Wound Care

Definition
Description
Diagnosis/Preparation
Risks
Normal results

Definition

A wound is a disruption in the continuity of cells—anything that causes cells that would normally be connected to become separated. Wound healing is the restoration of that continuity. Several effects may result from the occurrence of a wound: immediate loss of all or part of organ functioning, sympathetic stress response, hemorrhage and blood clotting, bacterial contamination, and death of cells. The most important factor in minimizing these effects and promoting successful care is careful prevention of infection, which can be accomplished using sterile techniques when treating a wound.

Description

Wound healing is a biological process that begins with trauma and ends with scar formation. There are two types of tissue injury: full and partial thickness. Partial thickness injury is limited to the outermost layers of skin, with no damage to the dermal blood vessels. Healing occurs by regeneration of the outer layers of tissue. Full thickness injury involves loss of the dermis, extends to deeper tissue layers, and disrupts blood vessels. Wound healing involves the synthesis of several types of tissue and scar formation.

The three phases of repair are lag, proliferative, and remodeling. Shortly after an injury, blood flow ceases when a clot is formed. The initial clot acts like a magnet for the migration of more platelets and protein strands, called fibrin, which seal the wound from the inside. Within the first four hours of injury, certain white blood cells called neutrophils begin to appear. These inflammatory cells kill microbes, and prevent infection of the wound. Next, white blood cells called leukocytes also arrive and act to kill microbes and break down wound debris. The inflammatory response is dependent on the depth and volume of tissue loss from the injury. Leukocytes also secrete cytokines that initiate the proliferative phase of repair.

During the proliferative phase, synthetic cells, or fibroblasts, proliferate and synthesize new connective tissue, replacing the fibrin matrix. At this time, an efficient nutrient supply develops through the arborization (terminal branching) of adjacent blood vessels. This in-growth of new blood vessels is called angiogenesis. This new and very vascular connective tissue is referred to as granulation tissue. In this process, acute inflammation releases cytokines, promoting fibroblast infiltration of the wound site, and then creating a high density of cells. Collagen is the major connective tissue protein produced and released by fibroblasts. The connective tissue physically supports the new blood vessels that form, and endothelial cells promote in-growth of new vessels. These new blood vessels are necessary to meet the nutritional needs of the wound healing process. The mark of wound closure is when a new epidermal cover seals the defect. The process of wound healing continues beneath the new surface. This is the remodeling or maturation phase and is the third phase of healing.

The first principle of wound care is the removal of nonviable tissue, including dead tissue, slough, foreign debris, and residual material from dressings. Removal of nonviable tissue is referred to as debridement; removal of foreign matter is referred to as cleansing. Chronic wounds are colonized with bacteria, but not necessarily infected. A wound is colonized when a limited number of bacteria are present in the wound and are of no consequence in the healing process. A wound is infected when the bacterial burden

KEY TERMS

Allograft— Skin donated from another person to reat burns.

Asepsis— Freedom from infection or infectious material; also, the absence of viable pathogenic organisms. Asepsis can be accomplished using aseptic techniques, which are the use of surgical practices that restrict microorganisms in the environment and prevent contamination of the surgical wound; they include sterilization of instruments and the wearing of sterile caps, gloves, and masks.

Cadaver skin— Skin donated from another person to treat burns.

Cytokine— A protein that regulates the duration and intensity of the body’s immune response.

Dermis— The thick layer of skin below the epidermis.

Epidermis— The outermost layer of the skin.

Exudate— Fluid, cells, or other substances that are slowly discharged by tissue, especially due to injury or inflammation.

Fibroblast— An undifferentiated connective tissue cell that is capable of forming collagen fibers.

Hemostasis— Slowing down or stopping bleeding.

Langerhans’ cells— Cells in the epidermis that help protect the body against infection.

Melanocytes— Cells within the epidermis that give skin its color

Neutrophil— A type of white blood cell.

Scar tissue— Scar tissue is the fibrous tissue that replaces normal tissue destroyed by injury or disease.

overwhelms the immune response of the host and bacteria grow unchecked. Clinical signs of infection are redness of the skin around the wound, purulent (pus-containing) drainage, foul odor, and edema.

