Wound care and dressing King Saud University College of Nursing Fundamental of nursing Module five Wound care and dressing

THE SKIN

FUNCTIONS OF THE SKIN Healthy Skin Defense against microorganisms Protection against injury Sensation Defense against microorganisms Maintenance of hydration Waste removal Thermoregulation Synthesis of Vitamin D Immune function Healthy Skin

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

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

Wound Classification Intentional wounds and Unintentional wounds Open wounds and closed wounds Acute and chronic wounds

PHASES OF WOUND HEALING Healing is a quality of living tissue; it is also referred to as regeneration (renewal) of tissue. The inflammatory phase The regenerative (Proliferative) phase The Maturative (Remodeling) phase (Manley, Bellman, 2000)

The inflammatory phase (Initiated immediately after injury and last 3-4-6 days Injury /damage Cells Histamine Blood Clot Dry Vasodilation Permeability Uniting the wound edges Neutrophils& Monocytes -Dilated blood vessels Microcirculation slow down Oedema& Engorgement 0-3 days

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

The Regenerative phase cont’d This phase of healing: Last from 0-24 days Signs of inflammation should subside although the wound will often remain red in colour and to some degree raised in relation to its surrounding tissue .

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

Factors affecting wound healing (Manley.K, Bellman. L,2000) Developmental consideration/Age Nutrition Life-style Medication Infection Wound perfusion PH of the wound interface Foreign bodies Contamination Bacteria present on surface Colonization Bacteria attach to tissue and multiply Infection Bacteria invade healthy tissue and overwhelm immune defenses

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

Classification of surgical wounds (Altmeire 1999, Ayliffe & Lowbury 1992, NAS 1996) Clean wounds: Operations in which a viscus is not opened. This category includes non- traumatic, uninfected wounds where no inflammation is 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.

Classification of surgical wounds cont’d (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.

Classification of wounds by depth Partial-thickness: Confined to the skin, the dermis and epidermis. Full-thickness : Involve the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone Partial Thickness Full Thickness

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

Wound assessment cont’d (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

A- Intrinsic risk factors: 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

B- Extrinsic risk factors: Risk Factors Which Increase Patient Susceptibility to infection cont’d (Manley.K, Bellman. L,2000) B- Extrinsic risk factors: Drug therapy as a risk factor: e.g. Cytotoxic Breach in the integrity of the skin Items as foreign bodies Bypass of defence mechanism through devices e.g. Intubations

S&S 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.

Kinds 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 The presence of microorganisms

Kinds of Wound Drainage cont’d 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.

Kinds of Wound Drainage cont’d 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

Wound Complications Infection Hemorrhage Dehiscence and evisceration Fistula formation

The RYB color code (Stotts,1999) This concept is based on the color of the open wound rather than the depth or size of a wound. On this scheme, the goal of wound care are to protect ( cover) red, cleanse yellow, and debride black. The RYB code can be applied to any wound allowed to heal by secondary intention. R=Red Y=Yellow B= Black

The RYB color code cont’d (Stotts,1999) 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.

The RYB color code cont’d (Stotts,1999) Red wounds cont’d How to protect red wounds: Gentle cleansing Avoid the use of dry gauze or wet- to-dry saline dressings Appling a topical antimicrobial agent Appling a transparent film or hydrocolloid dressing Changing the dressing as infrequently as possible

The RYB color code cont’d (Stotts,1999) 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.

The RYB color code cont’d (Stotts,1999) B – 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.

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

Purposes of wound dressing cont’d To prevent hemorrhage (when applied as a pressure dressing or with elastic bandages). To splint or immobilize the wound site and thereby facilitate healing and prevent injury. To provide psychologic (aesthetic) comfort.

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).

Principles of asepsis cont’d Cleaning : Is the removal of dirt, debris and organic material. Disinfection: Removes or destroys harmful microorganisms but not bacterial spores or slow viruses. Sterilisation: is the complete destruction or removal of all living microorganisms including bacterial spores.

Principles of asepsis cont’d 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

Guidelines for cleaning wounds (AJN, 1999) Use physiologic solution, such as isotonic saline or lactated ranger solution When possible , warm the solution to body temperature before use If the wound is grossly contaminated by foreign material , bacteria, slough, or necrotic tissue clean the wound at every dressing change If a wound is clean , has little exudate , and reveals healthy granulation tissue , avoid repeated cleaning

Guidelines for cleaning wounds cont’d (AJN, 1999) Use gauze squares . Avoid using cotton bolls Consider cleaning superficial noninfected wound by irrigating them with normal saline rather than using mechanical means To retain wound moisture , avoid drying a wound after cleaning it

Topics for Home Care Teaching Supplies Infection prevention Wound healing Appearance of the skin/recent changes Activity/mobility Nutrition Pain Elimination

Sutures and staples Types of sutures: Plain interrupted Mattress interrupted Plain continuous Mattress continuous Blanket continuous Retention

Sutures and staples Removing interrupted suture Suture removal set Removing staples Staple removal