4. Objectives
Up on completion of this session students will able to
Identify types of wounds
Discuss current evidence-based standard wound management
Discuss Wound management strategies
Provide standardized nursing care for client with skin intact
problem
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5. Introduction
• Wounds have substantial adverse impact on client’s
quality of life and have a predictive risk with mortality.
• Better understanding of the etiology of the wound and
following the evidenced based management protocols
can;
– extremely improve client’s health outcomes and
– lower the cost of the medical care.
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6. Wounds - Classification
• Intentional – results from planned treatment
• Unintentional wounds- results from unexpected trauma…accident/
burns/ shooting
• Open -skin broken, portal of entry
• Closed – trauma from force, skin intact, soft tissue damage, internal
injury, possible bleeding
• Acute – goes through normal/timely healing process
• Chronic – fails to go through normal stages of healing; no timely
progress in healing
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7. Wounds –Classification
• Superficial
• Penetrating
• Perforating
• Laceration
• Puncture
• Abrasion
• Contusion
• Clean
• Contaminated
• Infected
• Colonized
• Pressure Ulcers
Stage I
Stage II
Stage III
Stage IV
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8. Types of Wounds
Types
of
Wounds
Pressure ulcers
Diabetic ulcer
Venous stasis ulcers
Arterial ulcers
Fungating wounds
Surgical wounds
Burn wound
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9. Pressure Ulcers
• A pressure ulcer is localized injury to the skin or underlying
tissue usually over a bony prominence, because of
unrelieved pressure and or in combination with shear and/or
friction.
• Pressure causes poor tissue perfusion and tissue damage can
occur within 2 -6 hours.
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11. Pressure Ulcers Stages
Stage -I Non-blanchable erythema
• Intact skin with non-blanchable redness of a localized area usually over a
bony prominence.
• Darkly pigmented skin may not have visible blanching; its color may
differ from the surrounding area.
• The area may be painful, firm, soft, warmer or cooler as compared to
adjacent tissue.
• Category I may be difficult to detect in individuals with dark skin tones.
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13. Pressure Ulcers Stages
Stage-II Partial thickness
• Partial thickness loss of dermis presenting as a shallow open ulcer with a
red pink wound bed, without slough (yellow, tan, gray, green or brown).
• May also present as an intact or open/ruptured serum-filled or sero-
sanginous filled blister.
• Presents as a shiny or dry shallow ulcer without slough or bruising.
• This category should not be used to describe skin tears, tape burns,
incontinence associated dermatitis.
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15. Pressure Ulcers Stages
Stage-III Full thickness skin loss
• Loss of epidermis & dermis with tissue loss extended to the
subcutaneous fat.
• Subcutaneous tissue may be visible but bone, tendon or muscle are
not exposed.
• Slough may be present but does not obscure the depth of tissue loss.
• In contrast, areas of significant adiposity can develop extremely
deep.
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17. Pressure Ulcers Stages
Stage-IV Full thickness tissue loss
• Full thickness tissue loss with exposed bone, tendon or muscle.
• Partial slough or eschar may be present.
• Often includes undermining and tunneling.
• The depth of a Stage IV pressure ulcer varies by anatomical
location.
• The bridge of the nose, ear, occiput and malleolus do not have
(adipose) subcutaneous tissue and these ulcers can be shallow.
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19. P.U. Management Principles
• Friction & Shear management, Use lift/turn sheets ,Maintaining Head of Bead at <30 degrees
• Turn & Reposition frequently
• Pressure reduction & pressure redistribution utilizing low air loss mattress with alternating pressure
• Skin protection dressings over high risk areas. Pain management
• Optimal Nutrition & Hydration management
• Temperature : keeping skin cool, clean and dry
• Off-loading of pressure areas e.g. heel protectors
• Moisture barrier & skin protectant ointments
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20. Diabetic/Neuropathic Ulcers
• A diabetic or Neuropathic ulcer is defined as an injury causing
loss of skin or tissue often on the feet due to lack of sensation
(neuropathy).
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24. Diabetic/Neuropathic Ulcers
Sensory Neuropathy
• The most common type of diabetic neuropathy,
causes pain or loss of feeling in the toes, feet,
legs, hands, and arms
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25. Diabetic/Neuropathic Ulcers
Motor Neuropathy
• Leads to paralysis of the foot's
• muscles resulting in muscle atrophy that
• predispose patients with diabetes to plantar
ulceration by increasing plantar pressures and
shear forces.
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26. Diabetic/Neuropathic Ulcers
Autonomic Neuropathy
• Increases the risk of neuropathic ulceration due to
disturbances in sweating mechanisms, callus formation, and
blood flow.
