NURSING CARE FOR PATIENT WITH WOUND

ByPurwaningsih

Break in skin or

mucous membranes

What are wounds ?

The Wound

Injury to any of the tissues of the

body, especially that caused by physical

means and with interruption of

continuity is defined as a wound.

Wound healing is a natural and spontaneous

phenomenon.

When

tissue h

as

been disr

upted

so sev

erely

that

it can

not heal

natural

ly :

* dead tissue and foreign bodies must be removed,

* infection treated,* and the tissue must be

held in apposition

Until the healing process provides the wound with

sufficient strength to with stand stress

without mechanical

support.

A wound may be approximated

with sutures, staples, clips, skin closure

strips, or topical adhesives.

Classification of wounds

1. Intentional Vs. Unintentional.2. Open Vs. Closed.3. Degree of contamination. 4 . Depth of the

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.

Degree of contamination

Clean wounds: are uninfected wounds in which minimal inflammation exist, are primarily closed wounds.

Clean –contaminated wound: are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered. There is no evidence of infection.

Degree of contamination

Contaminated wounds: include open, fresh, accidental wounds. There is evidence of inflammation.

Dirty or infected wounds: includes old, accidental wounds containing dead tissue and evidence of infection such as pus drainage.

Depth of the wound

Partial thickness: the wound involves dermis and epidermis.

Full thickness: involving the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone.

Types of wounds

1. Incision: open wound, painful, deep or shallow, due to sharp instrument.

2. Contusion: closed wound, skin appears ecchymotic because of damaged blood vessels, due to blow from blunt instrument.

Types of wounds

3. Abrasion: open wound involving skin only, painful, due to surface scrape.

4. Puncture: open wound, penetrating of the skin and often the underlying tissues by a sharp instrument.

Types of wounds

5. Laceration: open wound edges are often jagged, tissues torn apart. Often from accidents.

6. Stab wound: open wound, penetration of the skin and the underlying tissues, usually unintentional.

Wound Healing

• Primary Intention– skin edges are approximated (closed) as in a surgical

wound– Inflammation subsides within 24 hours (redness, warmth,

edema)– Resurfaces within 4 to 7 days

• Secondary Intention: tissue loss– Burn, pressure ulcer, severe lasceration– Wound left open– Scar tissue forms

Wound Healing• Inflammatory Response

– Serum and RBC’s form fibrin network– Increases blood flow with scab forming in 3 to 5 days

• Proliferative Phase: 3-24 days– Granulation tissue fills wound– Resurfacing by epithelialization

• Remodeling: more than 1 year– collagen scar reorganizes and increases in strength– Fewer melanocytes (pigment), lighter color

Some Factors Influencing Wound Healing

• Age• Nutrition: protein and Vitamin C intake• Obesity decreased blood flow and increased risk for infection• Tissue contamination: pathogens compete with cells for

oxygen and nutrition• Hemorrhage• Infection: purulent discharge• Dehiscence: skin and tissue separate • Evisceration: protrusion of visceral organs• Fistula: abnormal passage through two organs or to outside

of body

Complications of wound healing

1. Hemorrhage: some escape of blood from a wound is normal, but persistent bleeding is abnormal.

2. Hematoma: localized collection of blood underneath the skin, and may appear as a reddish blue swelling.

3. Infection

Risk Assessment

• Alterations in mobility• Level of incontinence• Nutritional status• Alteration in sensation or response to discomfort• Co-morbid conditions• Medications that delay healing• Decreased blood flow to lower extremities when

ulceration is present

Assessment and Documentation

• Location

• Stage and Size

• Periwound

• Undermining

• Tunneling

• Exudate

• Color of wound bed

• Necrotic Tissue

• Granulation Tissue

• Effectiveness of Treatment

Pressure Ulcer Assessment

• Tissue Type– Granulation Tissue: red and moist– Slough: yellow stringy tissue attached to wound

bed; removal essential for healing– Eschar: necrotic tissue which is brown or black

appearance must be debrided

Pressure Ulcer Assessment

• Wound Deterioration– Skin surrounding ulcer

• Redness, warmth, edema

• Exudate– Amount, color, consistency, odor

Assessment

• In emergency settings– Bleeding?– Foreign bodies or contamination?– Size of wound?– Need for protection of wound?– Need for tetanus antitoxin

Assessment

• Stable Setting– Wound appearance– Character of drainage

• Serous• Sanguineous• Serosanguineous• Purulent

Assessment• Stable setting

– Drains• Penrose• Evacuator units

– Jackson Pratt drains– Hemovac drains

– Wound closures• Sutures• Steel staples• Clear strips• Wound glues

Drains and Wound Closures

Pressure Ulcer Staging2

Stage I Stage II Stage III Stage IV

Pressure Ulcer Stages

• Stage I: No Skin Break– Skin temperature, consistency (firm), sensation

(pain or itching)– Persistent redness in light skin tones– Persistent red, blue or purple hue in darker skin

tones

Pressure Ulcer Stages

• Stage II: Superficial– Partial-thickness skin loss (epidermis and/or dermis– Abrasion, blister or shallow crater

