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Wound healing and care presentation

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  • 1. Wound Healing and Care
  • 2. Objectives  Demonstrate use of four senses in observing skin/wounds (listening, looking, touching, smelling)  List ways to promote healing  Demonstrate routine care of wounds and surgical drains
  • 3. Objectives  Recognize signs/symptoms of inflammation  Demonstrate use of four senses in observing dressing over wound site  Demonstrate correct technique of changing clean and sterile dressings  Document and report care related to skin integrity
  • 4. Anatomy of Skin The skin or integumentary system is the largest system of the body. Hair, nails, and skin glands are a part of this organ system. The skin is a thin, relatively, flat organ that is classified as a cutaneous membrane. It forms a protective boundary between the internal environment of the body and the external environment.
  • 5. Skin Layers Three layers of the skin: 1. Epidermis 2. Dermis 3. Subcutaneous tissue
  • 6. Diagram of the Skin
  • 7. Epidermis  The outer skin layer that is in direct contact with the environment  The epidermis has five layers  Contains skin pigment (melanin) that gives color to the skin Contains a water repellant protein called keratin
  • 8. Epidermis  Cells in the epidermis constantly change and regenerate (research suggests 35 days)  Injury to these cells may cause blisters & calluses
  • 9. Dermis  Contains no skin cells  Composed of collagen (a tough fibrous protein layer), blood vessels, and nerve cells  70% of the dermis layer is collagen which is very important in wound healing  Dermis restores the physical properties of the skin and its structural integrity
  • 10. Dermis  Provides mechanical strength of the skin  Provides a reservoir storage area for water and important electrolytes  Contains a specialized network of nerves and nerve endings for sensation of pain, pressure, touch, and temperature
  • 11. Dermis  Hair follicles  Collagen makes the skin stretchable & elastic  Point of attachment for smooth and voluntary muscles
  • 12. Subcutaneous Layer  Is not part of the skin itself, but supplies the major blood vessels and nerves to the skin above  Loose spongy texture  Ideal site for rapid and relatively pain-free absorption of injected medications (subcutaneous injection)
  • 13. Functions of the Skin Functions of the skin are crucial for maintenance of homeostasis. 1.Protection Barrier against bacteria, foreign matter, dehydration, ultraviolet (UV) light 2. Sensation Sense organ 3. Movement without injury 4. Excretion Regulating the volume and chemical content of sweat
  • 14. Functions of the Skin 5. Vitamin D production Exposure of skin to UV light 6. Immunity Specialized cells that attack and destroy pathogenic microorganisms 7. Temperature regulation Heat production and heat loss (shivering, vasoconstriction, etc)
  • 15. Wound - Definition A break in the skin or mucous membrane; An alteration in the integrity of the skin and underlying tissues.
  • 16. Wound - Causes Causes 1. Surgical incisions 2. Trauma 3. Pressure 4. Shearing force 5. Friction 6. Poor circulation
  • 17. Risk Factors for Developing a Wound  Broken skin  Age (young or old)  Nutritional Status  Stress  Hereditary  Disease process (acute or chronic)  Medical therapies - steroids, chemotherapy, radiation, diuretics
  • 18. Type of Wounds 1. Intentional - created for therapy i.e., surgical 2. Unintentional - resulting from trauma i.e., fall 3. Open wound - skin or mucous membrane is broken 4. Closed wound - tissues are injured but the skin is not broken
  • 19. Type of Wounds 5. Clean wound - not infected, usually intentional 6. Contaminated wound - high risk of infection usually unintentional 7. Infected wound - (dirty wound) contains bacteria; signs of infection
  • 20. Type of Wounds 8. Chronic wound - wound that does not heal easily; can be due to pressure or circulation 9.Partial-thickness wound - epidermis & dermis of the skin is broken (superficial) 10. Full-thickness wound - epidermis, dermis, subcutaneous tissue are involved and may involve muscle and bone (penetrating)
  • 21. Description of Wounds Wounds can be described by cause: 1. Abrasion - scraping or rubbing away of the skin 2. Contusion - closed wound caused by a blow to the body 3. Incision - open wound with clean straight edges
  • 22. Description of Wounds 4. Laceration – open wound with torn tissues and jagged edges 5. Penetrating wound – skin and underlying tissue are pierced 6. Puncture wound - open wound from a sharp object
  • 23. Skin Tears  Occur most frequently in the elderly due to skin changes in the elastic fibers in the dermis, increased fragility of blood vessels, changes in the membrane between the epidermis & dermis, & thickening of collagen  These changes cause the skin to age and the skin appears translucent, wrinkled, thin, dry, fragile & lacking tensile strength
  • 24. Skin Tears  Upper and lower extremities most common site  80% of skin tears occur on the arms and hands  Tears are caused by friction and shearing  Tears are painful and can lead to wound complications