• It also effects heart, blood vessels, digestive system, urinary
tract, eyes, lungs & sex organs.
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27. Diabetic/Neuropathic Ulcers
Wagner Grading Scale
Grade 1: Superficial Diabetic Ulcer
Grade 2: Ulcer extension Involves ligament, tendon, joint capsule or fascia,
– No abscess or Osteomyelitis
Grade 3: Deep ulcer with abscess or Osteomyelitis
Grade 4: Gangrene to portion of forefoot
Grade 5: Extensive gangrene of foot
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28. Diabetic/Neuropathic Ulcers
Management Principles
1. Wound Infection prevention: Wound Culture
2. MRI to Rule Out Osteomyelitis
3. Ankle Brachial Index & Toe Pressures
4. Hemoglobin A1c 7% or below
5. Serial debridement to minimize callous
6. Off-Loading
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33. Arterial / Ischemic Ulcers
• Arterial or ischemic ulcers, are caused by the poor
blood circulation to the lower extremities;
peripheral artery disease (PAD).
• Inadequate supply of oxygenated blood leads to
tissue ischemia and necrosis.
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35. Arterial / Ischemic Ulcers
Clinical Findings:
• pain relief w/dependency,
• loss of hair,
• Atrophic,
• shiny skin,
• Muscle wasting of calf or thigh,
• Trophic nail changes
• Poor tissue perfusion,
• Color changes,
• Coldness of the foot,
• Gangrene of toes,
• Absence of palpable pulse,
• Par aesthesia (numbness)
• Pulse-lessness (absence of pulses
below the occlusion)
• Paralysis (sudden weakness in the
limb)
• Extremity cool to touch
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36. Arterial / Ischemic Ulcers
Management Principles
• Pain management
• Vascular Surgery Referral for possible Revascularization
• Hyperbaric Oxygen Therapy (HBOT)
• If patient is not appropriate for surgical intervention
• Keep the wounds clean, dry and free from infection
• No compression !!! No Elastic or stretchable gauze rolls
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37. Malignant / Fungating Wounds
• A Fungating or Malignant wound occur when malignant cells invade
the skin, blood and lymph vessels, and penetrate the epidermis.
• This results in a loss of vascularity and therefore nourishment to the
skin, leading to tissue death and necrosis.
• The lesion might be the result of a primary cancer or a metastasis to
the skin.
• The term “Fungating” is utilized to describe a proliferative process
in this types of wounds.
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39. Malignant / Fungating Wounds
Clinical Findings:
• Malignant wounds are usually polymicrobic, containing
both aerobic and anaerobic bacteria causing foul odor and
purulent drainage from the tissue necrosis.
• Anaerobic bacteria emit putrescine and cadaverine, which
results in foul odors and some aerobic bacteria such as
Proteus and Klebsiella can also produce foul odors.
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40. Malignant / Fungating Wounds
Management Principles:
• Managing malignant wounds is frequently based on expert opinion
and the experiences of the clinicians.
• The assessment of a malignant wound requires clinician to gain
insight into the patient’s perception of the wound and its consequent
impact on his/her life.
• Nursing care requires counseling skills and knowing how to provide
care that is based on an awareness of and insight into the patients’
experience
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41. Malignant / Fungating Wounds
Management Principles:
• Treatment selections should include those that provide
– minimum side effects and maximum benefit to the client.
• Establish goal of care Healing vs Palliation
• Wound bed preparation will vary based on the goal.
• If palliation is the goal, tissue debridement and management of
bacterial overload is required to minimize odor and decrease risk of
infection.
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42. Malignant / Fungating Wounds
Management Principles:
• Negative pressure wound therapy (NPWT) for moderate to high
exudating wounds.
• Foul odor management
• Charcoal based dressings to minimize odors.
• Lavender oil soaked gauze for odor control & inflammation.
• Metronidazole powder : Topical treatment to minimize odors
• Pain management
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43. Surgical Wounds
• A surgical wound is defined as an incision or wound
which is associated with a surgical procedure.
• This includes surgically dehisced / disrupted wounds
which fail to heal after a surgical procedure.
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45. Surgical Wounds
There are (3) three methods of surgical closures to
promote surgical wound healing:
1. Heal by Primary Intention
2. Heal by Secondary Intention
3. Heal by Tertiary Intention
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46. Surgical Wounds
Management Principles:
• Keep surgical incision site clean and covered; away
from external trauma.
• Change dressings every other day. (QOD)
• If noted, increased inflammation & drainage at the site,
collect swab culture and send for DNA based Culture &
Sensitivity (C&S) testing.
