Wound Care Management PDF

WOUND CARE MANAGEMENT 4. Metabolism – it converts dehydrocholesterol to Vit D. for the absorption of GI tract to Excretion SKIN...

WOUND CARE MANAGEMENT 4. Metabolism – it converts dehydrocholesterol to Vit D. for the absorption of GI tract to Excretion SKIN to Body Image. Largest Organ WOUND 16% body weight Any damage on the skin can be considered to be also has 2 major layers: EPIDERMIS AND DERMIS a wound Intentional – venipuncture EPIDERMIS Unintentional – accidental wound thickness.5mm eyelids to 4.0 mm heels Classification of the wounds by depth: CELLS Partial Thickness – partial loss of skin epidermis at 1. Keratinocytes – outer most layer 90% of the dermis. Healed by regeneration. cells, deepest layer ng epidermis. Stranum Basale to Corneum Full Thickness Wound – involved lahat ng skin layers also 2. Melanocytes – skin and eyes produces melanin the muscles and bones. for skin pigmentation. Deepest part rin ng Classification of the wounds by duration: epidermis 3. Langerhans – outermost guard. Bone marrow Acute wounds - recent and nag pprogress sa lahat ng releases Langerhans then mag-travel sa blood to stages ng wound healing skin to protect. After niya malabanan yung Chronic - nag sstay lang wound sa inflammatory phase nakapasok na pathogens magiging protein na ng healing DM. lang yun. 4. Markel – top layer right below of epidermis, Type of Wounds: responsible sa sensation, close sa nerve endings. 1. Clean Wounds - minimal infection, mga close 5 LAYERS all stratum: wounds. 2. Clean contaminated wound – surgical wounds, 1. Basale – divide through the process of mitosis to lungs and appendix surgery. create new cells. 3. Contaminated wounds - includes open fresh 2. Spinosum – help skin to be flexible and strong. accidental wounds show evidence of Desmosomes (protein) inflammation. 3. Granulosum – may granules na dito yung 4. Dirty or Infected wounds – dead tissue (+) of keratinocytes infection may discharge. 4. Lucidum – thin transparent layer ng 5. Incision – sharp object may kasalan, open or keratinocytes, less round yung shape close wound. It can be deep or shallow 5. Corneum – top layer ng epidermis, keratinocytes 6. Contusion – from a blood instrument. May will be converted to corneocytes. This help us or ecchymotic or bruised damaged dahil sa trauma protect us from any harm. Then mag sshed off (close wound) aangat na yung mga bagong keratinocytes from 7. Abrasion – Gasgas Basale. 8. Puncture – May penetration sa skin dahil sa Physiology of the skin: sharp instrument 9. Laceration – yung tissue ay na turn part. Jagged 1. Protection – mech assault, bacterial and viral yung edges infection/invasion, and UV radiation 10. Penetrating Wound – this extend to body cavity 2. Thermoregulation – conservation 3. Sensation – temp, pain, touch, vibration because PRESSURE ULCERS of markel cells Injury to skin or underlying tissue usually nasa bony preminense. EXAMPLES: TYPES OF WOUND HEALING: Decubitus Ulcers, Pressure sores or Bedsores. 1. Primary Intention Healing – also known as Compressed tissue low O2 and nutrients supply sa PRIMARY UNION or First Intention Healing. tissue = anerobic metabolism which produces LACTIC - The tissue surfaces has been closed and there is ACID (toxic sa tissue) then dito na mag kakaroon ng no minimal or no tissue loss. necrotic tissue or CELL DEATH - It is characterized by minimal granulation tissue and scarring. RISK FACTORS: EXAMPLE: Friction – narub sa skin = to abrasion and dito na magde- develop ang pressure ulcers or skin breakdown Closed surgical wounds Immobility - decreased and movement kaya impede ang 2. Secondary Healing – extensive and considerable circulation tissue loss, and which the edges of the wound cannot or should not be approximated or closed. Inadequate Nutrition - kapag mababa ang nutrition mag Heals by SECONDARY INTERTION HEALING. kocause ito ng weight loss or maaring mag-karoon ng muscle atrophy or lumiit yung muscle = LOSS OF SECONDARY INTERTION HEALING differs into 3 ways: SUBCUTANEOUS TISSUES ( baba ang padding between Repair Time - mas matagal compared kay skin and bone) = developing of pressure ulcers Primary Intention Healing Fecal and Urinary Incontinence – the moisture coming Scarring – greater ang scar compared to primary from Fecal and Urinary