Care of Clients with Wound

Care of Clients with Wound

IntroductionWounds occur when the skin is broken or damaged because of injury. Causes of injury may be the result of mechanical, chemical, electrical, thermal, or nuclear sources. The skin can be damaged in a variety of ways depending upon the mechanism of injury.

Definition of Terms

Seroma- A swelling of blood, usually clotted, which forms as a result of a broken blood vessel.Hydrophobic- water-resistantHydrophillic- water-absorbingAngiogenesis- formation of new blood vessels

Causes of WoundsFriction rubbing against an abrasive surfaceSharp pointed object entering the skinHuman and animal bitesPressure sores

Types of WoundContusion A contusion is more commonly called a bruise. It is usually caused by a blunt blow, the overlying skin is unbroken, but tissues and blood vessels below are damaged. Abrasion -An abrasion is a scrape or graze. Typically, there is a superficial surface wound involving the epidermis and part of the dermis. As dermal nociceptors are exposed in the damaged dermis, these wounds are often very painful. Avulsion This term describes a wound where there is tissue loss, preventing the closure of the wound edges. Laceration -Laceration describes a wound made by a blunt object, and has often involved considerable force. The wound edges are usually split or torn with ragged edges as the skin has been burst rather than cut. Incised woundThis is a cut caused by a sharp object. These wounds usually appear neat and the edges can be readily approximated to allow primary healing to take place. Puncture wounds -These may well present as misleadingly small wounds and are also described as penetrating wounds. They are made by pointed or sharp objects. Strains Strains are injuries to muscles, fascia or tendons caused by stretching forces. Patients complain of pain and stiffness and there may be some associated swelling.Sprains -A sprain describes an injury to the fibrous tissues surrounding a joint. Fibrous ligaments around the joint are injured, usually as a result of excessive movement of the joint. Signs and Symptoms

PainSwellingBleeding

Types of InflammationAcute InflammationHealing occurs in 3-4 weeks and usually leaves no residual damage. SubacuteHas the features of the acute process but lasts longer, persists throughout weeks or months.ChronicLasts for weeks, months or even years. The injurious agent persists or repeatedly injuries tissues.

Local Manifestations of Inflammation

RuborColorDolorTumorFunctio laesa

Types of Inflammatory Exudates

Hemorrhagic, sanguineousBright-red or bloodySmall amounts expected after surgery or traumaLarge amount may indicate hemorrhage;Sudden large amount of dark-red blood may indicate a draining hematoma

SerosanguineousBlood-tinged yellow or pinkExpected for 48-72 hour after injury or trauma a sudden increase may indicate a draining seromaSerous Thin, clear, yellowExpected for up to 1 week after trauma or surgery a sudden increase may indicate a draining seroma

PurulentThin, cloudy, foul-smellingMay be thick if filled with dead cells. Usually indicates infection; may drain suddenly from an abscessCatarrhal Thin, clear mucusSeen with upper respiratory infection.

Healing Process

Phases of Wound Healing

Vascular ResponseInflammationProliferationMaturation or Reconstruction

Phases of HealingPlateletsFibrin meshworkCapillary dilationNeutrophilsMacrophagesMediators of inflammationLymphocytes and other WBCFibroblastsCollagen DepositionAngiogenesisGranulation tissueEpithelium Endothelium Collagen remodelingScar maturationVascularInflammationProliferationMaturationRegenerationThe ability to replace lost cells.

RepairThe ability to heal as a result of lost cells being replaced by connective tissue.

3 Repair IntentionsPrimary IntentionThe use of suture (stitches) or other wound closures to approximate (place close together) the edges of an incision or clean laceration. Secondary IntentionThis method of repair is called healing by granulation, and it takes place whenever pus is formed or when loss of tissue has occurred for any reason. When the post-operative wound is to be allowed to heal by secondary intention, it is usually packed with saline-moistened sterile dressings and covered with a dry sterile dressing.

Tertiary IntentionThird-intention healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two opposing granulation surfaces.

Medical Management

Therapeutic Baths- Baths or soaks, known as Balneotherapy, are useful when large areas of the skin are affected. The baths remove crusts, scales, and previously applied topical medications and relieve the inflammation and pruritus (itching).

Pharmacologic TherapyLotionsPowdersCreamsGelsPastesOintmentsSprays & aerosolsCorticosteroids

Pharmacologic TherapyLotions - are frequently used to replenish lost skin oils or to relieve pruritus.Powders - usually have a talc, zinc oxide, bentonite, or cornstarch base and are dusted on the skin with a shaker or with cotton sponges. Creams - may be suspensions of oil in water or emulsions of water in oil, with additional ingredients to prevent bacterial and fungal growth.

