin
• Torn, jagged edges
• Skin and underlying tissues pierced
• Open wound caused by sharp object
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Skin Tears
A skin tear is a break or rip in the skin.
The epidermis separates from the underlying
tissues.
The hands, arms, and lower legs are common
sites for skin tears.
Causes include:
Friction and shearing
Pulling or pressure on the skin
Bumping a hand, arm, or leg on any hard surface
Holding the client’s arm or leg too tight
Repositioning, moving, or transferring client
Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
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Skin Tears (Cont’d)
Skin tears are painful.
Skin tears are portals of entry for microbes.
Tell the supervisor at once if you cause or find a skin
tear, bruise, bump, or scrape.
Persons at risk for skin tears:
Need moderate to complete help in moving
Have poor nutrition or are
are very thin
Have poor hydration
Have altered mental awareness
Are older
Careful and safe care helps prevent skin tears and
further injury.
Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
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Guidelines for Preventing Skin Tears
Follow care plan and safety measures for
moving, lifting, repositioning.
Keep client’s nails and your nails short/filed.
Do not wear rings.
Gently transfer or position the client.
Use a turning sheet.
Prevent friction during moving/positioning.
Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
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Pressure Ulcers
Decubitus ulcers, bed sores, and pressure
sores
A pressure ulcer is an injury caused by
unrelieved pressure to the skin and/or
underlying tissue.
The back of the head, shoulder blades, elbows,
hips, spine, sacrum, knees, ankles, heels, and
toes are bony prominences and considered
pressure points.
Pressure points that are moist are especially
prone to developing a pressure ulcer.
Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
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Causes of Pressure Ulcers
Pressure, shearing, and friction are common
causes.
Risk factors include:
Breaks in the skin
Poor circulation to an area
Moisture
Dry skin
Irritation by urine and feces
Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
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Clients at Risk for Pressure Ulcers
Clients at risk for pressure ulcers are those who:
Are confined to a bed or chair
Require moderate to complete help in moving
Have loss of bowel or bladder control
Have poor nutrition
Have altered mental awareness
Have problems sensing pain or pressure
Have circulatory problems
Are older
Are obese or very thin
Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
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Signs of Pressure Ulcers
Pale skin, warm reddened area
Complaints of pain, burning, itching, or
tingling in the area
Some clients may not feel anything unusual.
Immediately notify supervisor of any signs of
a pressure ulcer.
Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
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Signs of Pressure Ulcers (Cont’d)
Pressure usually occurs over bony areas
called pressure points.
Pressure on the ears can be caused by:
• The mattress when in the sideside-lying position
• Eyeglasses and oxygen tubing
In obese people, pressure ulcers can occur in
areas where skin has contact with skin.
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Between abdominal folds
The legs
The buttocks
The thighs
Under the breasts
Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
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Stages of Pressure Ulcers
Pressure ulcer stages
Stage 1 (Skin intact)
• There is usually redness over a bony prominence. The
colour does not return to normal when skin is relieved of
pressure.
Stage 2 (Partial(Partial-thickness skin loss)
Stage 3 (Full(Full-thickness skin loss)
• Skin cracks blisters or peels.
• Skin is gone.
• There may be drainage from the area.
Stage 4 (Full(Full-thickness tissue loss)
• Muscle, tendon, and bone exposure
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Prevention and Treatment
Preventing pressure ulcers is much easier
than healing them.
Good nursing care, cleanliness, and skin care are
essential.
The health team must develop a plan of care for
each person at risk.
The client at risk for pressure ulcers is placed on a
surface that reduces or relieves pressure.
The doctor orders wound care products, drugs,
treatments, and special equipment to promote
healing.
Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
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Protective Devices
These protective devices are used to prevent and
treat pressure ulcers and skin breakdown:
Special beds
Bed cradles
Heel and elbow protectors
Flotation pads, gel, or fluidfluid-filled pads and cushions
Eggcrate--like mattress
Eggcrate
Pillows
Trochanter rolls
Foot boards
Other positioning devices
Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
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Leg and Foot Ulcers
Some diseases affect blood flow to and from
the legs and feet.
Edema
Gangrene
Infection and gangrene can result from an open
wound and poor circulation.