The second principle of wound care is to provide a moist environment. This has been shown to promote re-epithelialization and healing. Exposing wounds to air dries the surface and may impede the healing process. Gauze dressings provide a moist environment provided they are kept moist in the wound. These are referred to as wet-to-dry dressings. Generally, a saline-soaked gauze dressing is loosely placed into the wound and covered with a dry gauze dressing to prevent drying and contamination. It also supports autolytic debridement (the body’s own capacity to dissolve dead tissue), absorbs exudate (thick layer of discharge), and traps bacteria in the gauze, which are removed when the dressing is changed.

Preventing further injury is the third principle of wound care. This involves elimination or reduction of the condition that allowed the wound to develop. Factors that contribute to the development of chronic wounds include losses in mobility, mental status changes, deficits of sensation, and circulatory deficits. Patients must be properly positioned to eliminate continued pressure to the chronic wound. Pressure-reducing devices, such as mattresses, cushions, supportive boots, foam wedges, and fitted shoes can be used to keep pressure off wounds.

Providing nutrition, specifically protein for healing, is the fourth principle of healing. Protein is essential for wound repair and regeneration. Without essential amino acids, angiogenesis, fibroblast proliferation, collagen synthesis, and scar remodeling will not occur. Amino acids also support the immune response. Adequate amounts of carbohydrates and fats are needed to prevent the amino acids from being oxidized for caloric needs. Glucose is also needed to meet the energy requirements of the cells involved in wound repair.

Diagnosis/Preparation

Effective wound care begins with an assessment of the entire patient. This includes obtaining a complete health history and a physical assessment. Assessing the patient assists in identifying causes and contributing factors of the wound. When examining the wound, it is important to document its size, location, appearance, and the surrounding skin. The healthcare professional also examines the wound for exudate, dead tissue, signs of infection, and drainage, and documents how long the patient has had the wound. It is also important to know what treatment, if any, the patient has previously received for the wound.

Actual components of wound care include cleaning, dressing, determining frequency of dressing changes, and reevaluation. Dead tissue and debris can impede healing: the goal of cleaning the wound is its removal. When cleaning the wound, protective goggles should be worn and sterile saline solution should be used. Providone iodine, sodium hypochlorite, and hydrogen peroxide should never be used, as they are toxic to cells.

Gentle pressure should be used to clean the wound if there is no dead tissue. This can be accomplished by utilizing a syringe to apply the cleaning solution. If the wound has dead tissue, more pressure may be needed. Whirlpools can also be used for wounds having a thick layer of discharge, known as exudate. At times, chemical or surgical debridement may be needed to remove debris.

Dressings are applied to wounds to provide the proper environment for healing, to absorb drainage, to immobilize the wound, to protect the wound and new tissue growth from mechanical injury and bacterial contamination, to prevent bleeding, and to provide mental and physical patient comfort. There are several types of dressings and most are designed to maintain a moist wound bed, including:

Alginate. Made of non-woven fibers derived from seaweed, alginate forms a gel as it absorbs exudate. It is used for wounds with moderate-to-heavy exu-date or drainage, and is changed every 12 hours to three days, depending on when the exudate penetrates the secondary dressing.
Composite dressings. Combining physically distinct components into a single dressing, composite dressings provide bacterial protection, absorption, and adhesion. The frequency of dressing changes vary.
Foam. Made from polyurethane, foam comes in various thicknesses having different absorption rates. It is used for wounds with moderate-to-heavy exudate or drainage. Dressing change is every three to seven days.
Gauze. Available in a number of forms, including sponges, pads, ropes, strips, and rolls, gauze can be impregnated with petroleum jelly, antimicrobials, and saline. Frequent changes are needed because gauze has limited moisture retention properties, and there is little protection from contamination. With removal of a dried dressing, there is a risk of wound damage to the healing skin surrounding the wound. Gauze dressings are changed two to three times a day.
Hydrocolloid. Made of gelatin or pectin, hydrocolid is available as a wafer, paste, or powder. While absorbing exudate, the dressing forms a gel. Hydrocolloid dressings are used for light-to-moderate exu-date or drainage. This type of dressing is not used for wounds with exposed tendon or bone, third-degree burns, or in the presence of bacterial, fungal, or viral infection or active cellulitis or vasculitis because it is almost totally occlusive. Dressings are changed every three to seven days.
Hydrogel. Composed primarily of water, hydrogel dressings are used for wounds with minimal exudate. Some are impregnated in gauze or non-woven sponge. Dressings are changed one or two times a day.
Transparent film. An adhesive, waterproof mem-brane that keeps contaminants out while allowing oxygen and water vapor to cross through, it is used primarily for wounds with minimal exudate. It is also used as a secondary material to secure non-adhesivegauzes. Dressings are changed every three to five days if the film is used as a primary dressing.

