Wound classification based on color

Wound classification based on color – instead of extent of damage to tissues

1. this system can be applied to any type of wound that is healing by secondary intention

2. surgical wounds left open due to infection can be used with this system

3. sometimes wound can have two to three colors – go by most undesireable color

4. wound colors are red, yellow, and black

Red Wound

1. characteristics – traumatic or surgical wound, and wounds created surgically to allow for healing

2. possible serosanguinous drainage: pink to bright or dark red

3. healing chronic wound with granulation tissue present ie. skin tears, stage II pressure ulcers

4. wounds that are classified as clean with reepithelializing & granulating should be kept slightly moist & free from trauma to encourage healing

5. a dressing should be used that assists the wound with epithelialization

6. dressing can be used are transparent films or adhesive semi-permeable dressings

ie. Opsite, Tegaderm allow O₂ to get to wound

9. antimicrobials can be used such as bacitracin or neomycin if infection present

10. If there is an infection the wound usually covered with sterile dressing

11. You want to avoid unnecessary handling of the tissues during dressing change. don't want to

interrupt granulation (sensitive!)

Yellow wound has the presence of slough or soft necrotic tissue, liquid to semi-liquid, slough with exudate ranges from creamy / ivory to yellow / green

1. ideal place for bacteria to grow – must be removed

2. the wound is continuously cleansed to remove exudates & soft necrotic tissue

3. the wound is continuously cleaned – use absorbent dressing to pull excess drainage from wound

4. examples of this dressing are hydrogel & foam.

5. changes depend on amount of drainage

6. when you remove dressing, you should use saline or sterile water to wash wound

7. a hydrocolloid dressing such as duoderm – can be used for yellow wounds.

8. inner of portion of dressing combine with the exudates & form hydrating gel over wound

9. when the dressing is removed then the gel stays on the wound

10. the dressing is meant to be left in place for 7 days or until leakage that occurs around dressing

Black wound – covered with thick, dried black necrotic tissue also called escar

1. examples are full-thickness burns, pressure ulcers stage III – IV, & gangrenous ulcers

2. the more necrotic tissue that is present – greater risk of infection

3. immediate treatment is debridement

   a. can be surgically.

   b. mechanical – wet to dry dressing

   c. autolytic – ie. semi-occlusive or occlusive dressing

   d. enzymatic debridement – collagenase

   e. can use negative pressure wound therapy or vac pac – this uses suction to remove drainage & promote wound healing.

   f. hyperbaric oxygen therapy delivers oxygen at different atmospheric pressure

Factors delaying wound healing

1. nutritional deficiencies: protein, vit C, CHOs, zinc

2. inadequate blood supply slows the bloods ability to carry nutrients to the wound, not carry exudates away from wound & inhibit inflammatory response

3. corticosteroids impair phagocytosis by WBCs – depress formation of granulation tissue & inhibit wound contracture

4. infection

5. mechanical friction on wound

6. advanced age – slow collagen synthesis by fibroblast, impaired circulation requires longer time for epithelialization of skin & alters phagocytic & immune responses

7. obesity – ↓blood flow due to fatty tissue

8. diabetes mellitus

9. poor general health – generalized absence of factors necessary to promote wound healing

10. anemia↓O₂ at tissue level

Complications of healing – shape, location of wound are going to affect healing ability

1. hypertrophic scars & keloid formation occur when too much collagen tissue

   a. hypertrophic scar is improperly large, red, raised, & hard

   b. it does remain to the wound edges but becomes smaller over time

2. keloids are permanent. they have a larger protrusion of scar tissue that goes beyond wound edges & forms tumor-like mass

3. contracture is necessary for wound healing. it is abnormal for excessive contracture that cause malformation or contracture of skin or muscle.

   a. usually occurs if the injury is near a joint or in burns that involve large amounts of skin damage & loss

4. dehiscence is the separation of previously (primary healing) approximated wound

   b. infection caused by inflammation

   c. granulation tissue is weak & unable to hold up to stress applied to wound

   c. obese pts have increased risk due to poor wound healing

5. Evisceration can occur with dehiscence

   a. evisceration is when organs protrude through wound

   b. if this does occur you want to put on sterile saline water with sterile gauze

6. excess granulation occurs above wound surface

7. adhesions or bands of scars around organs can develop & lead to strangulation or necrosis of surrounding tissue

Anaphylaxis

Anaphylaxis

1. 1. acute systemic response that occurs in highly sensitive persons following injection of particular antigen (see pg 333 box13-1)