• Stage III– Full-thickness skin loss (subcutaneous damage or necrosis

and may extend down to but not through fascia– Deep crater

Pressure Ulcer Stages• Stage IV: full thickness skin loss and destruction, necrosis of

the tissue, damage to muscle, bone, tendons and joint capsules and sinus tract

• Types of Dressings• Transparent film (Tegraderm, Bioclusive)• Hydrocolloid (Duoderm, Comfeel)• Hydrogel• Gauze Roll (Kerlix)

– Provide moist environment– Loosen slough and necrotic tissue– Wick drainage from wound

Nursing Diagnosis

• Impaired Skin Integrity• Impaired Tissue Integrity• Risk for Infection• Pain• Imbalanced Nutrition, Less than body

requirements

Care Planning .

Overall strategy and scope of the treatment plan depends on patient’s

condition, prognosis, and reversibility of the wound.

Appropriate Goals

• Prevent complications or the deterioration of an existing wound

• Prevent additional skin breakdown• Minimize harmful effects of the wound on the

patient’s overall condition• Promote wound healing

Interventions

Dressing considerations should include:

• Patient’s condition and prognosis• Caregiver ability• Ease and continuity of use• Ability to maintain moisture balance• Frequency of change

Specific Points AffectingWound Healing

• Keep wound clean and scab free• Keep wound moist• Avoid steroid creams• Suturing wound splints skin• Wounds actually shrinks

Pain Management

1) Medicate the resident prior to dressing changes

2) Some treatment regimes may be uncomfortable for the resident

3) Provide maintenance doses of medication for those patients who have pain.

4) Adjuvant therapy may be appropriate5) Consider non-medicinal approaches

Wound Preparation

• Removal of hair– Not eyebrow

• Scrubbing the wound• Irrigation with saline

– Avoid peroxide, betadine, tissue toxic detergents

Basic Elements of Wound Care

• Cleanse Debris from the Wound

• Possible Debridement• Absorb Excess Exudate• Promote Granulation and

Epithelialization When Appropriate

• Possibly Treat Infections• Minimize Discomfort

Interventions Stage I

GOALS:• Maintain skin integrity• Skin to remain clean and odor free• Protect and moisturize skin

TREATMENTS:

Preferred agents (dry skin)• Aloe Vesta skin creamPreferred agents (at risk for breakdown due to incontinence/pressure)• Aloe Vesta protective ointment• Dermarite Perigaurd barrier ointment

Interventions Stage II, III, IV

Dry to Minimal Exudate

GOALS:• Minimize dressing changes• Maintain moist environment• Prevent infection• Prevent additional skin

breakdown

TREATMENTS:

Preferred agents:• Hydrofiber (Aquacel)• Viscopaste• Hydrocolloid (DuoDERM

Extra Thin)

Follow product guidelines for frequency of dressing change

InterventionsStage II, III, IV

Moderate Exudate

GOALS:• Minimize dressing changes• Maintain moist environment• Prevent infection• Prevent additional skin

breakdown

TREATMENTS:

Preferred Agents:• Hydrofiber (Aquacel)• Hydrocolloid (DuoDERM

Signal)

Follow product guidelines for frequency of dressing change

InterventionsStage II, III, IV

Copious Exudate

GOALS:• Minimize dressing changes• Manage Exudate• Prevent infection• Prevent additional skin

breakdown

TREATMENTS:

Preferred Agents:• Hydrofiber (Aquacel)• Hydrocolloid (DuoDERM

Signal)

Follow product guidelines for frequency of dressing change

InterventionsInfected Wounds…

Diagnosis of wound infection:• Swab Cultures not recommended• Based on clinical signs (fever,

increased pain, friable granulation tissue, foul odor)

Tissue culture or biopsy is not optimal for the hospice patient.

Treatments:

Preferred agents:• Hydrofiber (Aquacel Ag)• Silvadene ointment and non-

sterile gauze

DO NOT USE:• Providine Iodine• Iodophor• Dakin’s solution• Hydrogen peroxide• Acetic Acid

Cleaning a Wound

Securing A Dressing

REFERENCES

1. Bucky Boaz, Principles of Wound Closure2. Magdy Amin RIAD, Wound care, University of Dundee3. Teresa V. Hurley, Skin Integrity and Wound Care4. UNC Emergency Medicine, Wound Management5. VITAS Healthcare Corporation, Wound CareBest Practice Guidelines

Thank you