Wound Assessment

Wound Assessment and Aseptic Wound Assessment and Aseptic TechniqueTechnique

Jed Montayre, RN, MSN, PhD(c)Jed Montayre, RN, MSN, PhD(c)

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Learning Learning OutcomesOutcomes

1. Provide definition of wounds, wound 1. Provide definition of wounds, wound assessment and aseptic techniqueassessment and aseptic technique

2. Demonstrate understanding of 2. Demonstrate understanding of performing the correct aseptic performing the correct aseptic technique processtechnique process

3. Identify different types of wounds3. Identify different types of wounds

4. Identify basic nursing measures to 4. Identify basic nursing measures to prevent pressure ulcer formation prevent pressure ulcer formation

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Part 1Part 1

DEFINING THE DEFINING THE CONCEPTSCONCEPTS

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THE ANATOMY & THE ANATOMY & PHYSIOLOGY OF THE PHYSIOLOGY OF THE

SKINSKINOur skin is the largest Our skin is the largest organ in the body.organ in the body.

Average adult has Average adult has about 2 square metres about 2 square metres of skin.of skin.

Accounts for about Accounts for about 15% of body weight.15% of body weight.

Skin weighs between Skin weighs between 13-22 kg.13-22 kg.

Receives Receives approximately 1/3 of approximately 1/3 of the body’s circulating the body’s circulating blood volume.blood volume.

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THE THE PHYSIOLOGY PHYSIOLOGY OF THE SKINOF THE SKIN

6.5 cm of skin contains 6.5 cm of skin contains 4.5 m of blood vessels.4.5 m of blood vessels.

Skin varies in thickness Skin varies in thickness from 0.5 mm on eyelids from 0.5 mm on eyelids

to 4 mm or more on to 4 mm or more on palms/soles.palms/soles.

Protection from the Protection from the external environment is external environment is

its main homeostatic its main homeostatic function.function.

Average pH of the skin is Average pH of the skin is 5.5.5.5.

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THE PHYSIOLOGY THE PHYSIOLOGY OF THE SKINOF THE SKIN

Capillary perfusion Capillary perfusion pressure of skin = 32 mm pressure of skin = 32 mm Hg. Any pressure Hg. Any pressure exceeding this can exceeding this can compromise blood supply compromise blood supply to the area. (A healthy to the area. (A healthy person exceeds 40-60 mm person exceeds 40-60 mm Hg on sacrum, buttocks, Hg on sacrum, buttocks, heels).heels).

Maintaining skin integrity Maintaining skin integrity is a complex process, too is a complex process, too often taken for granted.often taken for granted.

Knowing the normal Knowing the normal healing patterns helps the healing patterns helps the nurse recognise nurse recognise alterations that require alterations that require interventions.interventions.

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ANATOMICAL ANATOMICAL STRUCTURESTRUCTURE

11 EPIDERMISEPIDERMIS• Outer layerOuter layer• Is avascularIs avascular• Receives nutrients from dermisReceives nutrients from dermis

22 DERMISDERMIS• Firmly attached to the epidermisFirmly attached to the epidermis• Has two layers – the papillary layer – the Has two layers – the papillary layer – the

reticular layerreticular layer

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33 SUBCUTANEOUS SUBCUTANEOUS LAYERLAYER

• The thickest layerThe thickest layer

• Main support for Main support for the skinthe skin

• Made up of Made up of connective and connective and adipose tissue and adipose tissue and blood vesselsblood vessels

• Forms a protective Forms a protective layer for the layer for the organsorgans

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ANATOMICAL ANATOMICAL STRUCTURESTRUCTURE

EPIDERMISEPIDERMIS

Dead cells – water repellent and Dead cells – water repellent and protects the deeper cells protects the deeper cells

Function is to resurface wounds and Function is to resurface wounds and restore the barrier against invading restore the barrier against invading organismsorganisms

Stratum corneumStratum corneum – dead flattened cells – dead flattened cells

Stratum malpighiiStratum malpighii – these cells divide, – these cells divide, proliferate and migrate towards the proliferate and migrate towards the epidermal surface.epidermal surface.

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DERMISDERMISPapillary layerPapillary layer

Temperature and touch receptorsTemperature and touch receptors

Fine lymph vessels and nerve endingsFine lymph vessels and nerve endings

Connective tissue and capillary loopsConnective tissue and capillary loops

Sweat glands – produce sweatSweat glands – produce sweat

Sebaceous glands – produce sebum which maintains Sebaceous glands – produce sebum which maintains hair and skin condition, pH and is anti-microbialhair and skin condition, pH and is anti-microbial

Hair follicles – lined with epidermal cells which produce Hair follicles – lined with epidermal cells which produce hair for insulation and increased skin sensitivity hair for insulation and increased skin sensitivity (especially to light touch)(especially to light touch)

Collagen and elastic fibres form a network giving skin its Collagen and elastic fibres form a network giving skin its tensile strength and elasticity (Collagen is a tough, tensile strength and elasticity (Collagen is a tough, fibrous protein)fibrous protein)

