Wound Care

Reconstructive Plastic Surgery and Burns CenterKorlebu Teaching Hospital

Presented By Abdulsalam Mohammed

Nursing Officer//06.june.2013

WOUND CARE

PRELIMINARY STATEMENTSImportance of

PresentationPlatform for assessment

and re-evaluation of our nursing activities and duties

Period of transfer of experience among us

Assertiveness Training

Highlight new trends in the nursing profession

NOTE: Gone are the days when nursing were not considered a profession

Today nursing has a body of knowledge

Is dynamic and rest on the shoulders of constant reading, researching

RPS/BC Cant be left out

OUTLINE OF PRESENTATTION

Introduction and Background

Objectives

Definition of terms

Anatomy of the skin

wound healing

Wound care as a concept

Wound Dressing vs. Wound care

Nursing management

Treatments of wounds

Challenges and recommendation

conclusion

INTRODUCTION & BACKGROUND

Wound care is a very vital issue affecting nursing worldwide

It is a concern that transcends medical ,surgical as well as all others departments of health service.

In RPS/BC about 100% of all patients have wounds of one sort or the other

Dressing items are very expensive

However, when care is not taken wound will deteriorate rather than heal at the hands of health professionals

Hence wound management is an integral process and care providers must constantly upgrade skills and knowledge appropriately.

DEFINITION

Wound…. A break in the integrity of the skin or any tissue

E.g. Pressure ulcer, Burns , Buruli ulcer, Avulsion injury surgical incision, Carcinoma ulceration, Cellulitis wound, ulceration of boil etc

It may or may not include underlying tissuesMay be Acute ( Expected to heal) or chronic May be surgical or traumaticMay be clean or infected.

SKIN

The skin is the largest organ of the body, making up 16% of body weight.

It has several vital functions, which include; immune function, temperature regulation, sensation and vitamin production.

Skin is a dynamic organ in a constant state of change; cells of the outer layers are continuously shed and replaced by inner cells moving to the surface.

ANATOMY OF SKIN Epidermis: outer layer . comprised of

epithelial cells avascular 0.04mm thick Regenerated

every 2-4weeks, receives nutrients

from the dermis below

comprised of 4 to 5 layers depending on the body location

Hypodermis: inner most layer

(subcutaneous layer)

supports the dermis and epidermis

varies in thickness and depth

comprised of adipose tissue, connective tissue and blood vessels

store lipids, protect underlying organs, provide insulation and regulate temperature

Skin Appendages: Includes Sweat glands, hair, nails and sebaceous glands which are all considered epidermal appendages.

Dermis: middle layer

0.5mm thick o made of two

layers very vascular contains nerves,

connective tissue, collagen, elastin and specialized cells such as fibroblasts and mast cells

Responsible for inflammatory reactions

o receptors for heat, cold, pain, pressure, itch and tickle

PHASES OF WOUND HEALING Phase 1 - INFLAMMATORY PHASE (0-3 Days) the body's

normal response to injury. This phase activates vasodilatation leading to increased blood flow causing HEAT, REDNESS, PAIN, SWELLING, LOSS OF FUNCTION (e.g. arm swells and cannot bend). Wound ooze may be present and this is also a normal body response.

Phase 2 - PROLIFERATIVE PHASE (3-24 Days) the time when the wound is healing. The body makes new blood vessels, which cover the surface of the wound. This phase includes reconstruction and epithelialization. The wound will become smaller as it heals.

Phase 3 - MATURATION PHASE (24-365 Days) the final phase of healing, when scar tissue is formed. The wound at this stage is still at risk and should be protected where possible.

This process forms the underlying knowledge base for the care and management of Wounds

MECHANISMS OF WOUND HEALING TO CONSIDER

healing by first intention that in which union or restoration of continuity occurs directly without intervention of granulations.

healing by second intention union by closure of a wound with granulations.

healing by third intention treatment of a grossly contaminated wound by delaying closure until after contamination has been markedly reduced and inflammation has subsided.

WOUND CARE AS A CONCEPT

Is not just the few minutes or hours spend in the treatment room or theater, for dressing, cleaning, and bandaging of the wound

It includes all activities before, during and after the wound dressing that has direct or indirect, local or systemic bearing on the healing of the wound

Wound dressing is a vital part of the process Example include eg nutritional status, pain management,

psychological management, management of underlying conditions, etc

We are aware of it but we may lack the sense of coordinating all nursing on activities too often.

NURSING ACTIVITIES BEFORE WOUND DRESSING

Detail Assessment of Wound

History taken

Estimation of the Wound size or TBSA

Tetanus prophylaxis

Psychological preparation

Pain management

Antibiotic therapy

Support

choose appropriate lotion

set up trolley

WOUND DRESSING STEPS

Reassure patient Position the patient in comfortable situation eg chair or bath Assessment of wound site Removal of old dressing layer one at a time

Communicate with the patient

Work in unison with your assistance or team members

Maintain accept techniques throughout Primary dressing should not be forced Observe the patient , throughout the process for any changes eg pain,

bleeding ,color Clean with antiseptic agents eg savlon, saline, acetic Irrigation with saline is very ideal Cleaning or dubbing is dependent on the wound Apply appropriate lotion Apply dressing and bandage, and secure well with plaster Decontaminate the instruments and bath accordingly

CLEANSING & DRESSING LOTIONSlotion indication Remarks

Normal saline Irrigation, Irrigation & Dressing

………………………………….

