Kaitlin O.

Lim
BSN-3A

NCM 104

Wound Management

Wounds
have
several
classifications:
1. Etiology (incision, contusion, abrasion, puncture, laceration, penetrating
wound,
avulsion,
amputation)
2. Degree of contamination (clean wounds, clean-contaminated wounds,
contaminated
wounds,
dirty
or
infected
wounds)
3. Depth (partial thickness and full thickness)

Use REEDA (redness, ecchymosis, edema, drainage/discharge, approximation)

assessment, assess for inflammation, WBC levels and differential counts,
measure edematous area's circumference, pulses, skin temperature, CRT,
sensation, and movement in areas distal to inflammation

Types of wound healing include primary intention (also known as primary union
or first intention healing), secondary intention, and tertiary intention

The
phases
of
1.
Inflammatory
2.
3. Maturation

Types
of
wound
exudate:
1. Sanguinous: red, thin and watery, low blood vessel growth or disruption
2. Sero-sanguinous: light red to pink, thin and watery, normal during inflammatory
and
proliferative
phases
of
healing
3. Serous: clear, light color, thin and watery, normal during inflammatory and
proliferative
phases
of
healing
4. Seropurulent: cloudy, yellow to tan, thin and watery, may be first signal of
impending
wound
infection
5. Purulent/pus: yellow, tan, or brown, thick and opaque, indicates wound
infection

Two types of ineffective wound healing are wound dehiscence and wound
evisceration.

Classifications

of

wound

wound
(reactive

dressings

are

healing

as

are:
phase)
Proliferative

follows:

1.

Wet dressing: cools and dries wound as moisture evaporates

-room temp. tap water, Burrow's sol'n, silver nitrate, Dakin's sol'n
2. Moisture retentive dressing: keeps wound moist to remove exudates
-hydrogels, hydrocolloids, foam dressings, and calcium alginates
3. Occlusive dressing: prevents air from drying out a wound bed or protect from
unwanted moisture

5
rules
in
using
wound
dressing
Rule 1: Categorization- the nurse needs to know and use the proper dressing
along
with
their
indication,
c/i,
and
s/e
Rule 2: Selection- the nurse must choose the most appropriate, safest, and
effective
dressing
method
Rule 3: Change- changing the dressing depends on the type of wound and its
discharges
Rule 4: Evolution- the dressing method is changed as wound healing progresses
Rule 5: Practice- practice with a dressing kit is necessary for learning

Color
code
1. Red: This means that the wound is healthy and normal healing is occuring.
Keep wound clean and slightly moist and use transparent film dressing and
topical
antimicrobial.
2. Yellow: The yellow may indicate a film of fibrin on the tissue which aids in
tissue rebuilding. If the wound is unhealthy or dry, debridement may be needed.
Use alginate dressing. Rinse the wound with saline between dressings.
Hydrocolloid
dressing
should
be
changed
every
7
hours.
3. Black: This is a sign of necrosis. Eschar covers the wound and slows healing.
Wound debridement must be done along with application of hydrogel
dressing/transparent film dressing. The same management for the "yellow color"
should be done.

Larval/Maggot/Maggot debridement therapy or biodebridement uses disinfected

maggots to clean the necrotic tissue from the non-healing skin and soft tissue
wound.

Factors
affecting
wound
healing:
1.
Age
2.
Handing
of
tissues
3.
Hemorrhage
4.
Edema
5.
Inadequate
dressing
technique
(too
small/too
tight)
6.
Inadequate
nutritional
intake
7.
Foreign
bodies
8.
Oxygen
deficit
9.
Drainage
collection
10. Intake of corticosteroids, anticoagulants, broad-spectrum/specific antibiotics

11.
Patient
overactivity
12. Systemic d/o (hemorrhagic shock, acidosis, hypoxia, renal failure, hepatic
dse,
sepsis)
13.
Immunosuppressed
state
14. Wound stressors (vomiting, valsalva maneuver, heavy coughing, straining)