Wounds And wound dressing (Advanced Nursing I) .pptx

This document gives you an inside information about Wounds.

1. WOUNDS PRESENTED BY GLORIA E. KUAGBENU(MRS)

2. layers of the skin EPIDERMIS DERMIS SUBCUTANEOUS TISSUE

3. The skin The skin is the body’s largest organ and is the primary defense against infection. The body’s complex physiological processes promote skin and wound healing, restoring the function and structure of the skin. A disruption in the integrity of body tissue is called a wound.

4. Wound A wound is a break in the continuity of the skin or mucous membrane

5. Causes of wounds Accidents or injuries/trauma Surgical incision Chemicals e.g. acid, alkaline Temperature extremes (frostbite) ,burns Radiation Infections

6. Signs and symptoms Bleeding or oozing of blood Redness Swelling Pain and tenderness Heat Possible fever with infection Loss of function (or mobility) Oozing pus, foul smell (in infected wounds only)

7. Classification of wounds 1. Cause of Wound Intentional wounds occur during treatment or therapy. These wounds are usually made under aseptic conditions. Examples include surgical incisions and venipunctures . Unintentional wounds are unanticipated and are often the result of trauma or an accident. These wounds are created in an unsterile environment and therefore pose a greater risk of infection.

8. Classification cont. 2. Cleanliness of Wound Clean wounds are intentional wounds that were created under sterile conditions, and the respiratory, alimentary, genitourinary, and oropharyngeal tracts were not entered. Clean-contaminated wounds are intentional wounds that were created by entry into the alimentary, respiratory genitourinary, or oropharyngeal tract under controlled conditions .

9. Cleanliness of wound cont. Contaminated wounds are open, traumatic wounds or intentional wounds in which there was a major break in aseptic technique, spillage from the gastrointestinal tract, or incision into infected urinary or biliary tracts. These wounds have acute nonpurulent inflammation present. Dirty and infected wounds are traumatic wounds with retained dead tissue infected with microrganisms or intentional wounds created in situations where purulent drainage was present.

10. Classification cont. 3. Classification by Thickness of Skin Loss Superficial epidermal (first-degree) wounds are confined to the epidermis layer, which comprises outermost layer of skin. Partial-thickness (first- to second-degree) wounds involve the epidermis and upper dermis, the layer of skin beneath the epidermis. Deep (second-degree) wounds involve the epidermis and deep dermis. Full-thickness (third degree) wounds refer to skin loss that extends through the epidermis and the dermis and into subcutaneous fat and deeper tissues.

11. Types of wounds 1. Open Open wounds can be classified according to the object that caused the wound. The types of open wound are: Incisions or incised wounds , caused by a clean, sharp-edged object such as a knife, a razor or a glass splinter. They bleed profusely and heal faster with little contamination

12. Lacerations , irregular tear-like wounds caused by some blunt trauma, the wound is large and gaping. Bleeding is less profuse, usually contaminated and takes longer time to heal by secondary intension.

13. Open wounds cont. Abrasions ( grazes, scrape, rug) are superficial wounds in which the topmost layer of the skin(the epidermis) is scraped off leaving a raw tender area. Abrasions are often caused by a sliding fall onto a rough surface. Exposure of nerve endings makes this type of wound painful, and the presence of debris from the scraped surface (rug fibers, gravel, sand) makes abrasions highly susceptible to infection.

14. Open wounds cont. Puncture wounds are caused by pointed object puncturing the skin, such as a nail, pencil or needle. If a piece of the object remains in the skin, or if there is little bleeding due to the depth and location of the puncture, infection is likely. Anaerobic bacteria like clostridium tetani may infect the wound. The entry point of the object is usually small but underlying tissues may be damaged.

15. Open wounds cont. Gunshot wounds are caused by a bullet or similar projectile driving into or through the body. There may be two wounds, one at the site of entry and one at the site of exit, generally referred to as a "through-and-through .“ Damage to internal organs occur Avulsion results when the skin or tissue is torn away from the body, either partially or completely. The bleeding and pain will depend on the depth of tissue affected.

16. Identify the types of wound

17. Identify the types of wound

18. Types of wounds cont. 2. Closed Closed wounds have fewer categories, but are just as dangerous as open wounds. The types of closed wounds are: Contusions or bruises, caused by a blunt force trauma that damages tissue under the skin causing bleeding beneath the skin surface. A bruise in a light-skinned individual will change from red to purple to greenish yellow before fading; in a dark-skinned person, the bruise will first look dark red then darker red, brown, or purple, and slowly fade.