Savlon Antiseptic Cleansing agent for wound

Skin reactions may occur

Acetic Acid1:19

Pseudomonas infections …wound is greenish/Pink

Can cause allergic reacrion

Dermazine CreamHilder

For debridement of burns wound..penetrate deep into the burnt tissues

Less toxicity, but contraindicated with patient who react to silver

Nadoxine cream Anbiotic topical cream Sensititivity

Povidine/Betadine (Aqeous base)

For debridement and granulation formation

Toxicity if used on wide area

Ionsil Antimicrobial gell hypersensitify

Chloranphenicol cream Antibiotic mostly for perenial and face

Hydrgen peroxide Outmoded and not in use

NURSING MANAGEMENT AFTER DRESSING

Documentation It is an expectation that all aspects of care, including

assessment, treatment and management plans, implementation and evaluation are documented clearly and comprehensively.

All wounds should be assessed regularly and outcomes of the assessment documented. A Wound care Chart can be used to monitor and record the progress of the wound through its stages of healing. Simple wound documentation can be captured in progress notes and treatment plan

Date

Color Red/Pinkish moist tissue shows healthy granulation tissues

pink, almost white, on healthy granulation tissue is epithilium

Slough the presence of devitalized yellowish tissue

Necrotic: wound containing dead tissue. It may appear hard dry and black

Odor

exudates

Serous Clear, straw coloured Thin, watery Normal. An increase may be indicative of infection

Haemoserous

Clear, pink Thin, watery

Normal

SanguinousRed Thin, watery

Trauma to blood vessels

Purulent Yellow, grey, green Thick

Infection. Contains pyogenic organisms and other inflammatory cell

size

% take

Lotion of dressing

Frequency

Remarks

Signature

PRINCIPLES OF WOUND HEALING

Wound cleansing should not be undertaken to remove 'normal' exudate

Cleansing should be performed in a way that minimises trauma to the wound

Wounds are best cleansed with sterile isotonic saline or water

The less we disturb a wound during dressing changes the lower the interference to healing

Fluids should be warmed to 37°C to support cellular activity

Skin and wound cleansers should have a neutral pH and be non-toxic

Avoid alkaline soap on intact skin as the skin pH is altered, resistance to bacteria decreases

IMPORTANT NOTES

Maintain a moist environment at the wound/dressing interface

Be able to control (remove) excess exudates. A moist wound environment is good, a wet environment is not beneficial

Not stick to the wound, shed fibres or cause trauma to the wound or surrounding tissue on removal

Protect the wound from the outside environment - bacterial barrier

Good adhesion to skin

Sterile

Aid debridement if there is necrotic or sloughy tissue in the wound (caution with ischaemic lesions)

Keep the wound close to normal body temperature

Conformable to body parts and doesn't interfere with body function

Be cost-effective

Diabetes - choose dressings which allow frequent inspection

Non-flammable and non-toxic

SIGNS OF WOUND INFECTION

Local indicators

Redness (erythema or cellulitis) around the wound

Increased amounts of exudate

Change in exudates colour

Localised pain Localised heat Delayed or abnormal

healing Wound breakdown

Systemic indicators Increased systemic

temperature

General malaise

Increased leucocyte count

Lymphangitis

FACTOR DELAYING WOUND HEALING Malnutrition- inadequate supply

of protein, carbohydrates, fatty acids, and trace elements essential for all phases of wound healing

Reduced Blood supply - Cardiovascular disorders and Ischaemia

Medication - Non-steroidal anti inflammatory drugs and Corticosteroids.

Chemotherapy - suppresses the immune system and inflammatory response

Radiotherapy - increases production of free radical which damage cells

Psychological stress and lack of sleep- increase risk of infection and delayed healing

Obesity - decreases tissue perfusion

Infection -prolong inflammatory phase, use vital nutrients, impair epithelialisation and release toxins

Reduced wound temperature - prolonged dressing changes or use of cold cleansing products.

Underlying Disease - Diabetes Mellitus and Autoimmune disorders

Inappropriate wound management

Patient compliance

Unrelieved pressure

Immobility

Substance abuse including alcohol and cigarette smoke

TREATMENT Antibiotic Therapy –

Medications used to address bacterial contamination of the wound

Compression Therapy – The application of pressure dressings and wraps may reduce swelling of tissues and may promote proper venous blood drainage and arterial blood supply

Debridement – this is the process of removing dead tissue from the wound bed in order to stimulate the wound bed and promote healing

* Education – The Wound Care Staff will provide information regarding ambulation and exercise, diet and nutrition, and self care

Offloading – Reduction of pressure from bony area of the body and other areas creating pressure is important to address the underlying disorder of the wound itself

Skin Grafts – The physician staff can take a patient into the operating room for an autologous (graft is from the patient’s own skin) or in the Wound Care Center using a skin substitute product

Wound Vaccum – “Wound Vac” – This treatment has proven to be very effective to reduce the and remove unnecessary fluid and bacteria from around your wound

* Hyperbaric Oxygen Therapy – "HBOT” – This is a therapy that is available in the Wound Care Center. It is designed to deliver increased concentrations of oxygen directly to the wound site – oxygen rich blood is a necessary component to effective healing.

CHALLENGES

Nursing staff

Logistical challenges

Documentation

RECCOMENDATION

Remember always wound care is not just wound dressing

Conclusion

The most important practical lesson that can be given to nurses is to teach the

what to observe, how to observe, what symptoms indicate improvement, what is

the reverse, which kind of importance, which are none, which are the evidences

of neglect and what kind of neglect”

Florence nightingale ,1992.p59

References Australian Wound Management Association Inc. (August 2011). Bacterial impact on wound healing: From contamination to infection. Position Paper, Version 2.# Ashton J, Morton N, Beswick S, Barker V, Blackburn F, Wright C, Turner L, Morton K, Jennings A. BoltonNHS - Primary Care Trust. (March 2008) "Wound care Guidelines"

THANK YOU

I PUT IT

TO YOU THAT

THIS PRESENTATION

IS FAAAANTASTIC