Break in skin or mucous membranes Break in skin or mucous membranes What are wounds ?
The Wound Injury to any of the tissues of the body, especially that caused by physical means and with interruption of continuity is defined as a wound. Injury to any of the tissues of the body, especially that caused by physical means and with interruption of continuity is defined as a wound.
Wound healing is a natural and spontaneous phenomenon. When tissue has been disrupted so severely that it cannot heal naturally : * dead tissue and foreign bodies must be removed, * infection treated, * and the tissue must be held in apposition * dead tissue and foreign bodies must be removed, * infection treated, * and the tissue must be held in apposition
Until the healing process provides the wound with sufficient strength to with stand stress without mechanical support. A wound may be approximated with sutures, staples, clips, skin closure strips, or topical adhesives.
Classification of wounds 1. Intentional Vs. Unintentional. 2. Open Vs. Closed. 3. Degree of contamination. 4. Depth of the
Intentional Vs. Unintentional wounds Intentional wound: occur during therapy. For example: operation or venipuncture. Unintentional wound: occur accidentally. Example: fracture in arm in road traffic accident.
Open Vs. Closed wounds Open wound: the mucous membrane or skin surface is broken. Closed wound: the tissue are traumatized without a break in the skin.
Degree of contamination Clean wounds: are uninfected wounds in which minimal inflammation exist, are primarily closed wounds. Clean – contaminated wound: are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered. There is no evidence of infection.
Degree of contamination Contaminated wounds: include open, fresh, accidental wounds. There is evidence of inflammation. Dirty or infected wounds: includes old, accidental wounds containing dead tissue and evidence of infection such as pus drainage.
Depth of the wound Partial thickness: the wound involves dermis and epidermis. Full thickness: involving the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone.
Types of wounds 1. Incision: open wound, painful, deep or shallow, due to sharp instrument. 2. Contusion: closed wound, skin appears ecchymotic because of damaged blood vessels, due to blow from blunt instrument.
Types of wounds 3. Abrasion: open wound involving skin only, painful, due to surface scrape. 4. Puncture: open wound, penetrating of the skin and often the underlying tissues by a sharp instrument.
Types of wounds 5. Laceration: open wound edges are often jagged, tissues torn apart. Often from accidents. 6. Stab wound: open wound, penetration of the skin and the underlying tissues, usually unintentional.
Wound Healing Primary Intention – skin edges are approximated (closed) as in a surgical wound – Inflammation subsides within 24 hours (redness, warmth, edema) – Resurfaces within 4 to 7 days Secondary Intention: tissue loss – Burn, pressure ulcer, severe lasceration – Wound left open – Scar tissue forms
Wound Healing Inflammatory Response – Serum and RBC’s form fibrin network – Increases blood flow with scab forming in 3 to 5 days Proliferative Phase: 3-24 days – Granulation tissue fills wound – Resurfacing by epithelialization Remodeling: more than 1 year – collagen scar reorganizes and increases in strength – Fewer melanocytes (pigment), lighter color
Some Factors Influencing Wound Healing Age Nutrition: protein and Vitamin C intake Obesity decreased blood flow and increased risk for infection Tissue contamination: pathogens compete with cells for oxygen and nutrition Hemorrhage Infection: purulent discharge Dehiscence: skin and tissue separate Evisceration: protrusion of visceral organs Fistula: abnormal passage through two organs or to outside of body
Complications of wound healing 1. Hemorrhage: some escape of blood from a wound is normal, but persistent bleeding is abnormal. 2. Hematoma: localized collection of blood underneath the skin, and may appear as a reddish blue swelling. 3. Infection
Risk Assessment Alterations in mobility Level of incontinence Nutritional status Alteration in sensation or response to discomfort Co-morbid conditions Medications that delay healing Decreased blood flow to lower extremities when ulceration is present
