8/10/2019 Wound Care Slides Revised -Final
1/59
Presented by
Helen E. Gomes RN,MSN CNS, CDE, BC-ADM
Associate Professor
CCRI
1
Wound Care
8/10/2019 Wound Care Slides Revised -Final
2/59
Objectives
Identify the characteristics of wound healing.
Describe the nature of sterile technique when
performing a wound dressing change.
2
8/10/2019 Wound Care Slides Revised -Final
3/59
Integumentary SystemStructures
3
Epidermis / top layer Top or outermost layer
Dermis
2nd
layer, framework of elastic connective tissue Nerves, hair follicles, blood vessels located here
Subcutaneous tissue Under layer consists of adipose and connective tissue
Anchors the skin layers to underlying tissue
8/10/2019 Wound Care Slides Revised -Final
4/59
Cross-Section of Normal Skin
8/10/2019 Wound Care Slides Revised -Final
5/59
Functions of Skin
5
Protection
Sensory
Excretion of waste Thermoregulation
Synthesis of Vitamin D
Contributes to Body Image
Absorption (meds)
8/10/2019 Wound Care Slides Revised -Final
6/59
8/10/2019 Wound Care Slides Revised -Final
7/59
Wounds
7
Definition
A break or disruption of normal integrity of
skin and tissue
8/10/2019 Wound Care Slides Revised -Final
8/59
Wound Classifications
8
Status of SkinIntegrity
OpenClosed
Acute
Chronic
Cause
Intentional
Unintentional
8/10/2019 Wound Care Slides Revised -Final
9/59
Wound Classifications (cont)
9
Severity of Injury
Superficial
PenetratingPerforating
8/10/2019 Wound Care Slides Revised -Final
10/59
Types of Wounds
10
Incision
Contusion
Abrasion
Laceration Puncture
Penetrating
8/10/2019 Wound Care Slides Revised -Final
11/59
Phases of Wound Healing
Hemostasis Occurs immediately after initial injury
Involved blood vessels constrict /clotting begins
After a brief period vessels dilate, capillary
permeability increases, allowing plasma and bloodcomponents to leak into the area (exudate).
Redness, swelling, and pain may occur.
Scab may begin to form.
11
8/10/2019 Wound Care Slides Revised -Final
12/59
Phases of Wound Healing
12
Inflammatory phase
Begins after hemostasis/ Lasts 4-6 days
Phagocytosis
leukocytes enter wound 1st & begin removal ofbacteria & debris
Macrophages arrive about 24 hours later
Foreign material or necrotic tissues prolonginflammatory phase
Preventing passage to next phase
8/10/2019 Wound Care Slides Revised -Final
13/59
Phases of Wound Healing (cont)
13
Proliferative (fibroplastic) phase
Begins within 2-3 days
Lasts for several weeks.Collagen synthesis
Development of new capillaries
Granulation formation
8/10/2019 Wound Care Slides Revised -Final
14/59
Phases of Wound Healing (cont)
14
Maturation or Remodeling
Final phase begins after approx. 3 weeks
Lasts for months or years
Collagens reorganizedScar tissue thins out
Mature scar forms
Firm & in-elastic.If over a joint or other bony
structure may limit mobility
8/10/2019 Wound Care Slides Revised -Final
15/59
Factors Affecting
Wound Healing
15
LocalPressure
Maceration
Necrosis Systemic
Age
Circulation and oxygenation
Nutrition
8/10/2019 Wound Care Slides Revised -Final
16/59
Local Factors
Pressure disrupts blood supply
Dessication (drying out of cells) cells die in a dry
environment
Maceration (overhydration) moisture especially
from waste products can impair skin integrity.
Edema interferes with the blood supply
Infection (increases stress to body.
Necrosis (dead tissue) impairs wound healing
16
8/10/2019 Wound Care Slides Revised -Final
17/59
Systemic Factors
17
AgeYounger age heals more rapidly then older adults.
Nutrition
Wound healing requires adequate proteins,carbohydrates, fats, vitamins, and minerals.
Vit A, C, and zinc are essential for
re-epithelialization and collagen synthesis.
8/10/2019 Wound Care Slides Revised -Final
18/59
18
Oxygenation and circulation
Adequate blood flow is needed to deliver
nutrients and oxygen as well as remove local
toxins, bacteria, and other debris.
Circulation impaired in older adults, those with
some chronic diseases, and smoking.
