Wound Care-std1 1

Wound Care Ella YU

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Learning objectives • Describe the classification of wound with emphasis on implication for healing. • Discuss normal processes of wound healing. • Describe the differences among wounds healing by primary, secondary and tertiary intention. • Describe complications of wound healing.

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Learning objectives • Explain the factors that impair or promote wound healing. • Conduct a wound assessment. • Describe the principles and practices of surgical asepsis. • Discuss and master the skills of wound dressing and wound irrigation. 3

Wound • What is a wound?

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Wound classification • Status of skin integrity: open, close, acute, chronic • Cause: intentional, unintentional • Severity of injury: superficial, penetrating, perforating • Cleanliness: clean, clean-contaminated, contaminated, infected, colonized • Descriptive qualities: laceration, abrasion, contusion

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(Potter, & Perry, 1997)

(Potter, & Perry, 1997) 7

Phase of Wound Healing • Inflammatory Phase • Initiated immediately after injury and lasts 3 to 6 days, 2 process: hemostasis, phagocytosis • Hemostasis (cessation of bleeding) – Vasoconstriction, deposition of fibrin→formation of blood clot→matrix of fibrin→framework for cell repair – Vascular and cellular response→↑blood supply→reddness and oedematous

• Phagocytosis

– Macrophages engulf microorganisms and cellular debris – Macrophages →secrete angiogensis factor (AGF)→stimulate the formation of epithelial buds at the end of injured blood vessels→formation of microcirculatory network→sustains the healing process

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Phase of Wound Healing • Proliferative Phase – Fibroblasts begin to synthesize collagen – Formation of granulation tissue

• Maturation Phase – Fibroblast continue to synthesize collagen→reorganise into a more orderly structure – The wound remodeled and contracted→the scar become stronger – Hypertrophic scar→Keloid 9

Wound healing process

(Taylor, Lillis, & LeMone, 2001) 10

Complications of wound healing • • • • • •

Hemorrhage Infection Dehiscence Evisceration Fistulas Delayed wound closure

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Complications of wound healing: Hemorrhage • indicate a slipped surgical suture, a dislodged clot, infection, or erosion of a blood vessel by a foreign object • may occur externally or internally • nursing intervention: – internal hemorrhage: detect hematoma, swelling of affected body part, change in type and amount of drainage from a surgical drain, hypovolemic shock – external hemorrhage: bloody discharge on dressing

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Complications of wound healing: Infection • Chances of wound infection are greater when the wound contains dead or necrotic tissue, there are foreign bodies in or near the wound, and the blood supply and local tissue defenses are reduced – Signs and symptoms of infection: • • • • •

_______________________________ _______________________________ _______________________________ _______________________________ _______________________________

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Complications of wound healing: Dehiscence & Evisceration • Dehiscence: partial or total disruption of wound layers • Evisceration: protrusion of viscera through the incisional area • risk factors: obesity, malnutrition, infected wounds, excessive coughing, vomiting, or straining • signs and symptoms: increase in flow of serosanguineous fluid from wound between postoperative days 4 and 5 • nursing interventions: – cover the wound with sterile towels soaked in normal saline – inform physician and prepare for emergency operation

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Complications of wound healing: Fistulas • Fistulas: an abnormal passage between two organs or between an organ and the outside of the body • Cause: poor wound healing associated with trauma, infection, radiation exposure, and disease • consequence: increase risk of infection, fluid and electrolyte imbalance from fluid loss, skin breakdown

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Complications of wound healing: Delayed wound closure • Referred as third-intention wound healing • Deliberate attempt by surgeon to allow effective drainage of a clean-contaminated or contaminated wound. The wound is not closed until all evidence of edema and wound debris has been removed. • Nursing intervention: – apply occlusive dressing to prevent bacterial contamination of the wound

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(Potter, & Perry, 1997)

Assessment of wounds • Appearance – _________________________________

• Pain – __________________________________

• Wound drainage – _________________________________

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(Potter, & Perry, 1997) 19

The RYB Color Code • Based on the colour of the open wound rather than the depth of the wound • Red, yellow and black (RYB) • Goals: protect (cover) red, cleanse yellow and debride black

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The RYB Color Code • Red wound – Are usually in the late regeneration phase of tissue repair (developing granulation tissue) – They need to be protected to avoid disturbance to regenerating tissue – The nurse protects red wounds by • • • •

Gentle cleansing Avoiding use of dry gauze or wet-to-try dressings Applying antimicrobial agent Apply appropriate dressing such as gauze, transparent film or hydrocolloid dressing • Changing the dressing as infrequently as possible 21

The RYB Color Code • Yellow wounds – Are characterized primarily by liquid to semiliquid slough that is often accompanied by purulent drainage – Need to remove nonviable tissue – Applying wet-to-damp dressing, absorbent dressing, hydrogel dressing, irrigating the wound, +/- topical antimicrobial 22