Incontinence promotes Susceptibility to Infection - mas mataas ang risk maceration ng infection kapag secondary healing kesa kay primary Maceration – the tissue is too soft dahil sa prolonged na pagkakababad or basa kaya yung epidermis ay more EXAMPLE: easliy ERODED = more prone sa injury Pressure Ulcers Decreased of Mental Status – mga unconscious, sedated or yung may demetia at risk sila sa pressure ulcer dahil 3. Tertiary Intention Healing – also called as hindi na nila makarecognize or response sa pain na cause DELAYED PRIMARY INTENTION ng pressure - wounds that are left open for 3-5 days to allow edema on infection to resolve or exudate to drain Diminished Sensation – decreased in normal sensation then closed with sutures, stales, or adhesive skin touch may numbness ganern closures heal by tertiary intention. Stages of Pressure Ulcers: 3 PHASES OF WOUND HEALING: Stage 1 - Nonblachable Erythema nagsi-signal lang ng Inflammatory (homoestatis) - wala ng bleeding, dahil sa ptoencial ulceration, may redness lang over bony vasoconstriction ng malaking blood vessels. prominence 1. During homeostatis mayroong retraction of injured Stage 2 – dito naman may partial thickness skin loss na blood vessel 2. Deposition on fibrin and the formation of blood clots EXAMPLE: Abrasion, Blister or may shallow crater ( may this provides of became the framework for cell repair. uka na sa skin). Involved na ang epidermis at dermis 3. Scab formation yung epithealial cells magma-migrate Stage 3 – Full Thickness skin loss involving NECROSIS OF siya under the scab to SERVED AS BARRIER between SUBCUTANEUOS TISSUE skin and environment to prevent the entry of micro- organisms. Stage 4 – Full Thickness + Necrosis umabot na yung 4. Involved rin dito yung vascular and cellular responses damaged sa muscle, bone and other supporting intended siya para maremove yung foreign structures (tendon and joints) substances and dead dying tissues.  In this of vascular and cellular responses yung “So kapag malnourish si patient nagre-recur ng mas blood supply in the wound for oxygen and mahabang time to improve the wound healing” nutrients but is causes REDNESS and EDEMATUS Lifestyle – exercise=good flow. Pero kapag nag-smoke “exudate fluid and cell debris is normal accumulation nababa yung hemoglobin that affects the wound healing because it helps to cleanse the wound” Medications - anti – inflammatory (steroids and aspirin) 5. Cell Migration – sa phase na to yung leukocytes and yung prolonged used ng antibiotics will make a pupunta sa INTERSTITIAL SPACE kapag nandito na person susceptible sa mga wound infection na may after 24 hrs papalitan siya ng MACRO PHAGES to resistant organism. engulf the micro-organisms and cellular debris. COMPLICATIONS OF THE WOUND HEALING: “macro phages also secrete angiogenesis factors causing Hemorrhage – massive yung bleeding at hindi formation of epithealial blood sa end ng injury ng blood nacontrolled = hematoma vessel” Infection – kapag hindi natreat ng maayos yung = Proliferative Phase – this extend to day 3 – day 4 until day infected wound delayed or impaired na yung wound 21. In this stage or phase the FIBROBLAST will migrate healing papunta sa wound after 24 hrs to synthesize siya ng collagen for tensile strength. Dehiscence vs. Evisceration – dehiscence (rupture) or parang bumuka yung tahi. Evisceration (protrusion) DURING PROLIFERATIVE PHASE: bumuka yung tahi at sumama yung internal organ, for 1. Capillaries grow increasing the blood supply into the example abdominal surgery (tinahi) kapag yung INTRA wound. ABDOMINAL PRESSURE (IAP) pwede bumuka yung tahi. 2. Fibroblast will travel to blood stream depositing “management: sterile dressing soaked with sterile fibrin = capillary network then the tissue will become normal solution then takpan” translucent red color (eto yung granulation tissue) 3. Kapag yung Granulation Tissue ay nag-matured yung WOUND ASSESSMENT: MARGINAL EPITHEALIAL CELLS magma-migrate papunta sa GT para paramihin/mafill yung wound Assessment Tool “TIME”: (CLOSED) T – Tissue “ if hindi naclose yung wound gamit ang epithelialization Epithelial Tissue: pink/pearly white pwede siya macover ng dried plasma protein (ESCAR) Granulating Tissue: red and moist occur siya Maturation Stage – will start from day 21 and it will kapag