Scribd
Upload
474 views1 page

Nursing Wound Care Essentials

There are three main types of wounds: open wounds which expose internal tissue, closed wounds where the skin remains intact, and pressure wounds which can be open or closed depending on their stage. Wound closure involves primary intention where edges are approximated, secondary intention allowing granulation tissue to form, or tertiary intention leaving the wound open initially. Nursing priorities for wound care include assessment, monitoring for healing and infection, pain management, cleaning, dressing selection and changes, and patient education.

Uploaded by

Jamie W.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
474 views1 page

Nursing Wound Care Essentials

There are three main types of wounds: open wounds which expose internal tissue, closed wounds where the skin remains intact, and pressure wounds which can be open or closed depending on their stage. Wound closure involves primary intention where edges are approximated, secondary intention allowing granulation tissue to form, or tertiary intention leaving the wound open initially. Nursing priorities for wound care include assessment, monitoring for healing and infection, pain management, cleaning, dressing selection and changes, and patient education.

Uploaded by

Jamie W.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

WOUND TYPES

Classifying Wounds
Open wounds: Pressure wounds may be Closed wounds:
involve a break in the skin, open or closed depending skin remains intact,
internal tissue exposed on their stage. internal tissue not exposed

Incision Laceration Abrasion Puncture Pressure Contusion Hematoma

Types of Wound Closures


Primary intention Secondary intention Tertiary intention
Wound edges are approximated, Wound edges cannot be Wound is left open and later closed
either on their own or by approximated due to significant due to risk of infection or risk for poor
intervention. Fastest type of wound tissue loss. Granulation tissue and healing. Wound is cleansed, monitored, and
closure, low risk of infection/ wound contraction occur to close surgically closed when appropriate.
scarring. the defect. Higher risk of infection/
scarring.
E.g.: surgical incisions, paper cuts E.g.: lacerations, burns, ulcers E.g.: animal bite, avulsion

Gaping irregular Increased Late suturing


Clean incision Early suture Granulation Wound
wound granulation with wide scar

Nursing Care Priorities Risk Factors for Delayed Healing


• Assess and document wound. • Medications: • Infections
• Monitor for signs of healing and infection. 9 Corticosteroids • Poor tissue perfusion
• Treat for pain prophylactically prior to procedures. 9 Anticoagulants • Diabetes
• Perform wound cleaning/irrigation as ordered. 9 Immunosuppressants • Malnutrition
• Obtain wound culture if ordered. 9 Chemotherapy • Obesity
• Select appropriate dressing. 9 NSAIDs • Genetic conditions
• Perform dressing changes.
• Educate client on wound care.

Client Education
Provide anticipatory Inform client when Educate client
Instruct client how
guidance. Inform client stitches, staples, or on signs of
to clean wound
that soreness, tingling, steri-strips should be infection and
and perform
and/or itching can be removed. Schedule when to call
dressing changes.
normal during healing. follow-up. provider.

NOTES

www.lecturio.com/nursing Watch Video

You might also like