3FUNCTIONS OF THE SKIN Regulates body temperature. Prevents loss of essential body fluids, and penetration of toxic substances.Protection of the body from harmful effects of the sun and radiation.Excretes toxic substances with sweat ( waste removal).Mechanical support.Immunological function mediated by Langerhans cells.Sensory organ for touch, heat, cold, socio-sexual and emotional sensations.Vitamin D synthesis from its precursors under the effect of sunlight and introversion of steroids.
4Wound-definitions (Manley, Bellman, 2000) A loss of continuity of the skin or mucous membrane which may involve soft tissues, muscles, bone and other anatomical structure.Any disruption to layers of the skin and underlying tissues due to multiple causes including trauma, surgery, or a specific disease state.
5WOUND HEALING Classification of wound healing (According to the amount of tissue loss)Primary intention healingSecondary intention healingTertiary intention healing
6PHASES OF WOUND HEALING Healing is a quality of living tissue; it is also referred to as regeneration (renewal) of tissue.The inflammatory phase (3-6 days)The regenerative (Proliferative) phase (day 4-day21)The maturation (Remodeling) phase (day or 2 yrs)(Manley, Bellman, 2000)
7The inflammatory phase (Initiated immediately after injury and last 3-6 days Injury /damage CellsHistamineBlood ClotDryVasodilationPermeabilityUniting thewound edgesNeutrophils&Monocytes-Dilated blood vesselsMicrocirculation slow downOedema& Engorgement0-3 days
8The Regenerative (Proliferative) phase Blood vessels near the edge of the wound become porousBegins 2-3 days of injuryLasting up to 2-3 weeksAllowing excess moisture to escape- Resultant tissue filling is referredTo as granulation tissue- process of wound contraction beginsMacrophage activityTraps other blood cells &damaged blood vesselsBegin to regenerate withinthe wound marginsStimulatesFormation& multiplicationof fibroblastsThis fibrous networkWhich- Laying down of a ground substance- Beginning the synthesis of collagen fibers (granulation tissue )migrate along fibrin threadsResulting
9The Maturative phaseBegins about day 21 and can extend up to 6 months up to one or two years after the injury.Fibroblasts continue to synthesize collagenThe collagen fibers recognized into a more orderly structureThe scar become a thin ,less elastic, white line
11Description and Characteristics Types of WoundDescription and CharacteristicsCauseTypeOpen wound; painfulSharp instrument eg. KnifeIncisionClose wound, skin appears ecchymotic (bruised) because of damaged blood vesselsBlow from a blunt instrumentContusionOpen wound; involving the skin ; painfulSurface scrape, either unintentional (eg, scraped knee from fall) or intentional (eg, dermal abrasion to remove pockmarks)AbrasionOpen wound; can be intentional or unintentionalPenetration of the skin and, often the underlying tissues from a sharp instrumentPunctureOpen wound; edges are often jaggedTissues torn apart, often from accidents (eg, machinery)LacerationOpen wound; usually accidental ( bullet or metal fragments)Penetration of the skin and the underlying tissuesPenetrating wound
12Classification of surgical wounds according to the degree of contamination Clean wounds: Operations in which a viscus is not opened. This category includes non- traumatic, uninfected wounds where is no inflammation encountered and no break in technique has occurred. Clean-contaminated: A viscus is entered but without spillage of contents. This category included non- traumatic wounds where a minor break in technique has occurred.
13Classification of surgical wounds cont’d (Altmeire 1997, Ayliffe & Lowbury 1992, NAS 1996) Contaminated: Gross spillage has occurred or a fresh traumatic wound from a relatively clean source. Acute non-purulent inflammation may also be encountered. Dirty or infected : Old traumatic wounds from a dirty source, with delayed treatment, devitalised tissue, clinical infection, faecal contamination or a foreign body.