  • 25. Principles of Tissue Healing  The body’s ability to handle tissue trauma is influenced by: Extent of damage, i.e. skin intact or broken Person’s state of health, i.e. nutritional status Body’s response to trauma Healing is promoted when wound is free of foreign bodies and bacteria
  • 26. Phases of Wound Healing Inflammatory or Defensive Stage  Starts when skin integrity is impaired and continues from 4 - 6 days  Homeostasis - blood vessels constrict, platelets stop bleeding forming clots to scabs  Inflammatory response - increased blood flow and vascular permeability causing redness & edema
  • 27. Phases of Wound Healing Inflammatory or Defensive Stage  White blood cells - arrive & clean cell of debris  Epithelial cells - move to base of wound margins for 48 hours
  • 28. Phases of Wound Healing Proliferative or Reconstruction Stage  Closure begins on day 3 or 4 & continues for 2 - 3 weeks  Fibroblasts with vitamin C & B for repair  Collagen - provides strength and structure  Epithelial cells - duplicate damaged cells
  • 29. Phases of Wound Healing Maturation Stage  Final stage of healing & may last for 1 year as the scar strengthens
  • 30. Cleaning a Wound
  • 31. Types of Wound Healing  Primary intention - Incision edges of a clean surgical incision remain close, tissue loss is minimal & skin quickly regenerates  Secondary intention - Open wound with tissue loss and jagged edges, there is a gap between the edges, granulation tissue gradually fills in the area of defect with scar tissue
  • 32. Types of Wound Healing  Tertiary intention Sometimes called delayed intention or closure Surgical wounds are left open 3 - 5 days & then stapled or sutured closed
  • 33. Wound Healing Influencing Factors  Age  Nutrition  Obesity  Extent of wound  Wound stress  Circulating oxygen  Smoking  Drugs  Chronic diseases  Infection (local/systemic)
  • 34. Signs & Symptoms of Infection 1. Erythema and edema 2. Painful and tender 3. Drainage & odor - tan, cream, green, yellow 4. Fever 5. Fatigue
  • 35. Signs & Symptoms of Infection 6. Rash 7. Change in WBC 8. Loss of appetite 9. Mucous membrane sores 10. Elderly: confused, agitated, incontinent
  • 36. Wound Drainage The exudate deposited in or on tissue surfaces during inflammatory & destructive phases of healing.  Drainage must leave the wound for healing to occur  Trapped drainage can lead to infection and other complications
  • 37. Types of Wound Drainage 1. Serous drainage Clear, watery fluid 2. Sanguineous drainage Bloody drainage Large amount - suspect hemorrhage Bright drainage - indicates fresh bleeding Darker drainage - indicates older bleeding
  • 38. Types of Wound Drainage 3. Serosanguineous drainage Thin watery drainage that is blood tinged 4. Purulent drainage Thick green, yellow, or brown drainage
  • 39. Drains When large amounts of drainage are expected, the physician inserts a drain to aid in healing. drainage systems can be opened or closed.  Penrose drain An open drain that drains exudate onto the dressing; no suture; safety pin prevents slippage into the wound; drains by gravity
  • 40. Drains  Hemovac Closed suction drainage, sutured in place  Jackson-Pratt Closed suction drainage, sutured  T-tube Closed drainage, sutured; drains by gravity
  • 41. Drains  Keep drainage tubes free of kinks  Drainage collection reservoir is emptied every eight hours and when 1/2 to 1/3 full  Drainage volume decreases 2 - 3 days after insertion  Report any purulence, foul odor, redness around insertion site, bleeding
  • 42. Hemovac
  • 43. Jackson - Pratt
  • 44. T - Tube
  • 45. Measuring Drainage  Note the number and size of dressings with drainage (describe amount)  Weighing dressing before and after removal  Measuring the amount of drainage in the collection receptacle  Record on I&O form
  • 46. Wound Complications  Hemorrhage  May be internal or external  Shock  Low or falling blood pressure; rapid, weak pulse; rapid respirations; skin - cold, moist, and pale; restless; confusion; loss of consciousness  Infection  Dehiscence Separation of wound layers, usually abdominal, caused by wound stress (coughing, vomiting, abdominal distention); surgical emergency
  • 47. Wound Complications  Evisceration Separation of wound with protrusion of abdominal organs, surgical emergency, cover with normal saline sterile dressings, notify RN immediately  Fistula An abnormal tube-like passage from a normal cavity or tube to a free surface or to another cavity
  • 48. Wound Observations  Wound location May have multiple wounds from surgery or trauma  Wound size and depth Measure in centimeters Size - measure from top to bottom, side to side Depth - use a sterile swab into the depth of the open wound, RN supervision  Wound appearance Red, swollen, area around wound warm to touch, sutures, staples - intact or broken
  • 49. Wound Observations  Drainage COCA (Color, Odor, Consistency, Amount)  Drains  Odor of wound  Surrounding skin Intact, color, swollen  Pain Review facility’s pain assessment tool