Wound and wound care

• Abrasion "Rug Rash"

  friction, rubbing, or scraping of skin
• Contusion

  blunt instrument, overlying skin remains intact with injury to

  underlying soft tissue
• Incision “Intentional”

  cutting or sharp instrument; wound edges in close approximation/ aligned.
• Laceration "Jagged"

  tearing of skin and tissue with blunt or irregular instrument, tissue not aligned, often loose flaps of skin or tissue
• Penetrating Wound "Stab wound"

  foreign object entering the skin or mucous membrane and lodging in underlying tissue
• Puncture "Stepping on a nail or tack"

  blunt or sharp instrument puncturing the skin, intentional/accidental
• Fistula "vaginal to rectal"

  abnormal passage from an internal organ to the skin
• Abscess

  collection of infected fluid that has not been drained
• Children under 2

  skin is thinner/ weakerThe infant’s skin is easily injured/ easier for infection.
• What is Approximation

  edges of wounds come together*Important because shows if wound is healing
• What is Non-approximated edges

  can be referred to as jagged
• Skin (or integument)

  largest organ. essential for maintain life. first line of defense, acts as barrier from microorganisms, infections
• Epidermis

  no blood vessels, regenerates quickly/ easily
• Dermis

  elastic connective tissue, nerve, glands, blood vessels
• Subcutaneous Tissue

  adipose tissue, fat is stored here, heat / cushion
• Intentional Wound

  results of planned invasive therapy/ treatment, purposefully for therapeutic purposes

  Wound edges clean/ bleeding controlled/ low risk for infection/ healing facilitated
• What is an example of an intentional wound

  surgery, IV therapy
• Unintentional Wound

  accidental from unexpected trauma

  Wound edges jagged/ bleeding uncontrolled/ longer healing time/ high risk for infection
• What are some examples of unintentional wound

  accidents, gun shots, stabbing
• What is an open wound

  intentional/unintentional
• What is an example of open wound

  incisions, abrasions
• Closed Wound

  from blow, force, strain

  Skin is not broken/ soft tissue is damaged/ internal injury and hemorrhage may occur Example: ecchymosis/ hematoma
• what are examples of closed wound

  falls, assault, MVCs
• Acute Wound

  Well healed within days- weeks/ wound edges well approximated/ low risk for infections
• what is an example of an acute wound

  surgery
• Chronic Wound

  No normal sequence of repair/ healing process impeded/ edges are not approximated/ high risk for infection/ remain in inflammatory phase
• what is an example of a Chronic wound

  arterial, venous, pressure injuries
• Inflammation

  pain, heat, redness, swelling at site/ injury Pulses would still be good w/ edema
• Pressure injury

  localized damaged skin and underlying tissue usually occurs over a bony prominence. develops when soft tissue is compressed between bony prominence and external surface for a prolonged period of time OR when soft tissue undergoes pressure in combination of shear/ friction
• Where are Pressure injury

  sacrum and coccyx, followed by the trochanter and the calcaneus (heel)
• What are the interventions for pressure injury

  change position every 2 hours (happens with obese patients often)
• Arterial injury

  result of inadequate circulation of oxygenated blood from heart to extremity (circulation in arteries)
• What is the appearance and location of Arterial injury

  Appearance: small, round, pale, smooth border.F ound: ankles, toes, shins
• What are the interventions of Arterial Injury

  Assess peripheral pulse/ capillary refill (posterior tibial/dorsalis pedis)
• Venous Injury

  occurs from venous stasis, because valves in veins are not working properly, deep vein obstruction. results in venous pooling/ edema which causes pressure
• What is the appearance and location of the venous injury

  Appearance: shallow, irregular edges, red, edema Found: inner ankle, lower part of calf
• What is the intervention for Venous Injury

  Assess for edema
• What is the sign of infection in a chronic wound

  Pain, heat, redness, swelling at site/injury, drainage is increased/ possibly purulent, foul odor, wound edges may be separated, with dehiscence present. Increased WBC, increase temp (febrile), increased pulse
• Factors affecting wound healing

  Pressure: impedes blood flow/ oxygen

  Maceration (over hydration): softening/ breakdown of skinex. swimming for long time. fingers get wrinkles

  Trauma: removing tape too often

  Edema: interferes with blood supply

  Infection

  Excessive bleeding

  Necrosis ( death of tissue): delays healing*Dead tissue appears slough, moist, yellow, stringy tissue

  Eschar: dry, black, leathery tissue(healing will NOT happen with necrotic tissue, removal of dead tissue must occur for healing to begin

  Slough: dead tissue

  Desiccation: dried up
• What if drain is present with wound?

  Clean wound first then clean drain