Unerstanding skin and woUnd mangement Unerstanding skin and woUnd mangement

PrePared by

dr/ mohamed mohsen

PrePared by

dr/ mohamed mohsen

Objectives

• To know Anatomy and Physiology of related to wound Care .

• To know the wound classifications.• To know the wound healing process .• identify Types of wound dressing and drainage.• identify Factors affecting wound healing.• To know the Wound assessment.• Identify the common complications of wound.

outlines

1. Definition of wound

2. Types of wounds

3. Wound healing

4. Wound assessment

5. Kinds of wound drainage

6. Complications of wound healing

CONT,

7. Wound dressing Changing a dry sterile dressing Applying wet- to- dry dressing Applying a moist transparent wound barrier Applying a hydrocolloid dressing

8. Wound irrigation

9.Preventing wound infection

Functions of the skin

Thermoregulation

Fluid & electrolytebalance sensation

protection

Vitamin D synthesis

Function ofThe skin

Functional physiology of the skin

• Protection • Regulation of temperature • Regeneration• Absorption • Communication • Excretion /secretion• Vitamin D production• Sense of self-esteem• Health indicator

WOUND

A break or “ disruption” in the continuity of a body tissue that followed by restoration of that continuity (wound healing).

Classification of wounds

Wound my be classified in to different ways:

1. Mechanism of injury: Intentional Vs. Unintentional. Open Vs. Closed.Incised, contused, lacerated or puncture.

3. Degree of contamination.

4 . Depth of the wound.

Intentional Vs. Unintentional wounds

Intentional wound: occur during therapy. For example: operation or

venipuncture.

Unintentional wound: occur accidentally.Example: fracture in arm in

road traffic accident.

Open Vs. Closed wounds

Open wound: the mucous membrane or skin surface is broken.

Closed wound: the tissue are traumatized without a break in the

skin.

Types of wounds

Incised wounds: Made by a clean cut with a sharp instrument. Example, those made by the surgeon in every

surgical procedure and usually closed by sutures “ clean surgical wound”.

Contused wounds: closed wound are made by blunt force. Characterized by considerable injury of the soft parts

, hemorrhage and swelling.

Types of wounds cont-

Puncture wounds: open wound, penetrating of the skin and often

the underlying tissues by a sharp instrument.

Stab wound: open wound, penetration of the skin and the

underlying tissues, usually unintentional.

Types of wounds cont-

Laceration: open wound edges are often jagged, irregular

edges. Often from accidents that made by glass or

barbed wire الشائك .سلك

Abrasion: open wound involving skin only, painful, due

to surface scrape.

Degree of contamination

Wounds may be described as “ clean, clean-contaminated, contaminated or dirty or infected”

Clean wounds: are uninfected wounds in which minimal

inflammation exist, are primarily clean closed wounds; if necessary, a closed drainage system .

The respiratory, alimentary, genital, or uninfected urinary tracts are not entered.

The relative probability of wound infection is ” 1% to 5%”.

Degree of contamination

Clean –contaminated wound:

are surgical wounds in which the respiratory,

alimentary, genital, or urinary tract has been entered.

There is no evidence of infection.

The relative probability of wound infection is

” 3% to 11%”.

Degree of contaminationContaminated wounds:

include open, fresh, accidental wounds and surgical procedures with major breaks in a septic technique or gross spillage from the gastrointestinal tract.

There is evidence of inflammation. The relative probability of wound infection is

“ 10% to 17%”.

Dirty or infected wounds: includes old, accidental wounds containing dead tissue

and evidence of infection such as pus drainage. The relative probability of wound infection is

over 27%.

Depth of the wound

Partial thickness: the wound involves epidermis and dermis.

Full thickness: involving the epidermis, dermis, subcutaneous

tissue, and possibly muscle and bone.

Wound Healing

Healing is regeneration (renewal) of tissues.

The time needed for healing depends on location,

and size of wound, and health status of the client.

The response of tissue to injury goes through

several phases.

Wound healing

Inf lammatory phase

Proliferative phase

Maturation phase

Timetable of Wound Healing

• Hemostasis immediate

• Inflammation 1-4 days

• Granulation Tissue 5-20 days

• Tissue remodeling 21 days-2 years

or maturation

Inflammatory phase

Also called exudative phase

1-4 days

Blood clots forms

Wound becomes edematous

Debris of damaged tissue and blood clot are

phagocytized

Proliferative phase

Also called fibroblastic or connective tissue phase5-20 daysCollagen producedGranulation tissue formsWound tensile strength increases.After 2 weeks, the wound has only 3% to 5% of the

original skin strengths. by the end of a month, only 35% to 59% of wound

strength.Never more than 80% of strength is regained.

Maturation phase

Also called resorptive or remodeling phase

21 days to months or even years

Fibroblasts leave wound

Maximum tensile strength increases

Collagen fibers reorganize and tighten to

reduce scar size

Forms of Wound Healing

• The amount of tissue loss, the existence of contamination or infection and damage to tissue are all factors that determine the type of wound healing that will occur.

• Process of healing takes place in one of three waysHealing by primary (first) intentionHealing by secondary intention(granulation)Healing by delayed primary closure (third intention)

Healing by primary (first) intention

Wound is clean, in a straight line, with little

loss of tissue.

All wound edges are well approximated with

sutures.

Usually rapid healing with minimal scarring.

Drainage is minimal

Healing by secondary intention (granulation)

When surgical wounds are characterized by tissue loss

with inability to approximate wound edges, the process of

repair is less simple and takes longer.

