Title: Wounds
1Wounds
- Nursing Fundamentals
- Chapter 28
2Wound
- A break in the continuity of soft parts of body
structures caused by violence or trauma to
tissues - Damaged skin or soft tissue
3Skin
- Called the Integumentary System
- The largest organ of the body
- Skin is necessary to
- Protect against infection
- Protect against dehydration
- Regulates body temperature
- Collection of sensory information d/t nerve
endings
4Examples of tissue trauma
- Cuts
- Blows
- Poor circulation
- Strong chemicals
- Excessive heat or cold
- Such trauma produces 2 types of wounds?
5Open Wounds vs. Closed Wounds
- Open the surface of the skin or mucous membrane
is no longer intact perhaps due to a surgeon that
incises the tissue (to cut cleanly as with a
sharp instrument) - Closed there is no opening in the skin or
mucous membrane. These wounds occur more often
from blunt trauma or pressure
6Open Wound- Abrasion
7Closed WoundContusion-Note Ecchymosis
8Healing or wound repair
- Regardless of the type of injury, the body
immediately starts to heal the injury. The
process of wound repair happens in 3 sequential
phases - Inflammation
- Proliferation
- Remodeling
9Inflammation
- The physiologic defense immediately after tissue
injury - This lasts approximately 2-5 days
10Purpose of inflammation
- To limit the local damage
- To remove injured cells and debris
- To prepare the wound for healing by sending
protein, WBCs to site to heal
11Several stages of Inflammation
- First, local changes occur
- Blood vessels constrict to control blood loss and
confine damage - Then, blood vessels dilate to deliver platelets
to form a loose clot - Discomfort starts d/t the membranes of the
damaged tissue release plasma and a chemical
substance - The person has the signs symptoms of
inflammation ?
12Signs Symptoms of Inflammation
- Swelling
- Redness
- Warmth
- Pain
- Decreased function
132nd step of inflammation
- Leukocytes and macrophages migrate to the site of
injury - The body then produces more and more WBCs to go
to the injury site - Blood work can be obtained to check WBC levels
14WBC lab values
- Leukocytosis increased production of WBCs
- An increase in the WBCs, neutrophils and
monocytes, suggest an inflammatory or even
infectious process - Neutrophils are responsible for phagocytosis.
They consume pathogens, coagulated blood, and
cellular debris. - Neutrophils and monocytes clean the injured area
ansd prepare the site for wound healing
15Inflammation
16Proliferation
- Period in which new cells fill and seal the wound
- This occurs 2 days to 3 weeks after the
inflammatory phase - Its characterized by the formation of
granulation tissue - Repair depends on the type and extent of damage
17Granulation Tissue
- This tissue is pink to red in color because of
the extensive projections of capillaries in the
area - Granulation tissue grows from the wound margin
toward the center - This granulation skin is fragile and can be
easily disrupted - Fibroblasts produce collagen which is a tough,
protein substance - The adhesive strength of the wound increases
18At the end of the proliferative phase
- The new blood vessels degenerate causing the
previous pink color to regress
19What happens in skin repairing(general)
- Resolution- process by which damaged cells
recover and re-establish their normal function - Regeneration cell duplication
- Scar formation replacement of damaged cells
with fibrous tissue -
20Remodeling
- Period in which the wound undergoes changes and
maturation, the wound contracts and the scar
shrinks - This follows the proliferative phase
- This phase can last 6 months 2 years
21Wound Healing
- The speed of wound repair and extent of a scar
depends on whether the wound heals by 1st, 2nd or
3rd intention
22Some scars form keloids
- Keloids are a collection of collagen in one area
over a scar - Some people form keloids and some people do not
- Can be lasered off for cosmetic purposes
23- Keloids
- Exuberant amounts of collagen giving rise to
prominent raised scars - Genetic
24First Intention healing(easiest method of
healing)
- This is a reparative process
- The wound edges are directly next to each other
- The space between the edges is so small, only a
small amount of scar tissue forms - This looks like most surgical wounds
25First Intention Healing
26First Intention Healing
27Second Intention
- The wound edges are widely separated, this leads
to more time consuming and complex reparative
process - The granulation tissue between the widely spread
edges, needs additional time to extend across the
expanse of the wound - Healing by 2nd intention takes even longer if
body fluid or other debris is present - Wound care must be done cautiously as to not
disrupt the new granulation tissue and retarding
the healing process
28Second Intention Healing
Gaping irregular Granulation epithelium
wound grows over
scar
29Second Intention Healing
- Third intention healing occurs when the edges are
surgically brought together later after healing
has begun
30Third intention
- The wound edges are widely separated and are
later brought together with some type of closure
material - This results in a broad, deep scar
- These wounds are deep and contain extensive
drainage and tissue debris - To speed healing, these wounds are packed with
absorbent gauze and may even contain a drainage
device
31Third Intention
Wound
Increased Granulation
Late suturing with wide scar
32Third Intention Healing
33What type of diet is needed for skin repair?
