1 Module five Wound care and dressing. 2 THE SKIN.
-
date post
19-Dec-2015 -
Category
Documents
-
view
226 -
download
2
Transcript of 1 Module five Wound care and dressing. 2 THE SKIN.
33
FUNCTIONS OF THE SKIN
Protection against injury
Sensation
Defense against microorganisms
Maintenance of hydration
Waste removal
Thermoregulation
Healthy SkinImmune function
Synthesis of Vitamin D
44
Wound-definitions(Manley, Bellman, 2000)
A loss of continuity of the skin or A loss of continuity of the skin or mucous membrane which may mucous membrane which may involve soft tissues, muscles, involve soft tissues, muscles, bone and other anatomical bone and other anatomical structure.structure.
•Any disruption to layers of the skin and underlying tissues
•Due to multiple causes including trauma, surgery, or a specific disease state
55
WOUND HEALING
Classification of wound healing(According to the amount of tissue loss)
Primary intention healing
Secondary intention healing
Tertiary intention healing
66
Wound Classification Wound Classification
Intentional wounds and Unintentional Intentional wounds and Unintentional wounds wounds
Open wounds and closed wounds Open wounds and closed wounds Acute and chronic wounds Acute and chronic wounds
77
PHASES OF WOUND HEALING
Healing is a quality of living tissue; it is also
referred to as regeneration (renewal) of tissue.
A. The inflammatory phase
B. The regenerative (Proliferative) phase
C. The Maturative (Remodeling) phase
(Manley, Bellman, 2000)
88
Injury /damage Cells
Blood Clot
Uniting the wound edges
Histamine
Vasodilation Permeability
Neutrophils &Monocytes
Oedema& Engorgement
0-3 days
Dry
-Dilated blood vessels-Microcirculation slow down
The inflammatory phase (Initiated immediately after injury and last 3-4-6
days
99
Blood vessels near the edge of the wound become porous
- Resultant tissue filling is referredTo as granulation tissue- process of wound contraction begins
Traps other blood cells & damaged blood vesselsBegin to regenerate within the wound margins
Allowing excess moisture to escape
Macrophage activity
Formation& multiplication of fibroblasts
migrate along fibrin threads
- Laying down of a ground substance- Beginning the synthesis of collagen fibers (granulation tissue )
The Regenerative (Proliferative) phase
Stimulates
Which
This fibrous networkR
esultin
g
Begins 2-3 days of injuryLasting up to 2-3 weeks
1010
The Regenerative phasecont’d This phase of healing:
Last from 0-24 daysSigns of inflammation should subside although the wound will often remain red in colour and to some degree raised in relation to its surrounding tissue .
1111
The Maturative phaseBegins about day 21 and can extend up to Begins about day 21 and can extend up to
6 months up to one or two years after the 6 months up to one or two years after the injury.injury.
Fibroblasts continue to synthesize Fibroblasts continue to synthesize collagen collagen
The collagen fibers recognized into a more The collagen fibers recognized into a more orderly structureorderly structure
The scar become a thin ,less elastic, white The scar become a thin ,less elastic, white line line
1212
Factors affecting wound healing(Manley.K, Bellman. L,2000)
Developmental consideration/Age Nutrition Life-style Medication Infection Wound perfusion PH of the wound interface Foreign bodies
ContaminationBacteria present on surface
ColonizationBacteria attach to tissue and multiply
InfectionBacteria invade healthy tissue and overwhelm immune defenses
1313
Types of Wound (Hahn,Olsen,Tomaselli, Goldberg ,2004)
TypeCauseDescription and Characteristics
IncisionSharp instrument eg. KnifeOpen wound; painful
ContusionBlow from a blunt instrumentClose wound, skin appears ecchymotic (bruised) because of damaged blood vessels
AbrasionSurface scrape, either unintentional (eg, scraped knee from fall) or intentional (eg, dermal abrasion to remove pockmarks)
Open wound; involving the skin ; painful
PuncturePenetration of the skin and, often the underlying tissues from a sharp instrument
Open wound; can be intentional or unintentional
LacerationTissues torn apart, often from accidents (eg, machinery)
Open wound; edges are often jagged
Penetrating wound
Penetration of the skin and the underlying tissues
Open wound; usually accidental ( bullet or metal fragments)
1414
Classification of surgical wounds (Altmeire 1999, Ayliffe & Lowbury 1992, NAS 1996)
Clean wounds: Operations in which a viscus is not opened. This category includes non- traumatic, uninfected wounds where no inflammation is encountered and no break in technique has occurred.