This type of wound is left open and allowed to heal from

the inside toward the outer surface

In infected wound this process allows the proper

cleansing and dressing of the wound as healthy tissue

builds up from the inside

Healing by secondary intention (granulation) cont-

The area of tissue loss gradually fills with

granulation tissue (fibroblasts and capillaries)

Scar tissue is extensive because of the size of

the tissue gap that must be closed. Contraction

of surrounding tissue also takes place

Consequently this healing process takes longer

than primary intention healing

Healing by delayed primary closure (third intention)

This healing process takes place when approximation of

wound edges is delyed by 3-5 days or more after injury or

surgery.

There is greater granulation , greater risk of infection,

greater inflamatory reaction and more scars. The condition contribute to a decision for a dalyed closure

are:

Traumatic Wound Heavy contamination of wound Surgical Debridement of a wound

Wound assessment Determine the client’s allergies to wound-

cleaning agents and tape Assess the wound for:

Appearance Size Depth Drainage Swelling Pain Drains or tubes

Cont,

Assess the client for factors that hinder wound healing

Malnutrition Obesity Medications Smoking Compromised host

Cont,

Determine results of laboratory data pertinent to healing: Leukocyte count Blood coagulation studies

Factors affecting wound healing

Age of patientHemorrhageHypovolemiaLocal factors • (too small or too tight dressing)

• edema

Nutritional deficits: : ( malnutrition, alcoholic) Foreign bodiesOxygen deficit (tissue oxygenation insufficient)

Cont,

Medications “Chemical effects “ as anticoagulants , prolonged use of steroids)

Patient over activityCaffeine and SmokingSystemic disorders(renal failure, sepsis, liver

disease, DM, immune disease, cancer)Procedural considerations( type of surgery, skin

preparation, duration of procedure, tissue handling techniques, dressing methods)

Radiation and chemotherapy

Kinds of wound drainage

Sanguineous exudate ( Dark or bright red) Serosanguineous exudate (mix between two pervious types) Serous exudate (watery , clear) Purulent exudate (viscous fluid varies in color e.g blue ,

white , green)

Complications of wound healing

1. Hemorrhage: 2. Haematoma:.3. Infection4. Abnormal scar formation as

Adhesion , Granuloma Keloid , Neuroma Hypertrophic scar , Contractures

5. Disruptions of wounds as Hernia Dehiscence, Evisceration, Fistula, Sinus tract

Complications of wound healing

Clinical signs of hemorrhage

Increased pulse rate

Increased respiratory rate

Lower blood pressure

Restlessness

thirst

cold clammy skin

Cont,

Clinical signs of infection

Redness

Pain

fever

increased leukocyte count

Swelling

indurations (hardening of the tissues)

Wound infection

Wound Dehiscence• Disruption of surgical incision or

wound.

• Clinical signs of dehiscence

-Unexplained fever

-Unexplained tachycardia

-Unusual wound pain

-prolonged paralytic ileus

WOUND DEHESCENCE

Wound Evisceration

Protrusion of wound contents.

Are especial serious when they involve

abdominal incisions or wounds.

Wound Evisceration

Wound dressing

Changing a dry sterile dressing

Applying wet- to- dry dressing

Applying a moist transparent wound

barrier

Applying a hydrocolloid dressing

Wound irrigation An irrigation (lavage):

is the washing or flushing out of an area. sterile technique is required because there is a break in the skin integrity.

Using piston syringes instead of Asepto syringes to irrigate a wound reduces the risk of aspirating drainage.

For deep wounds with small openings, a sterile straight catheter may be used.

Frequently used irrigation solutions are: Normal saline ,lactated ringer’s, antibiotic solutions Dakin’s solutions , hydrogen peroxide solutions

Preventing wound infection

Wash hands before and after caring for surgical wounds.

Touch an open or fresh surgical wound only when wearing sterile gloves or using sterile forceps.

Remove or change dressings over open and closed wounds when they become wet.

Take a specimen of any drainage from the wound that is suspected of being infected.

Apply universal precautions.

Wound DressingWound Dressing

Major dressings properties–Moist environment

–Debriding potential

–Comfort and analgesia

–Exsudation management

–Ease of application

The Principal Reasons for Applying a Dressing

The Principal Reasons for Applying a Dressing

• To produce rapid and cosmetically acceptable healing, • To remove or contain odour, • To reduce pain, • To prevent or combat infection,

• To control exudate, • To control bleeding• To cause minimum distress or disturbance to the patient, • To hide or cover a wound for cosmetic reasons. • To clean and debride the wound.

21 days

Diabetic ulcer for 5 month

Hydrocolloid

Hydrocolloid

Absorption base Absorption base dressingdressing

AlginateAlginate

HydrofibreHydrofibre

Moist woundMoist wound healinghealingMoist woundMoist wound healinghealing

Alginate : Indication

•For moderate to heavily exudating wounds

• Help to debride (in addition with mechanical debridement

Hydrofibre : AquacelHydrofibre : Aquacel• CMC fiber : gel formation• Same indications than

alginate• Non haemostatic

• For light to medium exuding wounds

• Granulating and epithelializating wounds

Foam dressing : Indication

For Cavity Wounds

Foams

• Examples

– Allevyn

– Cutinova Foam

– Epilock

– Flexzam

– Hydrasorb

– Lyofoam

– Mitraflex

– Nu-derm

Hydrocolloids

– AquaCel

– Comfeel

– Cutinova Hydra

– Duoderm

– Hydrapad

– Intrasite

– J&J Ulcer Dressing

– Procol

– Replicare

– Restore

Hydrogels

– AquaSorb– Carrington Gel– Carrasyn-V– Clear-Site– Curasol Gel– Flexderm– Hydron– Intrasite Gel– Solosite– SAF-Gel

Any question?