Stressors that Affect Skin Integrity Wound Care NUR101 Fall 2008 LECTURE # 8 K. Burger MSEd, MSN, RN, CNE PPP By: Sharon Niggemeier RN MSN Revised kburger906,907

Factors that Impair Wound Healing Age Malnutrition Obesity/Emaciation Poor circulation and oxygenation Immunosuppression Smoking Incontinence Medications ( Steroids ) Co-morbidities ( Diabetes) Wound Stress Radiation

Wounds - Classification Intentional – results from planned treatment Unintentional wounds- results from unexpected trauma…accident/ burns/ shooting Open -skin broken, portal of entry Closed – trauma from force, skin intact, soft tissue damage, internal injury, possible bleeding Acute – goes through normal/timely healing process Chronic – fails to go through normal stages of healing; no timely progress in healing

Wounds –Classification Superficial Penetrating Perforating Laceration Puncture Abrasion Contusion Clean Contaminated Infected Colonized Pressure Ulcers Stage I Stage II Stage III Stage IV

Wound Assessment Appearance: granulation tissue, eschar, slough, edema, tunneling, undermining, sinus tracts, color Drainage: serous, serosanguineous, sanguineous, purulent and amount Pain Size & location on body Presence of sutures/staples Presence of drains/tubes Wound edges

??Other Factors to Assess?? ODOR LAB VALUES WHAT CAUSED THE WOUND? NEED FOR TETANUS? WHEN DID WOUND OCCUR? WHAT (IF ANY) TREATMENTS HAVE BEEN TRIED?

Wound - Healing Healthy body has the ability to restore itself, it depends on the amount of damage and state of health of the individual. Referred to as regeneration (renewal) of tissue. There are (3) phases of regeneration

Phase I Wound Healing Inflammatory phase- begins immediately after injury. Includes Hemostasis (cessation of bleeding) due to vasoconstriction and platelet aggregation Release of histamine, increasing capillary permeability (plasma leaking) and vasodilation Also phagocytosis ( process when macrophages engulf microbes and secrete growth factors that promote angiogenesis) stimulates epithelial buds at the end of injured tissue resulting in increased circulation which sustains the healing process

Phase I CONTINUED Wound Healing Inflammatory Response 4 Cardinal S/S  Pain  Redness  Heat  Edema

Phase I Inflammatory Response SYSTEMIC RESPONSE Elevated temperature Elevated WBC ( norms ) Malaise

Phase II Wound Healing Proliferation (Fibroplasia) Phase - second phase, fibroblasts synthesize collagens which add strength to the wound. Begins 2-3 days after injury. Thin layer of epithelial cells forms, blood flow is reinstituted. Tissue forms - known as granulation tissue. Translucent red color/fragile/bleeds easily.

Phase III Wound Healing Maturation (Remodeling) Phase- final phase begins about 3 weeks after the injury. Collagen originally in haphazard order remodels and reorganizes into a a more orderly structure. Scar (cicatrix) forms - avascular tissue, doesn’t sweat, grow hair, or tan. Keloid- abnormal amount of collagen laid down, hypertrophic scar. ( common in dark skin).

Types of Wound Healing Primary Intention: clean, straight line, edges well approximated with sutures, rapid healing Secondary Intention: larger wounds with tissue loss, edges not approximated, heals from the inside out, granulation tissue fills in the wound, longer healing time, larger scars Tertiary Intention: delay 3-5 days before injury is sutured, greater access for pathogens to invade, greater inflammation, more granulation, larger scars.

Wound Complications Infection- S/S purulent drainage, pain, redness around wound, edema, increased temp, elevated WBC Hemorrhage – S/S large amts sanquineous drainage + other symptoms of hypovolemic shock. Check UNDER clients Dehiscence- S/S wound edges pulling away; not well- approximated. Early sign = increasing serosanquineous drainage Evisceration- S/S wound opens revealing internal organs. Emergency rx = sterile NS gauze to cover; prepare for OR Psychosocial impact – Encourage verbalization of feelings; encourage self-care as tolerated by client

Promotion of Wound Healing Dressings: keep wound covered & clean Wound bed moist / Surrounding skin dry Debridement when necessary Remove exudate: Drains, Wound VAC, Irrigation Pack wounds loosely Nutritional interventions

Debridement Methods Surgical Mechanical Enzymatic ( proteolytic enzymes) Autolytic Maggots

Wound Dressing Principles If exudate is present - Select one that absorbs exudate. Keep wound bed moist but surrounding skin dry Pack wounds loosely to avoid pressure on new granulation tissue Fasten securely using tape, binders etc… OR self-adhesive type dressing materials.

Dressings for DRY wounds Transparent: gas exchanged between wound & environment but bacteria prevented from entering. Creates moist healing environment Example: Tegaderm Hydrogels: High water content enhances epithelialization and autolytic debridment. Needs cover dressing and wound edge barrier Example: Carrasyn Wet – to- Moist Gauze dressings: keeps wound bed moist. Minimizes trauma to granulation tissues

Dressings for DRY wounds Wet – to Moist Gauze

Dressings for MOIST wounds Hydrocolloid: hydrophilic particles mix with water to from a gel... wound stays moist. DO NOT use in infected wounds. Example: Duoderm Absorption Materials: beads, powders, rope or sheets that absorb large amount of exudate Example: Calcium Alginate Foam: Made of hydrophilic material. Highly absorbent. Example: Allevyn Dry Gauze: Can absorb wound drainage. Can be impregnated with agents to promote healing

Dressings for MOIST wounds

Irrigations Cleanses a wound using pressure Sterile Normal Saline = usually prescribed Avoid caustic agents ie: peroxide, iodine etc. Pressure between 4-15 pounds per square inch (psi) i.e. 60ml syringe with catheter tip

Other Therapies Wound V.A.C. – negative pressure vacuum assisted closure system. Removes drainage and helps wounds close. Hydrotherapy – Pulse lavage, Whirlpool Aids in debridement and cleansing, warm water vasodilation. Hyperbaric Oxygen Electrical Stimulation

Other Therapies Electrical Stimulation: - electrical signals direct cell migration in wound healing

Bandages & Binders Secures dressings in place Determine size needed Outer covering must cover entire wound Tape to secure (initial,date time)

Heat & Cold Therapy Heat- reduces pain & promotes healing through vasodilation Increases oxygen and nutrients to aid in inflammatory response Reduces edema by promoting removal of excessive interstitial fluid Promotes muscle relaxation

Heat & Cold Therapy Cold- decreases pain by vasoconstriction Decreased blood flow to the area decreases inflammation and edema Raises the threshold of pain receptors thereby decreasing pain Decreases muscle tension

Safety Precautions Heat & Cold Therapy Need physician’s order Very young and very old Peripheral vascular disease Decreased LOC Spinal cord injury Presence of edema and/or scar tissue NO LONGER than 20-30minutes at a time. Rebound phenomena