Wound Management Presentation by Rebira.pptx

Institute of Health Science
Department of Nursing
Postgraduate Program of Adult Health Nursing
Wound Management Presentation
Set By: Rebira Workineh (AHN Student)
Rebira W. ( AHN student)
1 November 2023
1

Objectives
At the end of this lesson, the participants will be able to:
 Describe the structures and functions of the skin
 Understand the adverse impact of wound on quality of life
 List types of wounds
 Express wound healing
 Identify factors affecting wound healing
 Know how to manage wounds
1 November 2023
2

Objectives
 Describe complications of wound healing
 Explain how to manage chronic wounds
 Differentiate pressure sores
 Describe diabetic foot ulcer
 Differentiate hypertrophic scars from keloid scars
 Know how to develop nursing care plan for a patient with wounds
1 November 2023
3

Outlines
 Overview of the integument
 Introduction to wound
 Types of wounds
 Wound healing
 Factors affecting wound healing
 General principle of wound management
 Complications of wound healing
 Managing chronic wound
1 November 2023
4

Outlines
 Pressure sores
 Diabetic foot ulcers
 Hypertrophic scars
 Keloid scars
 Develop nursing care plan
 References
1 November 2023
5

Anatomy of the Integument
 The skin is the largest organ of the body and provides the interface between
the body and the rest of the world
 The skin provides the first line of host defense mechanisms and protects the
integrity and functioning of internal organ systems
 The psychosocial aspect of skin appearance is extremely important to a
person’s well-being.
Rebira W. ( AHN student) 1 November 2023
6

Skin Layers
Epidermis
 Outermost layer of skin, which is thin & avascular
 Further divided into five structurally and functionally distinct layers
 Corneum
 Lucidum
 Granulosum
 Spinosum
 Germinativum (basal layer)
Stratum
7

Skin Layers…
 These several thin layers of the epidermis contain the following:
Melanocytes
 Produce melanin, a pigment that gives skin its color and protects it from the
damaging effects of ultraviolet radiation.
Keratinocytes
 Produce keratin, a water repellent protein that gives the epidermis its tough,
protective quality.
8

Skin Layers…
Dermis
 The layer of skin lying beneath the epidermis
 Is highly vascular and tough connective tissue
 Contains collagen and elastic fibers, nerve fibers, lymphatics, sweat and
sebaceous glands, and hair follicles.
1 November 2023
9

Skin Layers…
SubcutaneousTissue
 Made up of dense connective & adipose tissue
 Houses major blood vessels, lymphatics, and nerves
 Acts as a heat insulator
 Provides a nutritional depot that is used during illness or starvation
 Also acts as a mechanical shock absorber and helps the skin move easily over the
underlying structures
1 November 2023
10

Skin Layers
Fascia
 Superficial fascia is below the subcutaneous tissue of the skin
 Is a type of dense, firm, membranous connective tissue
 Connects the skin to subjacent parts and facilitates movement
11

…
12

Age-Related Changes
 Sweat glands diminish in number
 Epithelial and fatty layers of tissue atrophy and become thin
 Thickness of subcutaneous fat on the legs or forearms diminishes, even if
abdominal or hip fat remains abundant
 Collagen and elastin shrink and degenerate
1 November 2023
13

Age…
 Collagen content of the skin decreases by approximately 1% per year
throughout adult life.
 The net effect of all these changes is thin, dry, and inelastic skin that is
increasingly susceptible to separation of dermis and epidermis as minor
friction or shearing forces cause an injury known as skin tear.
1 November 2023
14

Physiology of the integument
 Protection: intact skin prevents invasion of the body by bacteria
 Thermoregulation: intact skin facilitates heat loss and cools the body when
necessary
 Fluid and electrolyte balance: intact skin prevents the escape of water and
electrolytes from the body
 Vitamin D Synthesis
 Sensation
 Psychosocial
15

