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A self learning module designed for student nurses to help them understand the nursing care of patients with wounds. I am sharing this with other educators or nursing students to help them in this area. You have my permission to use this to learn about wounds but not to take as your own presentation. I hope you honor this request.

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  • This presentation is just to help you visualize some of the wounds in your self leaning module and reinforce the information. You will not be tested on this content, but examples and explanations of wounds and various dressings are important for you to understand what is happening in clinical and why some dressings are indicated or contraindicated! Depending upon where you have your clinical experiences you may or may not get to see these dressings but you may see other types of wound care treatments- if you do- stop by and share with me what you have seen in clinical!
  • In addition to systemic factors there are local factors that can be barriers to wound closure Mechanical stressors - inadequate reduction in pressure, friction and shear. Edema - increased fluid in the interstitial space can interfere with the diffusion of oxygen, which is essential for collagen synthesis, and contributes to the amount of exudate. This can be a major factor in patients with Chronic Venous Insufficiency and is the rationale for using compression therapy. Wound temperature - changes in temperature can cause capillary constriction which in turn may cause decreased perfusion, reduced phagocytic activity and altered cellular mitosis. Cytotoxic agents - can have a detrimental effect on cells necessary to support healing, for example fibroblasts. Excess exudate - wound fluid from chronic wounds has been shown to have a number of deleterious effects on the healing process. Dry wound bed - optimal cellular division and migration only occur in a moist environment. If the wound is allowed to dry out this will contributes to delayed healing. Devitalized tissue - the presence of necrotic tissue in the wound bed significantly impairs healing. This tissue needs to be removed or DEBRIDED- there is many ways to do this- surgically, with medications, or with new types of wound dressings (autolytic). Heavy bioburden - the burden resulting from heavily colonized wounds can impair healing Infection - wounds that are infected cannot heal.
  • If anyone could do a full and complete assessment, registered nurses would not be needed! This is an important area of nursing practice that we should never neglect or delegate to ancillary personnel.
  • Partial thickness wounds heal by process of migration of epithelial cells from the edges of a wound as well as from around the remaining hair follicles, and contraction of wound edges partial thickness wounds go down to but not completely through the dermis.
  • The first picture is a stage II pressure ulcer- over a bony prominence (sacrum) – it looks much like a blister that burst- you are looking at the dermis here. This needs pressure relief and occlusive dressings. The second picture is incontinence related skin damage which resulted in partial thinking skin loss (by the arrow). Look at the surrounding skin- it looks like very bad diaper rash. This is from urine/stool stripping away the epidermis. This is treated much differently from a pressure ulcer. This needs anti-fungal medication and skin protection with barriers such as zinc oxide. Occlusive dressings make this worse!!! Therefore nurses need to know the difference between these 2 problems.
  • This process will take many weeks to months to complete. Wounds that heal by secondary intention are filled with scar tissue and covered with a thin layer of epidermis.
  • Before topical therapy can be selected, all of these assessments are important!
  • Red = beefy granulation tissue Pink- new epithelial cell growth Yellow- slough, necrotic tissue or can also be from dried drainage
  • Picture one=eschar that is dry and leather like Picture two= necrotic tissue that is softening with an underlying abscess- this patient is septic and needs immediate surgical debridement.
  • “ bruising under intact skin” Remember this is a deep wound, and can develop in seriously ill patients! Frequent skin assessment might prevent or ensure early detection!
  • Examples
  • We used to believe that full thickness wounds were pain free- nothing could be further from the truth. Patient report burning, aching pains from full thickness wounds therefore pain management is imperative!
  • Yikes- no gloves!!!! Sharp debridement is the removal of necrotic tissue by surgical instruments- it is best when immediate debridement is needed for an infected wound. Patients should be given a local anesthetic and pain medication prior to this. Usually performed by surgeons but specially trained nurses can also do this procedure.
  • There are so many nursing diagnoses: take some time now and list some that you believe may be relevant Remember: Not all of our patient’s wounds may heal- it depends upon many factors. If the patient is at the end of life, the goal is to keep the wound as clean as possible and to prevent complications- healing may be impossible!