Clean-contaminated: A viscus is entered but without spillage of contents. This category included non- traumatic wounds where a minor break in technique has occurred.
1515
Classification of surgical wounds cont’d
(Altmeire 1997, Ayliffe & Lowbury 1992, NAS 1996)
Contaminated: Gross spillage has occurred or a fresh traumatic wound from a relatively clean source. Acute non-purulent inflammation may also be encountered.
Dirty or infected : Old traumatic wounds from a dirty source, with delayed treatment, devitalised tissue, clinical infection, faecal contamination or a foreign body.
1616
Classification of wounds by depth
I. Partial-thickness: Confined to the skin, the dermis and epidermis.
II. Full-thickness : Involve the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone
Partial Thickness Full Thickness
1717
Wound assessment
A complex process
Involve examination of the entire wound
Nurses visually assess wounds and
document their findings to monitor and
evaluate the progress of wound healing
1818
Wound assessment cont’d(Hahn,Olsen,Tomaselli, Goldberg ,2004)
What to assess?1.Location2.Dimensions/Size3.Tissue viability4.Exudate/Drainage5.Periwound condition6.Pain7.Stage or extent of tissue damage , dictates
how often a wound is reassessed8.Swelling
1919
Risk Factors Which Increase Patient Susceptibility to
infection (Manley.K, Bellman. L,2000) A- Intrinsic risk factors:
1. Extremes age: Defined as “ Children aged 1 year and under, and people aged 65 years and over’.
2. Underling Conditions/DisordersA. DiabetesB. Respiratory disordersC. Blood disorders
3. Smoking4. Nutrition and build
2020
Risk Factors Which Increase Patient Susceptibility to infection
cont’d (Manley.K, Bellman. L,2000)
B- Extrinsic risk factors:1. Drug therapy as a risk factor: e.g.
Cytotoxic
2. Breach in the integrity of the skin3. Items as foreign bodies4. Bypass of defence mechanism
through devices e.g. Intubations
2121
S&S of Presence of InfectionS&S of Presence of Infection Wound is swollen.Wound is swollen.Wound is deep red in color.Wound is deep red in color.Wound feels hot on palpation.Wound feels hot on palpation.Drainage is increased and possibly Drainage is increased and possibly
purulent.purulent.Foul odor may be noted.Foul odor may be noted.Wound edges may be separated with Wound edges may be separated with
dehiscence present.dehiscence present.
2222
Kinds of Wound Drainage
1.Exudate is material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and deposited in or on tissue surfaces. The Nature and amount of exudate vary according to:
A. Tissue involved
B. Intensity and duration of the inflammation
C. The presence of microorganisms
2323
Kinds of Wound Drainage cont’d2.A purulent Exudate
Is thicker than serous exudate because of the presence of pus.
It consists of leukocytes, liquefied dead tissue debris, dead and living bacteria.
The Process of pus formation is referred to as suppuration, and the bacteria that produce pus are called pyogenic bacteria.
Purulent exudate vary in color, some acquiring tinges of blue, green, or yellow. The color may depend on the causative organism.
2424
Kinds of Wound Drainage cont’d
3.A sanguineous (hemorrhagic) Exudate It consists of large amount or blood cells, indicating
damage to capillaries that is very severe enough to allow the escape of RBCs from plasma
This type of exudate is frequently seen in open wounds.
Nurses often need to distinguish whether the exudate is dark or bright. Bright indicate fresh blood, whereas dark exudate denotes older bleeding
2525
Wound ComplicationsWound Complications InfectionInfectionHemorrhageHemorrhageDehiscence and eviscerationDehiscence and eviscerationFistula formationFistula formation
2626
The RYB color code(Stotts,1999)
This concept is based on the color of the open wound rather than the depth or size of a wound.
