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Module fiveWound care and

dressing

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THE SKIN

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FUNCTIONS OF THE SKIN

Protection against injury

Sensation

Defense against microorganisms

Maintenance of hydration

Waste removal

Thermoregulation

Healthy SkinImmune function

Synthesis of Vitamin D

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Wound-definitions(Manley, Bellman, 2000)

A loss of continuity of the skin or A loss of continuity of the skin or mucous membrane which may mucous membrane which may involve soft tissues, muscles, involve soft tissues, muscles, bone and other anatomical bone and other anatomical structure.structure.

•Any disruption to layers of the skin and underlying tissues

•Due to multiple causes including trauma, surgery, or a specific disease state

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WOUND HEALING

Classification of wound healing(According to the amount of tissue loss)

Primary intention healing

Secondary intention healing

Tertiary intention healing

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Wound Classification Wound Classification

Intentional wounds and Unintentional Intentional wounds and Unintentional wounds wounds

Open wounds and closed wounds Open wounds and closed wounds Acute and chronic wounds Acute and chronic wounds

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PHASES OF WOUND HEALING

Healing is a quality of living tissue; it is also

referred to as regeneration (renewal) of tissue.

A. The inflammatory phase

B. The regenerative (Proliferative) phase

C. The Maturative (Remodeling) phase

(Manley, Bellman, 2000)

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Injury /damage Cells

Blood Clot

Uniting the wound edges

Histamine

Vasodilation Permeability

Neutrophils &Monocytes

Oedema& Engorgement

0-3 days

Dry

-Dilated blood vessels-Microcirculation slow down

The inflammatory phase (Initiated immediately after injury and last 3-4-6

days

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Blood vessels near the edge of the wound become porous

- Resultant tissue filling is referredTo as granulation tissue- process of wound contraction begins

Traps other blood cells & damaged blood vesselsBegin to regenerate within the wound margins

Allowing excess moisture to escape

Macrophage activity

Formation& multiplication of fibroblasts

migrate along fibrin threads

- Laying down of a ground substance- Beginning the synthesis of collagen fibers (granulation tissue )

The Regenerative (Proliferative) phase

Stimulates

Which

This fibrous networkR

esultin

g

Begins 2-3 days of injuryLasting up to 2-3 weeks

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The Regenerative phasecont’d This phase of healing:

Last from 0-24 daysSigns of inflammation should subside although the wound will often remain red in colour and to some degree raised in relation to its surrounding tissue .

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The Maturative phaseBegins about day 21 and can extend up to Begins about day 21 and can extend up to

6 months up to one or two years after the 6 months up to one or two years after the injury.injury.

Fibroblasts continue to synthesize Fibroblasts continue to synthesize collagen collagen

The collagen fibers recognized into a more The collagen fibers recognized into a more orderly structureorderly structure

The scar become a thin ,less elastic, white The scar become a thin ,less elastic, white line line

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Factors affecting wound healing(Manley.K, Bellman. L,2000)

Developmental consideration/Age Nutrition Life-style Medication Infection Wound perfusion PH of the wound interface Foreign bodies

ContaminationBacteria present on surface

ColonizationBacteria attach to tissue and multiply

InfectionBacteria invade healthy tissue and overwhelm immune defenses

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Types of Wound (Hahn,Olsen,Tomaselli, Goldberg ,2004)

TypeCauseDescription and Characteristics

IncisionSharp instrument eg. KnifeOpen wound; painful

ContusionBlow from a blunt instrumentClose wound, skin appears ecchymotic (bruised) because of damaged blood vessels

AbrasionSurface scrape, either unintentional (eg, scraped knee from fall) or intentional (eg, dermal abrasion to remove pockmarks)

Open wound; involving the skin ; painful

PuncturePenetration of the skin and, often the underlying tissues from a sharp instrument

Open wound; can be intentional or unintentional

LacerationTissues torn apart, often from accidents (eg, machinery)

Open wound; edges are often jagged

Penetrating wound

Penetration of the skin and the underlying tissues

Open wound; usually accidental ( bullet or metal fragments)

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Classification of surgical wounds (Altmeire 1999, Ayliffe & Lowbury 1992, NAS 1996)

Clean wounds: Operations in which a viscus is not opened. This category includes non- traumatic, uninfected wounds where no inflammation is encountered and no break in technique has occurred.

