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NURSING CARE FOR PATIENT

WITH WOUND

By Purwaningsih
By
Purwaningsih
Break in skin or mucous membranes
Break in skin
or
mucous membranes

What are wounds ?

Injury to any of the tissues of the body, especially that caused by physical means and
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.
Wound healing is a natural
and spontaneous
phenomenon.

* 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
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.
A wound may
be approximated
with sutures,
staples, clips,
skin closure
strips, or topical
adhesives.
1. Intentional Vs. Unintentional. 2. Open Vs. Closed. 3. Degree of contamination. 4 . Depth of
1. Intentional Vs. Unintentional.
2.
Open Vs. Closed.
3.
Degree of contamination.
4 . Depth of the

Classification of wounds

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

Risk Assessment • Alterations in mobility • Level of incontinence • Nutritional status • Alteration in

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

Assessment and Documentation • Location • Stage and Size • Periwound • Undermining • Tunneling •

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

Drains and Wound Closures
Drains and Wound Closures
Drains and Wound Closures

Pressure Ulcer Staging2

Stage I
Stage I
Stage II
Stage II
Stage III
Stage III
Stage IV
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.

Care Planning . Overall strategy and scope of the treatment plan depends on patient’s condition, prognosis,

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

Appropriate Goals • Prevent complications or the deterioration of an • existing wound Prevent additional skin

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

Interventions Dressing considerations should include: • Patient’s condition and prognosis • Caregiver ability • Ease and

Specific Points Affecting Wound 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 appropriate

5) Consider non-medicinal approaches

Wound Preparation

Wound Preparation • Removal of hair – Not eyebrow • Scrubbing the wound • Irrigation with

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

Basic Elements of Wound Care • Cleanse Debris from the Wound • Possible Debridement • Absorb
Basic Elements of Wound Care • Cleanse Debris from the Wound • Possible Debridement • Absorb

Interventions Stage I

GOALS:

Maintain skin integrity

Skin to remain clean and odor free

Protect and moisturize skin

Interventions Stage I GOALS: • Maintain skin integrity • Skin to remain clean and odor free

TREATMENTS:

Preferred agents (dry skin)

Aloe Vesta skin cream

Preferred 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

Interventions Stage II, III, IV Dry to Minimal Exudate GOALS: • Minimize dressing changes • Maintain

TREATMENTS:

Preferred agents:

Hydrofiber (Aquacel)

Viscopaste

Hydrocolloid (DuoDERM Extra Thin)

Follow product guidelines for frequency of dressing change

Interventions

Stage II, III, IV

Moderate Exudate

Interventions Stage II, III, IV Moderate Exudate GOALS: • Minimize dressing changes • Maintain moist environment

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

Interventions

Stage II, III, IV

Copious Exudate

Interventions Stage II, III, IV Copious Exudate GOALS: • Minimize dressing changes • Manage 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

Interventions Infected Wounds

Diagnosis of wound infection:

Swab Cultures not recommended

Based on clinical signs (fever, increased pain, friable granulation tissue, foul odor)

Treatments:

Preferred agents:

Hydrofiber (Aquacel Ag)

Silvadene ointment and non- sterile gauze

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

Interventions Infected Wounds … Diagnosis of wound infection: • Swab Cultures not recommended • Based on

DO NOT USE:

Providine Iodine

Iodophor

Dakin’s solution

Hydrogen peroxide

Acetic Acid

Cleaning a Wound

Cleaning a Wound

Securing A Dressing

Securing A Dressing

REFERENCES

  • 1. Bucky Boaz, Principles of Wound Closure

  • 2. Magdy Amin RIAD, Wound care, University of Dundee

  • 3. Teresa V. Hurley, Skin Integrity and Wound Care

  • 4. UNC Emergency Medicine, Wound Management

  • 5. VITAS Healthcare Corporation, Wound CareBest Practice Guidelines