Dr. Nahed Saied Al Nagger WOUND CARE Prepared By Dr. Nahed Saied Al Nagger Assistant Professor of Nursing 1430H

Intended Learning Outcomes Define wound. Identify classifications of wound. Recognize the difference between sutures, staples and Steri-Strips. Describe wound healing process. List factors affecting wound healing. Determine complications of wound. Discuss nursing management of wound in emergency and treatment settings.

Skin Integrity and Wound Care Structure: epidermis and dermis Function

An overview of wounds and open sores What is the meaning of wound? A wound or open sore is a break in the skin or mucous membrane, that is at high risk for infection.

Wound Classification perforating. abrasion. Skin integrity: open, closed, acute, chronic. Cause: intentional, or unintentional. Severity of injury: superficial, penetrating, or perforating. Cleanliness: clean, contaminated, or infected. Descriptive qualities (types): laceration, or abrasion.

Classifications of wounds (cont.) Open wounds can be classified into a number of different types, according to the object that caused the wound.

Types of open wounds are: Incisions caused by a clean, sharp- edged object such as a knife, a razor or a glass splinter. Lacerations rough irregular wounds caused by crushing or ripping forces. Abrasions ( grazes) a superficial wound in which the topmost layers of the skin are scraped off, often caused by a sliding fall into a rough surface. continue

SKIN Laceration

Puncture wounds caused by an object puncturing the skin such as a nail or needle. Penetration wounds caused by an object such as a knife entering the body. Gunshot wounds caused by a bullet or similar projectile driving into or through the body, there may be two wounds: One at the site of entry. One at the site of exit. Remember that: All gunshot wounds should be considered major wounds. continue

Sores can be caused by a wide range of factors, but the most are caused by infection, so treating the infection is essential to healing. There are many types: Pressure ulcers. Diabetic ulcers. Bedsore wounds.

Pressure Ulcers: Pathogenesis Pressure intensity Pressure duration Tissue tolerance

What is a Pressure Ulcer ? Any lesion caused by unrelieved pressure usually over a bony prominence that results in damage to underlying tissue

Mosby items and derived items © 2005 by Mosby, Inc. SHEARING FORCES From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders. Mosby items and derived items © 2005 by Mosby, Inc. 14

Pressure ulcer stages Stage 1: epidermis; nonblanching erythema. Stage 2: epidermis/dermis; shallow opening; blisters. Stage 3: Subcutaneous tissue/fascia Stage 4: fascia + bone, tendon, muscle, cartilage

Systemic Factors that affect Wound Healing Nutritional Status Vascular Status Metabolic Factors Immunological Factors Age Medications (Steroids, etc) Genetic

Pressure Ulcer Staging Stage I Stage I - An observable pressure related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. 17

Pressure Ulcer Staging Stage I Dark Skin

Pressure Ulcer Staging Stage II Stage 2: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. 19

Pressure Ulcer Staging Stage II Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. 20

Pressure Ulcer Staging Stage II

Pressure Ulcer Staging Stage III Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Stage III - Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue 22

Pressure Ulcer Staging Stage III Stage III - Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue 23

Pressure Ulcer Staging Stage IV Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint, capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers Stage IV - : Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers 24

Stage IV

Diabetic Ulcer

What does the surgeon use to close the surgical wound? Surgical wound will be closed in multiple layers, first close muscle layer and then skin layer. Sutures are what most people call stitches. 2. Steri-Strips method (which look like tape strips) are placed across the wound to hold the skin edges together. It requires a closure with many small stitches of the layer immediately below skin. continue

Contra-indications of Steri- Strip method The time of surgery is extended. Patient have had previous surgery in the area. Patient’s healing may be compromised due to other health problems. 4. Patient have any other health concerns that would not make this type of closure the best method.

