Providing Wound Care for Clinical Nursing PDF

# PROVIDING WOUND CARE for Clinical Nursing ## Lecture contents - Assessing and identifying wound - Planning wound care - Implementing wound care - Evaluate the outcomes of nursing actions - Nominal Duration: 83hrs Jiregna Chalchisa (BSc, MSc) ## Unit one: Assessing and identifying wound ## Unit...

# PROVIDING WOUND CARE for Clinical Nursing ## Lecture contents - Assessing and identifying wound - Planning wound care - Implementing wound care - Evaluate the outcomes of nursing actions - Nominal Duration: 83hrs Jiregna Chalchisa (BSc, MSc) ## Unit one: Assessing and identifying wound ## Unit one: Contents - Basic concept of wound - Type of wound - Phase of wound healing process - Factors affecting wound healing - Assessing wound - Wound debridement - Identifying dressing material - Wound dressing ## Learning objective At the end of the class, the students able to: - Define wound and classification of wound - Learn the wound healing process - Determine factors that affecting wound healing - To know how to assess wound, and debridement wound - Prepare material needs for wound dressing - Demonstrate wound dressing ## SKIN - The skin is the largest organ of the body and provides the interface between the body and the rest of the world - The skin provides the first line of host defense mechanisms and protects the integrity and functioning of internal organ systems - The psychosocial aspect of skin appearance is extremely important to a person's well-being ## Continued... - Skin thickness ranges from 1/50 of an inch over the eyelids to 1/3 of an inch on the palms of the hands and the soles of the feet - Specialized skin cells harden to form nails and elongate to form hair - The pH of skin normally ranges from 4.5 to 5.5, thus providing the protective mantle of the skin, which serves to maintain the skin's normal flora ## Vital Functions of the Skin - Regulating body temperature - Transmitting such sensations as touch, pressure, and pain - Preventing excessive loss of body fluids - Acting as an excretory organ - Providing an interface between the body and its environment - Protecting the inner tissues from invasion ## Skin Layers - Epidermis: -Outermost layer of skin, which is thin and avascular - Dermal-Epidermal Junction: -The dermal-epidermal junction provides structural support and allows exchange of fluids and cells between the skin layers - The epidermis has an irregular surface, with downward fingerlike projections known as rete ridges or pegs ## Continued... - These pegs of epidermis interface with upward projections of the dermis anchoring the epidermis to the dermis. - As the skin ages, this dermal-epidermal junction tends to flatten, as the contacting surfaces of epidermis and dermis decrease by one-third - This loss increases the potential for dermal-epidermal separation and places older people at risk for skin tears ## Normal skin and aged skin respectively **Diagram of normal skin** * Hair Follicle * Sweat Gland * Fat * Connective Tissue * Blood Vessels * Epidermis * Dermis * Hypodermis **Diagram of aged skin** Two panels, nearly identical to the diagrams on the left, but where the dermal-epidermal junction does not have a wavy pattern. ## Dermis - The layer of skin lying beneath the epidermis. - It is highly vascular, tough connective tissue, containing nerves, lymphatics, sebaceous glands, and hair follicles. ## Subcutaneous Tissue - This layer is made up of dense connective and adipose tissue - It houses major blood vessels, lymphatics, and nerves; acts as a heat insulator; and provides a nutritional depot that is used during illness or starvation - The subcutaneous fat also acts as a mechanical shock absorber and helps the skin move easily over the underlying structures ## Fascia - Below the subcutaneous layer - is a layer of superficial fascia, a type of dense, firm, membranous connective tissue which connects the skin to subjacent parts and facilitates movement ## Blood Supply - he vasculature of the dermis is the most expansive of any organ system - The main purpose of this vast blood supply to the skin is to regulate body temperature - The skin is oversupplied with blood when compared with its metabolic needs - Muscle and fatty tissue do not tolerate ischemia or hypoxia, and are more susceptible to the effects of pressure than are the dermis and epidermis ## 1.1). Wound - Have you concept about A wound? ## Continued... - A wound is a break in the integrity of the skin or tissues often, which may be associated with disruption of the structure and function. - wounds, may occur as a result of trauma or surgery. - Wound may not only include skin but also include muscle, bone, nerves and blood vessels ## 1.2). Wound classification Wound classification may be based on - Duration of the wound - The cause of the wound - The status of skin integrity - The extent of tissue damage - Cleanliness of wounds or - Descriptive qualities of the wound such as color ## Continued.... - Wounds can be classified based on duration:- - An acute wound heals uneventfully within an expected time frame unless underlying systemic conditions