49. Fig. 13-9. Wound measurements are made in centimeters. The
first measurement is oriented from head to toe, the second is
from side to side, and the third is the depth (if any). If there is
any tunneling (when cotton-tipped applicator is placed in wound,
there is movement) or undermining (when cotton-tipped
applicator is placed in wound, there is a “lip” around the wound)
this is charted in respect to a clock with 12 o’clock being toward
the patient’s head. This wound would be charted as a full-
thickness, red wound, 7 cm × 5 cm × 3-cm, with a 3-cm tunnel at
7 o’clock and 2 cm undermining from 3 o’clock to 5 o’clock.
49
Chemotaxis figure (eFig. 13-1) is available on Evolve website.
Types of wound healing. A, Primary intention. B, Secondary intention. C, Tertiary intention.
The area of injury is composed of fibrin clots, erythrocytes, neutrophils (both dead and dying), and other debris. Macrophages ingest and digest cellular debris, fibrin fragments, and RBCs. Extracellular enzymes derived from macrophages and neutrophils help digest fibrin. As the wound debris is removed, the fibrin clot serves as a meshwork for future capillary growth and migration of epithelial cells.
{See next slide of figure}Although wound is pink and vascular, the wound is friable, at risk for dehiscence, and resistant to infection.In a superficial wound, re-epithelialization may take 3 to 5 days.
A, Wound clean but not granulating (note lack of red cobblestone appearance), suggesting heavy bacterial contamination or other impediments to wound healing. B, Same wound granulating after 1 week of topical antibiotic use (note healthy red cobblestone appearance).
This is the reason abdominal surgery discharge instructions limit lifting for up to 6 weeks. Active movement of the myofibroblasts causes contraction of the healing area, helping to close the defect and bring the skin edges closer together.The scar may be more painful at this phase than in the granulation phase.
The inflammatory reaction may be greater than in primary healing. This results in more debris, cells, and exudate. The debris may have to be cleaned away (debrided) before healing can take place. The process of healing by secondary intention is essentially the same as healing by primary intention. The major differences are the greater defect and the gaping wound edges.
It also occurs when a primary wound becomes infected, is opened, is allowed to granulate, and is then sutured. Tertiary intention usually results in a larger and deeper scar than results from primary or secondary intention.
A superficial wound involves only the epidermis. Partial-thickness wounds extend into the dermis. Full-thickness wounds have the deepest layer of tissue destruction because they involve the subcutaneous tissue and sometimes even extend into the fascia and underlying structures such as the muscle, tendon, or bone.
The red-yellow-black classification can be applied to any wound allowed to heal by secondary intention, including surgically induced wounds left to heal without skin closure because of a risk for infection. A wound may have two or three colors at the same time. In this situation, the wound is classified according to the least-desirable color present.
{See Table 13-8} Nutritional deficiencies may include vitamin C, protein, and zinc.
{See Table 13-8}
{See Table 13-9}
{See Table 13-9}
Record the consistency, color, and odor of any drainage, and report if abnormal for the situation. Staphylococcus and Pseudomonas species are common organisms that cause purulent, draining wounds.{See next slide for wound measurement figure}If a wound fails to heal in a timely manner, assess and identify factors that may delay healing. The patient should be referred to a health care provider who specializes in wound management.
Wound measurements are made in centimeters. The first measurement is oriented from head to toe, the second is from side to side, and the third is the depth (if any). If any tunneling (when cotton-tipped applicator is placed in wound, there is movement) or undermining (when cotton-tipped applicator is placed in wound, there is a “lip”) is noted around the wound, this is charted with respect to a clock, with 12 o’clock being toward the patient’s head. This wound would be charted as a full-thickness, red wound, 7 cm x 5 cm x 3 cm, with a 3-cm tunnel at 7 o’clock and a 2-cm undermining from 3 o’clock to 5 o’clock.
Wound measurements are made in centimeters. The first measurement is oriented from head to toe, the second is from side to side, and the third is the depth (if any). If any tunneling (when cotton-tipped applicator is placed in wound, there is movement) or undermining (when cotton-tipped applicator is placed in wound, there is a “lip”) is noted around the wound, this is charted with respect to a clock, with 12 o’clock being toward the patient’s head. This wound would be charted as a full-thickness, red wound, 7 cm x 5 cm x 3 cm, with a 3-cm tunnel at 7 o’clock and a 2-cm undermining from 3 o’clock to 5 o’clock.
