NURS 3234 Lecture Notes - Lecture 9: Wound Dehiscence, Wound Healing, Granulation Tissue

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School
Department
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Skin Integrity and Wound Care
Skin Structure
Epidermis
o Made up of stratified epithelial cells
o Fusing of epithelial cells forms our waterproof layer of keratin
o Regenerates easily if nourished by underlying tissue
o 60% of nurses are colonized with MRSA
Dermis
o Elastic connective tissue
o Contains nerves, hair follicles, glands & blood vessels
o Rests on SQ (Hypodermis) tissue, which connects skin layers to tissues in our body
o SQ layer stores fat/cushions tissues
Function of Skin
Protection
Temperature control
Sensation… touch/feel
Vitamin D absorption
Immunologic intact skin protects us from infection
Body image/appearance or condition of skin
Allows us movement without injury
Elimination of waste materials… sweat/perspiration
Absorption of medications… transdermal
Excellent Nursing Care for Wounds
Eliminating risk factors, prevention/assessment of skin
Identifying types of wounds
Understanding and supporting wound healing processes
Identifying and managing complications of wound healing
Creative use of multiple nursing care options
Prevention: turning and positioning bed ridden patients frequently as much as every 2 hours
Complications: poor nutrition longer to heal, diabetic patients longer to heal, obese patients
prone to dehiscence secondary to large amounts of adipose tissue/strain on wounds from
excessive body tissues
o )nfections…does your patient have a temperature???
Assessment First: Classifying and Describing Wounds
Why?
Etiology from outside in, or inside out?
Loss of tissue or not? (primary or secondary)
Depth or thickness partial, or full
Size and shape, structures involved
Stage of healing types of tissue, exudate
Complications?
Surrounding tissue
Stages of healing: Granulation tissue is red, vascular rich a sign of healing!! Sloughs and eschar
are BAD and require debridement before you can stage a wound appropriately!
Type of wounds and drainage…Purulent drainage = infected wound, sanguineous = fresh open
cut/wound, serosanguinous = sutured closed wound and serous = fresh blister like wound that
just opened up
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Wounds and Healing Process
Primary intention approximated, no need to regenerate, less scarring, faster healing
Secondary intention missing tissue needs to be filled in, may not regenerate, so scar tissue
Partial thickness dermis still there, so can regenerate
Full thickness dermis missing, heals by scar formation
Primary Wound and Healing
Primary healing of a wound has the following characteristics:
o Clean and uninfected
o Surgically incised
o Without much loss of cells and tissue
o Edges of wound are approximated by surgical sutures
o Rapid healing with neat scar
o Default setting: secondary
o If wound is wide & deep, infected, foreign bodies
o Example: Stitches
Sterile water is not isotonic, saline is
Secondary Wound and Healing
Secondary healing of a wound having the following characteristics:
o Open with a large tissue defect, at times infected
o Having extensive loss of cells and tissues the wound is not approximated by surgical
sutures but is left open
o Always want it to heal from inside out otherwise we have to open it and try again
Example
o Top picture reveals the open wound
o Bottom picture demonstrates the extensive scarring seen with these types of wounds
o For contaminated/dirty wounds
o Wound is intentionally left open
o Healing occurs from bottom up
o Granulation tissue containing myofibroblasts forms wound contraction
Differences Between Primary/Secondary Wound Healing
Differs in having a larger tissue defect which has to be bridged
The healing by second intention is slow and results in a large, at times ugly scar
Healing with more inflammation and granulation tissue formation
Heals but with more scarring
4 Phases of Wound Healing
HEMOSTASIS: immediately following injury, if small wound a scab forms and if wound is large
exudate forms (plasma & blood components leak out)
o Larger wounds may be painful, red and tender during healing process
INFLAMMATORY STAGE: last a few days, cleaning up of wound by macrophages, still acute
inflammation
PROLIFERATION: lasts several weeks, new tissue is built (granulation tissue), scar tissue
development minor to major depending on depth and severity of wound
MATURATION: final stage, may last several weeks, to months even years
o Scar tissue forms, depending on location of injury scar tissue may limit mobility causing
disability
Phases of Wound healing is informational only so that you understand the physiologic process
4 Complications of Healing
Hemorrhage
o Early first 24-48 hours, postop
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o Internal hidden, hematomas, drains
o External more obvious, check for pooling
o Consequences: SHOCK
o Check dressings frequently.. Dry? Intact? Measure area of bleeding/exudate? Call
surgeon or NP/PA, know who changes first dressing??? Some surgeons request no
changes unless it is them!!
Infection
o Wound infections are the 2nd most common (A)’s
o Signs can be seen early within 2-7 days
o Purulent drainage, increase of drainage, fever/chills, redness, swelling and increased
WBC
o Earlier with trauma, later with surgical
o Wound cultures? Parenteral (IV) antibiotics?
o Wound infections are the SECOND most common hospital acquired infections (A)’s.
UTI’s are the MOST COMMON of all (A)’s!!
o Today you are caring for 29-year-old woman who had a cesarean section to deliver her
first baby 3 days ago, after a long labor and pregnancy complicated with diabetes and
obesity. The emergency light in her bathroom goes on at 0715 and you go to check on
her. You find her sitting on the toilet, flushed, and dizzy, complaining of tearing
incisional pain 8/10. You are waiting for assistance to get her back to bed for
assessment, and note a radial pulse of 120.
What is her problem
Wound dehiscence
See if she is breathing okay, dizzy, in pain
Did she have a hematoma that ruptured or is it just the wound itself?
o DIC: body doesn't know what to do
Clot/bleed
Happens with sepsis and multisystem organ failure
Bleeding and clotting
Dishiscence and Evisceration
Both are the most serious complications compromising wound healing!!
Dehiscence: partial or total separation of the wound
Evisceration: occurs as a complication of dehiscence wound is completely open & tissues
organs may protrude through the open wound
Which Patients are High Risk?
Obese or malnourished patients
Smokers
On anticoagulants
Diabetics
Patients with excess coughing, vomiting or straining to have a bowel movement
)NTERVENE! Cover wound with sterile moist dressing, low fowler’s position takes physical
strain off wound) may be a medical emergency! Call for help!!
Pressure Ulcers
AKA: Pressure sore, decubitus ulcer, or bed sore
Mainly caused by…
o Pressure intensity/duration (blanching/hyperemia)
o Lack of tissue tolerance/integrity
o Other factors include…
Surface moisture, incontinence
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Document Summary

Immunologic intact skin protects us from infection: vitamin d absorption, body image/appearance or condition of skin, allows us movement without injury, sensation touch/feel, elimination of waste materials sweat/perspiration, absorption of medications transdermal. Identifying types of wounds: eliminating risk factors, prevention/assessment of skin, understanding and supporting wound healing processes, creative use of multiple nursing care options. Sloughs and eschar cut/wound, serosanguinous = sutured closed wound and serous = fresh blister like wound that just opened up are bad and require debridement before you can stage a wound appropriately: size and shape, structures involved. 4 complications of healing: hemorrhage, early first 24-48 hours, postop. The emergency light in her bathroom goes on at 0715 and you go to check on her. You find her sitting on the toilet, flushed, and dizzy, complaining of tearing incisional pain 8/10. You are waiting for assistance to get her back to bed for assessment, and note a radial pulse of 120.

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