Gels - are semisolid emulsions that become liquid when applied to the skin or scalp. They are cosmetically acceptable to the patient because they are not visible after application, and they are greaseless and nonstaining.Pastes - are mixtures of powders and ointments and are used in inflammatory blistering conditions.Ointments - retard water loss and lubricate and protect the skin. They are the preferred vehicle for delivering medication to chronic or localized dry skin conditions, such as eczema or psoriasis.

Sprays and aerosols - preparations may be used on any widespread dermatologic condition. They evaporate on contact and are used infrequently.Corticosteroids - are widely used in treating dermatologic conditions to provide anti-inflammatory, antipruritic, and vasoconstrictive effects.

Surgical Management

Surgical or Autolytic Debridement - is a process that uses the body's own digestive enzymes to break down necrotic tissue. The wound is kept moist with occlusive dressings. Eschar and necrotic debris are softened, liquefied, and separated from the bed of the wound.

Nursing ManagementTypes of Wound Dressing:Occlusive dressings-Occlusive dressings cover topical medication that is applied to a skin lesion. The area is kept airtight by using plastic film.Wet Dressings-Wet dressings (wet compresses applied to the skin) were traditionally used for acute, weeping, inflammatory lesions.

Moist-Retentive DressingsCommercially produced moisture-retentive dressings can perform the same functions as wet dressings but are more efficient at removing exudate because of their higher moisture- vapor transmission rate; some have reservoirs that can hold excessive exudate. Hydrogels- They are semitransparent, allowing for wound inspection without dressing removal. They are comfortable and soothing for the painful wound. They require a secondary dressing to keep them in place. Hydrogels are appropriate for superficial wounds with high serous output.

Hydrocolloidsare composed of a water-impermeable, polyurethane outer covering separated from the wound by a hydrocolloid material. Foam Dressings-Foam dressings consist of microporous polyurethane with an absorptive hydrophilic surface that covers the wound and a hydrophobic backing to block leakage of exudate. They are nonadherent and require a secondary dressing to keep them in place. 7.Calcium Alginates-Calcium alginates are derived from seewed and consist of very absorbent calcium alginate fibers. They are hemostatic and bioabsorbable and can be used as sheets or mats of absorbent material. NURSING DIAGNOSES& its corresponding Nursing Interventions

A. Risk for deficient Fluid Volume

Monitor v/s, central venous pressure (CVP). Note capillary refill and strength of peripheral pulses. Monitor urinary output and specific gravity. Observe urine color and Hematest as indicated. Estimate wound drainage and insensible losses. Maintain cumulative record of amount and types of fluid intake. Weigh daily. Measure circumferences of wound as indicated. Investigate changes in mentation.

B. Risk for Infection 1. Implement appropriate isolation techniques as indicated. 2. Emphasize/ model good hand washing technique for all individuals coming in contact with client. 3. Use gowns, gloves, masks, and strict aseptic technique during direct wound care and provide sterile or freshly laundered bed linens/ gowns. 4. Monitor/ limit visitors, if necessary. If isolation is used, explain procedure to visitors.

C. Acute pain related to destruction of skin/ tissuesCover wounds as soon as possible unless open-air exposure care method required.Elevate extremities periodically.Provide bed cradle as indicated.Wrap digits/ extremities in position of function using splints and footboards as necessary. Change position frequently and assist with active and passive range-of-motion (ROM) exercises as indicated. Maintain comfortable environment temp., provide heat lamps, heat-retaining body coverings. Assess reports of pain, noting location/ character and intensity (0-10 scale).Administer analgesics as indicated.

D. Ineffective tissue perfusionAssess for color, sensation, movement, peripheral pulses and capillary refill. Compare with findings of unaffected limb.Remove jewelry/ arm band. Avoid taping around a wound.Obtain BP in the unaffected side of the arm if possible. Remove BP cuff after each reading, as indicated.Investigate reports of deep/ throbbing ache, numbness.Encourage active ROM exercises of unaffected body parts. Investigate irregular pulses.

E. Impaired skin integrityAssess/ document size, color, depth of wound, noting necrotic tissue and condition of surrounding skin.Provide appropriate wound care and infection control measures. Administer topical wound debridement ointment, as indicated. Keep skin free from pressure.Maintain wound covering as indicated.Wash sites with mild soap, rinse, and lubricate with cream several times daily after dressings are removed and healing is accomplished.