Staples: are small metal clips that hold the wound closed. This method allows the surgeon to close the wound more rapidly. Surgeon is the best judge as to the type of closure appropriate for the surgical wound. A combination of wound closure techniques. Staples

*Stages of Wound Healing Inflammation- (approx. 2-3 days) consists of a vascular and a cellular response acute and chronic inflammation (neutrophils, cytokines, oxygen, platelets rush to the site). Proliferation – (approx. 2-3 weeks) Begins at the time of injury Rebuilding begins with scaffolding of the skin Revascularization of the wound begins.

Maturation Stage- (Approx 2-3 years) Depositing of scar tissue The body attempts to contract or close the wound (Wounds are only ever 80% healed)

Wound Repair (Healing) Partial thickness: inflammatory response, epithelial proliferation and migration, reestablishment of epidermal layers Full thickness: inflammatory phase, proliferative phase, and remodeling

Factors Influencing Wound Healing Nutrition. Tissue perfusion. Medical problems such as diabetes. Medications e.g., taking daily steroids. Immune system disorder. Infection. Age. Genetic.

Is wound care different for a child? Children's wounds heal very quickly and normally without problem. Preventing child from itching the wound or touching the wound is very important. If the child requires the use of a diaper, an additional measure to protect a surgical wound in that area is necessary. Special bandage material that forms water tight protection for the wound will be used until the wound is healed.

Do all sutures dissolve? There are many types of suture material, some of which are dissolvable and some are not. Some of the suture material will dissolve once your wound is completely healed.

Is it painful to have sutures and staples removed? Removing either sutures or staples may be uncomfortable but should not be painful. Obviously, the longer the wound the greater time it will take to remove your sutures or staples. Removal of the closure material normally ranges from one to five minutes depending on the length of the wound and the number of sutures or staples to be removed.

Techniques for suture and staple removal

Complications of Wound Healing Hemorrhage—shock Infection Dehiscence Evisceration Fistula formation

Disinfectant Solutions

The aim of wound disinfecting: To destroy vegetative compounds, as bacteria, by preventing their growth. 1. Iodine: Action: Is a broad-spectrum antiseptic agent. It is available in both an alcohol and an aqueous solution. Uses: As a skin disinfection, and to clean grossly infected wound. Closed, and open wound. Availability: Is available in ointment, spray, and powder form

2. Acetic acid (0.5 %): Action: Is effective against gram (+ ve) and gram (- ve) bacteria. Mainly against pseudomonas bacteria. Side effect: It is toxic to the fibroblasts cells slow the epithelization. Uses: (Open wound)

3. Hydrogen peroxide (3%): Action: Has an oxidizing effect which destroys anaerobic bacteria. Side effect: Destruction of granulation tissue especially new growth. Uses: (superficial septic wound) N.B. Hydrogen peroxide shouldn't be used in deep open wounds because it may be absorbed into the vascular systems an embolism.

4. Saline ( 0.9%): Uses: (for open, closed wound, also, around the wound) 5. Glycerin magnesium: Action: Has hydroscopic action. It left without drying and pack with gauze can be used. Uses :For deep septic wound.

Nursing Management for wound

Assessment Skin: color, temperature, turgor, integrity Risk for pressure ulcers: Norton and Braden scales (p.1495). Nutritional status Exposure of skin to body fluids Pain

Assessment of Traumatic Wounds Wounds: emergency setting Abrasions Lacerations Punctures Appearance Amount of bleeding Size

Assessment of Wounds in a Stable Setting Appearance: size, healing Character of drainage: serous, sanguineous, serosanguineous, purulent (p.1494) Drains

Wounds: Stable Setting Closures: staples, sutures Palpation of wound Wound cultures: aerobic, anaerobic  Examples of suturing methods. A, Intermittent. B, Continuous. C, Blanket continuous. D, Retention. 48

Mosby items and derived items © 2005 by Mosby, Inc. Nursing Diagnoses Risk for infection Imbalanced nutrition: less than body requirements Pain Impaired skin integrity Impaired tissue integrity Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Planning Goals and outcomes Wound improvement within 2 weeks No further skin breakdown Increase in caloric intake by 10% Setting priorities Continuity of care Mosby items and derived items © 2005 by Mosby, Inc.

