Nursing Aspect – Wound management

7/30/2019 Nursing Aspect Wound management

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ZALIANA BRAHIM

WOUND CARE NURSE

HOSPITAL MIRI


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A wound is a disruption of continuity of skin

or underlying tissues with or with out anopening onto the body surface.


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Classification of wounds

1. Acute wound- caused by trauma, animal bites, burns and surgical incisions- generally managed by the surgical team


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Classification of wounds2. Chronic wound

3 basic types:

Pressure ulcers

Lower extremity ulcers Skin tears


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BURN


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BURN


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BURN


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Principles of wound Care

1. Relieving pain

2. Correcting nutritional deficits

3. Wound debridement

4. Wound dressing5. Management of infection


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Wound Management Nursing

aspect

1. Burns

2. Wound assessment

3. Wound care products

4. Nursing Process


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1 Burn (Superficial)

- involves epidermis

- produce pain and

redness- heal within a week

- no scaring


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2 Burn (Partial thickness)- involves epidermis,

superficial dermis

- produce pain, redness,blister

- heal within 2 to 3 weeks

- minimal scaring


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3 Burn (Full thickness)

- involves epidermis,

dermis, subcutaneous

tissue- appear pale and white

- no pain

- require grafting


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Burns

Rule of 9

- To estimate

severity of burns

d h


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LUND and BROWDER Chart


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Burns Nursing ManagementObjectives

1. Prevention of shock2. Prevention of infection

3. Prevention of contracture

4. Provision of psychotherapy


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Prevention of shock

1. Sedation for pain and restlessness (morphine stillbeing the most effective drug except in respiratory burn) timely, proper documentation in pain score chart. Evaluateeffectiveness of analgesics. Refer appropriately. DDA protocol inusage and recording to adhere to.

2. Use of colloids and crystalloids to combat shock (resuscitation formulas) Strict and accurate Intake /Output

chart recording


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Prevention of shock

3. Administration of oral fluids

- small amount of 10-50 mls hourly of bland fluids (water,glucose, plain ovaltine, barley water, orange juice, ribena etc)-

Accurate Intake and Output Chart

Burned patients are thirsty and if given toomuch to drink too quickly, they will vomitbecause of gastric dilatation and paralyticileus.


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Prevention of shock

4. Urinary output

Child 10mls / hour

Adult 30mls /hour

Hourly urine output must be done andaccurately recorded

Inform Doctor for any decrease in urinary outputor presence of blood


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Prevention of shock

5. Observations Hourly TPR, BP & SPO2

Temperature can be subnormal because the skin surfaces aredestroyed and elevated subsequently when infection sets in.

Pulse Rate, volume and regularity of pulse should be noted.

Increase in pulse rate indicates over transfusion and acute gastricdilatation.

Respiration observe for its depth and frequency and state ofairway.

Tracheostomy / intubation may be indicated for laryngeal edema,

respiratory distress, restrict chest movementSPO2 Any decrease in SPO2 must be referred.

Blood Pressure Any change must be referred. Can be over /under transfusion.


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Prevention of shock

Restlessness

- often an indication of under transfusion or can result from anoxia.

Color and temperature of extremities - any coldness accompanied with any changes indicates circulation

impairment . Inform doctor immediately


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Infection control measures1. Staff Barrier nursing

- Hand washing technique: prior & after.

2. Visitors- Restriction- close family members only- Hand washing prior to patient contact

3. Environmental measures

- Air conditioned room Temp 25-28C

- Bed linen- Sterile linen for exposed method dressings

- Soiled linen removed immediately

Prevention of Infection


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4. Wound Care- swabs for C&S on admission Technique!- strict aseptic dressing technique

5. General personal hygiene- promotion of independence- early mobilization- Encourage family support

6. Nutrition

- High calorie &Protein- Supplementary feed eg. Enercal- Vitamin C, B complex, Iron

Major burns- sips of water

-NG tube- Enteral feeding

Maintain strict intake output chart

Infection control measures


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Prevention of contracture

Physio & Occupational Therapy All joints into active & passive movements Encourage exercises

Involve family in activities

Need forJOBST Garment


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JOBST GARMENTpressure

garment


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Provision of PsychotherapyPsychotherapy On admission reassurance (allay fear and anxiety)

Adequate pain relief

Social worker role

Counselor role

Family support Constructive diversional therapy


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WOUND ASSESSMENT


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WHY IS WOUND ASSESSMENTNECESSARY?

To enable prompt and appropriate woundmanagement

Relieve the psychological burden of the person (andfamily members) with the wound

To give appropriate health information and thusadvice

Cost saving


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Wound Assessment Location Clinical appearance

Dimension

ExudatesWound edges

Surrounding skin

Infection

Pain

Psychosocial implications


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Location

Clinical appearance


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Clinical appearance

- Degree of tissue loss

- ? Black hardened, necrotic,

eschar, dry or moist

Necrotic(dead, dry

issue)

Sloughy wound

Cli i l


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Pusexudate

Exudate - Observe for color, consistency, amount & odor

Infected with heavy exudate

Clinical appearance


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Clinical appearance

Granulation


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Epithilialising

Clinical appearance


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Dimensions

Length Width

Depth


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Wound Surrounding skin


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Pain -Assessment


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WOUND CARE PRODUCTS


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Wound Care products

Today's market offers avast selection ofproducts, from simplegauzes to silver-containing dressings tonegative pressuretherapies.