Clean-contaminated: A viscus is entered but without spillage of contents. This category included non- traumatic wounds where a minor break in technique has occurred.

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Classification of surgical wounds cont’d

(Altmeire 1997, Ayliffe & Lowbury 1992, NAS 1996)

Contaminated: Gross spillage has occurred or a fresh traumatic wound from a relatively clean source. Acute non-purulent inflammation may also be encountered.

Dirty or infected : Old traumatic wounds from a dirty source, with delayed treatment, devitalised tissue, clinical infection, faecal contamination or a foreign body.

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Classification of wounds by depth

I. Partial-thickness: Confined to the skin, the dermis and epidermis.

II. Full-thickness : Involve the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone

Partial Thickness Full Thickness

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Wound assessment

A complex process

Involve examination of the entire wound

Nurses visually assess wounds and

document their findings to monitor and

evaluate the progress of wound healing

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Wound assessment cont’d(Hahn,Olsen,Tomaselli, Goldberg ,2004)

What to assess?1.Location2.Dimensions/Size3.Tissue viability4.Exudate/Drainage5.Periwound condition6.Pain7.Stage or extent of tissue damage , dictates

how often a wound is reassessed8.Swelling

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Risk Factors Which Increase Patient Susceptibility to

infection (Manley.K, Bellman. L,2000) A- Intrinsic risk factors:

1. Extremes age: Defined as “ Children aged 1 year and under, and people aged 65 years and over’.

2. Underling Conditions/DisordersA. DiabetesB. Respiratory disordersC. Blood disorders

3. Smoking4. Nutrition and build

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Risk Factors Which Increase Patient Susceptibility to infection

cont’d (Manley.K, Bellman. L,2000)

B- Extrinsic risk factors:1. Drug therapy as a risk factor: e.g.

Cytotoxic

2. Breach in the integrity of the skin3. Items as foreign bodies4. Bypass of defence mechanism

through devices e.g. Intubations

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S&S of Presence of InfectionS&S of Presence of Infection Wound is swollen.Wound is swollen.Wound is deep red in color.Wound is deep red in color.Wound feels hot on palpation.Wound feels hot on palpation.Drainage is increased and possibly Drainage is increased and possibly

purulent.purulent.Foul odor may be noted.Foul odor may be noted.Wound edges may be separated with Wound edges may be separated with

dehiscence present.dehiscence present.

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Kinds of Wound Drainage

1.Exudate is material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and deposited in or on tissue surfaces. The Nature and amount of exudate vary according to:

A. Tissue involved

B. Intensity and duration of the inflammation

C. The presence of microorganisms

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Kinds of Wound Drainage cont’d2.A purulent Exudate

Is thicker than serous exudate because of the presence of pus.

It consists of leukocytes, liquefied dead tissue debris, dead and living bacteria.

The Process of pus formation is referred to as suppuration, and the bacteria that produce pus are called pyogenic bacteria.

Purulent exudate vary in color, some acquiring tinges of blue, green, or yellow. The color may depend on the causative organism.

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Kinds of Wound Drainage cont’d

3.A sanguineous (hemorrhagic) Exudate It consists of large amount or blood cells, indicating

damage to capillaries that is very severe enough to allow the escape of RBCs from plasma

This type of exudate is frequently seen in open wounds.

Nurses often need to distinguish whether the exudate is dark or bright. Bright indicate fresh blood, whereas dark exudate denotes older bleeding

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Wound ComplicationsWound Complications InfectionInfectionHemorrhageHemorrhageDehiscence and eviscerationDehiscence and eviscerationFistula formationFistula formation

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The RYB color code(Stotts,1999)

This concept is based on the color of the open wound rather than the depth or size of a wound.

On this scheme, the goal of wound care are to protect ( cover) red, cleanse yellow, and debride black.