interrupt the process; examples include surgical incisions and trauma wounds - A wound is chronic when underlying pathophysiology causes the wound or interferes with the course of healing; - several types exist: leg ulcers, pressure ulcers ## Depending on the causes of wound: ### 1.Surgical (Intentional) wounds: - Occur during treatment or therapy. - These wounds are usually made under aseptic conditions. - E.g. surgical incisions and vein punctures or radiation burns ### 2. Accidental (Unintentional) wounds: - Are unanticipated and often the result of trauma or an accident - unintentional injury such as knife, gunshot, burn - These wounds are created in an unsterile environment & pose a greater risk of infection ## Depending on the Cleanliness of Wound - This classification system ranks the wound according to its contamination by bacteria and risk for infection - **Clean wounds:** are intentional wounds that were created under conditions in which no inflammation was encountered and the respiratory, alimentary, genitourinary and or pharyngeal tracts were not entered. - **Clean-contaminated wounds:** operative wounds in which the respiratory, alimentary, genital, or urinary tract is entered under controlled conditions ## Continued... - **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. - **Dirty or infected wounds:** are traumatic wounds with retained dead tissue or intentional wounds created in situations where purulent drainage was present ## According to the Skin Integrity - **Open wound-** when the skin or mucus membrane surface is broken. It may bleed with tissue damage and risk of infection. - Example:Abrasion, Incised, Laceration, Puncture and Avulsion - **Closed wound-** if the tissue traumatized without a break in the skin may have internal injury and bleeding. - Example: Contusion, Hematoma ## Individual Assignment - Write type of open wound and closed wound - Write the characteristics of both open and closed wound - Write the cause of both wound - Write the management of open wound and closed wound - Write the complication of wound - ==load=10%(5% for document and 5% for presentation) ## Classification by Thickness of Skin Loss - **Superficial epidermal (first degree):** - Are confined to the epidermis layer, outermost layers of skin. - **Partial-thickness (first to second degree):** - Involves the epidermis and upper dermis, which is the layer of skin beneath the epidermis. - **Deep (second degree):** Involves the epidermis and deep dermis ## Continued... - **Full thickness (third degree):** Refers to skin loss that extends through the epidermis and the dermis, and into subcutaneous fat and deeper structures. - **Fourth degree:** Are deeper than full-thickness loss, extending into the muscle and bone. ## The RYB Wound Classification System - This classification assist the nurses in assessing the wound surface color. - The three color system is a tool to direct treatment of open wounds. - With each color corresponding to specific therapy needs. - **Red wounds-** are the color of normal granulation tissue and are in the proliferative phase of wound repair. - These wounds need to be protected and kept moist and clean. ## Yellow wounds- - Have either fibrinous slough or purulent exudate from bacteria. - These wounds need to be cleansed of the purulent exudate, and nonviable slough needs to be removed. ## Black wounds- contain necrotic tissue (eschar). - Eschar may be either black, gray, brown, or tan. - These wounds need debridement, which is the removal of nonviable necrotic tissue. - Mixed color wounds often occur. - The rule for treatment is to treat the worst color first. ## R=Red ## Y=Yellow ## B= Black - Red wound - Yellow wound - Black wound ## 1.3 Phases of wound healing process **Diagram of phases of wound healing** * Defensive phase * Proliferation * Maturation Phase ## Defensive phase(inflammatory) - The defensive phase occurs immediately after injury and lasts about 3 to 4 days. - The major events that occur in this phase are hemostasis and inflammation. - **Hemostasis**, or cessation of bleeding, occurs by vasoconstriction of large blood vessels in the affected area. Platelets, activated by the injury, aggregate to form a platelet plug and stop the bleeding. - **Inflammation** is the body's defensive adaptation to tissue injury and involves both vascular and cellular responses. ## Proliferative Phase - The proliferative phase of wound healing overlaps the inflammatory phase - It begins 2-4 days after wounding and lasts for approximately 15 or 16 days - This phase contains the process of - collagen deposition, - angiogenesis, - granulation tissue development, and - wound contraction. ## Maturation phase - Known as Differentiation Phase - Maturation, the final stage of healing, begins about the twenty-first 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 and lysis and debridement of wound edges). ## 1.4 Factors affecting wound healing - Healing is influenced by systemic conditions or by local conditions in the wound - Tissue oxygenation - Stress - Advanced age - Nutrition - Infection - Lifestyle i.e. smoking - Age ## Tissue Oxygenation - Blood