19. Closed wounds cont. Hematomas, also called a blood tumor, caused by damage to a blood vessel that in turn causes blood to collect under the skin. Crush injury , caused by a great or extreme amount of force applied over a long period of time.

20. Lesson objectives By the end of the lesson students will be able to: Describe the phases of wound healing Describe the types of wound healing Describe the exudates from wounds Explain the factors affecting wound healing

21. Wound healing A complex integrated sequence of cellular physiologic and biochemical events initiated by injury to tissue. All repair occurs with an overlapping series of events to restore the function and integrity of the damaged tissue Phases Hemostasis and inflammation Reconstruction/proliferation Maturation

22. Wound healing cont. 1.Hemostasis and Inflammatory Phase This phase occurs immediately after injury and lasts about 3 to 4 days. Hemostasis is the cessation of bleeding, vasoconstriction of large blood vessels in the affected area occurs. Platelets aggregate to form a platelet plug and stop the bleeding.

23. Activation of the clotting factors forms fibrinous meshwork, which further entraps platelets and other cells. This provides initial wound closure, prevents excessive loss of blood and body fluids, and inhibits contamination of the wound by microorganisms.

24. Hemostasis and inflammatory phase cont. Inflammation is the defensive adaptation of tissue to injury and involves both vascular and cellular responses which eventually increases blood supply to the site and phagocytosis initially by neutrophils and subsequently macrophages . Release of histamine, increases capillary permeability (plasma leaking) and vasodilation

25. Macrophages also secrete several factors, including fibroblast activating factor (FAF) and angiogenesis factor (AGF). FAF attracts fibroblasts, which form collagen AGF stimulates the formation of new blood vessels to support and sustain the wound and the healing process. Inflammatory response is characterized by redness, heat, pain, swelling and loss of function

26. Inflammatory response

27. Wound healing cont’d 2 . Reconstructive (Proliferative) Phase The reconstructive phase begins on the 3 rd or 4 th day This phase contains the process of: collagen deposition angiogenesis granulation tissue development wound contraction

28. Collagen deposition Fibroblasts synthesize and secrete collagen for tissue repair. Initially, collagen is gel-like, but within several months it cross-links to form collagen fibrils and adds tensile strength to the wound to prevent gaping the deposited collagen causes a raised ‘‘healing ridge’’ which may be visible under the injury or suture line

29. Proliferative phase cont. Angiogenesis , the formation of new blood vessels, begins within hours after the injury. The endothelial cells in preexisting vessels begin to produce enzymes that break down the basement membrane. The membrane opens, and new endothelial cells build a new vessel . These capillaries grow across the wound, increasing blood flow, which increases the supply of nutrients and oxygen needed for wound healing .

30. Proliferative phase cont. Granulation tissue is filled with new capillaries that are fragile and bleed easily, thus giving the healing area a red/pink, translucent, granular appearance

31. Proliferative phase cont. Wound contraction As granulation tissue is formed , growth of epithelial tissue, begins. Epithelial cells migrate into the wound from the wound margins. Eventually , the migrating cells contact similar cells that have migrated from the outer edges. Contact stops migration. The cells then begin to differentiate into the various cells that compose the different layers of skin.

32. Contraction is noticeable 6 to 12 days after injury and is necessary for closure of all wounds. The edges of the wound are drawn together by the action of myofibroblasts , specialized cells that contain bundles of parallel fibers in their cytoplasm. If the wound does not close by epithelialization , the area becomes covered with plasma protein and dead cells called eschar .

33. Wound healing cont. 3. Maturation Phase Maturation, the final stage of healing, begins about the 21 st day and may continue for up to 2 years or more, depending on the depth and extent of the wound. During this phase, the scar tissue is remodeled (reshaped or reconstructed by collagen deposition, lysis and debridement of wound edges).

34. Maturation phase cont. Although the scar tissue continues to gain strength, it remains weaker than the tissue it replaces. Capillaries eventually disappear, leaving an avascular scar (a scar that is white because it lacks a blood supply). The scar tissue becomes strong but not as the original tissue

35. Types of wound healing Primary intention -healing occurs in wounds that have minimal tissue loss and edges that are well approximated (closed ). The wound is clean and dry with minimal granulation tissue and scarring within a week i f there are no complications, such as infection, necrosis, or abnormal scar formation. Example emergency laceration repair, closure of the surgical wound

36. Primary closure of wounds

37. Types of wound healing cont. Secondary intention healing is seen in wounds with extensive tissue loss and wounds in which the edges are gaping. The wound is left open, and granulation tissue gradually fills in the deficit. Repair time is longer Tissue replacement and scarring are greater T he susceptibility to infection is increased because of the lack of an epidermal barrier to microorganisms

38. Secondary wound closure

39. Types of wound healing cont. Tertiary intention healing, also known as delayed primary closure, is indicated when primary closure of a wound is undesirable. Conditions in which healing by tertiary intention may occur include poor circulation or infection. Suturing of the wound is delayed until the problems resolve and more favorable conditions exist for wound healing

40. Wound discharges Discharges or exudates are fluids and cells from the wound site The nature and amount of exudate vary depending on the tissue involved, the intensity and duration of the inflammation, and the presence of microorganisms .