Superficial skin injuries may only need cleansing. Adhesive strips or tissue adhesives may be used instead of sutures. The treatment plan can include covering these wounds with a film dressing to provide a moist healing environment and wound protection from trauma. Deeper skin wounds can be closed by suturing the edges together. If the wound is contaminated, it must be converted into a clean wound before healing can occur normally. Debridement of a wound that has multiple fragments or devitalized tissue may be necessary.
Most commonly, sutures are used to close wounds because suture material provides the mechanical support necessary to sustain closure. In contrast, fibrin sealant is a biologic tissue adhesive that can function as a useful adjunct to sutures. Example of drain: The Jackson-Pratt drainage device is a suction drainage device consisting of a flexible plastic bulb connected to an internal plastic drainage tube (see next slide for figure).
The red-yellow-black concept of wound care presented in Table 13-7 provides a method of dressing selection based on the wound tissue color. Examples of types of wound dressings are presented in Table 13-10.
A dressing material that keeps the wound surface clean and slightly moist is optimal to promote epithelialization. Transparent film or adhesive semipermeable dressings (e.g., OpSite, Tegaderm) are occlusive dressings that are permeable to oxygen. The wound then is usually covered with a sterile dressing.
Yellow Wounds After these preparations are saturated with exudate, they should be removed by washing with sterile saline or water. The quantities of wound secretions determine the number of dressing changes. Hydrocolloid dressings (i.e., DuoDerm) are designed to be left in place for up to 7 days, or until leakage occurs around the dressing.
Wound types suitable for this therapy include acute or traumatic wounds, surgical wounds that have dehisced, pressure ulcers, and chronic ulcers.
It can be given systemically with the patient placed in an enclosed chamber (or the injured limb), where 100% O2 is administered at 1.5 to 3 times the normal atmospheric pressure. Elevated O2 levels stimulate angiogenesis, kill anaerobic bacteria, and increase the killing power of WBCs and certain antibiotics (e.g., fluoroquinolones, aminoglycosides). Hyperbaric O2 therapy accelerates granulation tissue formation and wound healing.
Becaplermin should be used only when the wound is free of devitalized tissue and infection. It should not be used if cancer is suspected in the wound. Individuals at risk for wound-healing problems are those with malabsorption problems (e.g., Crohn’s disease, GI surgery, liver disease), deficient intake or high energy demands (e.g., malignancy, major trauma or surgery, sepsis, fever), and diabetes.Vitamins needed include C, B-complex, and A.
The culture should be taken before the first dose of antibiotic is given. Cultures can be obtained by needle aspiration, tissue culture, or swab technique. The Z-technique involves rotating a culture swab over the cleansed wound bed surface in a 10-point Z-track fashion. Levine’s technique involves rotating a culture swab over a cleansed 1-cm2 area near the center of the wound, using sufficient pressure to extract wound fluid from deep tissue layers.
When you are changing a dressing, inappropriate facial expressions can alert the patient to problems with the wound or your ability to care for it. Wrinkling your nose may convey disgust to the patient. You should also be careful not to focus on the wound to the extent that the patient is not treated as a total person.
Because patients are being discharged earlier after surgery and many have surgery as outpatients, it is important that the patient, the family, or both know how to care for the wound and perform dressing changes. Wound healing may not be complete for 4 to 6 weeks or longer. Drug-specific side effects and adverse effects, as well as methods to prevent side effects, should be reviewed with the patient.Awareness of the necessity to continue the drugs (i.e., antibiotics) for the specified time is an important point to teach the patient.
Pressure ulcers generally fall under the category of healing by secondary intention.
The incidence of pressure ulcers is estimated to be about 23% among residents of long-term care facilities. The prevalence is between 5% and 10% of hospitalized patients and about 15% of residents of long-term care facilities.
Care of a patient with a pressure ulcer requires local care of the wound and support measures for the whole person such as adequate nutrition, pain management, control of other medical conditions, and pressure relief. Assessment: For example, in acute care, a patient should be reassessed every 24 hours; in long-term care, a resident should be reassessed weekly for the first 4 weeks after admission and then minimally monthly or quarterly; in home care, a person should be reassessed every nurse visit.