Fibroblasts (responsible for collagen formation)Fibroblasts (responsible for collagen formation)

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DERMISDERMIS

Reticular layerReticular layerAs the baseAs the base

No clear division between these 2 layersNo clear division between these 2 layers

Main differences are the size of the Main differences are the size of the collagen fibres (increased) and the collagen fibres (increased) and the vascular supply becomes more densevascular supply becomes more dense

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FUNCTIONS OF FUNCTIONS OF THE SKINTHE SKIN

11 Protection Protection againstagainst• Bacteria and Bacteria and

virusesviruses• Cold, heat and Cold, heat and

radiationradiation• Chemical Chemical

substancessubstances• Mechanical Mechanical

damagedamage

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22 ExcretionExcretion• Facilitates Facilitates

excretion of excretion of water and water and waste waste productsproducts

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33 Thermoregulatory Thermoregulatory controlcontrol

• Secretion and Secretion and evaporation of evaporation of sweatsweat

• Circulatory Circulatory mechanisms – mechanisms – vasodilatation vasodilatation and constrictionand constriction

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Insulation by Insulation by adipose tissue and adipose tissue and hairhair

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44 SensationSensation• Nerve receptors Nerve receptors

are sensitive toare sensitive toPainPain

TemperatureTemperature

TouchTouch

Pressure and Pressure and vibrationvibration

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55 MetabolismMetabolism• Synthesis of Synthesis of

Vitamin DVitamin D

• Synthesis of Synthesis of melaninmelanin

66 ReservoirReservoir• Acts as a blood Acts as a blood

reservoir – reservoir – containing at least containing at least 1/3 of the blood 1/3 of the blood volumevolume

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77 CommunicationCommunication• Facial expressionsFacial expressions

• Alterations in skin Alterations in skin colour – blushing, colour – blushing, pallorpallor

• Sensation of Sensation of touchingtouching

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Can you imagine Can you imagine if we are skinless?if we are skinless?

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What is an alteration to the What is an alteration to the skin function called?skin function called?

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It can be called….It can be called….

A Pathologic Skin A Pathologic Skin Condition (Scabies) or Condition (Scabies) or a genetic skin a genetic skin alteration or a alteration or a combination of combination of factors.factors.

Yet the most common Yet the most common is the breakdown of is the breakdown of skin integrity.skin integrity.

--WOUNDS-----WOUNDS---

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CAUSES OF SKIN CAUSES OF SKIN DAMAGEDAMAGE

Differentiating between different types Differentiating between different types of skin injury leads to appropriate of skin injury leads to appropriate intervention and prevents further skin intervention and prevents further skin damage.damage.11 Extremes of temperatureExtremes of temperature22 Invasions by micro-organismsInvasions by micro-organisms33 DehydrationDehydration44 Mechanical damageMechanical damage55 Arterial insufficiencyArterial insufficiency66 Venous congestionVenous congestion77 Use of alkaline soapsUse of alkaline soaps

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A WOUND A WOUND DEFINEDDEFINED

“ “ Any damage Any damage leading to a break in leading to a break in the continuity of the the continuity of the skin can be called a skin can be called a wound”. (Dealy, wound”. (Dealy, 2005, p.1). There are 2005, p.1). There are several causes of several causes of wounding. wounding.

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Traumatic – mechanical, chemical, Traumatic – mechanical, chemical, physicalphysical

Intentional – surgeryIntentional – surgery

Ischaemia – e.g. arterial leg ulcerIschaemia – e.g. arterial leg ulcer

Pressure – e.g. pressure ulcerPressure – e.g. pressure ulcer

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ACUTEACUTE

CHRONICCHRONIC

OPENOPEN

NECROTICNECROTICLeathery, black appearance (dehydrated dead Leathery, black appearance (dehydrated dead cells)cells)

SLOUGHYSLOUGHYYellow/white (due to large amount of Yellow/white (due to large amount of leucocytes)leucocytes)

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What is the nurse’s role What is the nurse’s role in taking care of patients in taking care of patients

with woundswith wounds

Have we got a Have we got a role in the role in the

management management of wounds?of wounds?

WOUND WOUND DRESSINGDRESSING

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WHAT ARE 2 THINGS WHAT ARE 2 THINGS CONSIDERED IN WOUND CONSIDERED IN WOUND

DRESSING?DRESSING?WOUND ASSESSMENTWOUND ASSESSMENT PRINCIPLE OF ASEPSISPRINCIPLE OF ASEPSIS

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Management : Management : Wound DressingWound Dressing

Wound assessment MUST be underpinned Wound assessment MUST be underpinned with a thorough understanding of skin with a thorough understanding of skin pathology as wounding leads to a pathology as wounding leads to a breakdown in the protective function of the breakdown in the protective function of the skin. skin.

Aseptic Technique is utilised in order to avoid Aseptic Technique is utilised in order to avoid contamination and infection during wound contamination and infection during wound dressing.dressing.

