Fundamental%20of%20nursing

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King Saud University College of Nursing
Fundamental of nursing
Wound Care and Dressing
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THE SKIN
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FUNCTIONS OF THE SKIN

• Regulates body temperature.
• Prevents loss of essential body fluids, and
  penetration of toxic substances.
• Protection of the body from harmful effects of
  the sun and radiation.
• Excretes toxic substances with sweat ( waste
  removal).
• Mechanical support.
• Immunological function mediated by Langerhans
  cells.
• Sensory organ for touch, heat, cold, socio-sexual
  and emotional sensations.
• Vitamin D synthesis from its precursors under the
  effect of sunlight and introversion of steroids.

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Wound-definitions(Manley, Bellman, 2000)

• - A loss of continuity of the skin or mucous
  membrane which may involve soft tissues, muscles,
  bone and other anatomical structure.

- Any disruption to layers of the skin and
underlying tissues due to multiple causes
including trauma, surgery, or a specific disease
state.
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WOUND HEALING

• Classification of wound healing
• (According to the amount of tissue loss)
• Primary intention healing
• Secondary intention healing
• Tertiary intention healing

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PHASES OF WOUND HEALING

• Healing is a quality of living tissue it is also
  referred to as regeneration (renewal) of tissue.
• The inflammatory phase (3-6 days)
• The regenerative (Proliferative) phase (day
  4-day21)
• The maturation (Remodeling) phase (day 21- 1 or 2
  yrs)
• (Manley,
  Bellman, 2000)

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The inflammatory phase (Initiated
immediately after injury and last 3-6 days
Injury /damage Cells
Blood Clot
Histamine
Dry
Vasodilation Permeability
Uniting the wound edges
Neutrophils Monocytes

• -Dilated blood vessels
• Microcirculation slow down

Oedema Engorgement 0-3 days
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The Regenerative (Proliferative) phase
Blood vessels near the edge of the wound become
porous
Begins 2-3 days of injury Lasting up to 2-3 weeks
Allowing excess moisture to escape
- Resultant tissue filling is referred To as
granulation tissue - process of wound contraction
begins
Macrophage activity
Traps other blood cells damaged blood
vessels Begin to regenerate within the wound
margins
Stimulates
Formation multiplication of fibroblasts
This fibrous network
Which
- Laying down of a ground substance - Beginning
the synthesis of collagen fibers (granulation
tissue )
migrate along fibrin threads
Resulting
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The Maturative phase

• Begins about day 21 and can extend up to 6 months
  up to one or two years after the injury.
• Fibroblasts continue to synthesize collagen
• The collagen fibers recognized into a more
  orderly structure
• The scar become a thin ,less elastic, white line

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Factors affecting wound healing

• Developmental consideration/Age
• Nutrition
• Life-style
• Medication
• Infection
• Wound perfusion

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Types of Wound (Hahn,Olsen,Tomaselli, Goldberg
,2004)
Description and Characteristics Cause Type
Open wound painful Sharp instrument eg. Knife Incision
Close wound, skin appears ecchymotic (bruised) because of damaged blood vessels Blow from a blunt instrument Contusion
Open wound involving the skin painful Surface scrape, either unintentional (eg, scraped knee from fall) or intentional (eg, dermal abrasion to remove pockmarks) Abrasion
Open wound can be intentional or unintentional Penetration of the skin and, often the underlying tissues from a sharp instrument Puncture
Open wound edges are often jagged Tissues torn apart, often from accidents (eg, machinery) Laceration
Open wound usually accidental ( bullet or metal fragments) Penetration of the skin and the underlying tissues Penetrating wound
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Classification of surgical wounds according to
the degree of contamination

• Clean wounds Operations in which a viscus is not
  opened. This category includes non- traumatic,
  uninfected wounds where is no inflammation
  encountered and no break in technique has
  occurred.
• Clean-contaminated A viscus is entered but
  without spillage of contents. This category
  included non- traumatic wounds where a minor
  break in technique has occurred.

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Classification of surgical wounds contd
(Altmeire 1997, Ayliffe Lowbury 1992, NAS 1996)

• Contaminated Gross spillage has occurred or a
  fresh traumatic wound from a relatively clean
  source. Acute non-purulent inflammation may also
  be encountered.
• Dirty or infected Old traumatic wounds from a
  dirty source, with delayed treatment, devitalised
  tissue, clinical infection, faecal contamination
  or a foreign body.

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Classification of wounds by depth

1. Partial-thickness Confined to the skin, the
   dermis and epidermis.
2. Full-thickness Involve the dermis, epidermis,
   subcutaneous tissue, and possibly muscle and bone

Partial Thickness
Full Thickness
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Wound assessment

• A complex process
• Involve examination of the entire wound
• Nurses visually assess wounds and document their
  findings to monitor and evaluate the progress of
  wound healing

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Wound assessment contd(Hahn,Olsen,Tomaselli,
Goldberg ,2004)

• What to assess?
• Location
• Dimensions/Size
• Tissue viability
• Exudate/Drainage
• Periwound condition
• Pain
• Stage or extent of tissue damage , dictates how
  often a wound is reassessed
• Swelling

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Nursing Diagnoses

• Risk for Impaired Skin Integrity
• Impaired Skin Integrity
• Impaired Tissue Integrity
• Risk for Infection
• Pain

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Risk Factors Which Increase Patient
Susceptibility to infection (Manley.K, Bellman.
L,2000)

• A- Intrinsic risk factors
• Extremes age Defined as Children aged 1 year
  and under, and people aged 65 years and over.
• Underling Conditions/Disorders
• Diabetes
• Respiratory disorders
• Blood disorders
• Smoking
• Nutrition and build

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Risk Factors Which Increase Patient
Susceptibility to infection contd (Manley.K,
Bellman. L,2000)

• B- Extrinsic risk factors
• Drug therapy as a risk factor e.g. Cytotoxic
  drugs
• Break in the integrity of the skin
• Items such as foreign bodies
• Bypassing of defense mechanisms through devices
  e.g. Intubations

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SS of Presence of Infection

• Wound is swollen.
• Wound is deep red in color.
• Wound feels hot on palpation.
• Drainage is increased and possibly purulent.
• Foul odor may be noted.
• Wound edges may be separated with dehiscence
  present.