Introduction to Wound
Wounds have substantial adverse impact on client’s quality of life and have
a predictive risk with mortality.
Better understanding of the etiology of the wound & following the evidenced
based management protocols can:
o Extremely improve client’s health outcomes
o Lower the cost of the medical care
1 November 2023
16

Definition
Wound is defined as a break in the normal continuity of a tissue.
Is a disruption in the integrity of body tissue which may be intentional or
unintentional.
Caused by a transfer of any form of energy into the body w/c can be either to:
An externally visible structure like the skin
Deeper structures like muscles, tendons or internal organs
1 November 2023
17

CLASSIFICATION OF WOUNDS
1 November 2023
18

Based on the Origin
1. Mechanical
 Incisions or incised wounds
 Lacerations
 Abrasions
 Avulsions
 Ulceration
 Puncture
 Crush wound
 Shot wound
2. Chemical
 Acid
 Base
3. Wound caused by radiation
4. Wound caused by thermal forces
 Burning
 Freezing
5. Special
 Exotic, poisonous animals
19

Mechanical wounds
Abrasions
 A wound in which the surface layers of skin are scraped away.
 Superficial part of the epidermal layer.
 Good wound healing
20

Mechanical…
Puncture
 An opening of skin, underlining tissue, or mucous membrane caused by a
narrow, sharp, pointed object.
 Prone to anaerobic infection & injury of big vessels & nerves
21

Mechanical…
Incision wound
 A clean separation of skin & tissue with smooth , even wound edges.
 Sharp object
 Best healing
Cut wound
 Sharp object + blunt additional force
 Edge- uneven
22

Mechanical…
Laceration
 Separation of skin & tissue in which the
edges are torn & irregular.
Crush wound
 Blunt force
 Pressure injury
 Edges-uneven & torn
 Bleeding
Shot wound
 Close-burn injury
 Foreign materials
Bite wound
 Torn
 Infection
 Bone fracture
 Prevention of rabies
23

Wound Caused by Radiation
Symptoms and severity depends on:
 Amount of radiation
 Length of exposure
 Body part that was exposed
 Symptoms may occur immediately, after a few days, or even as long as months.
 Body parts mostly sensitive to radiation sickness:
 Bone marrow
 Gastrointestinal tract
1 November 2023
24

Wounds caused by thermal forces
Burning
1st degree – superficial injury (epidermis)
2nd degree –partial or deep partial thickness (epidermis+superficial or deep dermis)
3rd degree – full thickness (epidermis + entire dermis)
4th degree – (skin + subcutaneous tissue + muscle and bone)
Freezing
 Mild, moderate, severe (redness, bullas, necrosis)
 Rewarm – not only the frozen area but the whole body
1 November 2023
25

Surgical Wound Infection
 Traditional surgical wound classification scheme introduced in 1964 classifies the wounds
based on the rate of infection
Clean
 Non-traumatic , non-infected
 No break in sterility technique
 Respiratory tract , GI, & Gut not entered
Clean-contaminated
 Minor break in sterility technique
26

Surgical…
 GI , Resp tracts entered, no sign.
 Spillage GUT ,biliary tracts entered , no infected urine or bile
Contaminated
 Fresh traumatic wounds
 Major break in sterility
 Gross spillage from GI tract
 Entrance of Gut or biliary tract in the presence of infected urine or bile
1 November 2023
27

Surgical…
Dirty & infected
 Acute bacterial inflammation without pus
 Wound with heavy contamination
 Transection of clean wounds for the purpose of surgical access to collect pus,
traumatic wound with retained devitalized tissue
1 November 2023
28

SWI Risk Factors
 Age > 60 years
 Female
 Obesity
 Infections
 Underlying disease
 Diabetes, Congestive heart failure
 Liver disease, renal failure
 Duration of preoperative stay hospitalization > 72 hours, ICU stay
 Immunosuppression
1 November 2023
29