In cases where a wound is particularly severe, large, or, if it is a third-degree burn, cellular wound healing products may be used to close the wound and speed recovery. In some cases (i.e., a third-degree burn), a skin graft will often be used. Although most surgeons prefer to use skin donated from another person (known as cadaver skin, or human allograft), skin donations are not always available. Then surgeons must rely on other available products such as cellular wound dressings for the treatment of burns. For skin grafting of full-thickness burn wounds, surgeons use healthy skin from another part of the person’s own body (autografting) as a permanent treatment. Surgeons may use cellular wound dressings as a temporary covering when the skin damage is so extensive that there is not enough healthy skin available to graft initially. This helps prevent infection and fluid loss until autografting can be performed.

The survival rate for burn patients has increased considerably through the process of quickly removing dead tissue and immediately covering the wound. Burns covering half the body were routinely fatal 20 years ago, but today even people with extensive and severe burns have a good chance of survival, according to the American Burn Association.

Cellular wound dressings

In recent years, the technology of burn and wound care using cellular wound dressings and grafts has helped to transform the treatment of burns and chronic wounds by decreasing the risk of infection, protecting against fluid loss, requiring fewer skin grafts, and promoting and speeding the healing process. These dressings provide a cover that keeps fluids from evaporating and prevents blood from oozing out once the dead skin has been removed. Some of these products grow in place and expand natural skin when it heals.

Cellular wound dressings may look and feel like skin, but they do not function exactly the same as skin because they are missing hair follicles, sweat glands, melanocytes, and Langerhans’ cells. Some cellular wound dressings have a synthetic top layer structured like an epidermis. It peels away over time, or is replaced with healthy skin through skin grafting. How these products are involved in wound repair is a subject of great scientific interest; it is known that they promote a higher rate of healing than does standard wound care.

People with severe wounds, chronic wounds, burns, and ulcers can benefit from cellular wound dressings. Several artificial skin products for non-healing wounds or burns include:

Apligraf is a two-layer wound dressing that contains live human skin cells combined with cow collagen. It delivers live cells from a different donor (circumcised infant foreskin). Thousands of pieces of Apligraf are produced in the laboratory from one small patch of cells from a single donor.
Dermagraft is made from human cells placed on a dissolvable mesh material. The mesh material is gradually absorbed and the human cells grow and replace the damaged skin after being placed on the wound or ulcer.
Biobrane is used as a temporary dressing for a variety of wounds, including ulcers, lacerations, and full-thickness burns. It may also be used on wounds that develop on areas from which healthy skin is transplanted to cover damaged skin. It consists of an ultrathin silicone film and nylon fabric. As the wound heals, or until autografting becomes possible, the Biobrane is trimmed away.
TransCyte is used as a temporary covering over full-thickness and some partial-thickness burns until autografting is possible, as well as a temporary covering for some burn wounds that heal without auto-grafting. It consists of human cells from circumcised infant foreskin, and is grown on nylon mesh, combined with a synthetic epidermal layer. TransCyte starts with living cells, but these cells die when it is shipped in a frozen state to burn treatment facilities. The product is then thawed and stretched over a burn site. In one to two weeks, the TransCyte starts peeling off, and the surgeon trims it away as it peels.
Integra Dermal Regeneration Template is used to treat full-thickness and some partial-thickness burns. Integra consists of two layers. The bottom layer, made of shark cartilage and collagen from cow tendons, acts as a matrix onto which a person’s own cells migrate over two to three weeks. A new dermis is created as the cells gradually absorb the cartilage and collagen. The top layer is a protective silicone sheet that is peeled off after several weeks, while the bottom layer is a permanent cover. A very thin layer of the person’s own skin is then grafted onto the neo-dermis.
OrCel is also made from circumcised infant foreskin, grown on a cow collagen matrix, and used to treat donor sites in burn patients. It is also used to help treat epidermolysis bullosa, a rare skin condition in children.

