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Wounds

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Title: Wounds


1
Wounds
  • Nursing Fundamentals
  • Chapter 28

2
Wound
  • A break in the continuity of soft parts of body
    structures caused by violence or trauma to
    tissues
  • Damaged skin or soft tissue

3
Skin
  • 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

4
Examples of tissue trauma
  • Cuts
  • Blows
  • Poor circulation
  • Strong chemicals
  • Excessive heat or cold
  • Such trauma produces 2 types of wounds?

5
Open 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

6
Open Wound- Abrasion
7
Closed WoundContusion-Note Ecchymosis
8
Healing 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

9
Inflammation
  • The physiologic defense immediately after tissue
    injury
  • This lasts approximately 2-5 days

10
Purpose 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

11
Several 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 ?

12
Signs Symptoms of Inflammation
  • Swelling
  • Redness
  • Warmth
  • Pain
  • Decreased function

13
2nd 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

14
WBC 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

15
Inflammation
16
Proliferation
  • 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

17
Granulation 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

18
At the end of the proliferative phase
  • The new blood vessels degenerate causing the
    previous pink color to regress

19
What 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

20
Remodeling
  • 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

21
Wound Healing
  • The speed of wound repair and extent of a scar
    depends on whether the wound heals by 1st, 2nd or
    3rd intention

22
Some 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

24
First 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

25
First Intention Healing
26
First Intention Healing
27
Second 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

28
Second Intention Healing
Gaping irregular Granulation epithelium
wound grows over
scar
29
Second Intention Healing
  • Third intention healing occurs when the edges are
    surgically brought together later after healing
    has begun

30
Third 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

31
Third Intention
Wound
Increased Granulation
Late suturing with wide scar
32
Third Intention Healing
33
What type of diet is needed for skin repair?
  • High protein helps

34
Factors that delay wound healing
  • Nutritional deficiencies
  • Inadequate blood supply
  • Corticosteroid drugs
  • Infection
  • Mechanical friction on wound
  • Advanced age
  • Diabetes Mellitus
  • Anemia

35
Wound Management
  • Primary goal of wound management is to
    re-approximate the tissue to restore its integrity

36
Pressure Ulcer
  • A wound caused by prolonged capillary compression
    that impairs circulation to the skin and
    underlying tissue

37
Pressure Points
38
Causes
39
Pressure Effect
40
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41
Pressure sores have 4 stages with obvious signs
symptoms
  • Stage 1
  • Stage 2
  • Stage 3
  • Stage 4

42
Stage 1
  • Persistent redness

43
Stage 1
44
Stage 2
  • Skin tear

45
Stage 2
46
Stage 3
  • Shallow crater, drainage, relatively painless

47
Stage 3
48
Stage 4
  • Deep ulceration down to muscle or bone

49
Stage 4
50
Hip stage 4 healing
51
Pressure from equipment, why is this here?
52
Preventing Ulcers
53
Heel Decubitus
54
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55
Decubitus
56
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57
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58
Caring for the skin of a patient
59
Promoting Healthy skin
  • Nurses are responsible for the promotion of
    healthy skin
  • When we identify a sore, WE MUST ACT ON IT
    IMMEDIATELY

60
Positioning
61
Interventions of a wound
  • Observation of symptoms
  • Fever, could be infected
  • Assess wound and document
  • Consistency
  • Color
  • Odor
  • Drainage

62
Wound Management
63
The use of supplies
  • Steri-strips
  • Dressings
  • Gauze
  • Tape
  • Montgomery straps
  • Ace wraps
  • Kerlix
  • Duoderm
  • Transparent dressings

64
Steri-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

65
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66
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67
Applying Dressings to wounds
  • Several different types of dressings will work
  • Dr. orders the type
  • Or
  • Skin care team is involved and orders the
    treatment

68
Gauze 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

69
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72
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73
Non-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