Implementation: Health Promotion Prevention of pressure ulcers Skin care Positioning Use of support surfaces Mosby items and derived items © 2005 by Mosby, Inc.

Implementation: Acute Care Management of wounds and pressure ulcers

Wound Management Prevent and manage infection. Cleanse the wound. Remove nonviable tissue. Manage exudate. Protect the wound. Client education. Nutritional support.

                                                                            Necrosis of the skin

Removal of dead epidermis and dermis                                                                             Removal of dead epidermis and dermis

Normal fat at the base of a debrided wound of the heel                                                                             Normal fat at the base of a debrided wound of the heel

                                                                            Silvaden

Silvadene Is an excellent antibacterial cream to apply to a wound after debridement. One must insure that an 1/8 inch to 1/4 inch coat is applied to help insure that the dressing doesn't absorb all the cream and allow the wound subsequently dry out.

First Aid for Wounds Control of bleeding. Cleansing. Application of topical growth factors. Protection.

Dressings Purpose Types: gauze, wet-to-dry, Telfa, transparent, hydrocolloid, hydrogel, foam, alginate Changing or reinforcing dressings Packing a wound. Securing the dressing

Montgomery straps Transparent dressing hydrocolloid dressing absorbs drainage into its matrix

Hydrocolloids ( Duoderm)-

How is the wound bandaged? Immediately after surgery, the wound will be covered with sterile bandages. Normally this first bandage, often referred to as the surgical dressing, will be removed the day after surgery. The nurse will examine the wound to be sure that it looks as expected, another bandage may be applied. 66

Dressing Changes Administer required analgesic Explain steps of procedure to client Gather all necessary supplies Prepare sterile field, as indicated Remove old dressing, assess area, and provide necessary care using appropriate aseptic technique Answer client’s questions and document care provided

Wound Care Cleansing skin and drain sites Wound irrigations Suture/staple care and removal Drainage evacuation Comfort measures Wound irrigations

Wound Care Methods for cleansing a wound site. 69

Application of Bandages and Binders Inspect underlying skin Cover exposed wounds Assess condition of dressings Assess skin of areas distal to bandage Use appropriate technique to apply

Patient Education

How should the patient care for the wound? The most important aspect for the first 72 to 96 hours will be to keep the wound dry and clean. Wound will be assessed each day by surgeon and nurses to be sure that it is progressing and that no signs of infection are present. They will alert the patient to any concerns that they have about wound and give patient specific instructions regarding wound care. 72

Is it normal for the wound to itch? A few days after surgery, patient may notice some itching near surgical wound. Itching may be a sign of healing, but it may also be a result of the Steri-Strips or other tapes that have been used. It is best to avoid itching the wound. If it becomes too much of a problem, the surgeon or nurse may order medications by mouth or some topical cream to help make this more tolerable. 73

When the patient can take a shower? Surgical team will make a determination about when the patient can take a shower. In most cases, the patient can take a shower approximately 4 to 5 days after surgery. Normally baths are discouraged for the first couple of weeks due to difficulty getting in and out of a bathtub, as well as avoiding soaking the wound in bath water. 74

DECUBITUS IMPLEMENTATION Institute measures to prevent decubiti Assess the nutritional status of the client and provide adequate nutritional intake to promote tissue integrity Monitor for an alteration in skin integrity Relieve or remove pressure on the skin Turn and reposition the immobile client every 2 hours, or more frequently if necessary Ambulate the client 75

ASSESSMENT OF PRESSURE RELIEF From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes, ed 6, Philadelphia: W.B. Saunders. Modified from Gaymar Industries, Inc., Orchard Park, NY. Mosby items and derived items © 2005 by Mosby, Inc. 76

DECUBITUS IMPLEMENTATION Provide active and passive exercises every 8 hours Keep the skin clean and dry and the sheets wrinkle-free Apply moisture barrier as prescribed to protect the skin Use assistive devices to prevent pressure such as alternating air pressure mattress or sheepskin padding Apply medications or dressings to the wound as prescribed 77

Evaluation Client care Client expectations

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