Hydrofibre/Alginates

Hydrogel

Hydrocolloids

Negativepressuretherapy


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Selecting a Dressing

Consider the following general recommendations: Keep the wound moist (the standard rule)

- A moist wound heals twice as quickly as a dry one

Avoid standard wet-to-dry dressings

If it's wet, dry it; if it's dry, wet it.

- This means that a wound with heavy exudate will need a more absorptivedressing, such as a foam or alginate, while a dry wound will require rehydrationwith a hydrogel or an occlusive dressing, such as a hydrocolloid.


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Types of dressing1. Alginates.

- Derived from seaweed, these highly absorptive dressingsare soft, nonwoven, and non-adhesive, and conform tothe shape of the wound.

- When in contact with drainage, they form a gel.Alginates are most useful for wounds with heavy exudate.

- Don't use them for dry or eschar-covered wounds,because they won't form a gel and may stick to the

wound, causing tissue trauma when you remove them

- Some contain silver, which has an antimicrobial action

- If a patient has a silver dressing, you may need toremove it before magnetic resonance imaging (MRI).

l


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Cont Alginates

Alginates come in sheets that you can cut to size. They alsocome in rope form, which is especially good for areas of

undermining or tunneling. When using an alginate, you'll need to cover the wound

with a secondary dressing to hold the product in place andto protect the wound from outside contaminants. Leave the

alginate in place for one to three days, until it begins to geland shows evidence of breakthrough drainage.

Throughly irrigate the wound with sterile normal salinesolution before reapplying the alginate.


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Types of dressing2. Foams.

- Typically polyurethane-based, this type of dressing isnon-adhesive and comes in various sizes, shapes, anddegrees of thickness.

- foam dressings provide thermal insulation and help

keep the wound moist.- They may be used as a primary or secondary dressing, topromote autolytic debridement, and to inhibit hyper-granulation.

- When using a foam dressing, make sure it's one to two

inches larger than the wound; you can leave it in place forup to seven days.


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Types of dressing3. Hydrocolloids.

Hydrocolloid dressings contain hydrophilic colloidal particles in anadhesive compound laminated to a flexible wafer. Like foams, theycome in numerous sizes, shapes, and levels of thickness.

- Hydrocolloids have minimal absorptive capabilities.- They help keep the wound moist and promote

autolysis of necrotic areas.

- Don't use them on wounds that are infected or have heavyexudate.

- To avoid damaging fragile skin by removing the dressings toofrequently, keep them in place for as long as possible, but nolonger than seven days.


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Types of dressing4. Hydrogels.

- Available as gels, sheets, or gauze impregnatedwith various percentages of water,

- Hydrogels are hydrophilic polymers with few

absorptive properties.- Theyadd moisture to the wound bed and arenon-adherent, and they're used mainly for dryand minimally exudative


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Type of Dressing

5. Hydrofiber Hydrofiber Wound Dressing is indicated for:

- Management of exuding wounds including leg ulcers, pressure ulcers anddiabetic ulcers, surgical wounds, partial thickness burns, and traumatic wounds

Why choose Hydrofiber Wound Dressing?

- Absorbs and retains exudate and harmful components- Locks exudate in the dressing

- Conforms to the wound surface, thereby reducing dead space

- Does not damage tender, granulating wound tissue or healthy tissuesurrounding exudating wounds during dressing changes

- Absorbs wound f luid and creates a soft gel

- Aids in autolytic debridement (removal of nonviable tissue from the wound)- Removes without leaving residue or causing trauma to wound

- Manages painful wounds

Negative Pressure Wound therapy (NPWT)


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- This is an option for treating wounds that are draining

heavily, failing to heal, or healing slowly.- NPWT applies sub-atmospheric pressure to the woundthrough the use of special foam dressings occlusively sealedand connected to a pump and collection chamber. - NPWT isuseful in removing exudates and debris, promoting blood

flow, hastening tissue granulation, and encouraging thecontracture of wound edges.

- It's especially helpful in treating deep, cavernous wounds.

- The foam fills in dead space, and this can enhance closure of

tunneling and undermined areas.

Negative Pressure Wound therapy (NPWT) vacuum assisted closure


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Debride the wound first

Before you apply the dressing of choice, make sure that

nonviable tissue, such as slough, eschar, and fibrin,have been debrided.

Eschar that's dry, hard, and stable need not beremoved, however, unless signs of infection are

presentredness, pus, fluctuance (bogginess ormushiness), wound edge separation with drainage

Whenever you suspect infection, refer to doctor incharge; wound cultures and/or antimicrobial therapymay be indicated.

Taking wound swab for C&S properly please!!!


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Nursing Process


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Document what you have observed Location

Clinical appearance

Dimension

Exudates

Wound edges Surrounding skin

Infection

Pain

Psychosocial implications


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Identify Nursing Problems

1. Risk of hypovolemic shock/ Risk of deficit fluid volume

2. Risk of infection due to impaired skin/tissue integrity

3. Risk of 2 infection superimposed on the primary wound

4. Risk of imbalanced nutrition: less than the body requirement

5. Pain

6. Hypothermia

7. Hyperthermia

8. Altered body image

9. Altered sleeping pattern

10. Deficient knowledge regarding condition, prognosis, treatment, self

care and discharge needs


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Evaluation Is the wound getting better?

Draw the wound size

Take photos

Collectionfor case

presentation


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Any Question?


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Nursing Aspect – Wound management

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