Wound Management PDF

WOUND MANAGEMENT By: Mrs Kayal Medical Surgical Nursing 1 23 Jan 2025  Learning objectives At the end of this session, learners will be able to; Define wound Describe the different types of wounds Describe the physiology of wound healing Identify different factors affect...

WOUND MANAGEMENT By: Mrs Kayal Medical Surgical Nursing 1 23 Jan 2025  Learning objectives At the end of this session, learners will be able to; Define wound Describe the different types of wounds Describe the physiology of wound healing Identify different factors affecting wound healing Outline the complications of wound Describe the management of wound Health educate a patient on promotion of wound healing  DEFINITION OF WOUND A break or disruption in the normal integrity of the skin and tissues.  TYPES OF WOUNDS Incision Cutting or sharp instrument; wound edges in close approximation and aligned Contusion Blunt instrument, overlying skin remains intact, with injury to underlying soft tissue; possible resultant bruising and/or hematoma Abrasion Friction; rubbing or scraping epidermal layers of skin; top layer of skin abraded Laceration Tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue Puncture Blunt or sharp instrument puncturing the skin; intentional (such as venipuncture) or accidental Penetrating Foreign object entering the skin or mucous membrane and lodging in underlying tissue; fragments possibly scattering throughout tissues Burns (thermal, Destroys the layers of the skin chemical, irradiation) Pressure ulcers Compromised circulation secondary to pressure or  CLASSIFICATIONS OF Surgical WOUNDS Determinants of Category Category Clean Non traumatic site Uninfected site No inflammation No break in aseptic technique Clean- Entry into respiratory, alimentary, genitourinary or contaminat oropharyngeal tracts without unusual contamination ed (Appendectomy) Minor break in aseptic technique Mechanical drainage Contaminat Open, newly experienced traumatic wounds ed Gross spillage from gastrointestinal tract Major break in aseptic technique Entry into genitourinary or biliary tract when urine or bile is infected Dirty Traumatic wound with delayed repair, devitalized tissue, foreign bodies, or fecal contamination Acute inflammation and purulent drainage encountered during procedure  PHYSIOLOGY OF WOUND HEALING Wound healing is a process of tissue response to injury. Injured tissues are repaired by physiologic mechanisms that regenerate functioning cells and replace connective tissue cells with scar tissue. The wound healing process can be divided into phases;  PHASES OF WOUND Phase 1: HEMOSTASISHEALING occurs immediately after the initial injury. Involved blood vessels constrict and blood clotting begins through platelet activation and clustering. After only a brief period of constriction, these same blood vessels dilate capillary permeability increases, allowing plasma and blood components to leak out into the area that is injured, forming a liquid called exudate. The accumulation of exudate causes swelling and pain. Increased perfusion results in heat and redness. The clot loses fluid and a hard scab is formed to protect the injury. The platelets are also responsible for releasing substances that stimulate other cells to migrate to the injury to participate in the other phases of healing  Phase 2: INFLAMMATORY PHASE Follows hemostasis and lasts about 4 to 6 days. White blood cells move to the wound. Leukocytes arrive first to ingest bacteria and cellular debris. About 24 hours after the injury, macrophages enter the wound area and remain for an extended period.  Phase 2: INFLAMMATORY PHASE- cont….. Macrophages are essential to the healing process. They not only ingest debris, but also release growth factors that are necessary for the growth of epithelial cells and new blood vessels. These growth factors also attract fibroblasts that help to fill in the wound, which is necessary for the next stage of healing. Acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury. During the inflammatory phase, the patient has a generalized body response, Including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise.  Phase 3: PROLIFERATION PHASE known as the fibroblastic, regenerative, or connective tissue phase. Lasts for several weeks. New tissue is built to fill the wound space, primarily through the action of fibroblasts. Capillaries grow across the wound, bringing oxygen and nutrients required for continued healing. Fibroblasts form fibrin that stretches through the clot. A thin layer of epithelial cells forms across the wound, and blood flow across the wound is reinstituted.  Phase 3: PROLIFERATION PHASE- cont…. The new tissue, called granulation tissue, forms the foundation for scar tissue development. It is highly vascular, red, and bleeds easily. Collagen synthesis and accumulation continue, peaking in 5 to 7 days. Depending on the size of the wound, collagen deposit continues for several weeks or even years. By the end of the second week following the injury, the majority of white blood cells have left the wound area, and the wound is lighter in color. During this phase, adequate nutrition and oxygenation, as well as prevention of strain on the suture line, are important patient care considerations.  Phase 4: MATURATION PHASE The final stage of healing begins about 3 weeks after the injury, possibly continuing for months or years. Collagen that was haphazardly deposited in the wound is remodeled making the healed wound stronger and more like adjacent tissue. New collagen continues to be deposited, which compresses the blood vessels in the healing wound, so that the scar (an avascular collagen tissue that does not sweat, grow hair, or tan in sunlight) eventually becomes a flat, thin line. Scar tissue is strong but less elastic than uninjured tissue. If the scar is over a joint or other body structure, it may limit movement and cause disability.  