Wound Healing
 Wound healing is a mechanism whereby the body attempts to restore the
integrity of the injured part.
 The disruption in the integrity of tissue, whether surgical or traumatic,
stimulates a series of events that attempts to restore the injured tissue to a
normal state.
1 November 2023
30

Phases of Wound Healing
1. Hemostasis-inflammation
 Vasoconstriction
 Fibrin clot formation
 Proinflammatory citokines and
 Growth factors releasing
 Vasodilatation
 Infiltration PMNs, macrophages cytokines
releasing
→ Angiogensis
→ Fibroblast activation
→ B- and T-cells activation
→ Keratinocytes activation
→ Wound contraction
2. Granulation-proliferation
 Fibroblast migration
 Collagen deposition
 Angiogensis
 Granulation tissue formation
 Epithelisation
 Contraction
3. Remodelling-maturation
 Regression of many capillaries
 Physical contraction – myofibroblasts
 Collagen degeneration and
synthetisation
 New epithelium
 Tensile strength – max. 80%
31

Clinical Types of Healing
1 November 2023
32
Healing by first intention
 Clean, straight line, edges well approximated with sutures, rapid healing
 Healing occurs by epithelialization, minimal scar formation
Healing by second 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
Healing by third intention (delayed primary closure)
 Delay 3-5 days before injury is sutured, greater access for pathogens to invade, greater inflammation,
more granulation, larger scars.

Factors Affecting Wound Healing
 Ischemia
 Infection
 Foreign body
 Edema, elevated tissue pressure
 Age and gender
 Sex hormones
 Stress
 Ischemia
 Disease
 Obesity
 Medication
 Alcoholism and smoking
 Immunocompromised condition
 Nutrition
Local Factors Systemic Factors
1 November 2023
33

General Principle of Wound Management
Goal
 To aid the natural body process
 To produce optimal functional,
cosmetic results
Wound may require:
 Irrigation
 Suture
 Dressing
 Debridement
 Anesthesia
 Antibiotics and tetanus prophylaxis
1 November 2023
34

1 November 2023
35
 Reading assignment, read the following two points in details!
Suture
Dressing

Management…
1 November 2023
36
 Management of acute wounds begins with obtaining a careful history of the events
surrounding the injury
 History taking is followed by a meticulous examination of the wound.
 Examination assessment include:
 The depth and configuration of the wound
 The extent of nonviable tissue
 The presence of foreign bodies and other contamination

Management…
1 November 2023
37
 Lidocaine ( 0.5 to 1%), or bupivacaine (0.25 to 0.5%) combined with a
1:100,000 to 1:200,000 dilution of epinephrine to provide satisfactory
anesthesia and hemostasis.
 Epinephrine should not be used in wounds of the following organs.
o Fingers, toes, ears, nose, and penis
 B/c of risk of tissue necrosis secondary to terminal arteriole vasospasm in
these structures.

Antibiotics
1 November 2023
38
 Antibiotics should be used when there is an obvious wound infection
 Signs of infection
Erythema
Cellulitis
Swelling
Purulent discharge

Irrigation
1 November 2023
39
 Irrigation to visualize all areas of the wound and remove foreign materials is best
accomplished with normal saline.
 High-pressure wound irrigation is more effective in achieving complete debridement
of foreign material and nonviable tissues
 Iodine, povidone-iodine and H2O3 are organically based antibacterial preparations.
 They have been shown to impair wound healing b/c of injury to wound neutrophils
and macrophages, and thus should not be used.

Management…
1 November 2023
40
 After the wound has been anesthetized, explored, irrigated, and debrided, the
area surrounding the wound should be cleaned, inspected, and the
surrounding hair clipped.
 The area surrounding the wound should be prepared with povidone-iodine or
similar solution and draped with sterile towels.

