Wound care
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This document provides information on nursing care for patients with wounds. It begins by defining wounds and describing the wound healing process. It then classifies wounds by intent, whether open or closed, degree of contamination, and depth. Various types of wounds like incisions, contusions, and lacerations are described. Stages of pressure ulcers are defined. The document outlines factors that influence wound healing and potential complications. It discusses assessing wounds by location, appearance, drainage, and for pressure ulcers, the tissue type. Nursing diagnoses, care planning, interventions, and dressing considerations are presented for different wound stages. Cleaning and securing dressings is demonstrated. References are provided.
Wound care
- 1. NURSING CARE FOR PATIENT WITH WOUND By SHIVA NAGU M.Sc (N)
- 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.
- 5. Wound healing is a natural and spontaneous phenomenon. * 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
- 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 – 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 – 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
- 21. Assessment and Documentation • Location • Stage and Size • Periwound • Undermining • Tunneling • Exudate • Color of wound bed • Necrotic Tissue • Granulation Tissue • Effectiveness of Treatment
- 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 • 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
- 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 – 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.
- 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
- 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
- 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
- 37. 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
- 38. Wound Preparation • Removal of hair – Not eyebrow • Scrubbing the wound • Irrigation with saline – Avoid peroxide, betadine, tissue toxic detergents
- 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
- 40. 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
- 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
- 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
- 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
- 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
- 45. Cleaning a Wound
- 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