4Injury to any ofthe tissues of the body, especially that caused by physical means and with interruption of continuity is defined as a wound.The Wound
5Wound 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
6Until 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.
7Classification of wounds 1. Intentional Vs. Unintentional.2. Open Vs. Closed.3. Degree of contamination.4 . Depth of theClassification of wounds
8Intentional 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.
9Open Vs. Closed woundsOpen wound: the mucous membrane or skin surface is broken.Closed wound: the tissue are traumatized without a break in the skin.
10Degree 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.
11Degree 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.
12Depth of the woundPartial thickness: the wound involves dermis and epidermis.Full thickness: involving the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone.
13Types of wounds1. 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.
14Types of wounds3. 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.
15Types of wounds5. 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.
16Wound Healing Primary Intention Secondary Intention: tissue loss skin edges are approximated (closed) as in a surgical woundInflammation subsides within 24 hours (redness, warmth, edema)Resurfaces within 4 to 7 daysSecondary Intention: tissue lossBurn, pressure ulcer, severe lascerationWound left openScar tissue forms
17Wound Healing Inflammatory Response Proliferative Phase: 3-24 days Serum and RBC’s form fibrin networkIncreases blood flow with scab forming in 3 to 5 daysProliferative Phase: 3-24 daysGranulation tissue fills woundResurfacing by epithelializationRemodeling: more than 1 yearcollagen scar reorganizes and increases in strengthFewer melanocytes (pigment), lighter color
18Some Factors Influencing Wound Healing AgeNutrition: protein and Vitamin C intakeObesity decreased blood flow and increased risk for infectionTissue contamination: pathogens compete with cells for oxygen and nutritionHemorrhageInfection: purulent dischargeDehiscence: skin and tissue separateEvisceration: protrusion of visceral organsFistula: abnormal passage through two organs or to outside of body
19Complications 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
20Risk Assessment Alterations in mobility Level of incontinence Nutritional statusAlteration in sensation or response to discomfortCo-morbid conditionsMedications that delay healingDecreased blood flow to lower extremities when ulceration is presentThe assessment should include the patient’s skin condition, as well as those conditions which increase the risk for skin breakdown and influence the potential for wound healing. They are:Alterations in the patient’s mobilityThe patient’s level of incontinence and nutritional statusIf there is any alteration in sensation or response to discomfortCo-morbid conditions or medications that delay the patient’s ability toheal; andDecreased blood flow to the lower extremities when ulceration is presentThese conditions will influence the patient’s propensity for skin breakdown and also the potential for healing.
21Assessment and Documentation LocationStage and SizePeriwoundUnderminingTunnelingExudateColor of wound bedNecrotic TissueGranulation TissueEffectiveness of TreatmentThis is a list of your basic criteria for assessment and documentation.Review SlideIt is important to note the effectiveness of the treatment. If the current treatment is not effective, then it needs to be revised.
22Pressure Ulcer Assessment Tissue TypeGranulation Tissue: red and moistSlough: yellow stringy tissue attached to wound bed; removal essential for healingEschar: necrotic tissue which is brown or black appearance must be debrided
28Pressure Ulcer Staging2 Stage IStage IIStage IIIStage IVPlease Refer to page 6 in the Guidelines documentThe National Pressure Advisory Panel has redefined the definition of a pressure ulcer and the stages of pressure ulcers, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers. This work is the culmination of over 5 years of work beginning with the identification of deep tissue injury in 2001.Pressure Ulcer Definition A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.Pressure Ulcer StagesDeep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of the underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compares to adjacent tissue.Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark pigmented skin tones. May indicated “at risk” persons (a heralding sign of risk).Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising (bruising indicates suspected deep tissue injury). This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of the tissue loss. May include undermining and tunneling. The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III ulcers. Bone/tendon is not visible of directly palpable.Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage IV ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.
29Pressure Ulcer Stages Stage I: No Skin Break Skin temperature, consistency (firm), sensation (pain or itching)Persistent redness in light skin tonesPersistent red, blue or purple hue in darker skin tones
30Pressure Ulcer Stages Stage II: Superficial Stage III Partial-thickness skin loss (epidermis and/or dermisAbrasion, blister or shallow craterStage IIIFull-thickness skin loss (subcutaneous damage or necrosis and may extend down to but not through fasciaDeep crater
31Pressure Ulcer StagesStage IV: full thickness skin loss and destruction, necrosis of the tissue, damage to muscle, bone, tendons and joint capsules and sinus tractTypes of DressingsTransparent film (Tegraderm, Bioclusive)Hydrocolloid (Duoderm, Comfeel)HydrogelGauze Roll (Kerlix)Provide moist environmentLoosen slough and necrotic tissueWick drainage from wound
32Nursing Diagnosis Impaired Skin Integrity Impaired Tissue Integrity Risk for InfectionPainImbalanced Nutrition, Less than body requirements
33Care Planning.Overall strategy and scope of the treatment plan depends on patient’s condition, prognosis, and reversibility of the wound.Before selecting any treatment plan, identify the likelihood of the wound healing and the benefits of pursuing a specific treatment plan.Document all factors that may affect healing. Keep in mind that under ideal circumstances a wound needs at least 2 to 4 weeks to show evidence of healing. Many hospice patients will not have 2 to 4 weeks. In many terminally ill patients we do not expect a wound to heal, so aggressive intervention may not be appropriate.Review advance directives or other care instructions that may impact the scope or selection of treatment options.Comfort should always guide the selection of the treatment approach.
