Wounds (Infectious, Surgical, Trauma)

Definition/Etiology:

• Definition
  • Complex wound is the term used recently to group those well-known difficult wounds, either chronic or acute, that challenge medical and nursing teams
• Etiology
  • Infectious
    • diabetic wounds, pressure sores, chronic venous ulcers, postinfection soft tissue gangrene, and ulcers resulting from vasculitis.
  • Surgical
    • Purposeful incision, done in sterile conditions. Healing occurs by primary, secondary, or tertiary intention.

Pathophysiology:

• Normal phases of wound healing
  • Hemostasis
  • Inflammatory – macrophages
  • Proliferative
    • wound is rebuilt with new tissue made up of collagen and extracellular matrix
  • Remodeling or maturation
    • granulation tissue matures into scar and tissue tensile strength is increased
• Chronic Wounds
  • Patient has comorbidities such as diabetes, obesity, immune system deficiencies, peripheral vascular disease and cardiopulmonary disease.
  • These wounds often stall in the inflammatory stage.
  • Excess and persistent inflammation creates a hostile wound environment.

Noticing: Assessment & Recognizing Cues:

• Subjective
  • Medical History
  • Wound History
  • Pain
• Objective
  • Stage (NCLEX 101 information)
  • Tissue Type
    • Necrotic
    • Sloughing
    • Granulating
  • Exudate
    • Dry → High
    • Type
      • Thin/watery → Thick/Purulent
  • Infection
    • Local vs Systemic

Interpreting: Analyzing & Planning:

• Labs
  • H/H – Anemia delays healing
  • WBC – Infection
  • Sed Rate/CRP – Inflammatory markers
  • Albumin – Protein loss
  • A1C – DM
  • Wound Cultures – Culprit Organism
• Diagnostics
  • Wound photography – tracks healing potential
  • CT Scan – bone pathology
  • MRI – Soft tissue evaluation
  • Ultrasound – Blood Flow

Responding: Patient Interventions & Taking Action:

• Pharmacological
  • Antibiotics
    • Infection only
    • Does not penetrate necrotic tissue
  • Saline > Topical Antiseptic
    • Risk of antibiotic resistance
• Nonpharmacological
  • Reduce Pressure
  • Dressings
    • Semi Permeable adhesive films (Tegaderm)
      • Barrier to bacteria and water
    • Hydrocolloid (Duoderm)
      • Mild to moderate exudate
      • Absorb Exudate and debride
    • Foams
      • Large volumes of exudate
    • Hydrogels
      • Dry/Necrotic Wounds
• Procedures
  • Wound Vac (NPWT)
  • Surgical Debridement
    • removal of necrotic tissue from the wound edges and cavity is required for healing
  • Graft or Flap
    • Stage 3 and 4
  • Hyperbaric Chamber
• Adjunct Medical Therapy
  • Wound Nurse
  • Plastic Surgeon
  • Infectious Disease

Reflecting: Evaluating Patient Outcomes:

• Reduction of pressure
  • Increase blood flow
• Adequate debridement of necrotic and devitalized tissue
  • Control inflammation
• Control of infection
  • IX Abx if infection is present
• Meticulous wound care
  • Precise dressing for wound type
  • Changing appropriately

Linchpins (Key Points):

• Notice
  • Complex wound
    • Surgical, Trauma, Infection
• Interpret – Labs & Imaging
  • Is the patient anemic?
  • Do they have osteomyelitis too?
• Respond
  • Antibiotics only if infection
  • Consider wound type to select dressing
• Reflect
  • Wound Care = Healing
    • STOP inflammatory process