Management…
1 November 2023
41
 Having ensured hemostasis and adequate debridement of nonviable tissues
and removal of any remaining foreign bodies, irregular, macerated, or beveled
wound edges should be debrided to provide a fresh edge for re-
approximation.
 Initial sutures the realign the edges of these tissue types will speed and greatly
enhance the anesthetic outcome of the wound repair.

Management…
1 November 2023
42
 In general, the smallest suture required to hold the various layers of the
wound in approximation should be selected to minimize suture related
inflammation.
 In areas with significant superficial tissue loss, split-thickness skin grafting
may be required.
 After closing deep tissues and replacing significant tissue deficits, skin edges
should be re-approximated for cosmetic and rapid wound healing.

…
1 November 2023
43
 Failure to remove the sutures by 7 to 10 days after repair will result in a
cosmetically inferior wound.

Complications of wound healing
1. Early complications
 Seroma
 Hematoma
 Wound dehiscence & evisceration
 Superficial wound infection
 Deep wound infection
 Mixed wound infection
44

Complications…
2. Late complications
 Hyperthrophic scar
 Keloid formation
 Necrosis
 Inflammatory infiltration
 Abscesses
 Foreign body containing abscesses
45

Managing Chronic Wounds
 Pressure sore
 Diabetic foot ulcer
 Hypertrophic scars
 Keloids
NB: A chronic ulcer, unresponsive to dressings and simple treatments should be
biopsied to rule out neoplastic change.
1 November 2023
46

Brainstorming???????
Which one is true or false? Why?
1. Low pressure endured for long periods of time is believed to be more
significant in producing pressure ulcers than higher pressure of short
duration.
2. Higher pressure endured for short periods of time is believed to be more
significant in producing pressure ulcers than low pressure of long
duration.
1 November 2023
47

Pressure Sores
These can be defined as tissue necrosis with ulceration due to prolonged
pressure.
Less preferable terms are bed sores, pressure ulcers and decubitus ulcers.
They should be regarded as preventable but occur in approximately 5% of all
hospitalized patients.
Ulcers can form when a person constantly maintains any position causing
pressure to a site.
1 November 2023
48

Etiology of Pressure Ulcers
Pressure ulcers usually occur in soft tissue over bony prominences that remain in
contact with compressing surfaces.
Pressure ulcers are the clinical manifestation of local tissue death.
Cellular metabolism depends on blood vessels to carry nutrients to the tissues and to
remove waste products.
When the soft tissue is subject to prolonged pressure & insufficient nutrients the
result is cell death.
1 November 2023
49

Pressure
Muscle is more sensitive to compression than skin
The deeper muscle tissue may be necrotic before damage to the overlying skin
is apparent
The force of pressure increases as the affected body surface area decreases
The normal response to prolonged pressure is a change in body position before
tissue ischemia occurs.
1 November 2023
50

Time-Pressure
Low pressure endured for long periods of time is believed to be more significant in
producing pressure ulcers than higher pressure of short duration.
If the time-pressure threshold is reached or exceeded, tissue damage continues even
after pressure is released.
Pressure ulceration can result from one period of sustained pressure
Most pressure ulcers occur secondary to repeated ischemic events without adequate
time for recovery
1 November 2023
51

Bony Prominences
 Sacrum
 Coccyx
 Ischial tuberosities
 Greater trochanters
 Elbows
 Heels
 Scapulae
 Occipital bone
 Sternum
 Ribs
 Iliac crests
 Patellae
 Lateral malleoli
 Medial malleoli
52

53

Many other factors
 Shear
 Friction
 Moisture
 Infection
1 November 2023
54

Shear
 Shear occurs when two surfaces move in the opposite direction.
 For example, when a bed is elevated at the head, you can slide down in bed.
 As the tailbone moves down, the skin over the bone might stay in place-essentially
pulling in the opposite direction
 Shear is a mechanical force that is parallel rather than perpendicular to an area with
the main effect impacting deep tissues
 Elevating the head of the bed increases shear and pressure in the sacral and coccygeal
areas
1 November 2023
55