Risks

Various risks from wounds include:

Hematoma. Dressings should be inspected for hemorrhage at intervals during the first 24 hours after surgery. A large amount of bleeding should be reported to a healthcare professional immediately. Concealed bleeding sometimes occurs in the wound, beneath the skin. If the clot formed is small, it will be absorbed by the body, but if large, the wound bulges and the clot must be removed for healing to continue.
Infection. The second most frequent nosocomial (hospital-acquired) infection in hospitals is surgical wound infections with Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa. Prevention is accomplished with meticulous wound management. Cellulitis is a bacterial infection that spreads into tissue planes; systemic antibiotics are usually prescribed to treat it. If the infection is in an arm or leg, elevation of the limb reduces dependent edema and heat application promotes blood circulation. Abscess is a bacterial infection that is localized and characterized by pus. Treatment consists of surgical drainage or excision with the concurrent administration of antibiotics.
Dehiscence (disruption of the surgical wound) and evisceration (protrusion of wound contents). This condition results from sutures giving way, from infection, distention, and coughs. Dehiscence results in pain; the surgeon should be called immediately. Pro-phylactically, an abdominal binder may be utilized.
Keloid, which refers to excessive growth of scar tissue. Careful wound closure, hemostasis, and pressure support are used to ward off this complication.

Normal results

The goals of wound care include reducing risks that inhibit wound healing, enhancing the healing process, and lowering the incidence of wound infections.

Resources

BOOKS

Baranoski, Sharon and Elizabeth A. Ayello. Wound Care Essentials: Practice Principles, 2nd ed. Philadelphia: Lippincott Williams & Wilkins., 2008.

Dipietro, Luisa A. and Aime L. Burns, eds. Wound Healing: Methods and Protocols ( Methods in Molecular Medicine Ser). Totowa, NJ: Humana Press, 2003.

Hess, Cathy Thomas. Clinical Guide to Wound Care, 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2002.

Sheffield, Paul J., Adrianne P.S. Smith and Caroline E. Fife, eds. Wound Care Practice, 2nd ed. Flagstaff, AZ: Best Pub Co., 2007.

PERIODICALS

Collins, Nancy. “Obesity and Wound Healing.” Advances in Wound Care 16, no 1. (January/February 2003): 45.

Collins, Nancy. “Vegetarian Diets and Wound Healing.” Advances in Wound Care 16, no. 2 (March/April 2003): 65.

McGuckin, Maryanne, Robert Goldman, Laura Bolton, and Richard Salcido. “The Clinical Relevance of Microbiology in Acute and Chronic Wounds.” Advances in Wound Care 16, no 1. (January/February 2003): 12.

Trent, Jennifer T. and Robert S. Kirsner. “Wounds and Malignancy.” Advances in Wound Care 16, no 1. (January/February 2003): 31.

ORGANIZATIONS

American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 342-2383. E-mail:[email protected]. http://www.diabetes.org (accessed April 18, 2008).

American Professional Wound Care Association (APWCA). 853 Second Street Pike, Suite #A-1, Richboro, PA 18954. (215) 364-4100. Fax: (215) 364-1146. E-mail: [email protected]. http://www.apwca.org (accessed April 18, 2008).

National Institutes of Health. 9000 Rockville Pike, Bethesda, MD 20892. (301) 496-4000. Email: [email protected]. http://www.nih.gov (accessed April 18, 2008).

OTHER

Lippincott Williams & Wilkins. Advances in Skin & Wound Care, 2007, [cited December 29, 2007]. http://www.aswcjournal.com/ (accessed April 18, 2008).

Rene A. Jackson, RN

Crystal H. Kaczkowski, MSc

Robert Bockstiegel

Wound Care

views updated

Wound Care

Definition
Description
Diagnosis/Preparation
Risks
Normal results

Definition

Description

KEY TERMS

Allograft— Skin donated from another person to reat burns.