41. Examples of wound discharges Serous exudate - clear fluid (serum) Purulent exudate - dead and living bacteria, leucocyte and dead cells Hemorrhagic exudate /sanguineous exudate - red blood cells

42. Function of wound exudates Dilution of toxins produced by bacteria and dying cells Transport of leukocytes and plasma proteins, including antibodies, to the site Transport of bacterial toxins, dead cells, debris, and other products of inflammation away from the site

43. Types of wound tissue Necrotic tissue/ eschar - dark or brown tissue Slough- yellow or white tissue Granulation tissue - pink or beefy red tissue Epithelial tissue - pink or shiny tissue from wound edge Closed/ resurfaced -new skin or scar

44. Slough

45. Eschar

46. Granulation tissue

47. Epithelial tissue

48. Factors affecting wound healing Blood circulation and oxygen delivery to the wound Nutrition Obesity Smoking Medications – steroids, aspirin Chronic diseases Infection ongoing trauma debris and foreign bodies in the wound

49. Lesson objectives By the end of the lesson, students will be able to: describe assessment and examination of a patient with a wound describe the care of patient with a wound: Emergency care Subsequent wound care 3. explain the complications of wound healing

50. Wound assessment History taking- It is important to obtain the data in chronological order : when and how the wound occurred , the initial location and size, associated symptoms, such as pain and itching. t he aggravating and alleviating factors

51. Allergies to tape, latex, medications, or other substances. An assessment of the client’s nutritional status should evaluate albumin level, weight

52. Wound assessment cont. Physical examination- D ocument the location and size and noting length, width, and depth in centimeters. The appearance of the wound bed and surrounding skin is assessed for sinus tracts, undermining, tunneling, exudate, necrotic tissue, and signs of infection. Evaluate the skin, nails, hair, color, capillary refill, temperature, pulses, edema of the extremity, and hemosiderin (an iron pigment that is a product of RBC hemolysis) in the periulcer area.

53. Nursing diagnoses for wound Impaired skin integrity related to surgical incision Impaired tissue integrity related to pressure over bony prominence Risk for impaired skin integrity related to physical immobilization Risk for infection related to nutritional deficiency Acute pain related to inflammatory process Disturbed body image related to changes in body appearance secondary to scars, drains, and removal of body parts knowledge deficit (wound care) related to lack of exposure to information

54. General Care of wounds Educate client on measures to promote wound healing e.g. balanced diet, exercise Reassure patient of competency of staff Encourage local and general rest Observe the vital signs, amount and type of drainage Encourage the intake of foods high in protein, vitamin C , K, zinc and adequate fluid intake Dress wound aseptically with antiseptic solution e.g . normal saline and debridement of wound if slough is present

55. Care of wounds cont . 7.Administer prescribed medications such as analgesics, antibiotics ,TT, ATS 8. Use aseptic measures to prevent wound infection 9. Position client in such a way that pressure is relieved from the wound 10. Range of motion exercises should be done to promote blood circulation to wound 11. Encourage skin hygiene such as bathing twice daily 12. Avoid skin trauma

56. Comfort measures Tape should be supported and removed carefully by freeing all edges and lifting straight up to prevent stress on sensitive tissue. Position the client to decrease strain on the wound. Administer prescribed analgesics 30 to 60 minutes prior to dressing changes, depending on the drug’s time of peak action.

57. Matching wound colour and care Black………………….. Black wounds contain necrotic tissue ( eschar ). Eschar may be either black, gray, brown, or tan. These wounds need debridement (sharp, mechanical, chemical, autolytic ) and cleansing dressing Green…………………. antimicrobial dressing Wet yellow…………. Yellow wounds have either fibrinous slough or purulent exudate from bacteria. They need antimicrobial dressing(damp-damp), irrigation to remove purulent exudate , and removal of nonviable slough

58. Dry yellow…………. rehydrating dressing Red……………………… Red wounds are the colour of normal granulation tissue and are in the proliferative phase of wound repair. These wounds need to be protected from trauma and kept moist and clean. Hypergranulation . antimicrobial dressing Pink……………………. protect.

