1. AHMAD ATA 1

2. 2 Learning outcomes At the end of this lecture the students will be able to : 1. 1. Discuss the anatomy of human skin in relation to wound management. 2. 2. Brain storm terms commonly used to describe wounds. 3. 3. Describe the process of normal wound healing. 4. 4. Identify strategies to promote wound healing. 5. 5. Demonstrate an understanding of the factors that may delay or interfere with healing.

3. AHMAD ATA3 Learning outcomes cont’d 6. 6. Classify wounds according to how they are acquired, degree of wound contamination, and depth. 7. 7. Describe assessment parameters necessary to monitor and evaluate the progress of wound healing. 8. 8. Discuss current technology/advances in management of wounds.

4. AHMAD ATA4 Introduction:  The skin is the largest organ in the body and serves as variety of important function in maintaining health and protect from injury (discussed in chapter three).

5. AHMAD ATA5

6. 6 Skin integrity:  Intact skin: refer to the presence of normal skin and skin layers uninterrupted by wound.  Wound: is disruption of normal skin integrity.

7. AHMAD ATA7 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.

8. AHMAD ATA8 Factors effect on skin integrity:  Age.  Chronic illness (impaired peripheral circulation).  Medication such as corticosteroid.  Poor nutrition.

9. AHMAD ATA9 FUNCTIONS OF THE SKIN Protection against injury Sensation Defense against microorganisms Maintenance of hydration Waste removal Thermoregulation Healthy Skin Immune function Synthesis of Vitamin D

10. AHMAD ATA10 Skin consist of:  Epidermis  Dermis  Subcutaneous

11. AHMAD ATA11 THE SKIN

12. AHMAD ATA12   10 hairs   15 sebaceous glands   3 yards of blood vessels   4 yards of nerves   100 sweat glands   3,000 sensory cells   300,000 epidermal cells ONE CUBIC CENTIMETER OF SKIN CONTAINS

13. AHMAD ATA13 Wound classification as: Wound classification as:  Intentional or unintentional.  Open or closed.  Acute or chronic.  Partial thickness, full thickness and Complex.

14. AHMAD ATA14 Types of wound:  Incision may cause of sharp instrument such as knife.  Contusion closed wound that is result from blow from blunt instrument.  Abrasion open wound result from friction. ....

15. AHMAD ATA15 Incisional wound

16. AHMAD ATA16 Contusion wound

17. AHMAD ATA17 CONT:  Puncture wound: open wound made by sharp instrument that penetrates the skin and under lying tissue.  Laceration: open wound when tissues are torn apart may occur in RTA.  Penetrating wound when instrument is inserted in to the tissues such as bullets

18. AHMAD ATA18 Wounds may describe according degree of wound contamination:  Clean wound: uninfected (no inflammation).  Clean – contaminated wound: surgical wound in which the respiratory, alimentary and genital has been entered, no evidence of infection.

19. AHMAD ATA19 CONT:  Contaminated wound: open, fresh, accidental wound and surgical wound involving a major break in sterile technique, show evidence of inflammation.  Dirty or infected wound: old, accidental wound containing dead tissue with evidence a clinical infection

20. AHMAD ATA20 Types of wound healing:  1)Primary intention healing: occur where the tissue surfaces has been approximated (closed) and there minimal or no tissue loss. occur where the tissue surfaces has been approximated (closed) and there minimal or no tissue loss.

21. AHMAD ATA21  2) Secondary intention healing: is extensive and involves considerable tissue loss and in which the edges cannot be approximated and the repair time is longer, scarring is greater and susceptibility to infection is greater.

22. AHMAD ATA22 Phases of wound healing:  1) Inflammatory phase: initiated immediately after injury and lasts 3 to 6 days two major processes occur during this phase are homeostasis and Phagocytosis. A) homeostasis: result from vaso constriction in the large vessels in affected area, deposition of fibrin and formation of blood clot in the area. A) homeostasis: result from vaso constriction in the large vessels in affected area, deposition of fibrin and formation of blood clot in the area.

23. AHMAD ATA23 Inflammatory phase

24. AHMAD ATA24 CONT  B) Phagocytosis: the macrophage engulf microorganism and cellular debris.  Prolilifrative phase: extend 4 to 21 days and start of synthesize collagen, capillary grow across wound and granulation tissue forms foundation for scar tissue development.

25. AHMAD ATA25 Proliferative phase

26. AHMAD ATA26 CONT  Maturation phase: begins about 21 days and can extend to 1- 2 years after injury, the collagen fiber haphazardly arranged and the scar formation.

27. AHMAD ATA27 Maturation phase

28. AHMAD ATA28 Factors affecting on wound healing: 1. Vasculature: good blood supply promote healing because it provides nutrients for tissue repair. 2. Compromised host: client at risk for additional reasons such as infection, diabetes and patient who receiving radiation therapy. 3. Nutrition: wound healing requires additional demand to promote healing.

29. AHMAD ATA29 Factors affecting on wound healing: 4. Obesity: adipose tissue has limited blood supply. 5. Medication such as immuno suppression agent and anti inflammatory drugs may make mask on the symptom. 6. Smoking: reduce functional of hemoglubulin resultant reduce circulating oxygen. 7. Stress: stimulate body hormone which reduce blood supply.

30. AHMAD ATA30 PRESSURE ULCER  Is any lesion caused by un relieved pressure.  The etiology of pressure ulcer is due to ischemia ( deficiency of blood supply).  usually occur over bony promenance.

31. AHMAD ATA31 PRESSURE ULCER  Is any lesion caused by un relieved pressure.  The etiology of pressure ulcer is due to ischemia ( deficiency of blood supply).  usually occur over bony promenance.