remodeling phase or maturation phase ng extend 1-2 years. The fibroblast will continue to wound healing Slough Tissue: yellow or brown or grey created synthesized the collagen to reorganized and the wound by dead tissue or debris will be remodeled and contracted. The scar become stronger 80%. Necrotic Tissue: hard, dry, and black it impaired the wound healing or prevents the wound “ kapag naman sumobra sa collagen pwede mag-karoon healing ng hyperthropic scar/keloids” Hyper Granulating Tissue: red but uneven and granular over proliferation FACTORS AFFECTING WOUND HEALING: “ if mag-assess ng tissue always check if viable or non- Developmental Consideration – Age mas mabilis mag- viable” heal ng wounds ang mga healthy children and adult compared sa mga older adult dahil sa mga chronic VIABLE TISSUES – Epithelial and Granulating diseases. must protect NON-VIABLE – Necrotic and Slough need to Nutrition – wound healing demand on a diet high on debride protein, carbs, lipids, vitamins, and minerals. I - infection/inflammation Assess the surrounding skin (peri wound) for the following: INFLAMMATION is essential for wound healing however INFECTION causes the tissue damaged and it could Cellulitis – redness, swelling, pain/infection impedes the healing. Oedema - swelling Contamination – (+) microorganisms pero hindi Macerated – soft broken skin because of too much dumadami or multiply kaya yung wound healing moisture dito ay hindi impaired Colonization – (+) microorganism pero dito MEASURE TOOL” nagmu-multiply or dumadami pero hindi niy pinoproved yung wound healing. May infection M – measure contained sa wound kaya made-delay yung ruler based linear head (head to toe) using the vody as healing process face of an imaginary clock Local Infection – invasion na ng agent under favorable conditions. Yung microorganism and Kukuhanin ang greatest high and width perpendicular to bacteria nag move na papunta sa tissue and the greatest length. ineenvoke na niya yung (+)HOST RESPONSE = - Face should always on a twelve o’clock healing impaired - Feet must be on 6’o clock Spreading and Systemic Infection – yung - Heels 12’o clock lagi microorganism nag-spread na papunta sa vascular and lymphatic system. Impaired Healing E – exudate rin to na. Need ng “Topical Microbials” to prevent A - appearance sepsis or septic shock Biofilms – represent the survival of S – suffer microorganism. Complex, looks like slime The Three Major types of exudate: incased= community of microbes Serous – serum clear portion of the blood looks like M - Moisture Imbalanced watery. BLISTER Moisture or Exudate is an essential part of the healing Purulent - may presence ng pus ( PUS is composed with process leukocytes, liquified dead tissues, debris,and ded living Maintain a moist environment bacteria). Cleanse the wound Ang Pus formation – suppuration Provide nutrients and white blood cells Promote epithelialization Color blue, green ,nad yellow depende sa causative or sanhi Too wet or Macerated iaabsorb yung moisture Sanguineous – red blood cells indicating the capillaries Too dry/desiccation (ESCAR) need to contribute moisture where damage The overall goal of exudate is to donate moisture within the wound bed E – Edge Of Wound Advancing : yung edge ng wound pink and healing is taking phase Not Advancing : raised, rolled, red/dusky Surrounding Skin  Explore area using sterile swab. Sinus Track Or Tunnelling: - Narrow and quite long, seems to have destination - it is called passages way because of the skin and tissue WOUND CLEANSING SOLUTIONS: Tap water for home environment is acceptable Normal Saline 0.9% - safest cleansing agent because it does not interfere on wound healing Distilled Water for irrigation (out patient clinics) Povidone-Iodine Effective against gram positive and negative bacteria and other organism – 7.5% and 10% Potassium Permanganate is an oxidizing agent with disinfectant deodorizing and astringent properties ASSESSMENT PAIN ASSESSMENT Pain Intensity, Duration, Location, Frequency Used of pain assessment tool such as: 1. Modified Wong-Bakers/Face pain rating scale 2. Verbal Numerical Scale 3. Behavioral Pain Phase – facial expression, movement, compliance with ventilation UNDERMINING – indicates the loss of tissue underneath an intact skin surface.  