  • A local wound environment that mimics healthy tissue by providing hydration and maintaining normal temperature and pH. You can use this in your own life- an abrasion heals best when covered with a band-aid. When we let it “scab over” the new tissue needs to tunnel under the scab before the wound can close. If we protect and cover it, the moisture under the band-aid allows the new cells to “swim” and begin to close the wound.
  • When we teach you this semester about a moist saline dressing or a dry sterile dressing (DSD), this is different from a “wet to dry” dressing. Years ago before we had new topical therapy, the only way to debride (or remove necrotic tissue) was by mechanical debridement or actually “ripping off” the necrotic tissue. Not very pleasant for our patients (or us!) and we really shouldn’t be doing it anymore. So, if a physician orders a “wet to dry” dressing, you need to clarify what is meant because often what they mean is a moist saline dressing. Dry gauze is fine for a closed wound or to protect a surgical wound for a few days, however, not indicated for long term use in full thickness wounds.
  • A wonderful dressing for many uses- Op-site is just one example but it was the first. It is now used less often for wound care and more for IV sites but it is still a good option for wound care in some situations. It is great to place over other products in area that are prone to moisture (perineum, sacrum) to protect the wound from urine or stool As stated above, it should never be used in fragile geri-skin as it have a strong adhesive and makes skin tears worse.
  • Remember the names of the dressing are just examples- there are many hydrocolloids on the market. One of the oldest dressings now, but still an excellent choice in many situations.
  • Hydrogels- there are so many – and so many delivery systems- tubes, gel sheets, gel impregnated gauze. One of the most versatile dressing available. When in doubt a hydrogel is often the best selection. Only real concern is if used in heavily draining wounds as it does not absorb any drainage.
  • Next time you are at the Jersey Shore, take a look around at the seaweed at your feet and you will see where this dressing came from! A wonderful dressing for wounds with copious amounts of drainage! It is also good for wounds that tend to bleed often as it helps control bleeding.
  • There are many of these products available- there are wonderful dressings to help prevent pressure ulcers in high risk areas! This is a SMART dressing, by that I mean it “knows” when the wound needs more or less moisture less acts accordingly!
  • This is a medication that comes from the pharmacy; it is used frequently in home care and long term care.
  • Look for these dressings on your clinical units-as nursing students we don’t expect you to be experts at applying this modality but it is very interesting to see in action. Make sure you watch the nursing staff or wound care nurses apply these to wounds. These dressings are changed three times each week and the goal is absorption of drainage, stimulation of granulation tissue and wound closure. Patients now go home with portable units and are taught (by nurses!) how to care for and change this type of dressing.
  • Pressureulcerandwoundsextrahelp

    1. 1. NRB 121 Self Learning Module: Wound Assessment Tracey J. Siegel MSN RN CWOCN CNE
    2. 2. Mrs. Siegel Says: This may help you visualize pressure ulcers and other wounds! Don’t print this up! Save paper! Watch this as a slide show! Then read the information in the notes section to help you better understand the nursing care of wounds!
