Download Types of Wounds

Chapter 52:
Patient Management:
Integumentary System
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Types of Wounds
• Definition of a wound
• Classified according to time patient has had wound
– Acute wound
– Chronic wound
• Classified according to depth of wound
– Partial-thickness wounds
– Full-thickness wounds
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Pressure Ulcer
• Definition
• Causes/high-risk patients
– Immobile
– Decreased circulation
– Incontinent
– Malnourished
• Staging of pressure ulcers
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Question
A patient has nonblanchable erythema of the coccyx.
What stage pressure ulcer is this?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
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Answer
A. Stage I
Rationale: Nonblanchable erythema is consistent with a
stage I pressure ulcer. All others are much deeper.
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Comparison of Leg Ulcers
Location
Wound
margins
Color
Treatment
Venous
stasis
ulcers
Medial aspect of
lower leg
Irregular;
shallow craters
Ruddy;
hemosiderin
staining
Unna boot;
multiple wrap
dressing. Elevate
above heart.
Arterial
ulcers
Distal leg; medial
malleoli and
dorsal aspect of
toes, foot
Round, smooth;
punched-out
appearance
Pale and cool to
touch
Occlusive
dressing;
dependent leg
position increases
flow. Surgery for
revascularization.
Diabetic
foot ulcers
Plantar aspect of
foot, heels and
metatarsals
Nothing
significant
May be infected
with exudate
Moist
environment.
Débridement
needed. Special
shoes.
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The Healing Process: Stages of Wound
Healing
See Figure 52-1.
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Question
A wound is red, with a shiny, beefy appearance; when
touched, it bleeds easily. This wound is in what stage of
healing?
A. Injury
B. Inflammatory
C. Proliferative
D. Maturational
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Answer
C. Proliferative
Rationale: In the proliferative phase, the wound is growing
new blood vessels; this accounts for the bleeding. New
cells are being produced, giving the wound a red, beefy
appearance. This wound is beyond the injury or initial
phase, and there is no edema or exudate, so it cannot be
the inflammatory phase. Scar tissue marks the
maturational phase, and there is no information to
indicate this.
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Methods of Wound Healing
See Figure 52-2.
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Nursing Care of the Patient With a
Wound
ASSESSMENT
ASSESSMENT
• Exact anatomical location
• Tissue type
–
Photograph
• Sizing the wound
–
Necrotic tissue
–
Slough
–
Granulation tissue
–
Length
–
Width
• Drainage
–
Depth
• Wound margins
–
Undermining and
tunneling
• Drains or tubes
• Dressings
• Pain
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Solutions That Are Tissue Toxins
• H2O2
• Povidone-iodine
• Acetic acid
• Sodium hypochlorite (Dakin’s solution)
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Wound VAC Systems
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Wound Drainage
• Types of drains
– Penrose
– Jackson-Pratt
– Hemovac
– Chest tubes
• Wound cleansers
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Question
A nurse is to cleanse a wound around a chest tube. The
nurse could use all of the following cleansers to do this
without destroying epithelial cells EXCEPT:
A. Normal saline solution (NSS)
B. Betadine (povidone-iodine)
C. Bacitracin
D. Neosporin
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Answer
B. Betadine (povidone-iodine)
Rationale: Betadine contains iodine, which destroys
epithelial tissue. Normal saline solution (NSS) is the
same tonicity as tissue and blood, so it is an excellent
medium for cleansing a wound. Bacitracin and Neosporin
are over-the-counter broad-spectrum antibiotics and can
help with the healing process.
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Types of Wound Dressings
• Wet-to-dry
• Hydrogels
– No longer indicated
unless changed q4h
• Calcium alginates
• Foam dressings
• Absorptive wound dressings
• Silver (Ag) dressings
• Bilayered dressings
• Hydrocolloids
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Culturing a Wound
• Done if there are signs/symptoms of an infection
• Cleansed and irrigated with NSS
• Necrotic tissue isn’t cultured
• 10 points of contact
• Zigzag pattern from 12 o’clock to 6 o’clock
• Over 100,000 organisms/mL = positive culture
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Nursing Care to Prevent Pressure
• Keep wound off the bed
• Turning and repositioning
• Specialty beds
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Pharmacological Management
MEDICATIONS TO
RELIEVE PAIN
MEDICATIONS FOR
THE WOUND
• Premedication prior to
dressing changes,
cultures, and any
painful procedures
• Growth hormones
• Steroid creams
• Silver dressings
• PCA
• Epidurals
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Nutrition
• Nutritional assessment within first 48 hours
• Need all nutritional components: proteins, fats,
carbohydrates, minerals, and vitamins
• Caloric intake increases to 35 to 40 kcal/kg/day
• Protein requirements increase to 1.5 to 2 g/kg/day
• Monitor serum albumin, total protein, and electrolytes to
determine outcomes
• Daily weights, I & 0, and hydration status ongoing
assessments
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