Assessment and Documentation Location Stage and Size Periwound Undermining Tunneling Exudate Color of wound bed Necrotic Tissue Granulation Tissue Effectiveness of Treatment
Pressure Ulcer Assessment Tissue Type – Granulation Tissue: red and moist – Slough: yellow stringy tissue attached to wound bed; removal essential for healing – Eschar: necrotic tissue which is brown or black appearance must be debrided
Pressure Ulcer Staging 2 Stage I Stage II Stage III Stage IV
Pressure Ulcer Stages Stage I: No Skin Break – Skin temperature, consistency (firm), sensation (pain or itching) – Persistent redness in light skin tones – Persistent red, blue or purple hue in darker skin tones
Pressure Ulcer Stages Stage II: Superficial – Partial-thickness skin loss (epidermis and/or dermis – Abrasion, blister or shallow crater Stage III – Full-thickness skin loss (subcutaneous damage or necrosis and may extend down to but not through fascia – Deep crater
Pressure Ulcer Stages Stage IV: full thickness skin loss and destruction, necrosis of the tissue, damage to muscle, bone, tendons and joint capsules and sinus tract Types of Dressings Transparent film (Tegraderm, Bioclusive) Hydrocolloid (Duoderm, Comfeel) Hydrogel Gauze Roll (Kerlix) – Provide moist environment – Loosen slough and necrotic tissue – Wick drainage from wound
Nursing Diagnosis Impaired Skin Integrity Impaired Tissue Integrity Risk for Infection Pain Imbalanced Nutrition, Less than body requirements
Care Planning. Overall strategy and scope of the treatment plan depends on patient’s condition, prognosis, and reversibility of the wound.
Appropriate Goals Prevent complications or the deterioration of an existing wound Prevent additional skin breakdown Minimize harmful effects of the wound on the patient’s overall condition Promote wound healing
Interventions Dressing considerations should include: Patient’s condition and prognosis Caregiver ability Ease and continuity of use Ability to maintain moisture balance Frequency of change
Pain Management 1 ) Medicate the resident prior to dressing changes 2) Some treatment regimes may be uncomfortable for the resident 3)Provide maintenance doses of medication for those patients who have pain. 4)Adjuvant therapy may be appropriate 5)Consider non-medicinal approaches
Wound Preparation Removal of hair – Not eyebrow Scrubbing the wound Irrigation with saline – Avoid peroxide, betadine, tissue toxic detergents
Basic Elements of Wound Care Cleanse Debris from the Wound Possible Debridement Absorb Excess Exudate Promote Granulation and Epithelialization When Appropriate Possibly Treat Infections Minimize Discomfort
Interventions Stage I GOALS: Maintain skin integrity Skin to remain clean and odor free Protect and moisturize skin TREATMENTS: Preferred agents (dry skin) Aloe Vesta skin cream Preferred agents (at risk for breakdown due to incontinence/pressure) Aloe Vesta protective ointment Dermarite Perigaurd barrier ointment
Interventions Stage II, III, IV Dry to Minimal Exudate GOALS: Minimize dressing changes Maintain moist environment Prevent infection Prevent additional skin breakdown TREATMENTS: Preferred agents: Hydrofiber (Aquacel) Viscopaste Hydrocolloid (DuoDERM Extra Thin) Follow product guidelines for frequency of dressing change
Interventions Stage II, III, IV Moderate Exudate GOALS: Minimize dressing changes Maintain moist environment Prevent infection Prevent additional skin breakdown TREATMENTS: Preferred Agents: Hydrofiber (Aquacel) Hydrocolloid (DuoDERM Signal) Follow product guidelines for frequency of dressing change
Interventions Stage II, III, IV Copious Exudate GOALS: Minimize dressing changes Manage Exudate Prevent infection Prevent additional skin breakdown TREATMENTS: Preferred Agents: Hydrofiber (Aquacel) Hydrocolloid (DuoDERM Signal) Follow product guidelines for frequency of dressing change
Interventions Infected Wounds … Diagnosis of wound infection: Swab Cultures not recommended Based on clinical signs (fever, increased pain, friable granulation tissue, foul odor) Tissue culture or biopsy is not optimal for the hospice patient. Treatments: Preferred agents: Hydrofiber (Aquacel Ag) Silvadene ointment and non- sterile gauze DO NOT USE: Providine Iodine Iodophor Dakin’s solution Hydrogen peroxide Acetic Acid