8/10/2019 Wound Care Slides Revised -Final
19/59
Factors Affecting Wound Healing
19
Obesity
Large amounts of fat has fewer blood vessels,
place more stress on a wound, are difficult to
suture, are prone to infection and take longer to
heal.
Wound condition
Contaminated wounds heal slowly.
8/10/2019 Wound Care Slides Revised -Final
20/59
A Wound with Various Types of
Wound Surface Tissue
8/10/2019 Wound Care Slides Revised -Final
21/59
Wound Healing (cont)
21
Health Status
Chronic conditions may impair immune function
Examples are diabetes, cardiovascular disease,
impaired immune function such as AIDS.
Radiation therapy
Corticosteroid drugs
8/10/2019 Wound Care Slides Revised -Final
22/59
8/10/2019 Wound Care Slides Revised -Final
23/59
Wound Healing Process (cont)
23
Secondary Intention
Wounds with loss of tissue
Edges not approximated
Greater risk of infection
Healing process prolonged
Scar tissue
Ie: Healing by granulation, contraction, re-epithelialization
8/10/2019 Wound Care Slides Revised -Final
24/59
Wound Healing Process (cont)
24
Tertiary intention or Delayed wound closure
Wound contaminated, infected, or draining
Left open to drain
Wound closed after infection cleared
8/10/2019 Wound Care Slides Revised -Final
25/59
Pressure Ulcers
A wound with localized areas of tissue necrosis
Factors in development:
External pressure
Friction and shearRisks:
Immobility
Nutrition and hydration
Moisture
Mental status
Age
25
8/10/2019 Wound Care Slides Revised -Final
26/59
Pressure Points
8/10/2019 Wound Care Slides Revised -Final
27/59
Shearing
8/10/2019 Wound Care Slides Revised -Final
28/59
Classification of Pressure Ulcers
28
Stage I
Nonblanchable erythema of intact skin
Stage II
Partial-thickness skin loss Involves epidermis & / or dermis
Examples:
Abrasion
BlisterShallow crater
8/10/2019 Wound Care Slides Revised -Final
29/59
Stage 1
29
The skin is intact but shows apersistent pink or red areathat doesnot turn white when you press it with
your finger. The wound may look like amild sunburn. The affected skin may betender, painful or itchy. It may feelwarm, spongy or firm to the touch.
8/10/2019 Wound Care Slides Revised -Final
30/59
Stage 2
30
The skin outer layer is broken, red andpainful. Surrounding tissues may showareas of pale, red or purple
discoloration. Some swelling and/oroozing may be present. The wound is nolonger superficial and the ulcer is anopen sore that does not extend throughthe full thickness of the skin.
8/10/2019 Wound Care Slides Revised -Final
31/59
Classification of Pressure Ulcers (cont)
31
Stage III
Full-thickness skin loss
Damage / Necrosis of subcutaneous tissues
Does not include fasciaDeep crater / May have undermining
Stage IV
Full-thickness skin lossExtensive destruction, necrosis, damage to
muscle, bone, supporting structures
Unstageable when base covered with slough
or eschar.
8/10/2019 Wound Care Slides Revised -Final
32/59
8/10/2019 Wound Care Slides Revised -Final
33/59
Stage 4
33
There is full-thickness skin loss withextension beyond the deep fasciaand involvement of muscle,underlying organs, bone, and tendonor joint space. This deep openwound may show blackened tissuecalled eschar. The decubitus ulcer isnow extremely deep, having gonethrough the muscle layers and now
involving underlying organs andbone. Surgical removal of thenecrotic or decayed tissue is oftenused on wounds of larger diameter.Surgery is the normal course oftreatment. The wound is veryserious and can produce a life
threatening infection, especially ifnot treated aggressively.A Stage 4wound is extremely difficult to healand requires skilled medical woundcare.
8/10/2019 Wound Care Slides Revised -Final
34/59
Complication of Wound Healing
34
Hemorrhage Internal
External
Possible causes S & S
8/10/2019 Wound Care Slides Revised -Final
35/59
Complication of Wound Healing
35
InfectionsS & S
Dehiscence
Possible causeWhen to suspect it
8/10/2019 Wound Care Slides Revised -Final
36/59
Complication of Wound Healing
36
EviscerationEMERGENCY!
