wound care slides revised -final

8/10/2019 Wound Care Slides Revised -Final

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Presented by

Helen E. Gomes RN,MSN CNS, CDE, BC-ADM

Associate Professor

CCRI

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Wound Care


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Objectives

Identify the characteristics of wound healing.

Describe the nature of sterile technique when

performing a wound dressing change.

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Integumentary SystemStructures

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Epidermis / top layer Top or outermost layer

Dermis

2nd

layer, framework of elastic connective tissue Nerves, hair follicles, blood vessels located here

Subcutaneous tissue Under layer consists of adipose and connective tissue

Anchors the skin layers to underlying tissue


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Cross-Section of Normal Skin


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Functions of Skin

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Protection

Sensory

Excretion of waste Thermoregulation

Synthesis of Vitamin D

Contributes to Body Image

Absorption (meds)


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Wounds

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Definition

A break or disruption of normal integrity of

skin and tissue


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Wound Classifications

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Status of SkinIntegrity

OpenClosed

Acute

Chronic

Cause

Intentional

Unintentional


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Wound Classifications (cont)

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Severity of Injury

Superficial

PenetratingPerforating


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Types of Wounds

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Incision

Contusion

Abrasion

Laceration Puncture

Penetrating


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Phases of Wound Healing

Hemostasis Occurs immediately after initial injury

Involved blood vessels constrict /clotting begins

After a brief period vessels dilate, capillary

permeability increases, allowing plasma and bloodcomponents to leak into the area (exudate).

Redness, swelling, and pain may occur.

Scab may begin to form.

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Phases of Wound Healing

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Inflammatory phase

Begins after hemostasis/ Lasts 4-6 days

Phagocytosis

leukocytes enter wound 1st & begin removal ofbacteria & debris

Macrophages arrive about 24 hours later

Foreign material or necrotic tissues prolonginflammatory phase

Preventing passage to next phase


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Phases of Wound Healing (cont)

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Proliferative (fibroplastic) phase

Begins within 2-3 days

Lasts for several weeks.Collagen synthesis

Development of new capillaries

Granulation formation


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Phases of Wound Healing (cont)

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Maturation or Remodeling

Final phase begins after approx. 3 weeks

Lasts for months or years

Collagens reorganizedScar tissue thins out

Mature scar forms

Firm & in-elastic.If over a joint or other bony

structure may limit mobility


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Factors Affecting

Wound Healing

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LocalPressure

Maceration

Necrosis Systemic

Age

Circulation and oxygenation

Nutrition


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Local Factors

Pressure disrupts blood supply

Dessication (drying out of cells) cells die in a dry

environment

Maceration (overhydration) moisture especially

from waste products can impair skin integrity.

Edema interferes with the blood supply

Infection (increases stress to body.

Necrosis (dead tissue) impairs wound healing

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Systemic Factors

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AgeYounger age heals more rapidly then older adults.

Nutrition

Wound healing requires adequate proteins,carbohydrates, fats, vitamins, and minerals.

Vit A, C, and zinc are essential for

re-epithelialization and collagen synthesis.


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Oxygenation and circulation

Adequate blood flow is needed to deliver

nutrients and oxygen as well as remove local

toxins, bacteria, and other debris.

Circulation impaired in older adults, those with

some chronic diseases, and smoking.


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Factors Affecting Wound Healing

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Obesity

Large amounts of fat has fewer blood vessels,

place more stress on a wound, are difficult to

suture, are prone to infection and take longer to

heal.

Wound condition

Contaminated wounds heal slowly.


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A Wound with Various Types of

Wound Surface Tissue


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Wound Healing (cont)

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Health Status

Chronic conditions may impair immune function

Examples are diabetes, cardiovascular disease,

impaired immune function such as AIDS.

Radiation therapy

Corticosteroid drugs


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Wound Healing Process (cont)

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Secondary Intention

Wounds with loss of tissue

Edges not approximated

Greater risk of infection

Healing process prolonged

Scar tissue

Ie: Healing by granulation, contraction, re-epithelialization


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Wound Healing Process (cont)

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Tertiary intention or Delayed wound closure

Wound contaminated, infected, or draining

Left open to drain

Wound closed after infection cleared


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Pressure Ulcers

A wound with localized areas of tissue necrosis

Factors in development:

External pressure

Friction and shearRisks:

Immobility

Nutrition and hydration

Moisture

Mental status

Age

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Pressure Points


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Shearing


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Classification of Pressure Ulcers

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Stage I

Nonblanchable erythema of intact skin

Stage II

Partial-thickness skin loss Involves epidermis & / or dermis

Examples:

Abrasion

BlisterShallow crater


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Stage 1

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The skin is intact but shows apersistent pink or red areathat doesnot turn white when you press it with

your finger. The wound may look like amild sunburn. The affected skin may betender, painful or itchy. It may feelwarm, spongy or firm to the touch.