2. reaction begins within minutes of the exposure & can be simultaneous

Symptoms of anaphylaxis

1. feelings of uneasiness or foreboding

2. light headedness

3. itching palms & scalp

4. angioedema

5. edema of the uvula & larynx

6. pt may appear to be gasping for air, strider, wheezing, or barking cough

7. the respiratory effects can lead to death if not immediate interventions

Systemic Treatment

1. antihistamine – IV therapy benadryl

2. adrenaline – epinephrine can cause angina, restlessness, & taccycardia

3. bronchodilators – aminophylline

4. steroids – methyl prednisone, dexamethasone

5. hypotensives – dopamine

6. emergency O₂ – intubate

If you are administering drugs IV and pt shows anaphylaxis S&Sx

1. stop infusion immediately

2. stay with pt & hit call light

3. ask for medical support

4. maintain good IV line – ringer's lactate

5. place in supine position

6. take vitals every 2-5 minutes

7. administer emergency drugs as prescribed

8. maintain airway, give O₂

9. provide emotional support

Wound classification according to origin

1. surgical

2. non-surgical

3. know underlying cause of wound

4. acute

5. chronic

6. degree of tissue affected: burns

   a. superficial

   b. partial thickness

   c. full-thickness

Wound classification based on color – instead of extent of damage to tissues

1. this system can be applied to any type of wound that is healing by secondary intention

2. surgical wounds left open due to infection can be used with this system

3. sometimes wound can have two to three colors – go by most undesireable color

4. wound colors are red, yellow, and black

Diagnostic test for location & extent of inflammation

Diagnostic test for location & extent of inflammation

1. WBC with differential

2. erythrocyte sedimentation rate (ESR) or "sed rate"

3. C-reactive protein (CRP)

Medicines that deal with: infection, assist with affects, & destroy cause of inflammation

1. benadryl – antihistamine (blocks histamine)

2. Acetaminophen (Tylenol) will not reduce the of a inflammation process, but will aid in symptom relief and lower fever

3. antibiotics – destroy cause of inflammation

4. higher doses of NSAID's (aspirin)

5. for an acute hypersensitivity – corticosteroids (read nursing care Lemone 308-309)

Hypersensitivity is caused by an immune response by the body to an antigen that results in destruction to pt

1. if the antigen is exogenous – considered allergy

2. the body's response may be as simple as runny nose, itching at site, itchy eyes

3. it can be as serious as dyspnea, blood cell hemolysis,laryngeal spasms, angiodema localized tissue swelling: eyelids, lip, tongue, hands, feet, genitals

4. a hypersensitivity to latex: more common in healthcare workers – condom, balloons, rubberbands

5. a lot of people unaware that they sensitivity to latex until they get a rash which is apparent from exposure

6. recommendation of lemone is to use latex-free gloves – unless dealing with infections

7. the severity of a reaction to an allergen or antigen can be more severe with each exposure

8. other pts may be very sensitive to certain antigens & have more severe reactions each time

Tertiary Intention – known as "belated" primary intention

Tertiary Intention – known as "belated" primary intention

1. the wound may be left open to allow for granulation tissue to form & then be closed by sutures. ie contaminated wound

2. it also can be from a primary intention wound that has become infected & re-opened to allow granulation & then can be sutured

3. the scar is deep & wide

Causes of the inflammatory response

1. initiated by a particular agent

2. initiated by non-particular agent

3. exogenous agent

4. endogenous agent

Causes of inflammation

1. mechanical injuries – cuts, abrasions

2. physical injuries – burns

3. chemical injuries – toxins, poisons

4. microorganisms – viruses, fungi, or bacteria

5. temperature extremes – heat / cold

6. immunologic responses – hypersensitivity reaction

7. ischemic damage or trauma ie. stroke or MI

Cardinal signs of inflammation:

1. erythema

2. hyperemia

3. swelling due to accumulated fluid at the site

4. pain from tissue damage

5. chemical irritation of nerves

6. loss of function from swelling & pain

7. degree of functional loss will depend on site of injury & degree of injury

Signs of systemic manifestations:

1. temperature 100.4

2. pulse 90

3. respirations 20

4. WBC 12,000 or greater than 10% bands (10,000 leukocytes)

Basic types of inflammation

Basic types of inflammation are:

1. acute

2. subacute

3. chronic

Acute inflammation

1. the injury is healed in two to three weeks & most of the time no permanent damage occurs

2. the most prominent cell types are neutrophils

Subacute inflammation

1. consists of same appearance as acute

2. takes 2 wks to months to heal

Chronic inflammation

1. can last for months to years

2. it can start out when the acute inflammation is unable to remove foreign agent

3. the offending agent repeatedly injures tissue (s)

4. the most common cells are lymphocytes & macrophages

5. examples: rheumotoid arthritis (RA) & tuberculosis (TB )

6. process of continually having to fight the inflammation over extended time period can lead to immune dysfunction

Reconstruction – next phase of healing, has ability to intersect with inflammation phase

1. desired effect is that the tissue will be the same type & function as original tissue