Shear…
The mechanical forces can obstruct or tear and stretch blood vessels
Minimizing shearing forces involves raising the head of the bed to no more
than a 30 degree angle, except for short periods of time.
Shearing forces decreases the time tissue can remain under pressure.
If shear is present, vascular occlusion may occur at half the usual amount of
pressure.
1 November 2023
56

Shear & Friction
 Shear injury will not be seen at the skin level because it happens beneath
the skin
 Shear and friction go hand in hand—one rarely occurs without the other
 Friction is the force of two surfaces moving across one another
 Friction injury will be visible
1 November 2023
57

Friction
Erosion of surface tissue increases the potential for deeper tissue damage
because friction is the precursor of shear.
At risk for friction injuries:
o Individuals who have spastic conditions
o Patients who wear braces or appliances that rub against the skin
o The elderly
1 November 2023
58

Excessive Moisture
Moist skin is five times as likely to become ulcerated as dry skin
Constant exposure to wetness can waterlog or macerate the skin
Macerated epidermis is easily eroded
Wet skin surfaces increase the risk of friction as the patient is moved across
the surface of the bed linen.
1 November 2023
59

Causes of Moisture
Perspiration
Wound drainage
Soaking during bathing
Fecal and/or urinary incontinence
Maceration
1 November 2023
60

Stages of Pressure Sores
Stage 1: Non-blanchable erythema without a breach in the epidermis
Stage 2: Partial thickness skin loss involving the epidermis and dermis
Stage 3: Full-thickness skin loss extending into the subcutaneous tissue but not
through underlying fascia
Stage 4: Full-thickness skin loss through fascia with extensive tissue
destruction, may be involving muscle, tendon, joint or bone
1 November 2023
61

Stage I
.
1 November 2023
62

Stage II Partial thickness
63

Stage III
64

Stage IV
65

Unstageable Pressure Ulcer
Full thickness tissue loss in which the base of the ulcer is covered by slough
and/or eschar in the wound bed
Note: Until enough slough and/or eschar is removed to expose the base of the
wound, the true depth, and therefore stage, cannot be determined
1 November 2023
66

Unstageable
67

Evidence/Research
12 November 2023
Rebira W.( AHN student)
68
1. Study conducted at University of Turku in Finland (cross-sectional)
 Among 270 studied populations, the prevalence of PU was 158 (5%)- November 2015 to January
2016.
 The most prevalent stages of PU were stage II and I which was 39% and 37% respectively.
 The most common sites identified were:
 Heel=37%
 Sacrum=26%
 Buttocks=10.8%
 Lateral malleolus=10%
 Hip=8%

…
12 November 2023
69
2. Study conducted at seven sites in Ethiopia (cross-sectional)
 The prevalence of PU was 11.7% among 1881 studied participants (From January
1, 2000-June 1, 2019)
 Stages of pressure ulcers:
 Stage I=40.89%
 Stage II=32.11%
 Stage III=11.47%
 Stage IV= 4.31%

…
12 November 2023
70
3. Study conducted at Arba Minch, Jinka University in Southern Ethiopia (prospective
cohort study)
 Among adult patients in ICU 216 followed prospectively, 25 (11.57%) developed
pressure ulcers after 6 days of admission-June 2021 to April 2022.
 Predictors identified in this study were:
 Age >= 40 years-three times risk for developing pressure ulcers
 Friction/Shear-four times more risk for developing pressure ulcers than not
having friction/shear

…
12 November 2023
71
 Most common sites:
 Sacrum =84%
 Shoulder= 60%
 Most prevalent stages:
 Stage II=13(52%)
 Stage I=12(48%)

Manage Pressure
 Friction & shear management-use lift/turn sheets , and maintaining head of bed
at <30 degree
 Turn & Reposition frequently
 Pressure reduction & pressure redistribution utilizing low air loss mattress with
alternating pressure
 Skin protection dressings over high risk areas
 Pain management
1 November 2023
72