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Stage 2

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The skin outer layer is broken, red andpainful. Surrounding tissues may showareas of pale, red or purple

discoloration. Some swelling and/oroozing may be present. The wound is nolonger superficial and the ulcer is anopen sore that does not extend throughthe full thickness of the skin.


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Classification of Pressure Ulcers (cont)

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Stage III

Full-thickness skin loss

Damage / Necrosis of subcutaneous tissues

Does not include fasciaDeep crater / May have undermining

Stage IV

Full-thickness skin lossExtensive destruction, necrosis, damage to

muscle, bone, supporting structures

Unstageable when base covered with slough

or eschar.


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Stage 4

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There is full-thickness skin loss withextension beyond the deep fasciaand involvement of muscle,underlying organs, bone, and tendonor joint space. This deep openwound may show blackened tissuecalled eschar. The decubitus ulcer isnow extremely deep, having gonethrough the muscle layers and now

involving underlying organs andbone. Surgical removal of thenecrotic or decayed tissue is oftenused on wounds of larger diameter.Surgery is the normal course oftreatment. The wound is veryserious and can produce a life

threatening infection, especially ifnot treated aggressively.A Stage 4wound is extremely difficult to healand requires skilled medical woundcare.


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Complication of Wound Healing

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Hemorrhage Internal

External

Possible causes S & S


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InfectionsS & S

Dehiscence

Possible causeWhen to suspect it


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EviscerationEMERGENCY!

When to suspect it

Nsg interventions


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FistulasPossible causes

When to suspect it

Delayed wound healingMost common causes


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Wound Assessment (cont)

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Surgical wounds:

Incision & surrounding tissue appearance

Wound ClosureCondition of staples / Sutures

Palpation of Wound

Pain


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Wound Drainage

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Note Amount, Color, Odor and Consistency ofDrainage

Types of Drainage

Serous= Clear watery plasma

Sanguineous= Bright redSerosanguineous= Pale red, watery

Purulent= Thick yellow, green, tan orbrown


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Psychosocial Effects of Wounds

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PainAssess for changes in pain level

Address pain control with dressing changes

Monitor effects of pain medications

Anxiety and fear Demonstrate acceptance and empathy

Change in Body Image Reflects a persons view of him/herself


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Wound Healing - NSG Diagnoses

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Impaired Skin Integrity

Risk for Infection

Altered Nutrition: less than body requirements

Acute Pain

Disturbed Body Image


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Classification of Open Wounds

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R (red) = ProtectProliferative stage, granulating tissue

Y (yellow) = Cleanse

Oozing and purulent drainage B (black) = Debride

wound covered with eschar (necrotic tissue)

Which can be black, brown, gray, or tan.

Needs to be removed for wound to heal.

Can be done surgically, mechanically, or

chemically.

Interventions


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InterventionsWound Cleansing

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Use 0.9% normal saline /most common Use sterile gauze or swab

irrigation

Use gentile friction

Cleanse from area of least to most contamination

Drains highly contaminated Cleanse in circular motion moving outward

Cleanse away from incision toward drain


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Wound Debridement

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Sharp debridement

Mechanical debridement Enzymatic debridement

Autolytic debridement


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Dressings - Purpose

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Provide physical, psychosocial and aestheticcomfort

Remove necrotic tissue

Prevent, eliminate, or control infection

Absorb drainage

Maintain a moist wound environment

Protect the skin from further injury

Protect the skin surrounding the wound


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Wound dressings

Multiple types of products See chart page 945

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Changing Dressings

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Physician Orders

Dressing type, frequency of application, solutions orointments to be used

Sterile vs Clean Techniques

Surgical wounds use sterile techniques in hospital May change to clean techniques at home

Pressure ulcers - use clean techniques

***Remember, always use sterile techniques in

hospital settings


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Wound VAC System


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VAC


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How the Wound Vac works

VAC System works by: Drawing the wound edges together

Provides direct and complete wound bed contact

Removes exudate and infectious material

Reduces edema

Promotes perfusion

Keeps wound bed moist

Promotes granulation


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Drains

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Open Penrose

Closed

Jackson Pratt

Hemovac


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Penrose Drain


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Jackson-Pratt Drain


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Bandages and Binders

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Create pressure over body part

Immobilize a body part

Support wound Reduce or prevent edema

Secure a splint

Secure dressings


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The End

Remember

Care of wounds

NSG domainNurses can prevent them

Nurses can cure them

wound care slides revised -final

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