34Factors that delay wound healing
- Nutritional deficiencies
- Inadequate blood supply
- Corticosteroid drugs
- Infection
- Mechanical friction on wound
- Advanced age
- Diabetes Mellitus
- Anemia
35Wound Management
- Primary goal of wound management is to
re-approximate the tissue to restore its integrity
36Pressure Ulcer
- A wound caused by prolonged capillary compression
that impairs circulation to the skin and
underlying tissue
37Pressure Points
38Causes
39Pressure Effect
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41Pressure sores have 4 stages with obvious signs
symptoms
- Stage 1
- Stage 2
- Stage 3
- Stage 4
42Stage 1
43Stage 1
44Stage 2
45Stage 2
46Stage 3
- Shallow crater, drainage, relatively painless
47Stage 3
48Stage 4
- Deep ulceration down to muscle or bone
49Stage 4
50Hip stage 4 healing
51Pressure from equipment, why is this here?
52Preventing Ulcers
53Heel Decubitus
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55Decubitus
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58Caring for the skin of a patient
59Promoting Healthy skin
- Nurses are responsible for the promotion of
healthy skin - When we identify a sore, WE MUST ACT ON IT
IMMEDIATELY
60Positioning
61Interventions of a wound
- Observation of symptoms
- Fever, could be infected
- Assess wound and document
- Consistency
- Color
- Odor
- Drainage
62Wound Management
63The use of supplies
- Steri-strips
- Dressings
- Gauze
- Tape
- Montgomery straps
- Ace wraps
- Kerlix
- Duoderm
- Transparent dressings
64Steri-strips hold an incision closed
- These are usually placed on a patient in surgery
and these are not removed for approximately 2-3
weeks - Tell patient to shower and let water and shampoo
wash over strips. Strips will peel off on own.