• Swelling caused by fluid collecting in tissues
• A condition in which there is death of tissue
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Circulatory Ulcers
Circulatory ulcers (vascular ulcers) are open
sores on the lower legs or feet.
They are caused by decreased blood flow through
the arteries or veins.
Persons with diseases affecting the blood vessels
are at risk.
These wounds are painful and hard to heal.
Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
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Venous Ulcers
Venous ulcers (stasis ulcers) are open sores on the
lower legs or feet caused by poor blood flow through
the veins.
Can develop when valves in the legs do not close well
Veins cannot pump blood back to the heart in a normal way.
Blood and fluid collect in the legs and feet.
Pitting edema can occur.
The heels and inner aspect of the ankles are common sites
for venous ulcers.
They can occur from skin injury.
They can occur without trauma.
Venous ulcers are painful and make walking difficult.
Infection is a risk.
Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Slide 20
Appearance of Venous Ulcers
Edema in tissue give swollen appearance.
Skin may appear shiny and stretched.
Walking may be painful and difficult.
Venous ulcer may weep fluid.
Healing is slow, infection great.
Edema last for a long period.
Skin will change in appearance and texture –
brown leathery, hard.
Itching is common.
Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
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Prevention and Treatment
Follow the client’s care plan to prevent skin
breakdown.
Prevent injury.
Handle, move, and transfer the client carefully and
gently.
Clients at risk need professional foot care.
The doctor may order drugs for infection and to
decrease swelling.
Medicated bandages and other wound care products
are often ordered.
Devices used for pressure ulcers are often ordered.
The doctor may order elastic stockings or elastic
bandages.
Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
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Arterial Ulcers
Arterial ulcers are open wounds on the lower
legs or feet caused by poor arterial blood
flow.
They are caused by diseases or injuries that
decrease arterial blood flow to the legs and feet.
Smoking is a risk factor.
The doctor treats the disease causing the ulcer.
The doctor orders:
• Drugs and wound care
• A walking and exercise program
• Professional foot care
Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Slide 23
Appearance of Arterial Ulcers
Affected leg/foot may feel cool.
Appears blue or shiny
May be painful during rest – usually worse at
night.
Sites:
They are found between the toes, on top of the
toes, and on the outer side of the ankle.
Heels are common sites.
Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
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Study Notes
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Wound Healing
The healing process has three phases:
Inflammatory phase (3 days)
• Bleeding stops.
• A scab forms over the wound.
• Blood supply increases bringing nutrients and healing
substances to area.
• Redness, swelling, heat or warmth may be present.
• May have some loss of function and pain.
Proliferative phase (day 3 to day 21)
Maturation phase (day 21 to 2 years)
• Tissue cells multiply to repair the wound.
• The scar gains strength.
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Slide 25
Types of Wound Healing
Healing occurs in three ways:
First intention (primary intention, primary closure)
• Wound edges are brought together to close the wound.
• Sutures, staples, clips, adhesive strips
Second intention (secondary intention)
• Wounds are cleaned and dead tissue removed.
• Wound edges are not brought together.
• Scar forms slowly, threat of infection is great.
Third intention (delayed intention, tertiary
intention)
• The wound is left open and closed later.
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Complications of Wounds
Many factors affect healing and increase the
risk of complications.
The type of wound
The client’s age, general health, and lifestyle
Circulation
Nutrition
Immune system changes
Clients taking antibiotics
• An environment may be created that allows other
pathogens to grow and multiply.
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Hemorrhage
Excessive loss of blood in a short period of time
May be internal or external
Internal cannot be seen – bleeding occurs into tissues and
body cavities.
Hematoma – collection of blood under the skin
• Tissues appears swollen, reddishreddish-blue colour.
Signs and symptoms of internal bleeding
Shock, vomiting blood, coughing up blood, and loss of
consciousness.
External bleeding
Is visible bloody drainage and dressings soaked with blood
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Shock
Results when there is not enough blood supply to
organs and tissues
Signs and symptoms
Low or falling blood pressure, rapid, and weak pulse
Rapid respirations, cold, moist, and pale skin
Client is restless and may complain of thirst.
Confusion and loss of consciousness eventually occur.
