NSG 326 Adult Health IWound ClassificationSlide 3Wound HealingRepair of Wound- Primary IntentionPrimary IntentionRepair of Wound – Secondary IntentionSecondary IntentionRepair of Wound – Tertiary IntentionTertiary IntentionWound ClassificationWhat color wound?Factors Delaying Wound HealingSlide 14Nursing Management of Wound HealingSlide 16Wound ManagementDebridementSlide 19Nursing ManagementSlide 21Slide 22Slide 23Pressure UlcersRisk Factors for Pressure UlcersBraden Scale for Predicting Pressure Ulcer RiskPressure PointsSlide 28Staging of Pressure UlcersSlide 30Staging of Pressure UlcerPressure Ulcer StagesNursing Intervention for Pressure UlcerPrepared by Dr. K. A. EnnenNSG 326 Adult Health IWeek #6Wound Healing & Pressure Ulcers2Wound ClassificationWound - disruption of normal anatomic structure & function Wound assessment Location, cause, whenAppearance, size, drainage (Color, Odor, Consistency, Amount) (See Lewis Table 13-2, p. 189)Pain or tenderness, swelling, temperatureTreatments/care Associated symptoms – pains, itching, skin around wound, etc.Drains, wound closure (sutures, staples?)Last Tetanus Shot ???34Wound HealingRegeneration is replacement of lost cells & tissues with cells of same typeRepair: lost cells replaced by connective tissue; most common and result sin scar formationComplex processOccurs by primary, secondary, or tertiary intention5Repair of Wound- Primary IntentionPrimary Intention [Lewis, p.192, Table 13-6]Wound margins neatly approximated; surgical incision or a paper cutInitial phase•3-5 days; acute inflammatory reactionGranulation phase•Fibroblastic, proliferative, reconstructive; 5 days to 3 weeks; fibrous or scar tissue phaseMaturation phase•Scar contraction; may begin 7 days after injury & continue for several months or years6Primary Intentionwww.web.indstate.edu7Repair of Wound – Secondary IntentionSecondary Intention [Lewis, p. 192]Trauma, ulceration, & infection (e.g., a primary incision) have large amounts of exudate & wide irregular margins with extensive tissue lossInflammatory reaction greater with more debris, cells, & exudate; may need to clean debris away (debrided) before healing can occurGreater defect, gaping wound edgesHealing & granulation takes place from edges inward, bottom upward until defect filledMore granulation tissue = much larger scar8Secondary Intentionwww.web.indstate.edu9Repair of Wound – Tertiary IntentionTertiary Intention [Lewis, p. 193]Healing occurs with delayed suturing of a wound in which two layers of granulation tissue are sutured together.•Contaminated wound left open, allowed to granulate & is then sutured.Results in a larger and deeper scar than primary or secondaryHas been infected, starts to heal, they are going to close it anyway. “Delayed Primary”10Tertiary IntentionOccurs when there is delayed suturing of a wound in which two layers of granulation tissue are sutured togetherwww.web.indstate.edu11Wound Classification CauseSurgical or nonsurgical; acute or chronicDepthSuperficial, partial thickness, full thicknessColor [see Lewis, p. 194, Table 13-7]Red, yellow, black, or “mixed color”Applied to secondary intention healing woundIf a wound is made up of all three, treat the worst first, black, yellow then red.12What color wound?13Factors Delaying Wound HealingNutritional deficiencies of Vitamin C, Protein, ZincNatural food sources of zinc include oysters, red meat and poultry, beans, nuts, whole grains, pumpkin seed or sunflower seeds.Inadequate blood supplyCorticosteroid drugsInfection SmokingMechanical friction of woundAdvanced ageObesityDiabetes MellitusPoor general healthAnemia1415Nursing Management of Wound HealingAssessmentCOCA: color , odor, consistency, amountMeasure wound (Fig. 13-9, p. 196); lab findings; drainage cultureCleaning wound to remove dirt or debris; treating infection to prepare wound for healing; protecting clean wound from traumaWound dressings (be sure you read about these)Red-yellow-black concept of wound careSee Table 13-10, p. 197; Delegation decisions p. 198Negative-pressure wound therapyHyperbaric oxygen therapyInfection preventionPsychologic implicationsPatient teaching1617Wound ManagementRest and Immobilization Promote healing by inflammatory process, assisting in the repair process, metabolic needs18Debridement Surgical- quickest method and is indicated when there are large amounts of debris, patient may be septic Mechanical-minimal debrisWet-to-dry [really wet-to-moist] dressingsWound irrigationWhirlpoolAutolytic-open wounds with necroticdebris and no infectionEnzymatic-topical drugs are applied1920Nursing ManagementFever-Mild fevers up to 101°F antipyretics are not necessary unless patient is uncomfortableModerate fevers to 103°F antipyretics should be considered esp. in the young, the elderly and those with a significant medical problemSevere or high fevers greater than 104°F can damage body cells, cause delirium and seizures- antipyretics should be given21Nursing ManagementNutritional therapy-Increase fluidsDiet high in protein, carbohydrate, and vitamins-specifically vitamins C, A, B complex vitamins22Nursing ManagementProtect from further traumaPosition to support healing processProtect from pathogensMonitor pain response and TREATPlan for discharge23Nursing ManagementDrug Therapy-Antibiotics are a key class of drugs used in the treatment of woundsHowever resistance has become a major health concernNurses are responsible in helping to prevent transmission of organisms, resistant or not, by HANDWASHINGEducate families on the correct usage of antibiotics24Pressure UlcersBed sore, decubitus ulcerA localized area of injured skin and tissueDevelop from sitting or lying in one position for too longOccluding blood flow to tissuesCan develop from sliding down in a chair or in bed, or being dragged across a bed sheet“Shearing force” and “friction”Excessive moistureCommon sites include sacrum and heels25Risk Factors for Pressure UlcersSee Table 13-12,Lewis p. 199Individuals at risk include:ElderlyIncontinentBed- or wheelchair-bound (activity or mobility)Spinal cord injury; coma; hip fractureImbalanced nutritionAnesthesiaLower