Stressors that Affect Skin Integrity Wound Care

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

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

3. 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

4. Superficial Penetrating Perforating Laceration Puncture Abrasion Contusion Clean Contaminated Infected Colonized Pressure UlcersStage IStage IIStage IIIStage IV Wounds –Classification

5. 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

6. ??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?

7. 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

8. 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

9. Phase ICONTINUED Wound Healing • Inflammatory Response • 4 Cardinal S/S • Pain • Redness • Heat • Edema

10. Phase I Inflammatory ResponseSYSTEMIC RESPONSE • Elevated temperature • Elevated WBC ( norms 5000-10000 ) • Malaise

11. 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 redcolor/fragile/bleeds easily.

12. 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).

13. 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 .

15. 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

16. 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

17. Debridement Methods • Surgical • Mechanical • Enzymatic ( proteolytic enzymes) • Autolytic • Maggots

18. 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.

19. 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 barrierExample: Carrasyn • Wet – to- Moist Gauze dressings: keeps wound bed moist. Minimizes trauma to granulation tissues

20. Dressings for DRY wounds Wet – to Moist Gauze

21. 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 exudateExample: 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

22. Dressings for MOIST wounds

23. 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

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

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

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

27. 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

28. 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

29. 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