flow supplies the wound with oxygen and nutrients - Blood flow removes carbon dioxide and metabolic by-products - Any condition that reduces blood flow to a wound, such as arterial occlusion, vasoconstriction, or external pressure impedes healing ## Stress - Sympathetic nervous system and adrenal responses to stress (i.e. neural, hormonal, or metabolic changes) can impair wound healing - A plan that provides sleep and rest for the patient with a pressure ulcer will promote wound healing ## Advanced Age - Aging affects almost all aspects of the healing response - Slowing epidermal turnover and increasing skin fragility together reduce wound healing by a factor of four - The repair rate declines with: falling rates of cell proliferation, lack of development of wound tensile strength, impaired collagen deposition and wound contraction - Medical conditions occur in many elderly persons which adversely affect healing ## Continued... - The elderly tend to be malnourished and poorly hydrated, and have compromised respiratory and immune functions - Loss of dermal and subcutaneous mass, increases the risk for pressure-induced tissue injury ## Malnutrition - Wound healing and the immune response both require an adequate supply of various nutrients, including protein, vitamins, and minerals - Loss of more than 15% of lean body mass interferes with wound healing - Individuals with chronic wounds may need more protein and calories than the recommended daily allowances and may require dietary supplements ## Continued... - **Protein:**-Low serum albumin levels are a late manifestation of protein deficiency - Serum concentrations below 3.0 g/dl are an indicator of poor nutritional status - Serum concentrations below 2.5 g/dl reflect severe protein ## Vitamin C - Deficiency is associated with impaired fibroblastic function and decreased collagen synthesis which delay healing and contribute to breakdown of old wounds - Deficiency causes loss of resistance to infection - Is water-soluble and cannot be stored in the body ## Vitamin A - Associated with retarded epithelialization and decreased collagen synthesis - Deficiency is uncommon because it is fat-soluble and is stored in the liver ## Vitamin K -Coagulation ## Other vitamins, such as thiamine and riboflavin, are also necessary for collagen organization and the resultant tensile strength of the wound ## Minerals:-Various minerals, such as iron, copper, manganese, and magnesium play a role in wound healing ## Medication - **Corticosteroids-** - Suppress the inflammatory response; inflammation is necessary to trigger the wound-healing cascade - Steroid therapy begun after the inflammatory phase of healing (usually 4-5 days after wounding) has a minimal effect on wound healing ## Smoking - Nicotine interferes with blood flow in two ways - Is a vasoconstrictor - It increases platelet adhesiveness-causing clot formation - Cigarette smoke is a vasoconstrictor, contains carbon monoxide which prevents oxygen from binding to the hemoglobin molecule, and hydrogen cyanide in the smoke inhibits enzymes needed for oxygen transport and oxidative metabolism ## Diabetes - High levels of glucose compete with transport of ascorbic acid, which is necessary for the deposition of collagen, into cells - Tensile strength and connective tissue production are significantly lower in diabetics - Arterial occlusive disease is common in diabetics which can impair healing - Reduced sensation may leave wounds undetected - Patients with diabetes have more difficulty resisting infection and their wounds heal more slowly than non-diabetic patients ## Infection - Infectious complications wound include sepsis and osteomyelitis - Debridement, drainage, and removal of the necrotic tissue alone controls most infections - Open wounds do not have to be sterile to heal - Healing cannot proceed until all necrotic tissue has been removed from the wound - Parenteral antibiotics are indicated only when signs and symptoms suggest cellulitis, sepsis, or osteomyelitis ## Wound Dehydration - Wound healing occurs more rapidly when dehydration is prevented - Epidermal cells migrate faster and cover the wound surface sooner in a moist environment than under a scab ## 1.5.Assessing wound - Use a systematic and consistent method to record wound assessments - Examination should include: - Measurement of the wound's length, width, and depth measured in centimeters or millimeters - Observation of inflammation, wound contraction, granulation, and epithelialization - necrotic tissue characteristics, characteristics of drainage or exudate, drainage that contains dead cells and debris ## Continued... - TIME is a valuable acronym or clinical decision tool to provide systematic assessment and documentation of wounds. - T stands for Tissue, - I stand for Infection or Inflammation - M stand for Moisture balance - E stand for Edges of the wound or Epithelial advancement. ## Continued... ## TISSUE - VIABLE (PROTECT) - NON VIABLE (DEBRIDE) - Epithelial - Granulating - Slough - Necrotic ## Continued... - **Tissue:** is usually described by colour. - **Epithelial tissue:** Appears pink or pearly white