When to suspect it
Nsg interventions
8/10/2019 Wound Care Slides Revised -Final
37/59
8/10/2019 Wound Care Slides Revised -Final
38/59
Complication of Wound Healing
38
FistulasPossible causes
When to suspect it
Delayed wound healingMost common causes
8/10/2019 Wound Care Slides Revised -Final
39/59
Wound Assessment (cont)
39
Surgical wounds:
Incision & surrounding tissue appearance
Wound ClosureCondition of staples / Sutures
Palpation of Wound
Pain
8/10/2019 Wound Care Slides Revised -Final
40/59
Wound Drainage
40
Note Amount, Color, Odor and Consistency ofDrainage
Types of Drainage
Serous= Clear watery plasma
Sanguineous= Bright redSerosanguineous= Pale red, watery
Purulent= Thick yellow, green, tan orbrown
8/10/2019 Wound Care Slides Revised -Final
41/59
8/10/2019 Wound Care Slides Revised -Final
42/59
Psychosocial Effects of Wounds
42
PainAssess for changes in pain level
Address pain control with dressing changes
Monitor effects of pain medications
Anxiety and fear Demonstrate acceptance and empathy
Change in Body Image Reflects a persons view of him/herself
8/10/2019 Wound Care Slides Revised -Final
43/59
Wound Healing - NSG Diagnoses
43
Impaired Skin Integrity
Risk for Infection
Altered Nutrition: less than body requirements
Acute Pain
Disturbed Body Image
8/10/2019 Wound Care Slides Revised -Final
44/59
8/10/2019 Wound Care Slides Revised -Final
45/59
Classification of Open Wounds
45
R (red) = ProtectProliferative stage, granulating tissue
Y (yellow) = Cleanse
Oozing and purulent drainage B (black) = Debride
wound covered with eschar (necrotic tissue)
Which can be black, brown, gray, or tan.
Needs to be removed for wound to heal.
Can be done surgically, mechanically, or
chemically.
Interventions
8/10/2019 Wound Care Slides Revised -Final
46/59
InterventionsWound Cleansing
46
Use 0.9% normal saline /most common Use sterile gauze or swab
irrigation
Use gentile friction
Cleanse from area of least to most contamination
Drains highly contaminated Cleanse in circular motion moving outward
Cleanse away from incision toward drain
8/10/2019 Wound Care Slides Revised -Final
47/59
Wound Debridement
47
Sharp debridement
Mechanical debridement Enzymatic debridement
Autolytic debridement
8/10/2019 Wound Care Slides Revised -Final
48/59
Dressings - Purpose
48
Provide physical, psychosocial and aestheticcomfort
Remove necrotic tissue
Prevent, eliminate, or control infection
Absorb drainage
Maintain a moist wound environment
Protect the skin from further injury
Protect the skin surrounding the wound
8/10/2019 Wound Care Slides Revised -Final
49/59
Wound dressings
Multiple types of products See chart page 945
49
8/10/2019 Wound Care Slides Revised -Final
50/59
Changing Dressings
50
Physician Orders
Dressing type, frequency of application, solutions orointments to be used
Sterile vs Clean Techniques
Surgical wounds use sterile techniques in hospital May change to clean techniques at home
Pressure ulcers - use clean techniques
***Remember, always use sterile techniques in
hospital settings
8/10/2019 Wound Care Slides Revised -Final
51/59
Wound VAC System
8/10/2019 Wound Care Slides Revised -Final
52/59
VAC
8/10/2019 Wound Care Slides Revised -Final
53/59
How the Wound Vac works
VAC System works by: Drawing the wound edges together
Provides direct and complete wound bed contact
Removes exudate and infectious material
Reduces edema
Promotes perfusion
Keeps wound bed moist
Promotes granulation
8/10/2019 Wound Care Slides Revised -Final
54/59
Drains
54
Open Penrose
Closed
Jackson Pratt
Hemovac
8/10/2019 Wound Care Slides Revised -Final
55/59
Penrose Drain
8/10/2019 Wound Care Slides Revised -Final
56/59
Jackson-Pratt Drain
8/10/2019 Wound Care Slides Revised -Final
57/59
Bandages and Binders
57
Create pressure over body part
Immobilize a body part
Support wound Reduce or prevent edema
Secure a splint
Secure dressings
8/10/2019 Wound Care Slides Revised -Final
58/59
8/10/2019 Wound Care Slides Revised -Final
59/59
The End
Remember
Care of wounds
NSG domainNurses can prevent them
Nurses can cure them
Top Related