14Classification of wounds by depth Partial-thickness: Confined to the skin, the dermis and epidermis.Full-thickness : Involve the dermis, epidermis, subcutaneous tissue, and possibly muscle and bonePartial ThicknessFull Thickness
15Wound assessment cont’d (Hahn,Olsen,Tomaselli, Goldberg ,2004) What to assess?LocationDimensions/SizeTissue viabilityExudate/DrainagePeriwound conditionPainStage or extent of tissue damage , dictates how often a wound is reassessedSwelling
16Risk for Impaired Skin Integrity Impaired Skin Integrity DiagnosesRisk for Impaired Skin IntegrityImpaired Skin IntegrityImpaired Tissue IntegrityRisk for InfectionPain
17A- Intrinsic risk factors: Risk Factors Which Increase Patient Susceptibility to infection (Manley.K, Bellman. L,2000)A- Intrinsic risk factors:Extremes age: Defined as “ Children aged 1 year and under, and people aged 65 years and over’.Underling Conditions/DisordersDiabetesRespiratory disordersBlood disordersSmokingNutrition and build
18B- Extrinsic risk factors: Risk Factors Which Increase Patient Susceptibility to infection cont’d (Manley.K, Bellman. L,2000)B- Extrinsic risk factors:Drug therapy as a risk factor: e.g. Cytotoxic drugsBreak in the integrity of the skinItems such as foreign bodiesBypassing of defense mechanisms through devices e.g. Intubations
19S&S of Presence of Infection Wound is swollen.Wound is deep red in color.Wound feels hot on palpation.Drainage is increased and possibly purulent.Foul odor may be noted.Wound edges may be separated with dehiscence present.
20Types of Wound Drainage Exudate is material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and deposited in or on tissue surfaces. The Nature and amount of exudate vary according to: Tissue involved, Intensity and duration of the inflammation, and the presence of microorganisms.1. Serous ExudateMostly serumWatery, clear of cellsE.g., fluid in a blister
21A purulent ExudateIs thicker than serous exudate because of the presence of pus.It consists of leukocytes, liquefied dead tissue debris, dead and living bacteria.The Process of pus formation is referred to as suppuration, and the bacteria that produce pus are called pyogenic bacteria.Purulent exudate vary in color, some acquiring tinges of blue, green, or yellow. The color may depend on the causative organism.
22A sanguineous (hemorrhagic) Exudate It consists of large amount or blood cells, indicating damage to capillaries that is very severe enough to allow the escape of RBCs from plasmaThis type of exudate is frequently seen in open wounds.we often need to distinguish whether the exudate is dark or bright. Bright indicate fresh blood, whereas dark exudate denotes older bleeding.
23Complications of Wounds InfectionHemorrhageDehiscence and possible eviscerationFistula formation
24The RYB color code (Stotts,1999) This concept is based on the color of the open wound rather than the depth or size of the wound.On this scheme, the goal of wound care is to protect ( cover) red, cleanse yellow, and debride black.The RYB code can be applied to any wound allowed to heal by secondary intention.R=Red Y=Yellow B= Black
25Red woundsUsually in the late regeneration phase of tissue repair (ie, developing granulation tissue) and are clean and uniformly pink in appearanceThey need to be protected to avoid disturbance to regenerating tissue. Examples are superficial wounds, skin donor sites, and partial- thickness or second – degree burns.
26How to protect red wounds: Gentle cleansingAvoid the use of dry gauze or wet- to-dry saline dressings.Applying a topical antimicrobial agent.Appling a transparent film or hydrocolloid dressing.Changing the dressing as infrequently as possible.
27Yellow woundsCharacterized primarily by liquid to semiliquid ”slough” that is often accompanied by purulent drainage.clean yellow wounds to absorb drainage and remove nonviable tissue. Methods used may include .Applying wet-to-wet dressing; irrigating the wound; using absorbent dressing material such as impregnated nonadherent, hydrogel dressing, or other exudate absorbers; and a topical antimicrobial to minimize bacterial growth.
28Black Wound Covered with thick necrotic tissue or Eschar. e.g.. third degree burns and gangrenous ulcer.Required debridement .When the eschar is removed, the wound is treated as yellow, then red.
29Purposes of wound dressing To protect the wound from mechanical injuriesTo protect the wound from microbial contaminationTo provide or maintain high humidity of the woundTo provide thermal insulationTo absorb drainage and /or debride a wound
30Purposes of wound dressing 6. To prevent hemorrhage (when applied as a pressure dressing or with elastic bandages).7. To splint or immobilize the wound site and thereby facilitate healing and prevent injury.8. To provide psychological (aesthetic) comfort.