On this scheme, the goal of wound care are to protect ( cover) red, cleanse yellow, and debride black.
The RYB code can be applied to any wound allowed to heal by secondary intention.
R=Red Y=Yellow B= Black
2727
The RYB color code cont’d
(Stotts,1999)Red woundsUsually in the late regeneration phase of tissue repair
(ie, developing granulation tissue) and are clean and uniformly pink in appearance
They need to be protected to avoid disturbance to regenerating tissue. Examples are superficial wounds, skin donor sites, and partial- thickness or second – degree burns.
2828
The RYB color code cont’d
(Stotts,1999)Red wounds cont’dHow to protect red wounds:
Gentle cleansing
Avoid the use of dry gauze or wet- to-dry saline
dressings
Appling a topical antimicrobial agent
Appling a transparent film or hydrocolloid dressing
Changing the dressing as infrequently as possible
2929
The RYB color code cont’d
(Stotts,1999)Yellow wounds Characterized primarily by liquid to semiliquid ”slough”
that is often accompanied by purulent drainage. The nurse cleanses yellow wounds to absorb drainage
and remove nonviable tissue. Methods used may include . Applying wet-to-wet dressing; irrigating the wound; using
absorbent dressing material such as impregnated nonadherent, hydrogel dressing, or other exudate absorbers; and consulting with the physician about the need for a topical antimicrobial to minimize bacterial growth.
3030
The RYB color code cont’d
(Stotts,1999)B – Black WoundCovered with thick necrotic tissue or
Eschar.e.g.. third degree burns and gangrenous
ulcer. Required debridement .When the eschar is removed, the wound
is treated as yellow, then red.
3131
Purposes of wound dressing
To protect the wound from mechanical injuries To protect the wound from microbial
contamination To provide or maintain high humidity of the
wound To provide thermal insulation To absorb drainage and /or debride a wound
3232
Purposes of wound dressing cont’d
To prevent hemorrhage (when applied as a pressure dressing or with elastic bandages).
To splint or immobilize the wound site and thereby facilitate healing and prevent injury.
To provide psychologic (aesthetic) comfort.
3333
Principles of asepsis
The aim:Guarantee the safety of the equipment
used (cleaning/disinfection/sterilisation).Reduce the level of microbial
contamination of the site requiring manipulation (antisepsis).
Ensure that no microorganisms are introduced (asepsis).
3434
Principles of asepsis cont’dCleaning : Is the removal of dirt, debris and
organic material.
Disinfection: Removes or destroys harmful microorganisms but not bacterial spores or slow viruses.
Sterilisation: is the complete destruction or removal of all living microorganisms including bacterial spores.
3535
Principles of asepsis cont’d
Antisepsis: is the reduction of the number
of microorganisms already present on the
body site prior to a procedure.
Asepsis: Procedure designed to prevent
any introduction of microorganisms to the
site achieved by a non-touching
technique and use of sterile gloves
3636
Guidelines for cleaning wounds (AJN, 1999)
1. Use physiologic solution, such as isotonic saline or lactated ranger solution
2. When possible , warm the solution to body temperature before use
3. If the wound is grossly contaminated by foreign material , bacteria, slough, or necrotic tissue clean the wound at every dressing change
4. If a wound is clean , has little exudate , and reveals healthy granulation tissue , avoid repeated cleaning
3737
Guidelines for cleaning wounds cont’d (AJN, 1999)
5. Use gauze squares . Avoid using cotton bolls
6. Consider cleaning superficial noninfected wound by irrigating them with normal saline rather than using mechanical means
7. To retain wound moisture , avoid drying a wound after cleaning it
3838
Topics for Home Care TeachingTopics for Home Care TeachingSuppliesSupplies Infection preventionInfection preventionWound healingWound healingAppearance of the skin/recent changesAppearance of the skin/recent changesActivity/mobilityActivity/mobilityNutritionNutritionPainPainEliminationElimination
3939
Sutures and staples
Types of sutures: Plain interrupted
Mattress interrupted
Plain continuous
Mattress continuous
Blanket continuous
Retention