Wound care presented by abdulsalam mohammed nursing officer, reconstructive plastic surgery and burns center, korlebu teaching hospital ghana
Wound CareReconstructive PlasticSurgery and Burns CenterKorlebu Teaching HospitalPresented By Abdulsalam MohammedNursing Officer//06.june.2013WOUND CARE
Importance ofPresentationPlatform for assessmentand re-evaluation of ournursing activities anddutiesPeriod of transfer ofexperience among usAssertiveness TrainingHighlight new trends inthe nursing professionNOTE: Gone are the dayswhen nursing were notconsidered a professionToday nursing has a bodyof knowledgeIs dynamic and rest on theshoulders of constantreading, researchingRPS/BC Cant be leftout
Introduction and Background Objectives Definition of terms Anatomy of the skin wound healing Wound care as a concept Wound Dressing vs. Wound care Nursing management Treatments of wounds Challenges and recommendation conclusion
Wound care is a very vital issue affecting nursing worldwideIt is a concern that transcends medical ,surgical as well asall others departments of health service.In RPS/BC about 100% of all patients have wounds of onesort or the otherDressing items are very expensiveHowever, when care is not taken wound will deterioraterather than heal at the hands of health professionalsHence wound management is an integral process and careproviders must constantly upgrade skills and knowledgeappropriately.
Wound…. A break in the integrity of the skinor any tissueE.g. Pressure ulcer, Burns , Buruli ulcer,Avulsion injury surgical incision, Carcinomaulceration, Cellulitis wound, ulceration of boiletcIt may or may not include underlying tissuesMay be Acute ( Expected to heal) or chronicMay be surgical or traumaticMay be clean or infected.
The skin is the largest organ of the body,making up 16% of body weight.It has several vital functions, which include;immune function, temperature regulation,sensation and vitamin production. Skin is a dynamic organ in a constant state ofchange; cells of the outer layers arecontinuously shed and replaced by inner cellsmoving to the surface.
Epidermis: outer layer . comprised ofepithelial cells avascular 0.04mm thick Regeneratedevery 2-4weeks, receives nutrientsfrom the dermisbelowcomprised of 4 to 5layers depending onthe body locationHypodermis: inner most layer(subcutaneous layer) supports the dermis andepidermis varies in thickness anddepth comprised of adiposetissue, connective tissueand blood vessels store lipids, protectunderlying organs, provideinsulation and regulatetemperature Skin Appendages:Includes Sweat glands,hair, nails and sebaceousglands which are allconsidered epidermal Dermis:middle layer 0.5mm thick o made of twolayers very vascular contains nerves,connective tissue,collagen, elastinand specializedcells such asfibroblasts andmast cells Responsible forinflammatoryreactions o receptors forheat, cold, pain,pressure, itch andtickle
Phase 1 - INFLAMMATORY PHASE (0-3 Days) the bodysnormal response to injury. This phase activates vasodilatationleading to increased blood flow causing HEAT, REDNESS, PAIN,SWELLING, LOSS OF FUNCTION (e.g. arm swells and cannotbend). Wound ooze may be present and this is also a normalbody response. Phase 2 - PROLIFERATIVE PHASE (3-24 Days) the timewhen the wound is healing. The body makes new bloodvessels, which cover the surface of the wound. This phaseincludes reconstruction and epithelialization. The wound willbecome smaller as it heals. Phase 3 - MATURATION PHASE (24-365 Days) the finalphase of healing, when scar tissue is formed. The wound atthis stage is still at risk and should be protected wherepossible. This process forms the underlying knowledge base for thecare and management of Wounds
healing by first intention that in whichunion or restoration of continuity occursdirectly without intervention ofgranulations. healing by second intention union byclosure of a wound with granulations. healing by third intention treatment ofa grossly contaminated wound by delayingclosure until after contamination has beenmarkedly reduced and inflammation hassubsided.
Is not just the few minutes or hours spend in the treatmentroom or theater, for dressing, cleaning, and bandaging ofthe wound It includes all activities before, during and after the wounddressing that has direct or indirect, local or systemicbearing on the healing of the wound Wound dressing is a vital part of the process Example include eg nutritional status, pain management,psychological management, management of underlyingconditions, etc We are aware of it but we may lack the sense ofcoordinating all nursing on activities too often.