Best to remove them in the shower - TELL PT TO NOT PULL STRIPS OFF TO SOON, reopening
of wound is possible
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67Applying Dressings to wounds
- Several different types of dressings will work
- Dr. orders the type
- Or
- Skin care team is involved and orders the
treatment
68Gauze Dressings
- Gauze is made of woven fibers and is used for
absorption - Granular tissue may adhere to the gauze and may
be pulled off during a dressing change - We try not to moisten the dry gauze as to not
pull off good, new, healing skin
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73Non-stick dressings
- Such as Telfa, has a plastic-type backing on it
that goes directly over the wound to enable to
dressing NOT to stick
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75Xeroform
- This type of dressing has a yellow layer of
vaseline type gel on it, again, wounds wont
stick to this, good for tissue healing
76Xeroform
77Tegaderm
- Usually used over IV sites
- Problem with this type of dressing is that it is
not absorbent
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79Transparent Dressing (Vac Dressing)
80Transparent Dressing
81Hydro-colloidal Dressings
- Hydro water, these dressings are self adhesive,
wont come off with water, these types keep wound
moist and occludes debris. The hydro portion of
the dressing aids in healing of the skin with the
dressing on - This is Duoderm
82Colloid Dressing - Duoderm
83Colloid dressing used to protect skin, can place
this on the skin 1st then tape the topper down
over the duoderm
84Wound Drainage
- When changing the dressing of a wound, the nurse
must note the color of the drainage on the
dressing - Must record what you see
- May have pus or blood in the dressing
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86Dry Dressing (AV)
87Wet to Dry dressing, what are the things that are
wrong
88Pressure Dressing (AV)
89Drains
- Drains are used to keep body fluid away from the
wound so that effective healing can occur - There are several different types of drains
- Nurses MUST be aware of how to manage these drains
90Drainage Tube Dressing (AV)
91Penrose Drain
- Looks like a floppy macaroni noodle
- This drain is usually covered loosley with a
topper dressing - The nurse changes the topper dressing frequently
and weighs the gauze and records this as output
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94Jackson-Pratt Drain
- This drain looks like a gernade
- There is a plastic ball that is squeezed and the
end is closed. The drain will inflate itself
(the squeezed ball opens up) and as it does, it
pulls drainage away from the patient - This drain must be empties frequently in order to
keep working
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98Emptying JP Drain (AV)
99Hemovac Drain
- This drain looks similar to a frisby or a disc
- You pull the tab to empty the drain and then you
squeeze the disc down and plug it up. - Again, when the drain inflates, it pulls drainage
away from the pt - This must be emptied several times during a shift
to work effectively
100Hemovac
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102Hemovac
103Sutures and staples
- Nurses can remove staples with a staple remover,
this procedure pinches a bit - Doctors must remove sutures
104Problems with Wounds
- If skin is not healthy and pt is not eating
enough protein, 2 things can happen - 1. Dehiscence
- 2. Evisceration
105Dehiscence
- Separation, gaping, splitting open of a surgical
wound - This leaves room for infection, lots of bleeding
and potential for infection
106Evisceration
- The spilling out of the abdominal contents or
intestine through a surgical wound - This is somewhat of an emergency, the Dr. must be
called STAT. The wound is covered in a moist
sterile towel. NS must be used. Pt is put in
semi-fowlers position with knees bent to relieve
abdominal pressure - IVFs are started and VS are obtained
- The pt is prepared for the O.R.
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109Dehisence
110Different types of wounds
111Abscess Before Debridement
112Abscess Debrided
113Slough
114Necrotic Tissue
115Eschar
116Sacral decubitus before debridement
117Sacral decubutis after debridement
118Open wound, what do you think about healing?
119Healing after debridement
120Continued Healing
121Assessment of wound
122How to care for a wound
- ALWAYS MEASURE THE WOUND
- Wounds must be cared for in special ways
- Some wounds must be packed, some must be dressed
with a simple topper , some must be irrigated and
then packed and then dressed with a topper
123How to secure gauze
- We can secure gauze with tape
- Or
- Montgomery straps, these prevent usage of too
much tape. - Montgomery straps can hold a large dressing in
place
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126Montgomery Straps (AV)
127Other measures that secure dressings
- Abdominal binders are a stiff ace wrap that is
actually wrapped around the patients waist and
is used to secure a large dressing to the abdomen - This dressing is also used when a pump is
inserted into the abdominal cavity, this secures