Manage Pressure Cont’d…
Optimal Nutrition & hydration management
Temperature - keeping skin cool, clean and dry
Off-loading of pressure areas e.g. heel protectors
Topical agents to relieve skin dryness
o Lotions
o Creams
o Ointments
1 November 2023
73

Support Surfaces
74

Causes
 Peripheral neuropathy
 Vascular disease
 Trauma: acute-any injury to the foot or chronic – deformity
 Decreased immune response
 Delayed response to tissue injury
76

Wagner Grading System
Grade 1: Superficial diabetic ulcer
Grade 2: Ulcer extension
o Involves ligament, tendon, joint capsule or fascia
o No abscess or osteomyelitis
Grade 3: Deep with abscess or osteomyelitis
Grade 4: Gangrene to portion of forefoot
Grade 5: Extensive gangrene of foot
77

Treatment of Foot Ulcers
Wagner 0-2
 Surgical if deformity present that will reulcerate
o Correct deformity
o Exostectomy
Wagner 3
 Excision of infected bone
 Wound allowed to granulate
 Grafting (skin or bone) not generally effective
Wagner 4-5
 Amputation
78

Drug Treatment
First line
 Ampicillin 1 g IV QID for 2-3 weeks
PLUS
 Gentamicin 3-5 mg/kg IV QD in divided doses
PLUS
 Metronidazole 500mg IV QID, for 10-14 days
Alternatives
 Ceftazidime 1 gm IV TID
Plus
 Gentamicin 3-5 mg/kg I.V. daily QD in divided doses
Plus
 Metronidazole 500mg IV QID for 10-14 days
79

Prevention of Foot Ulcer
Regular inspection & examination of foot & foot wear
Identification of high risk patient
Education of patient, family & health care providers
Appropriate foot wear
Treatment of non ulcerative pathology
80

Hypertrophic Scars
 These lesions are raised and thickened.
 This process does not extend beyond the boundary of the scar.
 Exacerbated by tension lines on the area of surgery: knee & elbow
Treatment
 Nearly all hypertrophic scars undergo a degree of spontaneous resolvement
 If present after six months, surgical excision is indicated
 Pressure applied early to a lesion is also of benefit
 Intractable lesions can be injected with triamcinolone
1 November 2023
81

Keloids Scars
 Raised and thickened. This process extends beyond the boundary of the incision.
 Keloids scars will keep on evolving for two years, these scars are not contagious.
Site: Chest, shoulder, upper back, back of neck and earlobes.
Treatment
 Applying early pressure
 Injection of triamcinolone, or corticosteroids
 Excision with above activities
1 November 2023
82

Keloids…
83

NOTE
 Hypertrophy and keloid formations are an overactive response to the
natural process of wound healing.
 Hypertrophy scars don’t extend beyond the boundary of the incision.
 Keloid scars extend beyond the boundary of the incision.
1 November 2023
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Develop Nursing Care Plan (ADOPIE)
1 November 2023
85
1. Assessment: Data collection
2. Diagnosis: Analysis of data
3. Outcome Identification: Setting measurable criteria
4. Planning: Goals prioritized
5. Implementation: Intervention, action
6. Evaluation: Goal met? Reassessment

References
1. Bailey and loves, short practice of surgery, 26th edition
2. Schwartz, principle of surgery, 8th edition
3. Surgery lecture note for health officers
4. Demarco, Sharon. “Wound and Pressure Ulcer Management.” Johns Hopkins
Medicine. 11 March 2014.
5. Wilhelmy, Jennifer, RN, CWCN, CNP. “Save our Skin Heal our Holes: The
basics of pressure ulcer prevention and wound care. DDNA National
Conference 2014.
1 November 2023
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1 November 2023
87
MAY GOD BLESS YOU!

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