Wound Care

Risks
1. Know the patients age. With age, vascular changes occur, collagen tissue is less pliable, and
scar tissue is tighter. Because the dermoepidermal junction becomes flatter in older adults, their skin
tears more easily from mechanical trauma such as tape removal.

2. Know the patients nutritional status. Tissue repair and infection resistance are directly related
to adequate nutrition, including proteins, carbohydrates, lipids, vitamins, and minerals. Patients who
are malnourished are at increased risk for wound infections and wound infection-related sepsis (Stotts,
2012).

3. Understand the risks of obesity. Inadequate vascularization decreases delivery of nutrients and
cellular elements required for healing. The patient is at greater risk for wound infection and dehiscence
or evisceration (Gallagher-Camden, 2012).

4. Identify factors that decrease oxygenation, such as decreased hemoglobin level, smoking, and
underlying cardiopulmonary conditions. Adequate oxygenation at the tissue level is essential for white
blood cell activity and phagocytosis, for fibroblast proliferation and collagen synthesis, and for re-
epithelialization (Doughty & Sparks-Defriese, 2012). Tissue repair is negatively influenced by a
hematocrit value below 33% and a hemoglobin value below 10g/100mL or less than 100-120 mmoL/L.
Hemoglobin level is reduced, and oxygen release to tissues is reduced in smokers.

5. Know the types of medications prescribed. Steroids reduce the inflammatory response and
slow collagen synthesis. Cortisone depresses fibroblast activity and capillary growth. Chemotherapy
depresses bone marrow production of white blood cells and impairs immune function.

6. Identify the presence of chronic diseases or chronic trauma, such as diabetes or radiation.
Decreased tissue perfusion and failure to release oxygen to tissues result from diabetes.

7. Unwounded skin is always stronger than healed skin.

Types of Wound Healing

primary intention occurs when the edges of a clean surgical incision remain close together. The wound
heals quickly, and tissue loss is minimal or absent

left open and allowed to heal by scar formation are classified as healing by secondary intention. tissue
loss and there are open wound edges. Granulation tissue gradually fills in the area of the defect. This
process is typical of severe laceration or massive surgical intervention with skin loss. In secondary
intention, there is a gap between the edges. Connective tissue develops, which supports new
capillaries. This form of healing results in the formation of scar tissue to close the wound. The
slowness of this process places a patient at greater risk for infection because there is no epidermal
barrier until later in the healing process.

tertiary intention is sometimes called delayed primary intention or closure. It occurs when surgical
wounds are not closed immediately but left open for three to five days to allow edema or infection to
diminish. Then the wound edges are sutured or stapled closed. Scarring is usually minimal

Complicationsofwoundhealing
Hemmorage
A slipped surgical suture

A dislodged clot

Infection

Erosion of a blood vessel by a foreign object (e.g., a drain)

Howtodetect?
Looking for distention or swelling of the affected body part
 Noting a change in the type and amount of drainage from a surgical drain

Observing signs of hypovolemic shock (e.g., increased pulse; decreased blood pressure; cool,
clammy skin)

surgical wounds, in which the risk of hemorrhage is greatest during the first 24 to 48 hours after
surgery or injury.

hematoma is a localized collection of blood underneath the tissues that often takes on a bluish
discoloration. The area is swollen and involves a change in colour, sensation, or warmth.

Infection
local inflammation: redness and warmth in the area; presence of drainage, pain, or tenderness; and
an unusual odour

surgical site infection (SSI) involves the surgical site and presents within 30 days if there is no
implanted device or one year if there is a device left in place

When the wound contains dead or necrotic tissue

When there are foreign bodies in or near the wound

When the blood supply and local tissue defences are reduced

contaminated or traumatic wound may show signs of infection early, within two to three days. A
surgical wound infection usually develops postoperatively within four to five days.

Signs of infection include:

Fever

Tenderness and pain at the wound site

An elevated white blood cell (WBC) count

The edges of the wound may appear inflamed

If drainage is present, it is odorous and purulent, which causes a yellow, green, or brown
colour, depending on the causative organism.

Dehiscence
Dehiscence is the failure of wound healing in which the surgical wound separates and opens to the
fascial level. Dehiscence occurs fairly early after surgery, by postoperative day five to day eight

wound edges open, and serosanguineous drainage is present. These wounds are then allowed to heal
by secondary intention

Factors contributing to surgical wound dehiscence include anemia, malnutrition, obesity, and use of
steroids

Evlaceriation
Evisceration is a failure of wound healing, with total separation of the layers of the wound and
protrusion of the internal organs through the wound
nurse needs to cover the wound with a moist, sterile saline dressing, notify the surgeon immediately,
and prepare the patient for emergent surgery.

