Wound Care for Clinical Nursing

Wound Care for Clinical Nursing

• This lecture covers wound care for clinical nursing
• The lecture spans 83 hours
• Topics include: assessing and identifying wounds, planning wound care, implementing wound care, and evaluating outcomes of nursing actions

Unit One: Assessing and Identifying Wounds

• Contents:

  • Basic wound concepts
  • Types of wounds
  • Wound healing process phases
  • Factors affecting wound healing
  • Wound assessment
  • Wound debridement
  • Dressing material identification
  • Wound dressing

• Learning Objectives:

  • Define wounds and their classifications
  • Understand the wound healing process
  • Identify factors impacting wound healing
  • Assess and debride wounds
  • Prepare wound dressing materials
  • Demonstrate wound dressing techniques

Skin

• The skin is the largest organ, acting as an interface between the body and the environment
• It's the first line of defense, protecting internal organs and their systems
• Skin appearance has significant psychosocial impact on well-being

Skin Thickness and Characteristics

• Skin thickness varies from 1/50th of an inch on eyelids to 1/3rd of an inch on palms/soles
• Specialized cells form nails and hair
• Skin pH (4.5-5.5) maintains a protective mantle, supporting normal flora

Vital Functions of the Skin

• Regulates body temperature
• Detects touch, pressure, and pain
• Prevents excessive fluid loss
• Acts as an excretory organ
• Protects inner tissues from external invasion

Skin Layers

• Epidermis: Outermost, thin, avascular layer
• Dermal-Epidermal Junction: Provides structural support for exchange of fluids and cells between layers; features rete ridges (finger-like projections). Decreases with age, potentially leading to skin tears in older individuals

Wound Classification

• Based on duration (acute vs. chronic)
• Based on cause (surgical vs. accidental)
• Based on cleanliness (clean, clean-contaminated, contaminated, dirty/infected)
• Based on skin integrity (open vs. closed)

Wound Classification by Thickness of Skin Loss

• Superficial epidermal (first degree): Contained to epidermis
• Partial-thickness (first to second degree): Involves epidermis and upper dermis
• Deep (second degree): Involves epidermis and deep dermis
• Full thickness (third degree): Through epidermis, dermis, and into subcutaneous tissue
• Fourth degree: Deeper still, extending into muscle and bone

The RYB Wound Classification System

• A color system assists nurses in assessing wounds and directing their treatment
• Red wounds: Are the color of normal granulation tissues, active phase of wound healing; need moist, protected environment.
• Yellow wounds: Have fibrinous or purulent exudate; require cleansing and debridement.
• Black wounds: Have necrotic tissue ("eschar"): necessitate debridement
• Mixed color wounds are common, requiring treatment of the worst color first

Phases of Wound Healing

• Defensive (inflammatory): Occurs immediately after injury (3-4 days). Characterized by hemostasis (cessation of bleeding), inflammation (body's defense). Vascular and cellular reactions are involved.
• Proliferative: Overlaps inflammatory phase; occurs 2-4 days post-injury, lasting 15-16 days. Key processes include collagen deposition, angiogenesis (new blood vessel formation), granulation tissue development, and wound contraction.
• Maturation (differentiation): Final stage, beginning 21 days post-injury, potentially lasting up to two years, as the scar tissue remodels/changes.

Factors Affecting Wound Healing

• Tissue oxygenation: Blood flow essential for nutrients and waste removal
• Stress: Disrupts healing due to nervous & hormonal system responses
• Advanced age: Affects healing rate, collagen, and epidermal turnover.
• Nutrition: Crucial for adequate nutrient supply
• Infection: Impedes healing
• Lifestyle (e.g., smoking): Impacts blood flow and oxygen transport
• Dehydration: Poor healing
• Age: Impacts repair rate, tensile strength, and collagen deposition

Wound Assessment

• Systematic method for wound record use.
• Measurements, inflammation, contraction, epithelialization, necrotic and drainage, and exudate characteristics are assessed
• TIME acronym (Tissue, Infection/Inflammation, Moisture balance, Edges) is utilized for comprehensive evaluation
• Note tissue viability: (epidermal, granulating, slough, necrotic), distinguishing elements to protect/debride

Further Wound Assessment Details

• Assessing wound exudate color, common type, and significance.
• Peri-wound evaluation examining for cellulitis, edema, maceration, or other conditions.
• Pain assessment, addressing possible sources, providing context for therapeutic interventions
• Laboratory data (cultures, WBC count, albumin) inform causative organisms and infection severity

Wound Complications

• Infection (sepsis, osteomyelitis)
• Wound dehydration (impacting healing)

Other Important Factors

• Diabetes: High glucose levels impair collagen deposition and wound healing

This quiz covers essential aspects of wound care in clinical nursing. Topics include wound assessment, the healing process, and dressing techniques. Test your knowledge on identifying wounds, factors affecting healing, and effective wound care practices.