74
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75
Xeroform
  • This type of dressing has a yellow layer of
    vaseline type gel on it, again, wounds wont
    stick to this, good for tissue healing

76
Xeroform
77
Tegaderm
  • Usually used over IV sites
  • Problem with this type of dressing is that it is
    not absorbent

78
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79
Transparent Dressing (Vac Dressing)
80
Transparent Dressing
81
Hydro-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

82
Colloid Dressing - Duoderm
83
Colloid dressing used to protect skin, can place
this on the skin 1st then tape the topper down
over the duoderm
84
Wound 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

85
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86
Dry Dressing (AV)
87
Wet to Dry dressing, what are the things that are
wrong
88
Pressure Dressing (AV)
89
Drains
  • 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

90
Drainage Tube Dressing (AV)
91
Penrose 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

92
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94
Jackson-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

95
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98
Emptying JP Drain (AV)
99
Hemovac 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

100
Hemovac
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102
Hemovac
103
Sutures and staples
  • Nurses can remove staples with a staple remover,
    this procedure pinches a bit
  • Doctors must remove sutures

104
Problems with Wounds
  • If skin is not healthy and pt is not eating
    enough protein, 2 things can happen
  • 1. Dehiscence
  • 2. Evisceration

105
Dehiscence
  • Separation, gaping, splitting open of a surgical
    wound
  • This leaves room for infection, lots of bleeding
    and potential for infection

106
Evisceration
  • 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.

107
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109
Dehisence
  • Evisceration

110
Different types of wounds
111
Abscess Before Debridement
112
Abscess Debrided
113
Slough
114
Necrotic Tissue
115
Eschar
116
Sacral decubitus before debridement
117
Sacral decubutis after debridement
118
Open wound, what do you think about healing?
119
Healing after debridement
120
Continued Healing
121
Assessment of wound
122
How 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

123
How 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

124
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126
Montgomery Straps (AV)
127
Other 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

128
Packing of a wound
  • Most wounds heal rapidly with conventional care
  • Some wounds need debridement which is removal of
    dead tissue to promote healing

129
4 methods for debriding a wound
  • 1. Sharp debridement
  • 2. Enzymatic debridement
  • 3. Autolytic debridement
  • 4. Mechanical debridement

130
Sharp 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

131
Enzymatic 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

132
Enzymatic debridement
133
  • Panafil Ointment is an enzymatic
    debriding-healing ointment which contains
    standardized Papain, Urea and Chlorophyllin
    Copper Complex Sodium in a hydrophilic base.

134
Autolytic 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

135
Mechanical 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

136
Mechanical 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

137
Mechanical Debridement, type 3
  • 3. Irrigation technique for flushing debris
  • This technique is best used when granulation
    tissue has formed

138
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139
Packing the wound
140
Packed wound (AV)
141
Packed wound continued (AV)
142
Removing Packing
143
Packing a decubitus (AV)
144
Providing 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

145
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146
Wound from an ace wrap clip
147
Wound culture (AV)
148
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149
Comfort Measures for Wound care patients
  • Heat Cold Applications
  • Ice Bag Ice Collar
  • Chemical Packs
  • Compresses
  • Aqua-thermia pads
  • Soaks Moist packs
  • Therapeutic Baths

150
Heat 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

151
Cold Treatment (AV)
152
Ice Packs
  • Come as disposable sacs that you can fill, empty
    out and re-fill
  • These provide comfort to pts and have various uses

153
Moist Heat (AV)
154
Sitz 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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156
Sitz Bath (AV)
157
Heating 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

158
K-Pad
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160
Heating Blanket
  • Again, usually the pt can lay on this to provide
    comfort

161
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162
Chemical 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

163
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164
Measures of comfort to provide to the pt with a
wound or ulcer
  • ? ? ? ?

165
  • Rest and immobilization
  • Elevation
  • Oxygenation
  • Heat/Cold
  • Wound management
  • Prevent infection

166
Recording 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

167
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