2. simple resolution occurs when there is no devastation to the original tissue & body is able to successfully remove the cause

3. another type of resolution is "regeneration'

   a. the tissue is able to replace the original tissue with new tissue

   b. this varies by the type of tissue and cell type

   c. labile cells are able to restore themselves throughout life

*the cells are found where there is a constant change in the cells. ie. epithelial, bone marrow, mucous membranes, cervix, GI tract

d. stable cells continue to replace themselves until growing stops but they do have ability to

replace themselves if injury occurs

examples are osteocytes & parenchymal cells of kidneys, liver, & pancreas

Permanent or fixed cells

1. unable to replace themselves

2. when these cells are injured, they are replaced ("repair") with scar tissue

3. difference is tissue that has been repaired & can no longer function as it did previously

4. the wound is filled with scar tissue which provides tensile tissue strength

5. ie. nerve cells, skeletal muscles, cardiac muscle

Repair – more complex process that occurs by primary, secondary, or tertiary intention

1. primary intention

   a. occurs when the edges of the skin are well approximated

   b. wound is clean

   c. there is a small amount of tissue damage

   d. can occur naturally such as with a paper cut

   e. can occur with sutures

   f. glu (dermabond)

   g. staples (read stages of wound healing, pg 76 lemone)

2. secondary intention

   a. occurs when the wound has large, wide, jagged edges

   b. a lot of tissue damage

   c. these wounds can occur from trauma, infection, or ulceration

   d. inflammatory phase of the healing process may be more intense resulting in↑amount of

exudates, debris, & cells

e. this is where they might do I & D (irrigation & debridement)

f. this debris must be removed prior to healing

Primary Intention wound / incision becomes infected ie. splinter

1. wound will have to heal by secondary intention

2. wound heals from outer edges & from base to top & filled

3. because of the way it has to heal, greater amount of scar tissue results in larger scar

Types of Exudates

Types of Exudates

1. blister or pleural effusions will have serous exudates – primarily plasma & a few proteins

2. an injury that is moderate to severe has sanguineous fluid or hemorrhagic – has large # RBCs

3. a combination of serum & RBCs is called serosanguineous

As the plasma protein fibrinogen leaves the blood it is turned into fibrin, by products of injured cell tied into DIC

1. fibrin strengthens the clot that is formed by platelets

2. in the tissue it functions to trap bacteria, to prevent spread of bacteria, to serve as a framework for healing process

3. fibrinous exudate causes thick, sticky, meshwork of fibrinogen

Cellular Response – occurs less than 1 hr. after injury

1. blood flow through the capillaries is decreased due to fluid loss & thickness of fluid

2. leukocytes migrate to the inner surface of capillaries called "margination"

3. the lymphocytes move to the edge of the capillary wall & attach themselves – called "pavementing" - lemone p 293

4. after margination & pavementation have occurred then leucocytes leave blood & go into damaged tissues

5. the leukocytes are pulled into the injured tissue via "immigration" by chemotactic signals

6. Lemone states that the infectious agents, damaged tissues, & activated plasma substances ie.

   complement fractions, provide chemotactic signals that attract an army of neutrophils, monocytes, & macrophages at injury site.

7. Neutrophils are there first. The neutrophils are able to phagocytize bacteria & other damaged material

8. Lemone states neutrophils can digest 5-20 bacteria before they become inactivated or die

9. an accumulation of inactived neutrophils occurs

10. the bone marrow releases more neutrophils to keep up with ones inactivated or dead

11. these results in elevated WBCs (↑neutrophils)

When bone marrow not able to keep up with↑demand of neutrophils

1. immature neutrophils released into bloodstream

2. called "bands"

3. mature neutrophils are called "segmented neutrophils"

4. a "shift to the left" occurs when there are more bands than segmented neutrophils

5. healing is the last part of the inflammatory response

Inflammation: initial part of healing process

1. debridement occurs when particular matter, bacteria, damaged cells, & inflammatory exudates are removed by phagocytosis

2. this process sets wound for healing

3. nutrition is vital during inflammation process

4. leukocytes need the following: protein, glucose, O₂ for chemotactic, phagocytosis, & intracellular killings

5. diabetics are thought to have poor wound healing due to the small vessel disease which inhibits microcirculation &↓availability of O₂ to cells

6. glycosylated hemoglobin consumes O₂

7. the combination of the two further↓availability of O₂ to tissues

8. many of the symptoms of inflammation are produced by inflammatory mediators, histamines, kinins, & prostaglandins

Cardinal signs of inflammation (lemone) are: erythema, local heat caused by increased blood flow to the injured area, swelling due to accumulated fluid at the site, pain form tissue swelling, & chemical irritation of nerve endings & loss of function caused by swelling & pain