Hemorrhage and shock are emergencies.
Follow Standard Practices when in contact with
blood.
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Complications of Wounds
Infection can occur at any time.
• Signs and symptoms:
Wound is tender to the touch, may have drainage.
Client may have a fever.
Dehiscence and evisceration are surgical
emergencies.
• Dehiscence is the separation of wound layers.
• Evisceration is the separation of the wound along with
the protrusion of abdominal organs.
• Coughing, vomiting and abdominal distension place
stress on the wound.
• Sterile dressing saturated with sterile saline will be
placed over the wound.
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Wound Appearance
Doctors and nurses observe the wound and its
drainage.
You need to make certain observations when assisting with
wound care.
Report and record your observations according to agency
policy.
The amount and kind of wound drainage depends on:
Wound size and location
Bleeding and infection
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Wound Drainage
Wound drainage is observed and measured.
Serous drainage is clear, watery fluid.
Sanguineous drainage is bloody drainage.
Serosanguineous drainage is thin, watery
drainage that is bloodblood-tinged.
Purulent drainage is thick, green, yellow, or brown
drainage.
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Wound Drainage (Cont’d)
Drainage must leave the wound for healing.
When large amounts of drainage are expected,
the doctor inserts a drain.
A Penrose drain is a rubber tube that drains onto a
dressing.
• It is an open drain.
• Microbes can enter the drain and wound.
Closed drainage systems prevent microbes from
entering the wound.
• A drain is placed in the wound and attached to suction.
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Drainage Measurement
Drainage is measured in two ways:
Noting the number and size of dressings with
drainage
• The amount and kind of drainage on each dressing is
noted.
Measuring the amount of drainage in the collection
container if closed drainage is used
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Sterile Dressings
Wound dressings have the following
functions:
Protect wounds from injury and microbes.
Absorb drainage.
Remove dead tissue.
Promote comfort.
Cover unsightly wounds.
Provide a moist environment for wound healing.
Apply pressure (pressure dressings) to help
control bleeding.
Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Slide 35
Sterile Dressings (Cont’d)
Dressing type and size depend on many
factors.
The type of wound
Wound size and location
Amount of drainage
Presence or absence of infection
The dressing’s function
The frequency of dressing changes
The physician and nurse choose the best
type of dressing for each wound.
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Types of Dressings
Dressings are described by the material used and
application method.
The following are common:
• Gauze
Comes in squares, rectangles, pads, and rolls
• Nonadherent gauze
A gauze dressing with a nonnon-stick surface
• VapourVapour-permeable transparent adhesive film
Allows wound observation but does not allow fluid and microbes to
enter
Some dressings contain special agents to promote wound
healing.
Dressings are wet or dry.
• Dry dressing, wetwet-to
to--dry dressing, wetwet-to
to--wet dressing
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Securing Dressings
Microbes can enter the wound, and drainage
can escape if the dressing is dislodged.
Tape and Montgomery ties are used to secure
dressings.
Binders hold dressings in place.
Adhesive tape sticks well to the skin.
Paper, plastic, and cloth tapes usually do not
cause allergic reactions.
Elastic tape allows movement of the body part.
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Securing Dressings (Cont’d)
Tape comes in different sizes.
Tape is applied to the top, middle, and bottom parts of the
dressing (picture frame).
The tape extends several inches beyond each side of the
dressing.
Tape is not applied to circle the entire body part.
Montgomery ties are used for large dressings and frequent
dressing changes.
You may assist the nurse with dressing changes.
Some agencies let you apply simple, dry, nonnon-sterile
dressings to simple wounds.
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Binders
Binders are applied to the abdomen, chest, or
perineal areas.
Binders promote healing by:
Supporting wounds
Holding dressings in place
Reducing or preventing swelling
Promoting comfort
Preventing injury
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Slide 40
Binders (Cont’d)
Straight abdominal binder
Breast binder
Provides abdominal support and holds dressings
in place
Supports the breasts after surgery
Promotes comfort and supports swollen breasts
T-binders
Secures dressings in place after rectal and
perineal surgeries
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Slide 41
Heat and Cold Applications
Are often ordered for wound care
Promote healing and comfort.
Reduce tissue swelling.
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