Chapter 26 wound care
Types of wounds
Closed wounds: a wound in which the skin remains intact.
Open wound: a wound which the skin integrity has been breached.
Contusion: Bruise.
Abrasions: scrapes and scratches.
Penetrating: wound from a sharp item.
Lacerations: open wound from cutting or tearing.
Pressure injuries: wound from pressure or friction.
Contamination of Wounds
Clean: Wound that is not infected
Clean - contaminated: Surgical wound that is not infected but has a greater chance of
becoming infected.(respiratory tract, urinary tract, or gastrointestinal tract.)
Contaminated: Wound that has been contaminated by asepsis.
Infected: infected wound is one in which the infectious process is already established, as
evidenced by high numbers of microorganisms and either purulent (containing pus)
drainage or necrotic (dead) tissue. The classic signs of infection include erythema
(redness), increased warmth, edema (swelling), pain, odor, and drainage.
Colonized: Wound with higher numbers of infection.
Pressure Injuries
Occurs when external pressure is exerted on soft tissue especially over bony
prominences (sacrum, buttocks, greater trochanters, elbows, heels, ankles, occiput (back
of the head), and scapulae) for a prolonged period.
Shearing: Occurs when the patients skin moves in opposite directions than items the
patient is on.
Ischemia: Tissues and capillaries are compressed, resulting in reduced blood flow to the
area
The longer the pressure is maintained on the affected area, the worse the extent of
necrosis (dead)
, Risk factors for pressure wounds
Older: The skin of older individuals is thinner and less elastic, making the skin more
susceptible to friction and shearing force.
Emaciated or malnourished: Emaciation is the state of being very lean or having very
little muscle.
Incontinent of bowel or bladder: With incontinence of bowel or bladder, the skin of the
perineal area tends to be wet much of the time, leading it to become macerated, or
softened.
Immobile: This includes patients who are paralyzed or who have casts or splints, in
addition to those restricted to a bed or chair.
Impaired circulation or chronic metabolic conditions: Chronic metabolic conditions such
as diabetes result in impairment of circulation, which can increase the risk of ischemic
tissue.
Staging pressure injuries
Stage 1: Erythema of intact skin that does not blanch; turn white
Stage 2: Partial thickness loss with an exposed dermis
Stage 3: full- thickness loss involving damage to the epidermis, dermis, and subcutaneous
tissue but not muscle or bone
Stage 4: full- thickness and tissue loss, only involves deep tissue necrosis(dead) of
muscle, fascia, tendon, joint capsule, and sometimes bone
Unstageable: involves full thickness tissue loss but are impossible to accurately stage
because of the wound bed being obscured by Eschar or excessive slough(is hard, dry,
dead tissue that has a leathery appearance. )
Deep tissue: may be intact or no intact skin. Deep red, maroon, or purple in color and
does not blanch, blood filled blister, thin blister that overlies a dark wound bed, eschar
under blisters.
Medical device- related pressure injury: the use of a diagnostic or therapeutic device
and often appears in the shape or pattern of that device. These injuries are staged using
the previously noted staging pressure injury system. An example is injury caused by
splints, braces, or oxygen tubing pressing against the patient’s skin.
Mucosal membrane pressure injury: the use of a medical device in the area of mucous
membranes. These injuries cannot be staged. Examples of this type of injury include
damage to the tongue or lips from the pressure of an endotracheal tube.
Types of wounds
Closed wounds: a wound in which the skin remains intact.
Open wound: a wound which the skin integrity has been breached.
Contusion: Bruise.
Abrasions: scrapes and scratches.
Penetrating: wound from a sharp item.
Lacerations: open wound from cutting or tearing.
Pressure injuries: wound from pressure or friction.
Contamination of Wounds
Clean: Wound that is not infected
Clean - contaminated: Surgical wound that is not infected but has a greater chance of
becoming infected.(respiratory tract, urinary tract, or gastrointestinal tract.)
Contaminated: Wound that has been contaminated by asepsis.
Infected: infected wound is one in which the infectious process is already established, as
evidenced by high numbers of microorganisms and either purulent (containing pus)
drainage or necrotic (dead) tissue. The classic signs of infection include erythema
(redness), increased warmth, edema (swelling), pain, odor, and drainage.
Colonized: Wound with higher numbers of infection.
Pressure Injuries
Occurs when external pressure is exerted on soft tissue especially over bony
prominences (sacrum, buttocks, greater trochanters, elbows, heels, ankles, occiput (back
of the head), and scapulae) for a prolonged period.
Shearing: Occurs when the patients skin moves in opposite directions than items the
patient is on.
Ischemia: Tissues and capillaries are compressed, resulting in reduced blood flow to the
area
The longer the pressure is maintained on the affected area, the worse the extent of
necrosis (dead)
, Risk factors for pressure wounds
Older: The skin of older individuals is thinner and less elastic, making the skin more
susceptible to friction and shearing force.
Emaciated or malnourished: Emaciation is the state of being very lean or having very
little muscle.
Incontinent of bowel or bladder: With incontinence of bowel or bladder, the skin of the
perineal area tends to be wet much of the time, leading it to become macerated, or
softened.
Immobile: This includes patients who are paralyzed or who have casts or splints, in
addition to those restricted to a bed or chair.
Impaired circulation or chronic metabolic conditions: Chronic metabolic conditions such
as diabetes result in impairment of circulation, which can increase the risk of ischemic
tissue.
Staging pressure injuries
Stage 1: Erythema of intact skin that does not blanch; turn white
Stage 2: Partial thickness loss with an exposed dermis
Stage 3: full- thickness loss involving damage to the epidermis, dermis, and subcutaneous
tissue but not muscle or bone
Stage 4: full- thickness and tissue loss, only involves deep tissue necrosis(dead) of
muscle, fascia, tendon, joint capsule, and sometimes bone
Unstageable: involves full thickness tissue loss but are impossible to accurately stage
because of the wound bed being obscured by Eschar or excessive slough(is hard, dry,
dead tissue that has a leathery appearance. )
Deep tissue: may be intact or no intact skin. Deep red, maroon, or purple in color and
does not blanch, blood filled blister, thin blister that overlies a dark wound bed, eschar
under blisters.
Medical device- related pressure injury: the use of a diagnostic or therapeutic device
and often appears in the shape or pattern of that device. These injuries are staged using
the previously noted staging pressure injury system. An example is injury caused by
splints, braces, or oxygen tubing pressing against the patient’s skin.
Mucosal membrane pressure injury: the use of a medical device in the area of mucous
membranes. These injuries cannot be staged. Examples of this type of injury include
damage to the tongue or lips from the pressure of an endotracheal tube.
