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CHAPTER 32 Skin Integrity & Wound Healing
Table 32-4 ➤ Types of Tissue in the Wound Bed TYPE OF TISSUE DESCRIPTION
NURSING GOAL
Slough
Soft, moist, devitalized (necrotic) tissue; may be white, yellow, tan; may be stringy, loose, or adherent to bed Necrotic tissue; dry, thick, leathery; may be black, brown, or gray depending on moisture level Pink to red, moist tissue; made of new blood vessels, connective tissue, and fibroblasts; surface is granular or pebble-like. Absence of granulation tissue, but bed is pink, shiny, and smooth. Regenerating epidermis; may appear pink or pearly white as it crosses the wound bed; may begin as a ring around the wound or from epithelial cells lining hair follicles
Débride the wound.
Eschar
Débride the wound.
Granulation Tissue
Cleanse, protect. Promote epithelialization (epithelial growth).
Clean, Nongranulating
Cleanse, protect. Promote growth of healthy tissue.
Epithelial
Cleanse, protect.
Compare changes in the exudate with the patient’s pre- vious status. ■ Amount. Describe the amount as none, light, moder- ate, or heavy. Drainage amounts vary according to the type of wound (i.e., venous stasis ulcers usually pro- duce more drainage than arterial ulcers). ■ Drains. If a drain is present, measure the amount of fluid in the collection container. ■ Color. Describe the color or consistency as serous or clear, serosanguineous, sanguineous, purulent, or seropurulent (composed of serum and pus).
■ Odor. Describe odor as absent, faint, moderate, or strong. ■ Clean the wound of all exudate or foreign material before assessing for odor because odor characteris- tics vary depending on wound moisture, organisms present, amount of nonviable tissue, and types of dressings used. ■ Odor may indicate fistula formation or bacterial con- tamination. For example, if a patient has an abdom- inal wound that was odorless but begins to smell of bile or feces, you should carefully assess for the pres- ence of a fistula. If confirmed, notify the provider. service providers, including names and contact information, that are appropriate resources for the patient. Having easily accessible information about reliable care would lessen the burden on the patient. Think about it. ➤ What considerations are important when building an interprofessional team? ➤ What practical challenges may need to be addressed within the context of a wound care team? ➤ How can technology play a role in effective implementation of wound care teams? Source : Buggy,A., & Moore, Z. (2017).The impact of the multidisciplinary team in the management of individuals with diabetic foot ulcers:A systematic review. Journal of Wound Care, 26 (6), 324–339. https://doi. org/10.12968/jowc.2017.26.6.324; Moore, Z., Butcher, G., Corbett, L. Q., McGuiness,W., Snyder, R. J., & van Acker, K. (2014).AAWC,AWMA, EWMA position paper: Managing wounds as a team. International Journal of Wound Care, 23 (5), S1–S38. https://doi.org/10.12968/jowc.2014.23.Sup5b.S1
Improving Wound Care With Interprofessional Teams Key Concept: Wound Healing Competency: Collaborate with the interprofessional healthcare team Interprofessional collaboration is essential to providing quality patient care and strengthening the healthcare system.The use of a team approach in treating both acute and chronic wounds, including diabetic foot ulcers, venous stasis ulcers, and pressure injuries, has been a topic of research.Within this model, the patient remains central, with care efforts being provided based on patient needs and desires. Characteristics such as trust, effective communication, role clarity, and mutual respect are needed to create high-functioning teams.
The World Health Organization suggests a “wound navigator” as a wound care team leader.The navigator functions as a patient advocate, focusing on patient-perceived needs and involving the expertise of healthcare professionals.The wound navigator collaborates with other professionals to determine the best plan of care for each patient, using a referral and follow-up system. For example, the wound navigator could provide each patient with a list of care/
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