the pump under the skin so the patient can
ambulate easier
128Packing of a wound
- Most wounds heal rapidly with conventional care
- Some wounds need debridement which is removal of
dead tissue to promote healing
1294 methods for debriding a wound
- 1. Sharp debridement
- 2. Enzymatic debridement
- 3. Autolytic debridement
- 4. Mechanical debridement
130Sharp Debridement
- This is the removal of necrotic
- tissue (non-living tissue)
- The use of sterile scissors, forceps or other
instruments are used - This method is preferred when the wound is
infected because it helps the wound heal quickly - This can be painful and the wound may bleed
afterward - Can be done in the O.R. or at the bedside
131Enzymatic Debridement
- This involves the use of topically applied
chemical substance that break down and liquefy
wound debris - A dressing is used to keep the enzyme in contact
with the wound and to help absorb drainage - This is used for people who cant take the pain
from the sharp debridement
132Enzymatic debridement
133- Panafil Ointment is an enzymatic
debriding-healing ointment which contains
standardized Papain, Urea and Chlorophyllin
Copper Complex Sodium in a hydrophilic base. -
134Autolytic Debridement
- This is a painless physiologic process that
allows the bodys enzymes to soften, liquefy and
release devitalized tissue - It is used for people who have small infections
- An occlusive dressing keeps the wound moist
- Removal of tissue debris is slow in this process
135Mechanical Debridement 3 types of this
- 1. This involves physical removal of debris
- This is done by applying wet-dry dressings
- The wound is packed with wet gauze and then 6-8
hrs later, the gauze dries. Debris attaches
itself to the wet and then dry gauze and is
removed when the dressing is changed - This procedure can be painful and at times, it
disrupts the new formation of granulation tissue
136Mechanical Debridement
- 2. Hydrotherapy the use of agitating water
contains antiseptic and softens the dead skin. - Loose debris that remains attached, is then
removed by sharp debridement
137Mechanical Debridement, type 3
- 3. Irrigation technique for flushing debris
- This technique is best used when granulation
tissue has formed
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139Packing the wound
140Packed wound (AV)
141Packed wound continued (AV)
142Removing Packing
143Packing a decubitus (AV)
144Providing Comfort to the patient
- Teach the pt how to splint his incision for
easier ambulation - Teach pt to place a pillow or blanket over
abdomen and to push gently to support the
abdominal muscles - This splinting is also used when pt must cough or
sneeze
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146Wound from an ace wrap clip
147Wound culture (AV)
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149Comfort Measures for Wound care patients
- Heat Cold Applications
- Ice Bag Ice Collar
- Chemical Packs
- Compresses
- Aqua-thermia pads
- Soaks Moist packs
- Therapeutic Baths
150Heat vs. Cold
- Heat Cold
- Provides warmth reduces fever
- Promotes circulation prevents swelling
- Speeds healing controls bleeding
- Relieves muscle spasms relieves pain
- Reduces pain numbs sensation
151Cold Treatment (AV)
152Ice Packs
- Come as disposable sacs that you can fill, empty
out and re-fill - These provide comfort to pts and have various uses
153Moist Heat (AV)
154Sitz Bath
- A container is placed under the rim of the toilet
seat to allow warm water to squirt onto the pts
underside for example to alleviate hemorrhoids or
vaginal tear after delivery - The water soothes the perineum, or anus
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156Sitz Bath (AV)
157Heating Pad (K-Pad)
- This is a device used to provide comfort
- The machine is filled with water that heats and
the the water filters into a blanket and the pt
can either sit on the blanket or lay the blanket
over them - Temperature is pre-programmed to deliver one
temperature, the water never seems to get warm
enough
158K-Pad
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160Heating Blanket
- Again, usually the pt can lay on this to provide
comfort
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162Chemical warm or cool packs
- These provide temporary relief and may decrease
swelling - These can be used if an IV falls out of place and
the fluid is in between spaces causing pain - YOU MUST ALWAYS SQUEEZE THESE AWAY FROM THE
PATIENT TO ACTIVATE THEM TO AVOID THEM EXPLODING
ON THE PT
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164Measures of comfort to provide to the pt with a
wound or ulcer
165- Rest and immobilization
- Elevation
- Oxygenation
- Heat/Cold
- Wound management
- Prevent infection
166Recording and Documenting
- Once the old dressing has been removed and the
wound is assessed and re-dressed, the nurse must
properly dispose of the supplies, wash hands and
record what the wound looked like - Be as specific as you can, explaining what you
saw and what you did to that wound. If wound
needs to me measured, then do so and record your
findings
167The End