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The RYB Color Code • Black wounds – Wounds are covered with thick necrotic tissue, or eschar – Require debridement- removal of the necrotic material – Removal of nonviable tissue from a wound must occur before the wound can heal – Debridement • • • •

Sharp- using scalpel or scissors Mechanic- scrubbing force, wet-to-damp dressing Chemical- collagenase enzyme agents e.g. papain- urea Autolysis- dressing contain wound moisture and trap the wound drainage. The body’s own enzymes break down the necrotic tissue

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Types of dressing • Selection criteria: – location, size, and type of wound – amount of exudate – whether the wound requires debridement, is infected, or has sinus tracts – frequency of dressing change – cost 26

Types of dressing

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Assessment of wounds •

Wound – Inspect regularly to ensure clean, dry and intact – Any excessive drainage- hemorrhage, infection or an open wound – The appearance, size, drainage, swelling, pain and the atatus of a drain ot tubes

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Sutures and staples – assess the presence, types, and number of sutures and staples, signs of irritation around staple of suture sites, closure of the wound • Drains and tubes – assess the number of drains, drain placement, character of drainage, and condition of collecting apparatus

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Related assessment – clients’ general condition and laboratory findings

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Assessment of wounds • Sequential signs of healing – Absence of bleeding and the appearance of a clot binding the wound edges – Inflammation (redness and swelling) at the wound edges for 1-3 days – Reduction in inflammation when the clot diminishes, as granulation tissue starts to bridge the area – The wound is bridged and closed within 7-10 days (increased inflammation associated with fever and drainage is indicative of wound infection; the wound edges then appear brightly inflammed and swollen) 29

Assessment of wounds • Sequential signs of healing (cont’d) – Scar formation- collagen synthesis starts 4 days after injury and continues for 6 months or longer – Diminished scar size over a period of months or years – An increase in scar size indicated keloid formation 30

Sutures and staples

(Potter, & Perry, 1997) 31

Common types of drains

(Potter, & Perry, 1997) 32

(Taylor, Lillis, & LeMone, 33 2001)

Supporting wound healing • Nutrition and fluids – intake of at least 2500 ml of fluids a day unless contraindicated – sufficient intake of protein, vitamins B & C, iron, and calories

• Preventing infection – wound assessment and provide mechanism for documenting – emphasize principles of asepsis

• Positioning – positioned to keep pressure off the wound – assisted in ambulation to enhance circulation

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Wound dressing: Purposes • protecting a wound from microorganism contamination • aiding hemostasis • promoting healing by absorbing drainage and debriding a wound • supporting or splinting the wound site • protecting client from seeing the wound • promoting thermal insulation of the wound surface • providing maintenance of high humidity between wound and dressing

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Surgical asepsis • Asepsis is the freedom from disease-causing microorganisms • 2 types of aseptic techniques: – Medical asepsis: • all practices intended to confine a specific microorganism to a specific area, limiting the number, growth, and transmission of microorganisms • objects are referred to as clean (absence of almost all microorganisms) or dirty (likely presence of microorganisms)

– Surgical asepsis (sterile technique): • those practices that keep an area or object free of all microorganism, it includes practices that destroy all microorganisms and spores

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(Kozier, Erb, Berman, & Burke, 2000)

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(Kozier, Erb, Berman, & Burke, 2000)

Sterile procedures • • • • • •

Surgical handwashing Donning & removing sterile gloves Wound dressing Wound irrigation Removal of suture and staple Removal of drains 39

Basic techniques in skin cleansing • Clean in a direction from the least contaminated area • once swab once • use gentle friction when applying solutions local to the skin • when irrigating, allow the solution to flow from the least to most contaminated area

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Documentation: Wound dressing • After performing wound dressing, the following should be documented in the nursing kardex: – – – – – – –

characteristics of wound: appearance, size, location, color characteristics of drainage: color, amount, odor other characteristics: presence of staples, sutures, drains, etc. client’s response during the procedure requirement of analgesics before the procedure supply used: type of lotion, dressing materials special techniques used: wound irrigation or packing

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Reference • Kozier, B., Erb, G., Berman, A. J., & Burke, K. (2000). Fundamentals of nursing: Concepts, process, and practice. (6th ed.). New Jersey: Prentice Hall Health. • Kozier, B., Erb, G., Berman, A., & Snyder, S. (2004). Fundamentals of nursing: Concepts, process, and practice. (7th ed.). New Jersey: Prentice Hall. • Potter, P. A., & Perry, A. G. (1997). Fundamentals of nursing: Concepts, process, and practice. (4th ed.). St. Louis: Mosby. • Taylor, C., Lillis, C., & LeMone, P. (2001). Fundamentals of nursing: The art & science of nursing care. (4th ed.). Philadelphia: Lippincott.

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