Detail Assessment of WoundHistory takenEstimation of the Wound size or TBSATetanus prophylaxisPsychological preparationPain managementAntibiotic therapySupportchoose appropriate lotionset up trolley
Reassure patient Position the patient in comfortable situation eg chair or bath Assessment of wound site Removal of old dressing layer one at a timeCommunicate with the patientWork in unison with your assistance or team membersMaintain accept techniques throughout Primary dressing should not be forced Observe the patient , throughout the process for any changes eg pain, bleeding,color Clean with antiseptic agents eg savlon, saline, acetic Irrigation with saline is very ideal Cleaning or dubbing is dependent on the wound Apply appropriate lotion Apply dressing and bandage, and secure well with plaster Decontaminate the instruments and bath accordingly
lotion indication RemarksNormal saline Irrigation, Irrigation &Dressing………………………………….Savlon Antiseptic Cleansingagent for woundSkin reactions may occurAcetic Acid1:19Pseudomonas infections…wound is greenish/PinkCan cause allergic reacrionDermazine CreamHilderFor debridement of burnswound..penetrate deepinto the burnt tissuesLess toxicity, but contraindicatedwith patient who react to silverNadoxine cream Anbiotic topical cream SensititivityPovidine/Betadine(Aqeous base)For debridement andgranulation formationToxicity if used on wide areaIonsil Antimicrobial gell hypersensitifyChloranphenicol cream Antibiotic mostly forperenial and faceHydrgen peroxide Outmoded and not in use
Documentation It is an expectation that all aspects of care,including assessment, treatment and managementplans, implementation and evaluation aredocumented clearly and comprehensively. All wounds should be assessed regularly andoutcomes of the assessment documented. A Woundcare Chart can be used to monitor and record theprogress of the wound through its stages of healing.Simple wound documentation can be captured inprogress notes and treatment plan
Wound cleansing should not be undertaken to removenormal exudate Cleansing should be performed in a way that minimisestrauma to the wound Wounds are best cleansed with sterile isotonic saline orwater The less we disturb a wound during dressing changes thelower the interference to healing Fluids should be warmed to 37°C to support cellularactivity Skin and wound cleansers should have a neutral pH and benon-toxic Avoid alkaline soap on intact skin as the skin pH isaltered, resistance to bacteria decreases
Maintain a moist environment at the wound/dressing interface Be able to control (remove) excess exudates. A moist woundenvironment is good, a wet environment is not beneficial Not stick to the wound, shed fibres or cause trauma to the wound orsurrounding tissue on removal Protect the wound from the outside environment - bacterial barrier Good adhesion to skin Sterile Aid debridement if there is necrotic or sloughy tissue in the wound(caution with ischaemic lesions) Keep the wound close to normal body temperature Conformable to body parts and doesnt interfere with body function Be cost-effective Diabetes - choose dressings which allow frequent inspectionNon-flammable and non-toxic
Local indicators Redness (erythema orcellulitis) around the wound Increased amounts ofexudate Change in exudatescolour Localised pain Localised heat Delayed or abnormalhealing Wound breakdownSystemicindicators Increased systemictemperature General malaise Increased leucocyte count Lymphangitis
Malnutrition- inadequatesupply of protein, carbohydrates,fatty acids, and trace elementsessential for all phases of woundhealing Reduced Blood supply -Cardiovascular disorders andIschaemia Medication - Non-steroidalanti inflammatory drugs andCorticosteroids. Chemotherapy - suppressesthe immune system andinflammatory response Radiotherapy - increasesproduction of free radical whichdamage cells Psychological stressand lack of sleep- increase riskof infection and delayed healing Obesity - decreases tissueperfusion Infection -prolong inflammatoryphase, use vital nutrients, impairepithelialisation and release toxins Reduced woundtemperature - prolongeddressing changes or use of coldcleansing products. Underlying Disease -Diabetes Mellitus and Autoimmunedisorders Inappropriate wound management Patient compliance Unrelieved pressure Immobility Substance abuse including alcoholand cigarette smoke
Antibiotic Therapy –Medications used to addressbacterial contamination of thewound Compression Therapy – Theapplication of pressure dressingsand wraps may reduce swelling oftissues and may promote propervenous blood drainage and arterialblood supply Debridement – this is theprocess of removing dead tissuefrom the wound bed in order tostimulate the wound bed andpromote healing * Education – The Wound CareStaff will provide informationregarding ambulation andexercise, diet and nutrition, andself care Offloading – Reduction ofpressure from bony area of the bodyand other areas creating pressure isimportant to address the underlyingdisorder of the wound itself Skin Grafts – The physician staffcan take a patient into the operatingroom for an autologous (graft is fromthe patient’s own skin) or in theWound Care Center using a skinsubstitute product Wound Vaccum – “Wound Vac”– This treatment has proven to bevery effective to reduce the andremove unnecessary fluid andbacteria from around your wound * Hyperbaric Oxygen Therapy –"HBOT” – This is a therapy that isavailable in the Wound Care Center.It is designed to deliver increasedconcentrations of oxygen directly tothe wound site – oxygen rich bloodis a necessary component toeffective healing.
CHALLENGESNursing staffLogistical challengesDocumentationRECCOMENDATIONRemember always wound care is notjust wound dressingConclusionThe most important practical lesson thatcan be given to nurses is to teach thewhat to observe, how to observe, whatsymptoms indicate improvement, what isthe reverse, which kind of importance,which are none, which are the evidencesof neglect and what kind of neglect”Florence nightingale ,1992.p59ReferencesAustralian Wound Management Association Inc. (August2011). Bacterial impact on wound healing: Fromcontamination to infection. Position Paper, Version 2.# Ashton J, Morton N, Beswick S, Barker V, Blackburn F,Wright C, Turner L, Morton K, Jennings A. BoltonNHS -Primary Care Trust. (March 2008) "Wound careGuidelines"
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