Cadaver skin— Skin donated from another person to treat burns.

Cytokine— A protein that regulates the duration and intensity of the body’s immune response.

Dermis— The thick layer of skin below the epidermis.

Epidermis— The outermost layer of the skin.

Exudate— Fluid, cells, or other substances that are slowly discharged by tissue, especially due to injury or inflammation.

Fibroblast— An undifferentiated connective tissue cell that is capable of forming collagen fibers.

Hemostasis— Slowing down or stopping bleeding.

Langerhans’ cells— Cells in the epidermis that help protect the body against infection.

Melanocytes— Cells within the epidermis that give skin its color

Neutrophil— A type of white blood cell.

Scar tissue— Scar tissue is the fibrous tissue that replaces normal tissue destroyed by injury or disease.

overwhelms the immune response of the host and bacteria grow unchecked. Clinical signs of infection are redness of the skin around the wound, purulent (pus-containing) drainage, foul odor, and edema.

Diagnosis/Preparation

Alginate. Made of non-woven fibers derived from seaweed, alginate forms a gel as it absorbs exudate. It is used for wounds with moderate-to-heavy exu-date or drainage, and is changed every 12 hours to three days, depending on when the exudate penetrates the secondary dressing.
Composite dressings. Combining physically distinct components into a single dressing, composite dressings provide bacterial protection, absorption, and adhesion. The frequency of dressing changes vary.
Foam. Made from polyurethane, foam comes in various thicknesses having different absorption rates. It is used for wounds with moderate-to-heavy exudate or drainage. Dressing change is every three to seven days.
Gauze. Available in a number of forms, including sponges, pads, ropes, strips, and rolls, gauze can be impregnated with petroleum jelly, antimicrobials, and saline. Frequent changes are needed because gauze has limited moisture retention properties, and there is little protection from contamination. With removal of a dried dressing, there is a risk of wound damage to the healing skin surrounding the wound. Gauze dressings are changed two to three times a day.
Hydrocolloid. Made of gelatin or pectin, hydrocolid is available as a wafer, paste, or powder. While absorbing exudate, the dressing forms a gel. Hydrocolloid dressings are used for light-to-moderate exu-date or drainage. This type of dressing is not used for wounds with exposed tendon or bone, third-degree burns, or in the presence of bacterial, fungal, or viral infection or active cellulitis or vasculitis because it is almost totally occlusive. Dressings are changed every three to seven days.
Hydrogel. Composed primarily of water, hydrogel dressings are used for wounds with minimal exudate. Some are impregnated in gauze or non-woven sponge. Dressings are changed one or two times a day.
Transparent film. An adhesive, waterproof mem-brane that keeps contaminants out while allowing oxygen and water vapor to cross through, it is used primarily for wounds with minimal exudate. It is also used as a secondary material to secure non-adhesivegauzes. Dressings are changed every three to five days if the film is used as a primary dressing.

Cellular wound dressings

People with severe wounds, chronic wounds, burns, and ulcers can benefit from cellular wound dressings. Several artificial skin products for non-healing wounds or burns include:

Apligraf is a two-layer wound dressing that contains live human skin cells combined with cow collagen. It delivers live cells from a different donor (circumcised infant foreskin). Thousands of pieces of Apligraf are produced in the laboratory from one small patch of cells from a single donor.
Dermagraft is made from human cells placed on a dissolvable mesh material. The mesh material is gradually absorbed and the human cells grow and replace the damaged skin after being placed on the wound or ulcer.
Biobrane is used as a temporary dressing for a variety of wounds, including ulcers, lacerations, and full-thickness burns. It may also be used on wounds that develop on areas from which healthy skin is transplanted to cover damaged skin. It consists of an ultrathin silicone film and nylon fabric. As the wound heals, or until autografting becomes possible, the Biobrane is trimmed away.
TransCyte is used as a temporary covering over full-thickness and some partial-thickness burns until autografting is possible, as well as a temporary covering for some burn wounds that heal without auto-grafting. It consists of human cells from circumcised infant foreskin, and is grown on nylon mesh, combined with a synthetic epidermal layer. TransCyte starts with living cells, but these cells die when it is shipped in a frozen state to burn treatment facilities. The product is then thawed and stretched over a burn site. In one to two weeks, the TransCyte starts peeling off, and the surgeon trims it away as it peels.
Integra Dermal Regeneration Template is used to treat full-thickness and some partial-thickness burns. Integra consists of two layers. The bottom layer, made of shark cartilage and collagen from cow tendons, acts as a matrix onto which a person’s own cells migrate over two to three weeks. A new dermis is created as the cells gradually absorb the cartilage and collagen. The top layer is a protective silicone sheet that is peeled off after several weeks, while the bottom layer is a permanent cover. A very thin layer of the person’s own skin is then grafted onto the neo-dermis.
OrCel is also made from circumcised infant foreskin, grown on a cow collagen matrix, and used to treat donor sites in burn patients. It is also used to help treat epidermolysis bullosa, a rare skin condition in children.

