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8.1 Wound Classification

Wounds are classified in several ways and include intentional or unintentional wounds (i.e., from treatment/therapy or accidental), open or closed wounds (i.e., break in the skin or under the skin layers), acute or chronic wounds (i.e., follows normal healing process or is delayed and does not follow normal healing process), pressure injuries, and friction and shear. Pressure injuries are localized ischemic lesions of the skin and underlying tissue caused by external pressure that impair blood and lymph flow. Friction and shear are mechanical forces that tear and injure blood vessels and can contribute to the development of pressure injuries.

Risk factors for development of pressure injuries include exposure to excessive moisture, malnutrition and dehydration, and decreased mobility and cognition. Moisture weakens the skin integrity and makes it more susceptible to breakdown and infection. Malnourishment leads to cell damage, inadequate perfusion, and lack of padding for bony prominences. People who have mobility issues or are bedridden are unable to adjust themselves in response to pressure and are often in one position for a prolonged period of time. Those with altered mental status and who have decreased awareness (e.g., unconsciousness, sedation, or dementia) are at risk because they are less likely to recognize and respond to the discomfort from pressure.

Depending on the extent of damage, pressure injuries are assessed and classified as stages I through IV and as deep tissue or unstageable. A stage I pressure injury is characterized by localized, nonblanchable erythema of intact skin. Stage II pressure injuries are characterized by Partial-thickness (second-degree) skin loss involving the epidermis or dermis. Stage III pressure injuries are characterized by full-thickness skin loss in which the adipose, granulation, and deeper tissues are visible and may have a presence of slough or eschar. Stage IV pressure injuries are characterized by full-thickness skin loss with extensive destruction, necrosis, and exposed or palpable fascia, tendon, ligament, muscle, cartilage, and bone. Slough and eschar are often visible along with epibole, undermining, and/or tunneling. Deep-tissue pressure injuries are characterized by persistent, nonblanchable areas of intact skin that have maroon, deep red, or purple discoloration. Pressure injuries are classified as unstageable if they have full-thickness skin or tissue loss with excessive slough or eschar that obscures the extent of the damage.

8.2 Wound Assessment

Whether in physician’s offices, emergency rooms, or inpatient facilities, the nurse will encounter patients with wounds. Understanding wound assessment and description, such as appearance and types of wounds, is a critical skill for any registered nurse. There are many tools available to help nurses and other healthcare professionals assess and document wounds. Tools such as the Braden Scale and Wagner Ulcer Classification System assist healthcare providers in establishing a patient’s risk for developing wounds or experiencing complications from them. These tools and effective, knowledgeable assessment allow nurses to provide appropriate documentation, which can be used by other providers to effectively manage patient care and ensure accurate and timely treatment.

8.3 Wound Management

Wound management encompasses many nursing interventions that are essential for promoting healing and tissue regeneration. To effectively manage wounds, nurses must understand the phases of wound healing, factors affecting wound healing, psychological effects of wounds, complications affecting wound healing, and the nurse’s role in wound care management. Wounds are healed by primary, secondary, or tertiary intention. Wound healing can be broken down into the following phases: hemostasis, inflammatory phase, proliferation phase, and maturation. Several factors may influence the speed of wound healing and may be localized or systemic. Localized factors are those factors that occur directly in the wound (i.e., desiccation, maceration, trauma, edema, and infection). Systemic factors are not related to the wound itself. These factors take place throughout the body (i.e., age, venous insufficiency, poor oxygenation, obesity, diabetes, medications, and smoking and alcohol use). Wounds and pressure injuries causes stress and emotional challenges caused by pain, fear, disruption to activities of daily living, and an altered body image that can have a significant effect on an affected person’s self-identity and mental well-being. There are several events that can interfere with wound healing and cause complications. Infection, hemorrhage, dehiscence and evisceration, and fistulas can increase the risk of death or generalized illness, increase healthcare costs, and prolong the need for healthcare interventions. The nursing role includes assessment and documentation, positioning, dressing care, drain care, suture and staple care, cleaning, debridement, administration of growth factors and heat and cold therapy, wound care education and health promotion, and education of the patient to perform self-care at home. Other therapies that the nurse may be required to assist with include hyperbaric oxygen therapy and surgery. It is essential that nurses understand their role in wound care management to effectively implement interventions within their scope of practice.

8.4 Burn Injuries and Management

Burn injuries are both preventable and different from other wounds. Their assessment requires evaluation of the type of burn, its depth, and the amount of body surface area it covers. Management of burns is based on the type and degree of burn, and ranges from basic first aid to long-term inpatient care and surgeries requiring extensive support from a large interdisciplinary healthcare team. Due to the complexity of burns, there are a variety of complications related to them, including psychological trauma, respiratory dysfunction, sepsis, and potentially death. The healing process includes the rehabilitation phase, which can be extensive, lasting from weeks to years depending upon functional impairment and loss of ability. Nurses must prepare patients for realistic expectations in the healing process.

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