    3. 3. Objectives: <ul><li>Following this self directed Power Point, nursing students will be able to: </li></ul><ul><li>Describe the best practices to manage acute and chronic wounds. </li></ul><ul><li>Explain the role of the nurse when caring for acute and chronic wounds. </li></ul>
    4. 4. Why is this topic important to student nurses? <ul><li>New RN graduates are responsible for the prediction, prevention and management of pressure ulcers in all settings. As our population gets older, understanding pressure ulcers and the care of all wounds is a priority! </li></ul>
    5. 5. Everything Old is New Again! <ul><li>“ Nature alone cures…nature heals the wound. What nursing has to do…is put the patient in the best condition for nature to act upon him.” Florence Nightingale </li></ul>
    6. 6. Assessment! <ul><li>Often as nurses we get so wrapped up in the wound itself, we forget an important thing- we need to look at the whole patient….not just the hole in the patient! </li></ul>
    7. 7. Patient Assessment and Wound Care <ul><li>Subjective/Objective Data </li></ul><ul><li>Remember, the client is more than the wound- need to do a complete nursing history </li></ul><ul><li>Focus on: Nutrition, hydration, oxygen and vascular status, immune state, other illnesses </li></ul><ul><li>Contributing Factors: pressure, shear, friction, impaired mobility </li></ul><ul><li>Overall prognosis and/or client goals </li></ul>
    8. 8. Assessment : Objective Data <ul><li>Mechanical stressors </li></ul><ul><li>Edema </li></ul><ul><li>Wound temperature </li></ul><ul><li>Cytotoxic agents </li></ul><ul><li>Excess exudate </li></ul>Local Dry wound bed Presence of devitalized tissue Contaminated Infection
    9. 9. Assessment! <ul><li>“… it must never be lost sight of what observation is for. It is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort.” </li></ul>
    10. 10. Partial-Thickness Wounds <ul><ul><li>Tissue destruction through the epidermis extending into but not through the dermis </li></ul></ul><ul><ul><li>Heals by: </li></ul></ul><ul><ul><li>Epithelialization </li></ul></ul><ul><ul><li>Contraction of wound margins </li></ul></ul><ul><li>For example: Skin Tears, blisters, and Stage II pressure ulcers </li></ul>Skin Tear
    11. 11. Pressure Ulcer vs. Dermatitis Which is which?
    12. 12. Stage III and Stage IV Pressure Ulcers vs. Full Thickness Wounds <ul><li>All Stage III and IV PU are full thickness wounds but not all full thickness wounds are pressure ulcers! </li></ul><ul><li>Surgical, arterial, venous, and other wounds do not get staged…only pressure ulcers. </li></ul><ul><li>These wounds are classified as either partial or full thickness </li></ul>
    13. 13. Full-Thickness Wounds <ul><li>Tissue destruction extending through the dermis to involve subcutaneous tissue and possibly muscle or bone </li></ul><ul><li>Heals by: </li></ul><ul><li>Granulation </li></ul><ul><li>Wound Contraction </li></ul><ul><li>Epithelialization </li></ul>Clean dehised surgical wound Clean granular Stage III or IV Pressure Ulcer
    14. 14. “ ASSESSMENTS” <ul><li>A natomic Location- A ge of wound </li></ul><ul><li>S ize, S hape and S tage </li></ul><ul><li>S inus Tracts </li></ul><ul><li>E xudate </li></ul><ul><li>S epsis </li></ul><ul><li>S urrounding Skin </li></ul><ul><li>M aceration </li></ul><ul><li>E dges, E pithelialization </li></ul><ul><li>N ecrotic Tissue </li></ul><ul><li>T issue Bed </li></ul><ul><li>S tatus </li></ul><ul><li>Baranoski and Ayello (2007) </li></ul>
    15. 15. Assessment and Classification by Color <ul><li>RED WOUND </li></ul><ul><li>YELLOW WOUND </li></ul>If charting this wound- 60% slough 40% red granulation tissue
    16. 16. Assessment and Classification by Color <ul><li>BLACK WOUND </li></ul><ul><li>BLACK WOUND </li></ul>
    17. 17. Deep Tissue Injury- new classification of pressure ulcer <ul><li>Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Further description : Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. </li></ul>
    18. 18. Deep Tissue Injury
    19. 19. Measurement Undermining L x W x D Pain! Depth
    20. 20. Sharp Debridement What is wrong with this picture???