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47. Surgical Wounds
Management Principles:
• Negative Pressure Wound Therapy (NPWT)
• Xeroform gauze on incision sites.
• Cleansing of incision site with antimicrobial
solution with each dressing change.
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48. Surgical Wounds
Management Principles:
• Client & family education about wound & treatment regimen.
• Nurse to reinforce & reeducate client & family each visit.
• Ordering appropriate wound care supplies in an enclosed container.
• Having a copy of the recent Wound care orders available in the
patient’s folder.
• Document patient’s response to care regimen and progress.
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50. Burn
Initial Management: ABCDEs
• Airway
• Breathing
• Circulation
• Depth of Burn
• Extent of Injury(s)
• Pediatric (special) issues
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51. Acute phase
• Wound care and closure
• Prevention or treatment of cxn including
infection
• Nutritional support.
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52. Blister
• In the pre-hospital setting, there is no hurry to remove
blisters.
• Leaving the blister intact initially is less painful and
requires fewer dressing changes.
• The blister will either break on its own, or the fluid will be
reabsorbed.
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53. Blisters break on their own
Upper arm burn day 1 day 2
Burn “looks worse” the next day because of blisters
breaking and oozing
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60. Comprehensive Assessment
• Health History : Allergies, Smoking, Medications etc.
• Duration of Ulceration: Current & Previous treatments
• Diabetes Management: Hemoglobin A1c,RBS
• Foot & Shoe Exam: Deformity, Improper shoes , Circulation /
Pedal
• Pulses, Skin Color, Temperature, Neuropathy, Callous
• Mobility Status: Ambulatory, Wheelchair, Walker etc.
• Nutrition: Pre-Albumin, Vitamin D, Vitamin C
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61. Comprehensive Assessment
• Location of wound : Plantar | Lateral or Medial aspect
• Duration of Ulceration: When ulcer was first discovered
• Grading of Ulcer: Wagner grading scale
• Drainage or Odor: Type of drainage and odor; if any
• Wound edges: Calloused | Pink & soft | Rolled
• Presence of Pain: Assessing sensory loss
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62. Possible nursing diagnoses
• Imbalanced nutrition, less than body requirements, related to hyper
metabolism as evidenced by wt loss
• Impaired skin integrity related to injury as evidenced by physical
examination
• Impaired physical mobility related to joint contractures as evidenced
by physical examination.
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63. Possible nursing diagnoses
• Deficient knowledge about the course of wound care
& treatment as evidenced by patient verbalization
• Ineffective airway clearance related to effects of
smoke inhalation as evidenced by difficulty of
breathing.
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64. Outcome Identification and Planning
• The goals of care for clients with wounds
generally focus on
– Promoting wound healing,
– Preventing infection, and
– Educating the client
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65. Nursing Implementation
• Initiate Emergency Measures
• Prevention
• Cleanse the Wound
– Use Standard Precautions at all times
• Dressing the Wound
• Monitor Drainage of Wounds
• Provide Suture Care
• Checking Bandages, Binders, and Slings
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67. Evaluation
• The client should be free of infection, with no evidence of
fever, redness, or exudate. WBC and VS should be within
normal range within one week.
• The wound should exhibit beefy red granulation tissue, and
the wound edges should be contracting 1 week after
admission.
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68. Reference
1. .Armstrong, D. G., Boulton, A. J. M., & Bus, S. A. (2017). Diabetic foot ulcers and their recurrence. New England Journal of Medicine,
376(24), 2367-2375. https://arizonaprimo.hosted.exli
2. Sue C. DeLaune, MN, RN, C Fundamentals.of.Nursing.3HAXAP-1
3. 2020 Wound Care Study Guide line
4. Pressure ulcer staging. (2013). www.npuap.org
5. Home Health Potentially Avoidable Event Measures (2013). Centers for Medicare & Medicaid Services. www.cms.gov.
6. Management of the wounds. (2014). www.woundcarenurses.org
7. Ferrell BA, Josephson K, Norvid P, Alcorn H. Pressure ulcers among patients admitted to home care. J Am Geriatr Soc 2000;
48(9):1042-1047.
8. Bergquist S. Subscales, subscores, or summative score: evaluating the contribution of Braden Scale itemsfor predicting pressure
ulcer risk in older adults receiving home health care. J Wound Ostomy Continence Nurs 2001; 28(6):279-289.
9. Gorecki C, Brown JM, Nelson EA, Briggs M, Schoonhoven L, Dealey C et al. Impact of pressure ulcers on quality of life in older
patients: a systematic review. J Am Geriatr Soc 2009; 57(7):1175-1183
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