59. Complications of wound healing Hemorrhage Infection Dehiscence Evisceration Keloid Contracture/deformity Fistula formation Sinus formation

60. Cleansing of wounds The goal of cleansing the wound is to remove debris and bacteria from the wound bed with as little trauma to the healthy granulation tissue.

61. Wound dressing Reasons for wound dressing Protect the wound from mechanical injury Protect wound from microbial contamination Maintain moist wound healing Absorb drainage or debride a wound Prevent haemmorrhage Splint or immobilize the wound site

62. Emergency care of wounds Assesses the type and extent of injury that the client has sustained. If hemorrhage is detected, sterile dressings and pressure should be applied to stop the bleeding using standard precautions. Elevate the affected part Vital signs should be monitored frequently and notify the doctor immediately. When dehiscence or evisceration occurs, the client should be instructed to remain quiet and to avoid coughing or straining.

63. 5. The client should be assisted into the dorsal recumbent position to prevent further stress on the wound. 6. Sterile dressings soaked with sterile normal saline, should be used to cover the wound and abdominal contents to reduce the risk of bacterial contamination and drying of the viscera. 7. Notify the surgeon immediately and prepare the client for surgical repair of the area.

64. Types of dressing materials Transparent dressing- applied to burns and donor sites Hydrocolloid dressing- used over pressure ulcers, wounds with slough and exudates Non-adherent dressings e.g. vaseline gauze Gauze dressings

65. Types of dressing Dry to dry dressing wet-to-dry dressing Wet to dump dressing

66. Procedure for wound dressing Preparation Wash hands put on mask and Prepare a dressing trolley as follows Clean the shelves and rail of the trolley with soapy water, rinse and dry with an antiseptic lotion and dry Turn off fans, ensure less traffic activities

67. Requirement Top shelf Draped with sterile towel and has: 2 gallipots for lotion 2 pair of dressing forceps 2 pair of dissecting forceps Sinus forceps Probe Stitch scissors Kidney dish for cotton and gauze swabs

68. Bottom shelf Bottles of lotion Adhesive plaster Scissors Bandages receiver for used instruments mackintosh and towel Receptacle for soiled dressing and used swabs Packaged dressing set Packaged dressing materials

69. Procedure for wound dressing Explain procedure and ensure privacy Wash and dry hands Put on mask and prepare and take trolley to the bed side Assist patient into desired position Protect bed clothes with mackintosh and towel and expose the area Pour out lotions into gallipots Remove plaster and bandage

70. Wash and dry hands 9. Remove soiled dressing using dissecting forceps or disposable gloves and discard and wash hands 10. Put cotton /gauze into lotion and squeeze out excess lotion 11. Clean wound with the swab soaked in normal saline or methylated spirit using forceps or sterile gloves starting from inside of the wound to the periphery using one swab at a time

71. 12. Clean wound with series of swabs until clean 13. Apply sufficient sterile dressing and secure into position 14. Inform patient about the state of the wound 15. Thank patient and make him comfortable 16. Discard trolley, decontaminate used items and remove gloves 17. Wash and dry hands, remove screen, document and report the state of the wound

72. Wound drains A surgical drain is a tube used to remove pus, blood or other fluids from a wound Depending on the amount of drainage, a patient may have the drain in place one day to weeks. Wound drains are placed in the operative site and the other end is usually passed through a separate small stab wound near the main incision. Drains have protective dressings that will need to be changed daily or as needed.

73. Types of drains 1. Opened drains e.g. Penrose drains are flexible and function by gravity . They have an open end that drains onto dressings . 2. Closed suction drainage systems commonly have a reservoir that is capable of creating negative pressure or a vacuum. E.g Hemovac and Jackson-Pratt drains

74. Wound drain

75. Care of drainage tubes Requirement is same as for wound dressing but add a sterile safety pin, sterile scissors Steps Refer to dressing of wound up to point 12 For the penrose tube , open the sterile safety pin, grasp the end with forceps and clip in position Remove any stitch holding the drain in position Gently rotate the tube pull and hold with safety pin and cut 1cm with sterile forceps Swab with cleansing lotion, apply dressing and secure in position

76. For Closed system drainage system , Maintain the patency of the system and assess the amount, type, and colour of the drainage. Gently hold and Clean around the tube Rotate tube to prevent adhesions Apply dressing and secure in place taking care to prevent accidental removal

77. Empty the drainage bag when 2/3 full and document the amount, colour , odour and consistency of the drainage Removal of tube To remove the tube, cut the stitch holding it in place swab and gently pull out the tube into a receiver Clean and cover the stab wound

78. Sutures / stitches Stitches or sutures are used to close cuts and wounds. Sutures are a surgical means of closing a wound by sewing, wiring, or stapling the edges of the wound together. They can be used in every part of the body, internally and externally. Stitches are used to close a variety of wounds such as laceration, incisions

79. For surface closures, steel staples or sutures made of wire, nylon, cotton, or other materials are used. T hese need to be removed as the wound heals.