Risks

Various risks from wounds include:

Hematoma. Dressings should be inspected for hemorrhage at intervals during the first 24 hours after surgery. A large amount of bleeding should be reported to a healthcare professional immediately. Concealed bleeding sometimes occurs in the wound, beneath the skin. If the clot formed is small, it will be absorbed by the body, but if large, the wound bulges and the clot must be removed for healing to continue.
Infection. The second most frequent nosocomial (hospital-acquired) infection in hospitals is surgical wound infections with Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa. Prevention is accomplished with meticulous wound management. Cellulitis is a bacterial infection that spreads into tissue planes; systemic antibiotics are usually prescribed to treat it. If the infection is in an arm or leg, elevation of the limb reduces dependent edema and heat application promotes blood circulation. Abscess is a bacterial infection that is localized and characterized by pus. Treatment consists of surgical drainage or excision with the concurrent administration of antibiotics.
Dehiscence (disruption of the surgical wound) and evisceration (protrusion of wound contents). This condition results from sutures giving way, from infection, distention, and coughs. Dehiscence results in pain; the surgeon should be called immediately. Pro-phylactically, an abdominal binder may be utilized.
Keloid, which refers to excessive growth of scar tissue. Careful wound closure, hemostasis, and pressure support are used to ward off this complication.

Normal results

The goals of wound care include reducing risks that inhibit wound healing, enhancing the healing process, and lowering the incidence of wound infections.

Resources

BOOKS

Baranoski, Sharon and Elizabeth A. Ayello. Wound Care Essentials: Practice Principles, 2nd ed. Philadelphia: Lippincott Williams & Wilkins., 2008.

Dipietro, Luisa A. and Aime L. Burns, eds. Wound Healing: Methods and Protocols ( Methods in Molecular Medicine Ser). Totowa, NJ: Humana Press, 2003.

Hess, Cathy Thomas. Clinical Guide to Wound Care, 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2002.

Sheffield, Paul J., Adrianne P.S. Smith and Caroline E. Fife, eds. Wound Care Practice, 2nd ed. Flagstaff, AZ: Best Pub Co., 2007.

PERIODICALS

Collins, Nancy. “Obesity and Wound Healing.” Advances in Wound Care 16, no 1. (January/February 2003): 45.

Collins, Nancy. “Vegetarian Diets and Wound Healing.” Advances in Wound Care 16, no. 2 (March/April 2003): 65.

Trent, Jennifer T. and Robert S. Kirsner. “Wounds and Malignancy.” Advances in Wound Care 16, no 1. (January/February 2003): 31.

ORGANIZATIONS

American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 342-2383. E-mail:[email protected]. http://www.diabetes.org (accessed April 18, 2008).

National Institutes of Health. 9000 Rockville Pike, Bethesda, MD 20892. (301) 496-4000. Email: [email protected]. http://www.nih.gov (accessed April 18, 2008).

OTHER

Lippincott Williams & Wilkins. Advances in Skin & Wound Care, 2007, [cited December 29, 2007]. http://www.aswcjournal.com/ (accessed April 18, 2008).

Rene A. Jackson, RN

Crystal H. Kaczkowski, MSc

Robert Bockstiegel

The Gale Encyclopedia of Surgery and Medical Tests