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Wound Care Basics

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Daniel Le

on 4 April 2015

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Transcript of Wound Care Basics

Wound Assessment
* Many things affect if and how a wound heals. It may help to categorize these elements as
local and systemic elements
.
Influences on Wound Healing
Wound Healing Process
In the United States, the occurrence rate of chronic wounds has been assessed at
2% of the entire population
Over --
50 BILLION DOLLARS per year
- the approximated yearly cost to manage chronic wounds in the United States (Fife, Carter, Walker, & Thompson, 2012).
About 1% of overall population is affected by venous stasis ulcers
and of these, 3.5% are above 65 years old
Cost to care for venous stasis ulcers is approximated
above $40,000 dollars for each occurrence
15% of people with diabetes are affected by diabetic ulcers
Diabetic ulcers are responsible for over half of lower extremity amputations
(Hess, 2012).
Wounds: Definition
& Classifications


Wound Care Basics
Daniel Q. Le
BYU-Idaho
Nursing 450
Sister Urban
References
Fife, C. E., Carter, M. J., Walker, D., & Thompson, B. (2012). Wound care outcomes and associated cost among patients treated in US outpatient wound centers: Data from the US wound registry.
WOUNDS, 24
(1), 10-17.
Hess, C. T. (2012).
Clinical guide to skin and wound care
. Retrieved from https://books.google.com/books?id=KpmQOfSpSHMC&printsec=copyright#v=onepage&q&f=false.
=
Wound Prevalence
& Cost
"Wounds are disruptions of normal anatomic structure and function
resulting from pathological processes" (Korting, Schöllmann, & White, 2011, p. 130)
Korting, H. C., Schöllmann, C., & White, R. J. (2011). Management of minor acute cutaneous wounds: Importance of wound healing in a moist environment
. Journal Of The European Academy Of Dermatology & Venereology, 25
(2), 130-137. doi:10.1111/j.1468-3083.2010.03775.x
Wounds are classified in various ways, including
length of time
and
penetration
:
Length of time (duration):

"Acute"
wounds are those that typically do not last more than 3 weeks
"Chronic"
wounds usually last more than 3 months

Penetration (depth)
:
Superficial-thickness
only involve the epidermis and small amounts of dermis
Partial-thickness
reach deeper into dermis
Full-thickness
wounds involve epidermis, dermis, and at least subcutaneous tissue (and sometimes even deeper--muscle & bone) (Korting, Schöllmann, & White, 2011).
photo from www.urgo.co.uk
Moist Wound Healing


www.healthyfellow.com

In order to heal properly, a wound goes through three sequential phases of healing:
inflammatory, proliferative, and maturational
.
1.) Inflammatory Phase:
hemostasis and inflammation occur. Platelets gather to stop bleeding. Inflammatory cells gather as well as Neutrophils and Macrophages

2.) Proliferative Phase:
epithelialization, angiogenesis, development of granulation, and collagen accumulation occur

3.) Maturation Phase:
last phase of wound healing. Remodeling leads to granulation tissue contributing to scar formation. At about one year, a wound is thought to reach peak strength. Notably, a healed wound is considered to have 70% strength of previous skin (Sinno & Prakash, 2013).
Dressings
Sinno, H., & Prakash, S. (2013). Complements and the wound healing cascade: An updated review.
Plastic Surgery International
, 2013, 146764. doi:10.1155/2013/146764
Local elements:
scab formation- obstructs healing
Infection and/or high levels of bacteria--inhibits healing
Maceration
-a soggy or soaked state in a wound will impede healing
Necrosis (dead tissue)- will impede healing. There are 2 types--slough (wet) and eschar (dry)
Pressure- can decrease ability to blood to reach wound and prevent needed nutrients and oxygen to reach wound
Edema/Trauma- healing prolonged or prevented in the presence of edema or trauma as they can hinder oxygen and nutrients to wound (Hess, 2012).
Systemic elements:
Age
- elderly are more likely to suffer from underlying diseases and thus, make it more likely they will heal more slowly
Body factors-obesity slows wound healing as fat tissue is poorly vascularized
Chronic conditions- CAD, PVD, diabetes, and cancer can negatively alter the ability to heal wounds. It is important for such conditions to be addressed properly in order to heal.
Nutrition-inadequate nutrition can slow and stop healing. Labs that measure protein components, transferin, and lymphocytes need to be assessed and addressed as needed.
Vascular Issues-
wound blood supply problems of arterial, venous, diabetic, or pressure-related circumstances are vital to assess and address to allow healing (Hess, 2012).
Influences on Wound
Healing Cont.
Macerated wound
Age
Vasculature
Phases of Wound Healing
*The most vital skill in wound care-- will dictate
the plan of care and treatment.
**It is necessary to establish a systematic approach to assessing wounds for accuracy and consistency.
Remember to follow state practice regulations and facility-specific guidelines.
** The following are fundamental aspects of assessment guidelines, they do not represent a comprehensive wound assessment.
Wound Care Education Institute (2015). Wound documentation tips. Retrieved from http://www.wcei.net/woundconsultant
Location-
Note what kind of wound (include partial or full thickness) and where it is anatomically
Measurements
:
L x W x D