    21. 21. Nursing Diagnosis and Goals <ul><li>Impaired Skin Integrity </li></ul><ul><li>Altered Tissue Perfusion </li></ul><ul><li>???????????? </li></ul><ul><li>Cure vs. Palliative Care </li></ul><ul><li>Pain Management </li></ul><ul><li>Multidisciplinary Approach </li></ul>
    22. 22. Moist Wound Healing is the current Standard of Care <ul><li>Enhances angiogenesis </li></ul><ul><li>Enhances epithelial cell migration </li></ul><ul><li>↑ activity of fibroblasts, essential for collagen formation </li></ul><ul><li>Prevents dehydration and tissue cooling </li></ul>
    23. 23. Assessment- Management <ul><li>Wound care products are now classified by action and structure similar to medications-therefore just as all Beta Blockers or Penicillins act in a similar fashion- so do all hydrocolloids and calcium alginates! </li></ul><ul><li>It doesn’t matter what the brand name is- get to know wound care products by how they work in the wound environment! </li></ul>
    24. 24. Disadvantages to Gauze in Topical Therapy <ul><li>Non research based therapy </li></ul><ul><li>More painful </li></ul><ul><li>May impede wound healing </li></ul><ul><li>Increased risk for infection </li></ul><ul><li>Costly and labor intensive </li></ul>
    25. 25. Transparent Dressings ( Op Site ®) First dressings developed to promote moist wound healing <ul><li>Actions </li></ul><ul><li>semi permeable membrane that permits gaseous exchange but prevents bacterial invasion </li></ul><ul><li>Maintains moist wound environment </li></ul><ul><li>Supports autolytic debridement of dry eschar </li></ul><ul><li>Insulates and protects </li></ul><ul><li>Indicated for partial thickness wounds, prevention, and protection, secondary dressing </li></ul><ul><li>Contraindicated in fragile geriatric skin over skin tears </li></ul>
    26. 26. Hydrocolloids (Duoderm ® ) An occlusive moldable wafer <ul><li>Actions </li></ul><ul><li>Supports autolytic debridement </li></ul><ul><li>Absorbs moderate exudate </li></ul><ul><li>Protects and insulates wound </li></ul><ul><li>Normal for exudate to look yellow with a slight odor- doesn’t mean that wound is infected </li></ul><ul><li>Change q. 3-5 days </li></ul><ul><li>Indicated for partial and full thickness wounds with minimal exudate </li></ul><ul><li>Contraindications include infected diabetic ulcers </li></ul>
    27. 27. Hydrogel ( Intrasite ®) Water or glycerin based gels, sheets or impregnated gauzes <ul><li>Actions </li></ul><ul><li>Supports autolytic debridement </li></ul><ul><li>Rehydrates dry, desiccated wounds </li></ul><ul><li>Fills dead space as packing </li></ul><ul><li>Limited absorptive action </li></ul><ul><li>There are no contraindications for gels </li></ul><ul><li>Frequency of dressing changes depends upon type </li></ul><ul><li>Excellent for pain management as they soothe and cool especially radiation burns and herpes zoster </li></ul>
    28. 28. Calcium Alginate (Sorbsan®) Highly absorbent sheets or ropes of “seaweed” <ul><li>Actions </li></ul><ul><li>Exudate absorption </li></ul><ul><li>Wound packing </li></ul><ul><li>Supports autolytic debridement of yellow slough </li></ul><ul><li>Contraindicated in dry eschar and non draining wounds </li></ul><ul><li>Change q. 2-4 days </li></ul>
    29. 29. Foams ( Allevyn ®)- “Sponges” <ul><li>Actions </li></ul><ul><li>Creates a moist wound environment </li></ul><ul><li>Absorbs exudate </li></ul><ul><li>Insulates wound </li></ul><ul><li>Support autolytic debridement </li></ul><ul><li>Contraindicated in dry eschar and non draining wounds </li></ul><ul><li>Can be used on all partial and full thickness wounds </li></ul><ul><li>Change q. 3-7 days </li></ul>
    30. 30. Enzyme Debriders ( Santyl®) <ul><li>Actions </li></ul><ul><li>Selective debridement of fibrin slough </li></ul><ul><li>Digests nonviable protein but is harmless to granulation tissue </li></ul><ul><li>Only works in moist environment and thick eschar must be scored </li></ul><ul><li>Daily or BID dressing </li></ul>
    31. 31. Vacuum Assisted Closure ® <ul><li>The application of negative pressure to remove wound exudate and stimulate the growth of granulation tissue </li></ul><ul><li>Indicated for full thickness wounds, grafts and flaps </li></ul>
    32. 32. I hope this helped you understand the role of the nurse when caring with patients with wounds! See Mrs. Siegel if you have any questions or comments!
    33. 33. Reference <ul><li>Baranoski, S., & Ayello, E. A. (2007). Wound care essentials (2 nd ed.). New York: Lippincott, Williams & Wilkins. </li></ul>