Fistual
fistula is an abnormal passage between two organs or between an organ and the outside of the body

result of poor wound healing or as a complication of disease. Trauma, infection, radiation exposure,
and diseases such as cancer

F&E

Factors That Influence Wound Healing

Hypovolemia, hypotension, vasoconstriction, edema, and hypoxia will
negatively affect wound healing because adequate perfusion and
oxygenation are necessary for new vessel development, as well as for
collagen synthesis and development of tensile strength.
An adequate nutritional status is critical for collagen synthesis, tensile
strength, and immune function. Inadequate nutrition will negatively
affect wound healing.
Wound infection prolongs the inflammatory response, and the
microorganisms use nutrients and oxygen needed for wound repair.
The patient with diabetes mellitus may have impaired wound healing
because of abnormal and prolonged inflammation, reduced collagen
synthesis, and impaired epithelial migration. Hyperglycemia is
associated with compromised neutrophil function and impaired
migration.
Corticosteroid therapy or the use of other immunosuppressive agents
such as chemotherapy will increase the patients susceptibility to
infection.
Advanced age can contribute to a diminished proliferation of cells
critical to repair.

Wound Drainage Systems

Penrose (Open)
Insert a sterile safety pin through this drain, outside the skin, to prevent the tubing from moving into
the wound.

o remove the Penrose drain, the health care provider may pull the drain in stages as the wound heals
from the bottom up. Nursing interventions include caution to prevent accidental removal of the drain
during dressing changes and to protect skin surfaces in direct contact with the irritating drainage

do not delegate the care of Penrose drains that are covered with gauze pads to unregulated care
providers (UCPs)

closed drain system, such as the Jackson-Pratt (JP) drain or Hemovac drain, relies upon the presence
of a vacuum to withdraw accumulated drainage from around the wound bed into the collection device
JP drain collects in the range of 100 to 200 mL/24 hr
Hemovac drain accommodates more drainage, usually up to 500 mL/24 hr.
 Delegation
assessment of wound drainage and maintenance of drains and the drainage system cannot be
delegated to unregulated care providers (UCP). However, you may delegate to a UCP emptying a
closed drainage container or pouch, measuring the amount of drainage, and reporting the amount on
the patient's intake and output (I&O) record.
Discussing any modification of the skill such as increased frequency of emptying the drain to
more than once a shift

Instructing the UCP to report to the nurse any change in amount, colour, or odour of drainage

Reviewing the I&O procedure

Type Appearance
Serous Clear, watery plasma
Purulent Thick, yellow, pale green, or white: indicates infection
Serosanguineous Pale, red, watery: mixture of serous and sanguineous
Sanguineous Bright red: indicates active bleeding

wound culture may be ordered to identify bacteria growing within a wound. If the nurse detects
purulent or suspicious-looking drainage (i.e., there is a change in the amount or colour, or the
drainage has a foul odour)

Assessment
The nurse assesses the number of drains, drain placement, character of drainage (amount and type),
and condition of collecting apparatus (fullness and function of suction). This assessment includes the
following:
Identify presence, location, and purpose of closed wound drain or drainage system as patient
returns from surgery. Assess drainage present on patients dressing. Drainage tubing is usually placed
near the wound through small surgical incision.
Identify number of drain tubes and what each one will be draining. Label each drain tube with
a number or label. Assigning a labelling system to each drain helps with consistent documentation
when a patient has multiple drainage tubes.
Assess if drain tube needs self-suction, wall suction, or no suction by checking the health care
providers orders. Some drain tubes, such as Hemovacs, can be used with self-suction or wall suction.
Inspect system to determine presence of one straight tube or Y-tube arrangement with two
tube insertion sites. Allows nurse to plan skin care and identifies quantity of sterile dressing supplies
needed.
Inspect system to ensure proper functioning. A complete systematic inspection includes the
insertion site, drainage moving through tubing in direction of reservoir, patency of drainage tubing,
airtight connection sites, and presence of any leaks or kinks in the system. A properly functioning
system maintains suction until the reservoir is filled or drainage has ceased. Tension on the drainage
tubing increases injury to the skin and underlying muscle.