The RYB code can be applied to any wound allowed to heal by secondary intention.

R=Red Y=Yellow B= Black

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The RYB color code cont’d

(Stotts,1999)Red woundsUsually in the late regeneration phase of tissue repair

(ie, developing granulation tissue) and are clean and uniformly pink in appearance

They need to be protected to avoid disturbance to regenerating tissue. Examples are superficial wounds, skin donor sites, and partial- thickness or second – degree burns.

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The RYB color code cont’d

(Stotts,1999)Red wounds cont’dHow to protect red wounds:

Gentle cleansing

Avoid the use of dry gauze or wet- to-dry saline

dressings

Appling a topical antimicrobial agent

Appling a transparent film or hydrocolloid dressing

Changing the dressing as infrequently as possible

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The RYB color code cont’d

(Stotts,1999)Yellow wounds Characterized primarily by liquid to semiliquid ”slough”

that is often accompanied by purulent drainage. The nurse cleanses yellow wounds to absorb drainage

and remove nonviable tissue. Methods used may include . Applying wet-to-wet dressing; irrigating the wound; using

absorbent dressing material such as impregnated nonadherent, hydrogel dressing, or other exudate absorbers; and consulting with the physician about the need for a topical antimicrobial to minimize bacterial growth.

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The RYB color code cont’d

(Stotts,1999)B – Black WoundCovered with thick necrotic tissue or

Eschar.e.g.. third degree burns and gangrenous

ulcer. Required debridement .When the eschar is removed, the wound

is treated as yellow, then red.

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Purposes of wound dressing

To protect the wound from mechanical injuries To protect the wound from microbial

contamination To provide or maintain high humidity of the

wound To provide thermal insulation To absorb drainage and /or debride a wound

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Purposes of wound dressing cont’d

To prevent hemorrhage (when applied as a pressure dressing or with elastic bandages).

To splint or immobilize the wound site and thereby facilitate healing and prevent injury.

To provide psychologic (aesthetic) comfort.

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Principles of asepsis

The aim:Guarantee the safety of the equipment

used (cleaning/disinfection/sterilisation).Reduce the level of microbial

contamination of the site requiring manipulation (antisepsis).

Ensure that no microorganisms are introduced (asepsis).

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Principles of asepsis cont’dCleaning : Is the removal of dirt, debris and

organic material.

Disinfection: Removes or destroys harmful microorganisms but not bacterial spores or slow viruses.

Sterilisation: is the complete destruction or removal of all living microorganisms including bacterial spores.

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Principles of asepsis cont’d

Antisepsis: is the reduction of the number

of microorganisms already present on the

body site prior to a procedure.

Asepsis: Procedure designed to prevent

any introduction of microorganisms to the

site achieved by a non-touching

technique and use of sterile gloves

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Guidelines for cleaning wounds (AJN, 1999)

1. Use physiologic solution, such as isotonic saline or lactated ranger solution

2. When possible , warm the solution to body temperature before use

3. If the wound is grossly contaminated by foreign material , bacteria, slough, or necrotic tissue clean the wound at every dressing change

4. If a wound is clean , has little exudate , and reveals healthy granulation tissue , avoid repeated cleaning

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Guidelines for cleaning wounds cont’d (AJN, 1999)

5. Use gauze squares . Avoid using cotton bolls

6. Consider cleaning superficial noninfected wound by irrigating them with normal saline rather than using mechanical means

7. To retain wound moisture , avoid drying a wound after cleaning it

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Topics for Home Care TeachingTopics for Home Care TeachingSuppliesSupplies Infection preventionInfection preventionWound healingWound healingAppearance of the skin/recent changesAppearance of the skin/recent changesActivity/mobilityActivity/mobilityNutritionNutritionPainPainEliminationElimination

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Sutures and staples

Types of sutures: Plain interrupted

Mattress interrupted

Plain continuous

Mattress continuous

Blanket continuous

Retention

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Sutures and staples

Removing interrupted suture

Suture removal set

Removing staples

Staple removal