Chapter 20: Wound Care

20.1 Wound Care Introduction

Learning Objectives

• Assess tissue condition, wounds, drainage, and pressure injuries.
• Cleanse and irrigate wounds.
• Apply a variety of wound dressings.
• Obtain a wound culture specimen.
• Use appropriate aseptic or sterile technique.
• Explain procedures to patients.
• Adapt procedures for different age groups.
• Recognize and report significant deviations in wound healing.
• Document actions and observations.

Overview

Wound healing is a complex process influenced by various factors. Nurses collaborate with health care teams to manage these factors and optimize healing. Certified wound care nurses are specialists who handle complex wounds.

20.2 Basic Concepts Related to Wounds

Phases of Wound Healing

1. Hemostasis: Immediate clotting to stop bleeding.
2. Inflammatory: White blood cells clean wound; characterized by edema and erythema.
3. Proliferative: Formation of new tissue, including epithelialization and collagen formation.
4. Maturation: Collagen strengthens wound, leaving a scar.

Types of Wound Healing

• Primary Intention: Wounds are closed surgically.
• Secondary Intention: Wounds heal from the bottom up, used when edges cannot be approximated.
• Tertiary Intention: Wounds remain open or are reopened, closed later.

Wound Closures

• Sutures, staples, or dermabond are used to facilitate healing.

Common Types of Wounds

• Skin Tears: Caused by mechanical forces, common in older adults.
• Venous Ulcers: Due to poor blood return, common in lower legs.
• Arterial Ulcers: Caused by lack of blood flow, usually distal.
• Diabetic Ulcers: Often occur on feet due to neuropathy.
• Pressure Injuries: Localized damage from prolonged pressure.

Factors Affecting Wound Healing

Local Factors

• Blood flow, infection, foreign bodies, venous sufficiency.

Systemic Factors

• Nutrition, stress, diabetes, age, obesity, medications, alcohol, smoking.
• Lab values like hemoglobin, WBCs, platelets, albumin, glucose, BUN, creatinine, and wound culture results.

Wound Complications

• Hematoma: Blood collection outside vessels.
• Infection: Can be localized or systemic.
• Dehiscence: Wound reopening.

20.3 Assessing Wounds

• Components: Location, type, tissue damage, wound bed, size, edges, infection signs, and pain.
• Documentation: Use anatomical terms and images to support communication.

20.4 Wound Therapy

• Objectives: Prevent infection, cleanse, debride, maintain moisture, control odor, manage pain.
• Specifics: Use appropriate dressings and consider overall patient health.

20.5 Wound Dressings

• Selection: Based on wound type and characteristics.
• Types: Gauze, nonadherent, hydrocolloids, hydrogels, silicone, foam, alginate.

20.6 Sample Documentation

• Expected Findings: Clean, pink, healing wound.
• Unexpected Findings: Signs of infection, such as redness, drainage.

20.7 Checklist for Wound Assessment

• Steps: Gather supplies, perform safety steps, document findings.

20.8 Checklist for Simple Dressing Change

• Steps: Gather supplies, assess pain, cleanse wound, apply new dressing.

20.9 Checklist for Wound Culture

• Steps: Use sterile technique, document findings.

20.10 Checklist for Intermittent Suture Removal

• Steps: Confirm order, explain procedure, remove sutures, apply Steri-Strips.

20.11 Checklist for Staple Removal

• Steps: Use staple extractor, apply Steri-Strips, document.

20.12 Checklist for Wound Cleansing, Irrigation, and Packing

• Steps: Cleanse wound, apply packing, document.

20.13 Checklist for Drain Management

• Steps: Use sterile technique, document findings, ensure system function.

20.14 Learning Activities

• Analyzing patient case for factors affecting wound healing.

Glossary

• Definitions of key terms related to wound care, such as angiogenesis, debridement, eschar, etc.

References

• Cited sources for further reading.