34Appropriate GoalsPrevent complications or the deterioration of an existing woundPrevent additional skin breakdownMinimize harmful effects of the wound on the patient’s overall conditionPromote wound healingAppropriate care planning goals for hospice patients may include:Preventing complications of the wound, such as infection or odorOf course, you will work to prevent additional breakdown of the skinWe want to do our best to minimize harmful effects of the wound on thepatient’s overall condition. This would be things like depression, socialisolation or general discomfort.In many of our hospice patients, we know that promoting wound healingmay be unrealistic. Therefore, let’s take a look at some specificinterventions for wound care that might be more feasible.
35Interventions Dressing considerations should include: Patient’s condition and prognosisCaregiver abilityEase and continuity of useAbility to maintain moisture balanceFrequency of changeWhen choosing wound care interventions, some of the things to consider are:Condition and Prognosis – If patient has poor potential for healing or has a prognosis of less than 1 week, then aggressive measures may not be appropriate.Caregiver ability – Treatment needs to be provided consistently by all caregivers. So you want to choose one that will offer continuity and ease of use.Goal is to keep a moist wound environment which promotes re-epitheliazation and healing. Too much moisture can delay healing and cause further tissue damage (maceration).Research has shown that the prolonged period that the modern dressings remain in place, speeds up the healing time and decreases the chance of infection.
36Specific Points Affecting Wound Healing Keep wound clean and scab freeKeep wound moistAvoid steroid creamsSuturing wound splints skinWounds actually shrinksThe scab is a significant object in a sutures wound, so keeping the wound clean and scab free allows for quicker and smoother epithelization. This can accomplished by postoperative care, including daily cleaning with hydrogen peroxide or soap and water.The epithelial cells survive and move much better in a moist environment, so keeping the wound moist (without maceration) enhances this process.The wound’s natural inflammatory process is important because new collagen formation, which occurs under the epithelial cells, is catalyzed by normal inflammation.Epithelialization occurs only on the surface of the wound. The strength of a wound is in the collagen fibers and connective tissue supporting the surface. The rebuilding of these fibers takes some time, and suturing a wound splints the skin together until new connective tissue is built.Wounds actually shrink. This is a factor that must be considered in the placement of sutures and in the shape of wounds
37Pain Management1) Medicate the resident prior to dressing changes2) Some treatment regimes may be uncomfortable for the residentProvide maintenance doses of medication for those patients who have pain.Adjuvant therapy may be appropriateConsider non-medicinal approachesPain management is an important aspect of any plan of care.Medication schedules should coincide with dressing changes.Enzymatic debriders and some gels are known to be uncomfortable. Surgical debridement would also cause discomfort if administered without local anesthesia.Keep in mind that some wounds are more painful than others –ulcers due to arterial insufficiency.Muscle relaxants or anti-inflammatories may be indicated with large, invasive wounds where underlying structures are involved.Music or diversional therapy may be helpful at the time of dressing changes.
38Wound Preparation Removal of hair Scrubbing the wound Not eyebrowScrubbing the woundIrrigation with salineAvoid peroxide, betadine, tissue toxic detergentsRemoval of the hair surrounding a laceration helps facilitate meticulous wound closure. Because many bacteria normally reside in hair follicles, shaving of the hair before repair may increased wound infection rates. Reduced damage to hair follicles may be achieved with the use of hair clippers instead of a razor. Most practitioners avoid removal of the eyebrow hair, because its removal may result in abnormal regrowth.Direct scrubbing of the wound with a sterile surgical brush helps remove both bacteria and particulate matter that potentiate the risk of wound infection. However, scrubbing also contributes to tissue damage and reduces the ability of the wound to resist infection.High pressure irrigation (5-8 psi) is recommended for best outcome of reducing bacterial count and reducing infection rates.