WOUNF DRESSING MANAGEMENT: TYPES OF DEBRIDEMENT: OVER GRANULATION – grows above the level of the surrounding skin preventing epithelial cells from growing 1. Biological - sterile maggots by eating the old tissue 24 across the wound. to 72 hrs ginagamit kapag may resistant na sa mga gamot - Treatment Aims: to suppress overgrowing tissue 2. Enzymatic - ointment gel with enzyme to soften the - Treatment Options: hypertonic impregnated tissue 1-2 a day good for bleeding gauze dressing 3. Autolytic - uses the body’s enzyme to separate the - Colonized Infected: Antimicrobial and highly tissue from the wound absorbment dressing 4. Mechanical - removes the unhealthy tissue using - Other Consideration: bawal mag apply ng force moisture retentive dressing 5. Hydrotherapy using running water to wash away the MOIST SLOUGH – viscous yellow layer that is moist and dead tissue partial or loosely adherent to wound bed. 6. Wet-to-dry dressing - wet gauze apply on wound then remove para sumama yung dead tissue - Treatment Aims: remove loosly detached slough 7. Monofilament Pads – polyester pad binabrushs a tissue or remove all the debris wound para matanggal yung dead tissue - Treatment Options: 8. Conservative Sharp and Surgical Sharp – cut using - Superficial- hydrocolloids or moist Hydrofiber scalpel - Cavity – Hydrofiber/Hydrogel/moisture retentive dressing (foam dressing) - Other Consideration: refer to wound nurse DRY SLOUGH – viscous yellow layer that is dry and adherent to wound bed. - Treatment Aims: rehydration - Treatment Options: hydrocolloids/ moist hydrofiber “ note: film or foam as a secondary dressing when hydrogens is applied” Other Consideration: SKIN MACERATION NECROTIC/ESCAR - death living tissue due to inadequate blood supply - Treatment Aims: rehydration and reduce the risk of infection - Treatment Options: hydrocolloids/ hydrogel “ note: film or foam as a secondary dressing when hydrogels is applied” Other Consideration: Don’t rehydrate kapag may foot ESCAR NECROTIC (gangrene) DIGITS - necrosis due to lack of Granulation - pduring proliferative phase of healing blood supply sa foot/toes bright red from new capillary loops which the red moist - Treatment Aims: prevent infection/ amputation in appearance. - Treatment Options: - Dry – antimicrobial and dry dressing (or leave - Treatment Aims: promote and protect exposed) angiogenesis by maintaining warm moist - Wet – antimicrobial and alginate environment “ note: film or foam as a secondary dressing - Superficial – non-adherent, wound contact layer when hydrogels is applied” - Other Consideration: hypersensitivity Other Consideration: do not apply retentive - Shallow – alginate/hydrogel dressing seek doctors - Cavity - hydrofiber dressing - OC: don’t apply in nursing Partial Thickness Burn - scalded or fire burn involving dermal layers Epithelialization – final stage of wound healing where ep - Treatment Aims: prevent infection, and promote cell migrate across the surface of the wound healing by maintaining a warm moist - Treatment Aims: protect and promote the new environment tissue growth - Treatment Options: low and non-adherent, - Treatment Options: moist environment. non antimicrobial, wound with the contact of film adherent wound contact layers or hydrocolloid Other Consideration: History ng hypersensitive - Other Consideration: new form tissue is only 60- 80 percent Biofilm - are complex microbial communities containing bacteria and fungi attached firmly to a living on non living surface. - Treatment Aims: reduce biofilm - Treatment Options: regular debridement and antimicrobial dressing - Note – avoid moisture retentive dressing - Other Consideration: hypersensitivity Critical Colonised or Infected wound- multiplication of bacteria causing the delay of wound healing and disruption in wound healing damage. - Treatment Aims: reduce bioburden, treat infection and manage exudate and odor - Treatment Options: Inadine, antimicrobial dressing - Other Consideration: hypersensitivity, refer kay Doctor kapag lumalala and bawal moisture sa retentive dressing Friable Tissue - brittle or fragile tissue easily damage that easily bleed often indicate high bacterial load - Treatment Aims: reduce bioburden, treat infection - Treatment Options: high absorbent and antimicrobial - Other Consideration: hypersensitivity