and wrinkles when touched. Occurs in the final stage of healing when the wound is covered by healthy epithelium. - **Granulating tissue:** Appears red and moist. Occurs when healthy tissue is formed in the remodelling phase that is well vascularised and bleeds easily. - **Slough tissue:** Appears yellow, brown or grey. Slough is devitalised tissue made of dead cells or debris. - **Necrotic tissue:** Appears hard, dry and black. Necrotic tissue is dead tissue that prevents wound healing. ## Continued... - Infection/Inflammation - Inflammation is an essential part of wound healing - infection causes tissue damage and impedes wound healing. - **Contamination:** The presence of microorganisms that are contained and do not multiply. - It does not provoke a host response so healing is not impaired. Antimicrobials are not indicated. - **Colonization:** Microorganisms multiply but do not provoke a host response. The infection is contained but wound healing may be delayed. Antimicrobials are not indicated. ## Continued... - **Local infection:** Invasion by an agent that, under favourable conditions, multiplies and produces effects that are injurious to the patient. - When microorganisms and bacteria move into the wound tissue and invokes a host response. Healing is impaired and can lead to wound breakdown. - Topical antimicrobials are indicated. - **Spreading and systemic infection:** Microorganisms spread from the wound through the vascular and or lymphatic systems and involves either a part of the body (spreading) or the whole body (systemic). - Healing is impaired. A systemic approach is needed e.g. topical antimicrobials and the use of antibiotics to prevent sepsis. ## Continued... - **Moisture/ exudate** is an essential part of the healing process. - It is produced by all wounds to: - Maintain a moist environment - Cleanse the wound - Provide nutrients and white blood cells - Promote epithelialisation ## Continued... - The overall goal of exudate is to effectively donate moisture and contain it within the wound bed. - Excess exudate leads to maceration and degradation of skin, while too little moisture can result in the wound bed drying out. ## Continued... - Exudate description: - **Serous:** appears clear to yellow. Normal, typical in the inflammatory phase. Serous drainage is clear, thin, and watery. - **Haemoserous:** appears clear to yellow with a pink tinge. Typical in the inflammatory or proliferative phase. - **Sanguineous:** common exudate blood. Can be associated with hyper granulation. - **Purulent:** containing pus milky, typically thicker in consistency, grey, green or yellow. This indicates infection. - **Haemopurulent:** blood and pus. Often due to an established infection. ## Continued... - **Edges:**-Advancing of edges can be assessed by measuring the depth (cavity/sinus), length and width of the wound using a paper tape measure. - **Advancing:** edges are pink. Healing is taking place. - **Not advancing:** edges are raised, rolled, red or dusky - Go back to stages of wound healing and goals of wound management and consider factors affecting wound healing - Is there something that is not being addressed? ## Continued... - **Surrounding skin** - Assess the surrounding skin (peri wound) for the following: - Cellulitis: redness, swelling, pain or infection - Oedema: swelling - Macerated: soft, broken skin caused by increased moisture ## Continued... - **Pain** - Pain is an essential indicator of poor wound healing and should not be underestimated. - Pain can occur from the disease process, surgery, trauma, infection or as a result of dressing changes and poor wound management practices. - Assessing pain before, during, and after the dressing change may provide vital information for further wound management and dressing selection. ## Laboratory Data - Cultures of the wound drainage are used to determine the presence of infection and to identify the causative organism. - The sensitivity results list the antibiotics that will effectively treat the infection. - An elevated WBC count is indicative of an infectious process. - A decreased leukocyte count may indicate that the client is at increased risk for developing an infection related to decreased defense mechanisms. - Albumin is a measure of the client's protein reserves; if decreased, there are decreased resources of protein for wound healing ## Continued... - **Skin temperature:** May represent the presence of inflammation - **Local swelling and erythema** may also indicate inflammation or infection - **Pain**, **warmth**, **swelling**, or **tenderness** are all signs of inflammation. - **Note:** In a person with a wound, a palpable pulse in the distal extremity is expected. - This can be assessed at the wrist, the toes, or the ankle. - Absence of a pulse indicates compromised circulation, and often requires immediate attention. - Pulses should be bilaterally compared so that the nurse can determine if the patient is experiencing unusual abnormalities or is a new occurrence. - **Other factors, such as blood pressure, heart rate, and respiratory rate, may also be useful in assessing the patient's overall status.**