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Presentation on theme: "NURSING CARE FOR PATIENT WITH WOUND"— Presentation transcript:

By Purwaningsih


3 Break in skin or mucous membranes What are wounds ?

4 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. The Wound

5 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

6 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.

7 Classification of wounds
1. Intentional Vs. Unintentional. 2. Open Vs. Closed. 3. Degree of contamination. 4 . Depth of the Classification of wounds

8 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.

9 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.

10 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.

11 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.

12 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.

13 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.

14 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.

15 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.

16 Wound Healing Primary Intention Secondary Intention: tissue loss
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

17 Wound Healing Inflammatory Response Proliferative Phase: 3-24 days
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

18 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

19 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

20 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 The 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 mobility The patient’s level of incontinence and nutritional status If there is any alteration in sensation or response to discomfort Co-morbid conditions or medications that delay the patient’s ability to heal; and Decreased blood flow to the lower extremities when ulceration is present These conditions will influence the patient’s propensity for skin breakdown and also the potential for healing.

21 Assessment and Documentation
Location Stage and Size Periwound Undermining Tunneling Exudate Color of wound bed Necrotic Tissue Granulation Tissue Effectiveness of Treatment This is a list of your basic criteria for assessment and documentation. Review Slide It is important to note the effectiveness of the treatment. If the current treatment is not effective, then it needs to be revised.

22 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

23 Pressure Ulcer Assessment
Wound Deterioration Skin surrounding ulcer Redness, warmth, edema Exudate Amount, color, consistency, odor

24 Assessment In emergency settings Bleeding?
Foreign bodies or contamination? Size of wound? Need for protection of wound? Need for tetanus antitoxin

25 Assessment Stable Setting Wound appearance Character of drainage
Serous Sanguineous Serosanguineous Purulent

26 Assessment Stable setting Drains Wound closures Penrose
Evacuator units Jackson Pratt drains Hemovac drains Wound closures Sutures Steel staples Clear strips Wound glues

27 Drains and Wound Closures

28 Pressure Ulcer Staging2
Stage I Stage II Stage III Stage IV Please Refer to page 6 in the Guidelines document The 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 Stages Deep 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.

29 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

30 Pressure Ulcer Stages Stage II: Superficial Stage III
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

31 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

32 Nursing Diagnosis Impaired Skin Integrity Impaired Tissue Integrity
Risk for Infection Pain Imbalanced Nutrition, Less than body requirements

33 Care 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.

34 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 Appropriate care planning goals for hospice patients may include: Preventing complications of the wound, such as infection or odor Of course, you will work to prevent additional breakdown of the skin We want to do our best to minimize harmful effects of the wound on the patient’s overall condition. This would be things like depression, social isolation or general discomfort. In many of our hospice patients, we know that promoting wound healing may be unrealistic. Therefore, let’s take a look at some specific interventions for wound care that might be more feasible.

35 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 When 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.

36 Specific Points Affecting Wound Healing
Keep wound clean and scab free Keep wound moist Avoid steroid creams Suturing wound splints skin Wounds actually shrinks The 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

37 Pain Management 1) Medicate the resident prior to dressing changes 2) Some treatment regimes may be uncomfortable for the resident Provide maintenance doses of medication for those patients who have pain. Adjuvant therapy may be appropriate Consider non-medicinal approaches Pain 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.

38 Wound Preparation Removal of hair Scrubbing the wound
Not eyebrow Scrubbing the wound Irrigation with saline Avoid peroxide, betadine, tissue toxic detergents Removal 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.

39 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 These 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.

40 Interventions Stage I Aloe Vesta skin cream
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 Refer to page 10 and 11 in Guidelines Read Goals and Treatments

41 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 Refer to page 12 of the guidelines Review slide Although 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.

42 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 Refer to page 13 of the guidelines Review slide Again 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.

43 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 Refer to page 14 in Guidelines These 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.

44 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 The 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 agents Avoid 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.

45 Cleaning a Wound

46 Securing A Dressing

47 REFERENCES 1. Bucky Boaz, Principles of Wound Closure
2. Magdy Amin RIAD, Wound care, University of Dundee 3. Teresa V. Hurley, Skin Integrity and Wound Care 4. UNC Emergency Medicine, Wound Management 5. VITAS Healthcare Corporation, Wound CareBest Practice Guidelines

48 Thank you


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