39Basic Elements of Wound Care Cleanse Debris from the WoundPossible DebridementAbsorb Excess ExudatePromote Granulation and Epithelialization When AppropriatePossibly Treat InfectionsMinimize DiscomfortThese are examples of wound care interventions which may be part of the plan of care.Each resident’s plan of care will likely differ. There are many different methods of caring for a wound and all would be considered appropriate. Our goal is to define what makes sense in light of the resident’s status and desires.Additionally, each intervention should be re-evaluated every 2 weeks to determine whether the plan is still appropriate. It does not mean that a change is indicated, even if the wound is not responding to the current regime, but that it is the best option for this patient at this time. Failure of a wound to heal does not mean that all possible approaches should be exhausted, nor does it imply an alternate plan of care was more appropriate.A physician assessment can be helpful for a number of reasons.1) They will be able to help us identify appropriate interventions and realistic goals for each wound.2) They will also be able to document why the development of a wound or lack of healing was an unavoidable outcome.
40Interventions Stage I Aloe Vesta skin cream GOALS:Maintain skin integritySkin to remain clean and odor freeProtect and moisturize skinTREATMENTS:Preferred agents (dry skin)Aloe Vesta skin creamPreferred agents (at risk for breakdown due to incontinence/pressure)Aloe Vesta protective ointmentDermarite Perigaurd barrier ointmentRefer to page 10 and 11 in GuidelinesRead Goals and Treatments
41Interventions Stage II, III, IV Dry to Minimal ExudateGOALS:Minimize dressing changesMaintain moist environmentPrevent infectionPrevent additional skin breakdownTREATMENTS:Preferred agents:Hydrofiber (Aquacel)ViscopasteHydrocolloid (DuoDERM Extra Thin)Follow product guidelines for frequency of dressing changeRefer to page 12 of the guidelinesReview slideAlthough the preferred agents are listed here, there are 2nd and 3rd line agents in the guidelines.Take note that the recommended frequency of dressing change for Aquacel is 5-7 days & prn; Viscopaste is 3 days & prn; and Duoderm is 5-7 days & prn.There is a decrease in the number of required dressing changes with the use of these preferred products. This increases the quality of life for our patients.
42Interventions Stage II, III, IV Moderate ExudateGOALS:Minimize dressing changesMaintain moist environmentPrevent infectionPrevent additional skin breakdownTREATMENTS:Preferred Agents:Hydrofiber (Aquacel)Hydrocolloid (DuoDERM Signal)Follow product guidelines for frequency of dressing changeRefer to page 13 of the guidelinesReview slideAgain the preferred agents are listed here, there are 2nd and 3rd line agents in the guidelines.Take note that the recommended frequency of dressing change for Aquacel is 5-7 days & prn, Duoderm Signal is changed every 3-7 days.Again it is important to follow the guidelines for the frequency of dressing changes for these products.
43Interventions Stage II, III, IV Copious ExudateGOALS:Minimize dressing changesManage ExudatePrevent infectionPrevent additional skin breakdownTREATMENTS:Preferred Agents:Hydrofiber (Aquacel)Hydrocolloid (DuoDERM Signal)Follow product guidelines for frequency of dressing changeRefer to page 14 in GuidelinesThese preferred agents remain the same as with moderate exudate.Pleas note that the frequency for dressing change on a copious wound will be more frequent, usually 3-7 days. Always remember to follow the product guidelines.
44Interventions Infected Wounds… Diagnosis of wound infection:Swab Cultures not recommendedBased 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 gauzeDO NOT USE:Providine IodineIodophorDakin’s solutionHydrogen peroxideAcetic AcidThe current thinking suggests that wound infection should be diagnosed primarily on the basis of clinical signs (fever, increased pain, friable granulation tissue, foul odor).Necrotic tissue is not necessarily a sign of infection; however necrotic tissue does support microorganism growth.For hospice patients who have a good potential for wound healing, it may be appropriate to utilize a two-week trial of a topical antibiotic to a wound with clinical symptoms suspicious of a local infection. Tissue culture or biopsy would not be optimal for a hospice patient. The antibiotic selected should be effective against gram-negative, gram-positive, and anaerobic organisms.Appropriate topical antibiotic choices include Triple Antibiotic or silver sulfadiazine. Oral antibiotics are not indicated unless the wound is clearly infected.The preferred agents for an infected wound are: Review preferred agentsAvoid the use of antiseptics such as providone iodine, iodophor, Dakin’s solution, hydrogen peroxide, and acetic acid. These agents have been shown to be cytotoxic to granulation tissue and can actually delay the healing process. These solutions are also drying agents and a moist wound environment is necessary for healing. The constant application of an anti-microbial agent is not necessary to produce wound healing or avoid infection. These products should be used under careful direction of a wound care physician.Remember that tissue culture or biopsy is not optimal for the hospice patient.