Post on 11-Feb-2016
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Stressors that Affect Skin IntegrityWound Care
NUR101 Fall 2009LECTURE # 8
K. Burger MSEd, MSN, RN, CNE
PPP By: Sharon Niggemeier RN MSNRevised kburger906,907
Factors that Impair Wound Healing Age Malnutrition Obesity/Emaciation Poor circulation and oxygenation Immunosuppression Smoking Incontinence Medications ( Steroids ) Co-morbidities ( Diabetes) Wound Stress Radiation
Wounds - Classification Intentional – results from planned treatment Unintentional wounds- results from unexpected
trauma…accident/ burns/ shooting Open -skin broken, portal of entry Closed – trauma from force, skin intact, soft tissue
damage, internal injury, possible bleeding Acute – goes through normal/timely healing
process Chronic – fails to go through normal stages of
healing; no timely progress in healing
Wounds –Classification
SuperficialPenetratingPerforating
LacerationPunctureAbrasionContusion
CleanContaminated InfectedColonized
Pressure UlcersStage IStage IIStage IIIStage IV
Wound AssessmentAppearance: granulation tissue, eschar, slough,
edema, tunneling, undermining, sinus tracts, colorDrainage: serous, serosanguineous,
sanguineous, purulent and amountPainSize & location on bodyPresence of sutures/staplesPresence of drains/tubesWound edges
??Other Factors to Assess??
ODORLAB VALUESWHAT CAUSED THE WOUND?NEED FOR TETANUS?WHEN DID WOUND OCCUR?WHAT (IF ANY) TREATMENTS HAVE
BEEN TRIED?
Wound - Healing
Healthy body has the ability to restore itself, it depends on the amount of damage and state of health of the individual.
Referred to as regeneration (renewal) of tissue.
There are (3) phases of regeneration
Phase I Wound HealingInflammatory phase- begins
immediately after injury. Includes Hemostasis (cessation of bleeding) due
to vasoconstriction and platelet aggregation Release of histamine, increasing capillary
permeability (plasma leaking) and vasodilation Also phagocytosis ( process when
macrophages engulf microbes and secrete growth factors that promote angiogenesis) stimulates epithelial buds at the end of injured tissue resulting in increased circulation which sustains the healing process
Phase ICONTINUED Wound HealingInflammatory Response4 Cardinal S/S
PainRednessHeatEdema
Phase I Inflammatory ResponseSYSTEMIC RESPONSE
Elevated temperatureElevated WBC ( norms 5000-10000 )Malaise
Phase II Wound Healing
Proliferation (Fibroplasia) Phase - second phase , fibroblasts synthesize collagens which add strength to the wound. Begins 2-3 days after injury.
Thin layer of epithelial cells forms, blood flow is reinstituted. Tissue forms - known as granulation tissue. Translucent red color/fragile/bleeds easily.
Phase III Wound HealingMaturation (Remodeling) Phase- final
phase begins about 3 weeks after the injury. Collagen originally in haphazard order
remodels and reorganizes into a a more orderly structure.
Scar (cicatrix) forms - avascular tissue , doesn’t sweat, grow hair, or tan.
Keloid- abnormal amount of collagen laid down, hypertrophic scar. ( common in dark skin).
Types of Wound Healing Primary Intention: clean, straight line, edges well
approximated with sutures, rapid healing
Secondary Intention: larger wounds with tissue loss, edges not approximated, heals from the inside out, granulation tissue fills in the wound, longer healing time, larger scars
Tertiary Intention: delay 3-5 days before injury is sutured, greater access for pathogens to invade, greater inflammation, more granulation, larger scars .
Wound Complications Infection- S/S purulent drainage, pain, redness around wound,
edema, increased temp, elevated WBC
Hemorrhage – S/S large amts sanquineous drainage + other symptoms of hypovolemic shock. Check UNDER clients
Dehiscence- S/S wound edges pulling away; not well-approximated. Early sign = increasing serosanquineous drainage
Evisceration- S/S wound opens revealing internal organs. Emergency rx = sterile NS gauze to cover; prepare for OR
Psychosocial impact – Encourage verbalization of feelings; encourage self-care as tolerated by client
Promotion of Wound HealingDressings: keep wound covered & cleanWound bed moist / Surrounding skin dryDebridement when necessaryRemove exudate:
Drains, Wound VAC, IrrigationPack wounds looselyNutritional interventions
Debridement Methods
SurgicalMechanicalEnzymatic ( proteolytic enzymes)AutolyticMaggots
Wound Dressing Principles
If exudate is present - Select one that absorbs exudate.
Keep wound bed moist but surrounding skin dry
Pack wounds loosely to avoid pressure on new granulation tissue
Fasten securely using tape, binders etc…OR self-adhesive type dressing materials.
Dressings for DRY wounds Transparent: gas exchanged between wound &
environment but bacteria prevented from entering. Creates moist healing environment Example: Tegaderm
Hydrogels: High water content enhances epithelialization and autolytic debridment.Needs cover dressing and wound edge barrierExample: Carrasyn
Wet – to- Moist Gauze dressings: keeps wound bed moist. Minimizes trauma to granulation tissues
Dressings for MOIST wounds Hydrocolloid: hydrophilic particles mix with water to
from a gel... wound stays moist. DO NOT use in infected wounds.Example: Duoderm
Absorption Materials: beads, powders, rope or sheets that absorb large amount of exudateExample: Calcium Alginate
Foam: Made of hydrophilic material. Highly absorbent.Example: Allevyn
Dry Gauze: Can absorb wound drainage. Can be impregnated with agents to promote healing
IrrigationsCleanses a wound using pressureSterile Normal Saline = usually prescribedAvoid caustic agents ie: peroxide, iodine
etc.Pressure between 4-15 pounds per
square inch (psi) i.e. 60ml syringe with catheter tip
Other TherapiesWound V.A.C. – negative pressure
vacuum assisted closure system. Removes drainage and helps wounds close.
Hydrotherapy – Pulse lavage, WhirlpoolAids in debridement and cleansing, warm water vasodilation.
Hyperbaric Oxygen Electrical Stimulation
Bandages & Binders
Secures dressings in place
Determine size needed
Outer covering must cover entire wound
Tape to secure (initial,date time)
Heat & Cold TherapyHeat- reduces pain & promotes healing
through vasodilationIncreases oxygen and nutrients to aid in
inflammatory responseReduces edema by promoting removal of
excessive interstitial fluid Promotes muscle relaxation
Heat & Cold TherapyCold- decreases pain by vasoconstrictionDecreased blood flow to the area
decreases inflammation and edemaRaises the threshold of pain receptors
thereby decreasing painDecreases muscle tension
Safety Precautions Heat & Cold Therapy
Very young and very oldPeripheral vascular diseaseDecreased LOCSpinal cord injuryPresence of edema and/or scar tissueNO LONGER than 20-30minutes at a time.
Rebound phenomena