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Some historical Some historical perspectives of wound perspectives of wound

managementmanagementIt is a rapidly It is a rapidly expanding and dynamic expanding and dynamic specialty specialty

Prehistoric Prehistoric management basically management basically aimed at control of aimed at control of bleeding and to cover bleeding and to cover the wound eg mud, the wound eg mud, leaves, lichen, bark – leaves, lichen, bark – larger wounds held larger wounds held together with thorns, together with thorns, twine (still seen today twine (still seen today in some African tribes)in some African tribes)

Ancient Egypt greatly Ancient Egypt greatly favoured topical favoured topical applications – animal applications – animal dung, honey, resins to dung, honey, resins to stop bleedingstop bleeding

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Some historical Some historical perspectives of wound perspectives of wound

managementmanagementWater and milk Water and milk extensively used to extensively used to cleanse the woundcleanse the wound

Greeks Greeks hot irons to hot irons to cauterise, wine as an cauterise, wine as an antisepticantiseptic

Hippocrates (~ 400 BC) Hippocrates (~ 400 BC) advocated warm water, advocated warm water, vinegar or wine for vinegar or wine for cleansing – bringing cleansing – bringing the wound edges the wound edges together and covering together and covering with wool boiled in with wool boiled in HH22O. He said hands O. He said hands should be kept clean should be kept clean and fingernails short. and fingernails short. The principles of The principles of ASEPSIS BEGIN.ASEPSIS BEGIN.

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WOUND WOUND ASSESSMENTASSESSMENT

• Inspection and ObservationInspection and Observation• Careful Documentation of Wound Careful Documentation of Wound

ProgressProgress• On-going assessment for effective On-going assessment for effective

measures and ineffective management measures and ineffective management for modificationfor modification

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ASEPTIC ASEPTIC TECHNIQUETECHNIQUE

• SterilitySterility• Maintaining Sterile Field Maintaining Sterile Field • Preventing ContaminationPreventing Contamination..

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Concepts DefinedConcepts DefinedWound:Wound:

Wound Assessment:Wound Assessment:

Aseptic Technique:Aseptic Technique:

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Part 2Part 2

PRINCIPLES OF PRINCIPLES OF ASEPSISASEPSIS

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Basic Principles of Basic Principles of AsepsisAsepsis

The area where the sterile field is The area where the sterile field is placed must be clean and dry.placed must be clean and dry.

Sterile field must remain dry.Sterile field must remain dry.

Sterile touches SterileSterile touches Sterile

Unsterile items should never be placed Unsterile items should never be placed in the sterile field.in the sterile field.

If unsure consider item as If unsure consider item as contaminated.contaminated.

Never reach across a sterile area.Never reach across a sterile area.04/10/2304/10/23

ExerciseExercise

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Part 3Part 3

WOUND WOUND ASSESSMENTASSESSMENT

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COMMON TYPES OF COMMON TYPES OF WOUNDSWOUNDS

ABRASIONABRASIONSuperficial with little bleeding.Superficial with little bleeding.May have plasma leaking from damaged May have plasma leaking from damaged capillaries.capillaries.

LACERATIONLACERATIONBleeds more profusely depending on depth Bleeds more profusely depending on depth and location, eg scalpand location, eg scalp

PUNCTUREPUNCTUREBleeds in relation to depth and sizeBleeds in relation to depth and size

PRESSURE ULCERPRESSURE ULCER

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WoundsWounds

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GRANULATINGGRANULATINGNew tissue – shiny, red, irregular. New tissue – shiny, red, irregular.

EPITHEALISINGEPITHEALISING

Pink/whitePink/white

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OOZEOOZESerous = clear, watery plasmaSerous = clear, watery plasma

Haemoserous = blood and plasma Haemoserous = blood and plasma (serosanguineous)(serosanguineous)

Sanguineous = fresh bleedingSanguineous = fresh bleeding

Purulent = thick yellow, green or brownPurulent = thick yellow, green or brown

PUS!PUS!Dead neutrophils, digested bacteria and cell Dead neutrophils, digested bacteria and cell debrisdebris

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INFLAMMATIONINFLAMMATIONA reaction to cell injuryA reaction to cell injuryUsually always present with infectionUsually always present with infection

QQ What are the signs of inflammation?What are the signs of inflammation?

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INFECTIONINFECTIONInvasion of tissues or cells by a micro Invasion of tissues or cells by a micro organism, eg bacteria, fungi, virusorganism, eg bacteria, fungi, virusNot always present with inflammationNot always present with inflammation

ContaminationContamination = presence of bacteria = presence of bacteria without multiplicationwithout multiplication

ColonisationColonisation = bacteria with = bacteria with multiplication, but no host reactionmultiplication, but no host reaction

InfectionInfection = bacteria with multiplication = bacteria with multiplication and an associated host reactionand an associated host reaction

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NURSING PROCESS NURSING PROCESS

IN IN WOUND MANAGEMENTWOUND MANAGEMENT

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Documents

Wound Assessment