Wound Healing Phases Phase Time Frame Wound Healing Patient Effect Phase I Incision to second Inflammatory Fever, malaise HEMOSTASIS postoperative response day Phase II Third to Granulation Feeling better INFLAMMATORY fourteenth tissue forms postoperative day Phase III Third to sixth Collagen Raised scar PROLIFERATIVE postoperative deposited formed week Phase IV Months to 1 year Collagen Flat, thin scar MATURATION/ deposited REMODELLING Factors Affecting Wound Healing Local factors Pressure : - Pressure disrupts the blood supply to the wound area. It interferes with blood flow to the tissue and delays healing. Desiccation (the process of drying up): - Cells dehydrate and die in a dry environment. This cell death causes a crust to form over the wound site and delays healing. Maceration (Overhydration of cells). This damage is related to moisture, changes in the pH of the skin, overgrowth of bacteria and infection of the skin, and erosion of skin from friction on moist skin  Trauma: - Repeated trauma to a wound area results in delayed healing or the inability to heal. Edema :- Edema at a wound site interferes with the blood supply to the area, resulting in an inadequate supply of oxygen and nutrients to the tissue. Infection : - Infection requires large amounts of energy be spent by the immune system to fight the microorganisms, leaving little or no reserves to attend to the job of repair and healing. Toxins produced by bacteria and released when bacteria die interfere with wound healing and cause cell death. Necrosis :- Dead tissue present in the wound delays healing. Dead tissue appears as slough, moist, yellow stringy tissue, and eschar appears as dry, black, leathery tissue. Healing of the wound will not take place with necrotic tissue in the wound.  SYSTEMIC FACTORS Age: - Children and healthy adults heal more rapidly than older adults in whom physiologic changes caused by aging result in diminish fibroblastic activity and circulation. Older adults are more likely to have one or more chronic illnesses, with pathologic changes that impede the healing process. Circulation and Oxygenation :- Adequate blood flow to deliver nutrients and oxygen and to remove local toxins, bacteria and other debris is essential for wound healing. Certain physical conditions, because of their effect on circulation and oxygenation, can affect wound healing. Large amounts of subcutaneous and tissue fat (which has fewer blood vessels) in people who are obese may slow wound healing because fatty tissue is more difficult to suture, is more prone to infection and takes longer to heal.  Nutritional Status :- Wound healing requires adequate proteins, carbohydrates, fats, vitamins and minerals. Calories and protein are necessary to rebuild cells and tissues. Vitamin A and C are essential for re- epithelialization and collagen synthesis. Zinc plays a role in proliferation of cells. Fluids are necessary for optimal function of cells. All phases of the wound healing process are slowed or inadequate in the patient with poor nutritional status and fluid balance.  Wound condition:- The condition of the wound also affects how quickly and effectively it heals e.g. large, contaminated, infected wounds or wounds that retain foreign bodies heal slowly. Sutures are needed to close surgical wounds. However, sutures also act as foreign bodies, so they are removed as soon as possible. Medications and Health Status:- Patients who are taking corticosteroid drugs or require post operative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing. Radiation depresses bone marrow function, resulting in decreased leukocytes and an increased risk of infection. The presence of a chronic illness (such as cardiovascular disease or diabetes mellitus) or impaired immune function can impair wound healing. Appropriate antibiotics help in the healing of wounds Immunosuppression :- Suppression of the immune system as a result of disease , medication or age can delay wound healing.  Wound Complications Infection : Bacteria can invade a wound at the time of trauma, during surgery or at any time after the initial wound occurs. Hemorrhage: - Hemorrhage may occur from a slipped suture, a dislodged clot from stress at the suture line or operative site, infection or the erosion of a blood vessel by foreign body (such as a drain)..  Dehiscence is the partial or total disruption of wound layers. Evisceration is the protrusion of viscera through the incisional area. Patients at greater risks for these complications include those who are obese or malnourished, have infected wounds or experience excessive coughing, vomiting or straining. Fistula formation :- an abnormal passage from an internal organ to the skin or from one internal organ to another. Postoperative fistula formation is most often the result of delayed healing, commonly manifested by drainage from an opening in the skin or surgical site. The presence of a fistula increases the risk for infection, fluid and electrolyte imbalances and skin breakdown  Nursing management of wound ASSESSING THE WOUND Appearance assesses for the approximation of wound edges, colour of the wound and surrounding area, drains or tubes, staples or sutures and signs of dehiscence or evisceration. The edges of a healthy healing of surgical wound appear clean and well approximated, with a crust along the wound edges. Initially the edges are reddened and slightly swollen. After 1 week, the skin is closer to normal in appearance, with wound edges healing together. The skin surrounding the wound may at first be bruised, but this too returns to normal as blood is reabsorbed. When infection is present, the wound is swollen and deep red. It feels hot on palpation and drainage is increased and possibly purulent, a foul odor also may be noted. If dehiscence is impending or present, the wound edges are separated. Drainage The inflammatory response results in the formation of exudates, which then drains form the wound. The exudate is composed of fluid and cells that escape from blood vessels and are deposited in or on tissue surfaces. This exudates is called wound drainage and is described as serous, sanguineous or if infected purulent. Drains may be inserted in or near a wound to promote drainage, thereby reducing the risk of abscess formation and promoting wound healing. The amount, colour, odor and consistency of wound drainage are assessed. The amount and colour depend on the wound location and size. Drainage can be assessed on the wound, on the dressing, in drainage bottles or under the patient. Pain Can increase or patient can experience constant pain from the wound. Pain especially when accompanied by an increase or purulent flow of drainage may indicate delayed healing or an infection. Incisional pain is usually most severe for the first 2 to 3 days and then progressively diminished.  Patient Education on Wound Care  Keep the wound dry and clean  If wet or soiled inform to change dressing.  Report any signs of infection (redness, swelling, tenderness, increased warmth around the wound, pus or discharge , foul odor)  Elevate affected part to level of the heart to reduce swelling.  If soreness or pain causes discomfort apply dry cool pack or take analgesics.  Eat plenty of food rich in protein and vitamin C State the type and classification