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Types of Wound Drainage

• Exudate is material, such as fluid and cells,
  that has escaped from blood vessels during the
  inflammatory process and deposited in or on
  tissue surfaces. The Nature and amount of exudate
  vary according to Tissue involved, Intensity and
  duration of the inflammation, and the presence of
  microorganisms.
• 1. Serous Exudate
• Mostly serum
• Watery, clear of cells
• E.g., fluid in a blister

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• A purulent Exudate
• Is thicker than serous exudate because of the
  presence of pus.
• It consists of leukocytes, liquefied dead tissue
  debris, dead and living bacteria.
• The Process of pus formation is referred to as
  suppuration, and the bacteria that produce pus
  are called pyogenic bacteria.
• Purulent exudate vary in color, some acquiring
  tinges of blue, green, or yellow. The color may
  depend on the causative organism.

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• A sanguineous (hemorrhagic) Exudate
• It consists of large amount or blood cells,
  indicating damage to capillaries that is very
  severe enough to allow the escape of RBCs from
  plasma
• This type of exudate is frequently seen in open
  wounds.
• Nurses often need to distinguish whether the
  exudate is dark or bright. Bright indicate fresh
  blood, whereas dark exudate denotes older
  bleeding.

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Complications of Wounds

• Infection
• Hemorrhage
• Dehiscence and possible evisceration
• Fistula formation

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The RYB color code(Stotts,1999)

• This concept is based on the color of the open
  wound rather than the depth or size of the
  wound.
• On this scheme, the goal of wound care is to
  protect ( cover) red, cleanse yellow, and
  debride black.
• The RYB code can be applied to any wound allowed
  to heal by secondary intention.

RRed YYellow B Black
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• Red wounds
• Usually in the late regeneration phase of tissue
  repair (ie, developing granulation tissue) and
  are clean and uniformly pink in appearance
• They need to be protected to avoid disturbance
  to regenerating tissue. Examples are superficial
  wounds, skin donor sites, and partial- thickness
  or second degree burns.

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• How to protect red wounds
• Gentle cleansing
• Avoid the use of dry gauze or wet- to-dry saline
  dressings.
• Applying a topical antimicrobial agent.
• Appling a transparent film or hydrocolloid
  dressing.
• Changing the dressing as infrequently as possible.

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Yellow wounds

• Characterized primarily by liquid to semiliquid
  slough that is often accompanied by purulent
  drainage.
• The nurse cleanses yellow wounds to absorb
  drainage and remove nonviable tissue. Methods
  used may include .
• Applying wet-to-wet dressing irrigating the
  wound using absorbent dressing material such as
  impregnated nonadherent, hydrogel dressing, or
  other exudate absorbers and consulting with the
  physician about the need for a topical
  antimicrobial to minimize bacterial growth.

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• Black Wound
• Covered with thick necrotic tissue or Eschar.
• e.g.. third degree burns and gangrenous ulcer.
• Required debridement .
• When the eschar is removed, the wound is treated
  as yellow, then red.

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Purposes of wound dressing

• To protect the wound from mechanical injuries
• To protect the wound from microbial contamination
• To provide or maintain high humidity of the wound
• To provide thermal insulation
• To absorb drainage and /or debride a wound

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• 6. To prevent hemorrhage (when applied as a
  pressure dressing or with elastic bandages).
• 7. To splint or immobilize the wound site and
  thereby facilitate healing and prevent injury.
• 8. To provide psychological (aesthetic) comfort.

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Principles of asepsis

• The aim
• Guarantee the safety of the equipment used
  (cleaning/disinfection/sterilisation).
• Reduce the level of microbial contamination of
  the site requiring manipulation (antisepsis).
• Ensure that no microorganisms are introduced
  (asepsis).

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• Cleaning Is the removal of dirt, debris and
  organic material.
• Disinfection Removes or destroys harmful
  microorganisms but not bacterial spores or slow
  viruses.
• Sterilization is the complete destruction or
  removal of all living microorganisms including
  bacterial spores.
• Antisepsis is the reduction of the number of
  microorganisms already present on the body site
  prior to a procedure.
• Asepsis Procedure designed to prevent any
  introduction of microorganisms to the site
  achieved by a non-touching technique and use of
  sterile gloves

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Guidelines for cleaning wounds

1. Use physiologic solution, such as
   isotonic saline or lactated ringer solution.
2. When possible , warm the solution to body
   temperature before use.
3. If the wound is grossly contaminated by foreign
   material , bacteria, slough, or necrotic tissue
   clean the wound at every dressing change.
4. If a wound is clean , has little exudate , and
   reveals healthy granulation tissue , avoid
   repeated cleaning.

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1. Use gauze squares .
   Avoid
2. Consider cleaning superficial noninfected wound
   by irrigating them with normal saline rather than
   using mechanical means.
3. To retain wound moisture , avoid drying a wound
   after cleaning it.

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Topics for Home Care Teaching

• Supplies
• Infection prevention
• Wound healing
• Appearance of the skin/recent changes
• Activity/mobility
• Nutrition
• Pain
• Elimination