Stressors that Affect Skin IntegrityWound Care

NUR101 Fall 2009LECTURE # 8

K. Burger MSEd, MSN, RN, CNE

PPP By: Sharon Niggemeier RN MSNRevised kburger906,907

Factors that Impair Wound Healing Age Malnutrition Obesity/Emaciation Poor circulation and oxygenation Immunosuppression Smoking Incontinence Medications ( Steroids ) Co-morbidities ( Diabetes) Wound Stress Radiation

Wounds - Classification Intentional – results from planned treatment Unintentional wounds- results from unexpected

trauma…accident/ burns/ shooting Open -skin broken, portal of entry Closed – trauma from force, skin intact, soft tissue

damage, internal injury, possible bleeding Acute – goes through normal/timely healing

process Chronic – fails to go through normal stages of

healing; no timely progress in healing

Wounds –Classification

SuperficialPenetratingPerforating

LacerationPunctureAbrasionContusion

CleanContaminated InfectedColonized

Pressure UlcersStage IStage IIStage IIIStage IV

Wound AssessmentAppearance: granulation tissue, eschar, slough,

edema, tunneling, undermining, sinus tracts, colorDrainage: serous, serosanguineous,

sanguineous, purulent and amountPainSize & location on bodyPresence of sutures/staplesPresence of drains/tubesWound edges

??Other Factors to Assess??

ODORLAB VALUESWHAT CAUSED THE WOUND?NEED FOR TETANUS?WHEN DID WOUND OCCUR?WHAT (IF ANY) TREATMENTS HAVE

BEEN TRIED?

Wound - Healing

Healthy body has the ability to restore itself, it depends on the amount of damage and state of health of the individual.

Referred to as regeneration (renewal) of tissue.

There are (3) phases of regeneration

Phase I Wound HealingInflammatory phase- begins

immediately after injury. Includes Hemostasis (cessation of bleeding) due

to vasoconstriction and platelet aggregation Release of histamine, increasing capillary

permeability (plasma leaking) and vasodilation Also phagocytosis ( process when

macrophages engulf microbes and secrete growth factors that promote angiogenesis) stimulates epithelial buds at the end of injured tissue resulting in increased circulation which sustains the healing process

Phase ICONTINUED Wound HealingInflammatory Response4 Cardinal S/S

PainRednessHeatEdema

Phase I Inflammatory ResponseSYSTEMIC RESPONSE

Elevated temperatureElevated WBC ( norms 5000-10000 )Malaise

Phase II Wound Healing

Proliferation (Fibroplasia) Phase - second phase , fibroblasts synthesize collagens which add strength to the wound. Begins 2-3 days after injury.

Thin layer of epithelial cells forms, blood flow is reinstituted. Tissue forms - known as granulation tissue. Translucent red color/fragile/bleeds easily.

Phase III Wound HealingMaturation (Remodeling) Phase- final

phase begins about 3 weeks after the injury. Collagen originally in haphazard order

remodels and reorganizes into a a more orderly structure.

Scar (cicatrix) forms - avascular tissue , doesn’t sweat, grow hair, or tan.

Keloid- abnormal amount of collagen laid down, hypertrophic scar. ( common in dark skin).

Types of Wound Healing Primary Intention: clean, straight line, edges well

approximated with sutures, rapid healing

Secondary Intention: larger wounds with tissue loss, edges not approximated, heals from the inside out, granulation tissue fills in the wound, longer healing time, larger scars

Tertiary Intention: delay 3-5 days before injury is sutured, greater access for pathogens to invade, greater inflammation, more granulation, larger scars .

Wound Complications Infection- S/S purulent drainage, pain, redness around wound,

edema, increased temp, elevated WBC

Hemorrhage – S/S large amts sanquineous drainage + other symptoms of hypovolemic shock. Check UNDER clients

Dehiscence- S/S wound edges pulling away; not well-approximated. Early sign = increasing serosanquineous drainage

Evisceration- S/S wound opens revealing internal organs. Emergency rx = sterile NS gauze to cover; prepare for OR

Psychosocial impact – Encourage verbalization of feelings; encourage self-care as tolerated by client

Promotion of Wound HealingDressings: keep wound covered & cleanWound bed moist / Surrounding skin dryDebridement when necessaryRemove exudate:

Drains, Wound VAC, IrrigationPack wounds looselyNutritional interventions

Debridement Methods

SurgicalMechanicalEnzymatic ( proteolytic enzymes)AutolyticMaggots

Wound Dressing Principles

If exudate is present - Select one that absorbs exudate.

Keep wound bed moist but surrounding skin dry

Pack wounds loosely to avoid pressure on new granulation tissue

Fasten securely using tape, binders etc…OR self-adhesive type dressing materials.

Dressings for DRY wounds Transparent: gas exchanged between wound &

environment but bacteria prevented from entering. Creates moist healing environment Example: Tegaderm

Hydrogels: High water content enhances epithelialization and autolytic debridment.Needs cover dressing and wound edge barrierExample: Carrasyn

Wet – to- Moist Gauze dressings: keeps wound bed moist. Minimizes trauma to granulation tissues

Dressings for MOIST wounds Hydrocolloid: hydrophilic particles mix with water to

from a gel... wound stays moist. DO NOT use in infected wounds.Example: Duoderm

Absorption Materials: beads, powders, rope or sheets that absorb large amount of exudateExample: Calcium Alginate

Foam: Made of hydrophilic material. Highly absorbent.Example: Allevyn

Dry Gauze: Can absorb wound drainage. Can be impregnated with agents to promote healing

IrrigationsCleanses a wound using pressureSterile Normal Saline = usually prescribedAvoid caustic agents ie: peroxide, iodine

etc.Pressure between 4-15 pounds per

square inch (psi) i.e. 60ml syringe with catheter tip

Other TherapiesWound V.A.C. – negative pressure

vacuum assisted closure system. Removes drainage and helps wounds close.

Hydrotherapy – Pulse lavage, WhirlpoolAids in debridement and cleansing, warm water vasodilation.

Hyperbaric Oxygen Electrical Stimulation

Bandages & Binders

Secures dressings in place

Determine size needed

Outer covering must cover entire wound

Tape to secure (initial,date time)

Heat & Cold TherapyHeat- reduces pain & promotes healing

through vasodilationIncreases oxygen and nutrients to aid in

inflammatory responseReduces edema by promoting removal of

excessive interstitial fluid Promotes muscle relaxation

Heat & Cold TherapyCold- decreases pain by vasoconstrictionDecreased blood flow to the area

decreases inflammation and edemaRaises the threshold of pain receptors

thereby decreasing painDecreases muscle tension

Safety Precautions Heat & Cold Therapy

Very young and very oldPeripheral vascular diseaseDecreased LOCSpinal cord injuryPresence of edema and/or scar tissueNO LONGER than 20-30minutes at a time.

Rebound phenomena