80. Types of sutures Absorbable sutures rapidly break down in the tissues. This type of suture does not have to be removed e.g. vicryl , chromic gut Nonabsorbable sutures , maintain their strength and do not break down in tissues These sutures are used to close skin or external wounds and require removal once the wound has healed e.g. silk, prolene

81. Suture patterns Continuous suture is one in which a continuous, uninterrupted length of material is used They are made with one thread, tied at the beginning and end of the suture line. Interrupted suture is one in which each stitch is made with a separate piece of material. Sutures are each tied individually

82. Interrupted stitch

83. Surgical S taples Surgical staples are also useful for closing many types of wounds and have the advantage of being quicker, more economical, and causing fewer infections than stitches. Disadvantages of staples are permanent scars if used inappropriately and imperfect aligning of the wound edges, which can lead to improper healing. Staples are used on scalp lacerations and commonly used to close surgical wounds.

84. Removal of staples To remove staples, insert the end tips of the stapler remover under each wire staple. The end tips are placed in the middle of the staple; slowly squeeze together the handles of the stapler remover, freeing the staple from the skin.

85. Removal of sutures Different parts of the body require suture removal at varying times. Face:   3-5 days Scalp : 7-10 days Trunk : 7-10 days Arms and legs : 10-14 days Joints : 14 days

86. Procedure for stitch removal Refer to wound dressing up to step 12 Clean the wound with series of swabs and place a sterile swab near the wound Count the number of stitches Take dissecting and stitch removing scissors, grasp ends of stitch with dissecting forceps and pull gently to expose the area between the knot and skin

87. 5. Cut stitch between the knot and skin 6. Pull out suture gently and slowly 7. Inspect the removed sure carefully and discard on a piece of gauze 8. Note the number of sutures removed 9. Clean the wound, apply dressing and secure in position 10. Thank and make patient comfortable 11. Discard and decontaminate instrument 12. Document and report findings

88. Wound irrigation Wound irrigation is the steady flow of a solution across an open wound surface to achieve wound hydration , remove debris , and assist with visual examination. Requirements Sterile and Disposable gloves Protective gown and goggles Sterile dressing material irrigation syringe Irrigation solution (normal saline, povidone iodine) Kidney dish to receive used irrigation fluid Mackintosh and towel to protect bed

89. Procedure for wound irrigation Assess the patient’s condition and identify any allergies, specifically to povidone -iodine or other topical solutions or medications. Assess the wound, including the amount and character of drainage and the size and condition of the wound and surrounding tissue. Irrigation should be performed using strict aseptic technique. Wash hands, wear a protective gown and put on clean gloves. If applicable, remove soiled dressing and discard with gloves. Put on goggles, if needed.

90. 7.Hold the filled syringe just above the top edge of the wound and gently instill fluid into the wound, slowly and continuously until the syringe is empty. 8.Be sure the solution flows from the clean to dirty area of the wound. Use enough force to flush out debris, but do not squirt or splash fluid. 9. Irrigate all portions of the wound. Do not force solution into the wound’s pockets. Repeat irrigation procedure until the prescribed amount of solution is administered or the solution draining from the wound is clear.

91. 10.Remove and discard disposable irrigation equipment . 11.Clean around the wound with normal saline solution and wipe intact skin. 12.Gently pat dry the wound’s edges, unless the wound should be covered with a wet-to-dry dressing (dry only surrounding skin). Work from cleanest to most contaminated part of wound. 13.The patient should be positioned comfortably to allow further drainage into the basin. 14.Apply dressings as ordered.

92. 15. Record the date and time of irrigation, amount and type of irrigant , appearance of the wound, sloughing tissue or exudate, amount of solution returned, skin care performed around the wound, dressings applied, and the patient's tolerance of the treatment.

93. Heat and cold therapy Heat H eat reduces pain and promotes healing through vasodilation Increases oxygen and nutrients to aid in inflammatory response Reduces edema by promoting removal of excessive interstitial fluid Promotes muscle relaxation

94. Heat and cold therapy cont’d Cold Cold decreases pain by vasoconstriction Decrease blood flow to the area decreases inflammation and edema Raises the threshold of pain receptors thereby decreasing pain Decreases muscle tension

95. THE END THANK YOU