Expected Outcomes
Wound healing continues

Vacuum is re-established

Tubing is patent

Evaluation
Observe for drainage in suction device. Indicates presence of vacuum, patency of tubing, and
functioning of drainage suction device.
 Clinical Decision Point Clots or large collections of debris may block drainage flow. The Y site in the
drainage tubing is especially prone to clogging.
Inspect wound for drainage or collection of drainage fluid under the skin, causing a
seroma. Drainage should not be significant under suture line. May indicate inadequate functioning of
drainage suction device.
Measure drainage, empty drainage system, record on I&O form. Empty drainage collection
reservoir every 8 to 12 hours and as needed for large drainage volume. Collect diagnostic specimen in
the presence of unexpected purulence or pungent odour, report findings to the health care provider,
and record in progress or nurses note.
Assess patients level of comfort using the 0 to 10 scale. Ensures that procedure does not
increase patients pain.

Unexpected Outcomes
Unexpected Outcome Intervention
Site where tube exits becomes infected Notify health care provider

Use aseptic technique when changing dressings

Bleeding appears around drainage Determine amount of bleeding and notify health
collector care provider if excessive

Assess for tension on patients drainage tubing

Secure tubing to prevent pulling

Drainage suction device is not Assess drainage tubing for clots

accumulating drainage
Assess drainage system for air leaks or kinks

Notify health care provider

Patient experiences pain Assess pain level and provide medication

Stabilize drainage tubing to reduce tension and

pulling against incision

Dressings
Ideal Dresssing
Dressing Characteristics and Outcomes
Characteristics
Is nontraumatic and reduces volume of exudate, but does not allow
the wound to dry

Maintains a stable physiological wound environment

Keeps the wound bed continuously moist, but also keeps the
surrounding (periwound) intact skin dry

Easy to apply and remove with easy-to-follow instructions for

patient and family
 Cost-effective: reimbursable or affordable

Appropriate for infected wounds

Outcomes
Resolves the amount of periwound erythema by one week

Reduces by 50% wound dimensions or depth of sinus tract within

two weeks

Reduces volume of exudates

Reduces by 25% the amount of necrotic tissue (eschar) by one

week

Reduces pain intensity during dressing changes

Indications Contraindicatio Advantages Disadvantage Frequency of

Product for Use ns s Change (per
Category Manufacturers
Recommendation
s)
Gauze Dressings
Cotton or Prote Granulati Availabl May Usually 2
synthetic
material; ction of ng wounds as e in many sizes adhere to to 3 times per day
woven or surgical primary and forms healthy tissue, as needed.
nonwoven incision treatment causing injury
construction Sterile
when removed
. Mech and nonsterile
anical Lint

debridement fibers may be
(moist to left on wound
dry)
May
Seco interfere with
ndary wound healing
dressing for if gauze dries
other wound out in a moist-
products to-dry dressing

Packi *may come

impregnated
ng wounds with a variety
of substances
*Hea such as zinc
ling by oxide paste,
primary iodinated
agents,
intention petrolatum,
and crystalline
sodium
chloride.
 Impregnated
gauze can
hydrate a
wound and
absorbed
exudate or
deliver
antimicrobial
agents.
Transparent Films
Adhesive Shall Infected Easy to May Every 3 to
membrane
dressings; ow wounds wounds; wounds apply and cause skin 4 days or as
waterproof, that tunnel, remove without maceration needed
impermeabl Dry
undermine, or damage to
e to fluids to minimally May If using to
are full underlying
and exudative not adhere to facilitate autolytic
bacteria; thickness; tissue
allow wound. moist areas debridement,
wounds with
oxygen and Permit change every 24
Prom moderate to May
moisture viewing of a hours
vapour ote autolytic heavy exudate; cause skin
exchange wound
debridement third degree stripping if
burns Create improperly
Stag
a second skin, removed
e I or II
protects from
pressure
friction
ulcers
Waterp
roof

Create
a moist wound
that softens
thin slough and
eschar

Protecti
ve shield to
external fluids
and bacteria

Hydrocolloids
Adhesive Parti Third- Availabl Potenti Every 3-5
dressings
that contain al or full- degree burns, e in many sizes al for days
gel-forming thickness acutely infected periwound
agents; Promot
wound; wounds; arterial maceration if
mold to es autolytic
shallow. or diabetic ulcers dressing left in
body debridement
contours, (use with place too long
considered Mini
caution) Reduce
semiocclusiv mal to Draina
e dressings s pain
moderate Wounds ge (gelatinous
 exudating with dry eschar Imper mass) under
wounds meable to dressing is
Use with
fluids and often mistaken
Clean caution in people
bacteria for pus or
stage II and with diabetes or
infection
noninfected arterial disease Therma
shallow stage l insulator Adhesi
II, III, IV ve may be too
Easy to
pressure aggressive for
apply and
ulcers fragile skin
remove
Can
be used in
combination
with
absorbent
powder or
alginate