32. AHMAD ATA32 PRESSURE ULCER  Is any lesion caused by un relieved pressure.  The etiology of pressure ulcer is due to ischemia ( deficiency of blood supply).  usually occur over bony promenance.

33. AHMAD ATA33 PRESSURE ULCER  Is any lesion caused by un relieved pressure.  The etiology of pressure ulcer is due to ischemia ( deficiency of blood supply).  usually occur over bony promenance.

34. AHMAD ATA34 PRESSURE ULCER  Is any lesion caused by un relieved pressure.  The etiology of pressure ulcer is due to ischemia ( deficiency of blood supply).  usually occur over bony promenance.

35. AHMAD ATA35 Stages of pressure ulcer 1) stage one: Erythema of intact skin.

36. AHMAD ATA36 STAGE ONE

37. AHMAD ATA37  2) Stage Two: partial thickness skin loss involving epidermis, dermis or both. 

38. AHMAD ATA38 STAGE TWO

39. AHMAD ATA39  Stage three: thickness skin loss involving damage or necrotic of subcutaneous that may extend down.

40. AHMAD ATA40 Stage three

41. AHMAD ATA41  Stage four: full thickness skin loss with extensive destruction, tissue necrosis or damage to the muscle, bone or tendon

42. AHMAD ATA42 STAGE FOUR

43. AHMAD ATA43 Risk factors (ulcer)  Immobility.  Inadequate nutrition.  Decreased mental status ( unconscious patient).  Diminished sensation.  Excessive body heat.  Advanced age.

44. AHMAD ATA44 Kinds of wound drainage:  Serous exudates: compromised chiefly of serum and serous membrane of the body.  Purulent: presence of pus, consist of leukocyte, dead tissue debris and dead bacteria.  Sanguineous: large amount of RBC.

45. AHMAD ATA45 Complication of wound healing:  hemorrhage  Infection.  Dehiscence with possible evisceration.  Dehiscence: partial or total rupturing of a wound.  Evisceration: protrusion of the internal viscera through an incision.

46. AHMAD ATA46 Sign and symptom of infection:  Wound is swollen.  Redness.  Feels hot on palpated.  Foul odor may be noted.  Pain  Drainage is increase and possibility purulent.

47. AHMAD ATA47 Psychological effect of wounds:  Pain.  Anxiety.  Change in body image.

48. AHMAD ATA48 Assessment of wound: Untreated wound usually seen shortly after injury  a) Assess the size and severity of the wound  Control bleeding by applies direct pressure over the wound and elevating involved extremity.  Preventing infection by cleaning or flushing with water covering the wound with a clean dressing and tightly enough to apply pressure.

49. AHMAD ATA49  Control swelling and pain by applying ice over the wound.  If bleeding is sever or if internal bleeding is suspected, assess the client for sign of shock (rapid thready pulse, cold clammy skin, pallor and lowered blood pressure.

50. AHMAD ATA50 CONT  Assess the wound for contamination with foreign material and had lest tetanus toxiod injection.  Assess vital sign.

51. AHMAD ATA51 CONT:  Treated wound:  Usually assessed to determine the progress of healing involves observation for appearance, pain, size, drainage, swelling, redness and tubes.

52. AHMAD ATA52 Lapratory result:  Decreased WBC may delay healing because it increase possibility of infection.  Coagulation study.  Serum protein analysis may indicate body nutrition  Wound culture to confirm or rule out the presence of infection.

53. AHMAD ATA53 Caring for open and closed wound Dressing has following advantage:  Absorb drainage and depride the wound when remove.  Protect the wound from external microbial contamination.  Approximate wound edge.  Supporting and splinting the wound site, thus reduce mobility and trauma to the wound it self.  Covering unpleasant disfrugments.

54. AHMAD ATA54 CONT:  Open methods (no dressing is used) exposing wound to the air promote drying and discourage the growth of microorganism such as burns.

55. AHMAD ATA55 Color classification of open wound:  R= Red – proliferative stage of healing, reflect color of normal granulation.  Y= Yellow – characterized by oozing, need to cleansed.  B=Black – covered with thicker eschar, requires debridment.  Mixed wound contain component or RY&B wounds.

56. AHMAD ATA56 RED WOUND

57. AHMAD ATA57 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

58. AHMAD ATA58 YELLOW WOUND

59. AHMAD ATA59 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 non adherent, hydrogel dressing, or other exudates absorbers.   consulting with the physician about the need for a topical antimicrobial to minimize bacterial growth.

60. AHMAD ATA60 BLACK WOUND

61. AHMAD ATA61 B – Black Wound   Covered with thick necrotic tissue or Eschar.   e.g.. third degree burns and gangrenous ulcer.   Required debridment.   When the eschar is removed, the wound is treated as yellow, then red.

62. AHMAD ATA62 Debridment

63. AHMAD ATA63  Cleaning agent: 1. Povidine. 2. 70% alcohol. 3. Sterile normal saline.

64. AHMAD ATA64

65. AHMAD ATA65 Guidelines for cleaning wounds (AJN, 1999) 1. 1. Use physiologic solution, such as isotonic saline or lactated ranger solution 2. 2. When possible, warm the solution to body temperature before use 3. 3. If the wound is grossly contaminated by foreign material, bacteria, slough, or necrotic tissue clean the wound at every dressing change 4. 4. If a wound is clean, has little exudate, and reveals healthy granulation tissue, avoid repeated cleaning

66. AHMAD ATA66 CONT: 5. 5. Use gauze squares. Avoid using cotton bolls 6. 6. Consider cleaning superficial non infected wound by irrigating them with normal saline rather than using mechanical means 7. 7. To retain wound moisture, avoid drying a wound after cleaning it

67. AHMAD ATA67