Length
= North to South (head to feet)

Width
= East to West (side to side)

Depth
= most deep portion of wound bed you can see
All undermining, tunneling, and sinus tracking measured using
the "Clock Face" method
where 12 o'clock is at patient's head
"Tunneling
- course or pathway that can extend in any direction from the wound, results in dead space
Undermining
– tissue destruction underlying intact skin along wound margins
Sinus Tract
– A drainage pathway from a deep focus of acute infection through tissue and/or bone to an opening on the surface"
(WCEI, 2015).
The Wound Care Education Institute (WCEI) defines the following:
Wound Assessment Continued

Exudate
(drainage from wound) be sure to measure
type, amount and odor
characteristics:
Type:
"
Sanguineous
– thin, bright red

Serosanguineous
– thin, watery, pale red to pink
Serous
– thin, watery, clear

Purulent
– thick or thin, opaque tan to yellow

Foul Purulent
– thick opaque yellow to green with offensive odor
Amount:
None
– wound tissues dry
Scant
– wound tissues moist, no
measurable drainage
Small
– wound tissues very moist, drainage <25% dressing
Moderate
– wound tissues wet, drainage involves 25 – 75% dressing
Large
– wound tissues filled with fluid – involves > 75% dressing

Odor:
Describe presence or absence of odor-
strong, foul, pungent, fecal, musty, sweet
" (WCEI, 2015).
Wound Assessment Continued

Wound Tissues:
"
Slough
– usually lighter in color, thinner and stringy in consistency; Color – Can be yellow, gray, white, green, brown
Eschar
– usually darker in color, thicker and
hard consistency black or brown in color. Granulation Tissue
– it is usually beefy red, granular, bubbly in appearance; should be differentiated from a smooth red wound bed; color of tissue – red, pink, pale pink or full dusky red
Epithelialization
– can appear as deep pink, then progress to pearly pink/ light purple from the edges in full thickness wound or may form islands" (WCEI, 2015).
Determining
type of tissue
helps gauge healing progress.
Infection
impedes healing and early recognition is key.
Proper wound care is holistic
, many factors have the potential to help or prevent wound healing
S/S of wound infection:
"fever, streaking, redness, increased drainage, odor, warmth, elevated WBC, induration, malaise, edema, weeping, increased pain, discolorations" (WCEI, 2015).
Holistic Healing Considerations:
Current medications, ability and frequency of repositioning, nutrition, continence, labs, diseases, sickness, management of diagnosed health conditions, compliance to treatments (WCEI, 2015).
granulation tissue
Background---In the past, wounds were thought to heal best in a dry state, in an effort to avoid bacterial infection. Beginning in the 1960’s, it was discovered that wounds healed more efficiently in moist conditions. There is evidence
“that good hydration is the single most important external factor responsible for optimal wound healing”
(Korting, Schöllmann, & White, 2011, p.132).
WHY MOIST HEALING?

Faster healing times
less pain
positive effect on scar formation
(Korting, Schöllmann, & White, 2011).
Remember:
the goal is to maintain an environment with balanced moisture--
Moist but not wet.
How do you choose an appropriate dressing?
This will be determined by the desired outcome in consideration of other factors:
State of the wound
-- underlying cause, size, location, amount/type of exudate, and infectivity
Patient's lifestyle
(amount of activity)
Other personal needs
of patient
(Korting, Schöllmann, & White, 2011).
Remember:
Make sure patient does not have
allergies
to any component of a dressing before applying. If a wound is wet, select a dressing that will absorb. If it is dry, select a dressing that will donate moisture.
Keep in mind the moisture balance.
Dressing Types
Here is a brief overview of some major
dressing categories
:
Calcium Alginates:
consist of fibers from brown seaweed used to absorb moderate to heavy exudate

Gauzes:
consist of cotton (and sometimes other materials) used to absorb moderate to heavy exudate

Hydrocolloids:
occulusive, promotes moist healing and autolytic debridment (allows body to breakdown unwanted material in wound)


Hydrogels:
mostly a water or glycerin formula in a gel, sheet, or impregnated gauze to moisten wounds and support autolytic debridement
Full transcript