Hydrogel
Glycerin- or Parti Third- Non- Potenti Change
water-based
dressings al or full- degree burns adherent al for daily if adhesive
designed to thickness maceration or sheets or wound
maintain a Wounds Cool
wound; candidiasis of fillers are not used
clean, moist with heavy and soothing
shallow or periwound
wound; may exudate Change
also absorb deep Decrea area
a small adhesive covers up
ses pain
amount of Dry to 3 times per
exudate to minimally week
Facilitat
exudative es autolysis
wound with
or without a Confor
clean ms to wound
granular
wound base.

Shall
ow or deep
wounds

Woun
ds with
undermining

Necr
otic wounds

Alginates
Highly Mode Third- Nonadh More Change
absorbent,
nonwoven rate to degree burns ering, expensive than daily or as often as
material heavily nonocclusive gauze or gauze needed, usually
that forms a Nondrain
exudating packing strips every 24 to 48
gel when ing wounds Hemost
wounds; hours
exposed to atic properties Not
wound shallow or Dry
drainage; practical for
deep necrotic wounds May be
fibrous large wounds
product packed into
Parti
derived tunneled areas Gelled
from brown al- and full-
material may
seaweed. thickness Promot
be mistaken
wounds e autolytic
for purulence
debridement in
Leg
exudating
ulcers, donor
wounds
sites,
traumatic Highly
wounds absorbent

Foam Dressings
Absorbent, Mode Ischemic Highly Nonad Every 24
non-
adherent rate or wound with dry absorbent while hesive foams hours or prn
polyurethan heavily eschar maintaining require a
e or film- exudating moist wound secondary
coated layer Third-
wounds environment dressing
used to degree burns
protect
wounds and Parti Often Macera
Wounds
maintain a al- and full- used as a tion of
moist that tunnel or
thickness secondary periwound
healing have sinus
environment wounds; dressing along may occur if
tracts
shallow and with films and dressing is left
deep Nondrain absorbers. on too long

ing wounds
Stag Many
e II-IV are non-
pressure adherent to
ulcers wound bed

Gauze dressing = dry dressing

Moist-dry dressing
primary purpose is to mechanically debride wounds, specifically full-thickness
wounds healing by secondary intention and wounds with necrotic tissue
sterile isotonic solution, such as normal saline, lactated Ringer's, or hydrogel
to moisten dressings
Autolytic debriding products are applied to wounds to allow the enzymes to
digest dead tissue.
 Enzymatic debriding agents are applied directly to the wound bed and act by
breaking down dead tissue.

Motgomery ties > reduces skin irritation from frequent tape removal (used to secure
dressing)

Transparent dressing
moist exudate forms over the wound surface, which prevents tissue
dehydration and allows for rapid, effective healing by speeding epithelial cell
growth
has no absorbent capacity and it is impermeable to fluids and bacteria
good for: prophylaxis on high-risk intact skin superficial wounds with minimal
or no exudate, and eschar-covered wounds when autolysis is indicated and
safe
Select one that allows for a 2.5-cm (1-in) perimeter onto intact skin around the wound

Hydrocolloid dressings
provide a moist environment for wound healing while facilitating the softening and subsequent
removal of wound debris. They are indicated as primary dressings for minimally to moderately
exudative partial- and full-thickness wounds. Hydrocolloids are used as secondary dressings
over fillers, such as hydrocolloid powders and pastes
use of hydrocolloids for clean stage II and noninfected shallow stage III pressure ulcers in
anatomic locations where the product does not roll or melt
absorptive and hydrating properties
come in the form of granules, paste, or wafers
Change dressings when the wound gel appears to have migrated beyond the margins of the
wound or the seal is leaking

Hydrogeldressing
glycerin- or water-based dressings designed to hydrate a wound, thus promoting moist wound healing
and autolysis
recommended for dry to minimally exudative wounds with or without depth and are a good choice for
painful wounds since the dressings do not adhere to a wound base