31Principles of asepsis The aim: Guarantee the safety of the equipment used (cleaning/disinfection/sterilisation).Reduce the level of microbial contamination of the site requiring manipulation (antisepsis).Ensure that no microorganisms are introduced (asepsis).
32Cleaning : Is the removal of dirt, debris and organic material Cleaning : Is the removal of dirt, debris and organic material. Disinfection: Removes or destroys harmful microorganisms but not bacterial spores or slow viruses. Sterilization: is the complete destruction or removal of all living microorganisms including bacterial spores. Antisepsis: is the reduction of the number of microorganisms already present on the body site prior to a procedure. Asepsis: Procedure designed to prevent any introduction of microorganisms to the site achieved by a non-touching technique and use of sterile gloves
33Evaluation of Wounds ABC’s first Always! Ensure hemostasis Saline gauze dressingCompressionRemove obstructionsRings, clothing, other jewelryHistory
34History Symptoms Tetanus status Type of Force Allergies Contamination EventPotential for foreign bodyFunctionNon-accidental traumaTetanus statusAllergiesMedicationsComorbiditiesPrevious scar formation
35Wound Examination Location Vascular function Size Tendon function ShapeMarginsDepthAlignment with skin linesNeuro functionVascular functionTendon functionUnderlying structuresWound contaminationForeign bodies
36Wound Consultation Tarsal plate or lacrimal duct Open fracture or joint spaceExtensive facial woundsAssociated with amputationAssociated with loss of functionInvolves tendons, nerves, or vesselsInvolves significant loss of epidermisAny wound that you are uncertain about
37Wound Preparation - Hemostasis Physical vs. chemicalDirect pressureEpinephrineGelfoamCauteryRefractoryUse a tourniquet
38Wound Preparation – Foreign Body Removal Visual inspectionImagingGlass, metal, gravel fragments >1mm should be visible on plain radiographsOrganic substances and plastics are usually radiolucentAlways discuss and document possibility of retained foreign body
39Wound Preparation – Irrigation Local anesthesia prior to irrigationDo not soak the woundUse normal salineLarge syringe (60mL) with Zerowet attachmentDo not use iodine, chlorhexidine, peroxide or detergents
41Wound Preparation – Antibiotics Infections occur in ~3-5% of traumatic wounds seen in the EDFactors that increase riskHeavily contaminated wound, especially with soilImmunocompromised patientsDiabeticsHuman bites > animal bitesMost important prevention adequate irrigation & debridement
43Wound Preparation – Tetanus Prophylaxis Clean woundsIncomplete immunization toxoid>10 years, then give toxoidTetanus prone woundIncomplete immunizationToxoid & immune globulin> 5 years, give toxoidRemember to think about rabies!
44Guidelines for cleaning wounds Use physiologic solution, such as isotonic saline or lactated ringer solution.When possible , warm the solution to body temperature before use.If the wound is grossly contaminated by foreign material , bacteria, slough, or necrotic tissue clean the wound at every dressing change.If a wound is clean , has little exudate , and reveals healthy granulation tissue , avoid repeated cleaning.
45Use gauze squares .Consider cleaning superficial noninfected wound by irrigating them with normal saline rather than using mechanical means.To retain wound moisture , avoid drying a wound after cleaning it.
46Ideal Dressing provide mechanical protection protect against secondary infectionnon adherent and easily removed without traumaleave no foreign particles in the woundremove excess exudatescost effectiveoffer effective pain relief.
47other influencing factors Burns: First ContactAssessmentsitedepthsurface area involvedage of patientother influencing factors
49Superficial Partial Burn Characteristics epidermis and outer dermisblisters (fluid shift)shedding of skinpainful exposed (nerve endings to kinins)bleeds when pricked with needlehair present (hard to pull out)full sensationblanches on pressure.
50Burn Surface Area Wallace’s rule of nines Lund and Browder chart closed palmar hand of victim = 1% of body surface area.
51Anatomical Site Considerations handsfeetfaceperineumgenitaliajointscircumferential burnsAll these areas require special consideration to prevent cosmetic and functional problems secondary to hypertrophic scaring.51
52Other Considerationsextremes of age: very young or very old will need special careco-morbiditiesmedications.
53What to do about blisters? controversial: removal causes paintense blisters can interfere with dermal circulation, restrict movementbeware of blisters with “red rings”blisters can hide deep burnspopped blisters may need to be debrided.