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Wound Management Presentation by Rebira.pptx

This document outlines a presentation on wound management given by Rebira W., a student in the Adult Health Nursing postgraduate program. The objectives of the presentation are to describe the structures and functions of skin, understand the impact of wounds on quality of life, identify different types of wounds and factors affecting wound healing, and know how to manage both acute and chronic wounds. The presentation covers topics such as the anatomy of skin and its layers, types of wounds classified by origin, the phases of wound healing, and managing specific wound types like pressure sores and diabetic foot ulcers.

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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 Rebira W. ( AHN student) 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 Rebira W. ( AHN student)  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 Rebira W. ( AHN student)  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 Rebira W. ( AHN student)  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 Rebira W. ( AHN student) 1 November 2023 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. Rebira W. ( AHN student) 1 November 2023 8
Skin Layers… Rebira W. ( AHN student) 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… Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 1 November 2023 11
… Rebira W. ( AHN student) 1 November 2023 12
Age-Related Changes Rebira W. ( AHN student)  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… Rebira W. ( AHN student)  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 Rebira W. ( AHN student) 1 November 2023 15
Introduction to Wound Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 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
Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 1 November 2023 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 Rebira W. ( AHN student) 1 November 2023 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 Rebira W. ( AHN student) 1 November 2023 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 Rebira W. ( AHN student) 1 November 2023 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 Rebira W. ( AHN student) 1 November 2023 23
Wound Caused by Radiation Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 1 November 2023 26
Surgical… Rebira W. ( AHN student)  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… Rebira W. ( AHN student) 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 Rebira W. ( AHN student)  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 Rebira W. ( AHN student)  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% Rebira W. ( AHN student) 1 November 2023 31
Clinical Types of Healing 1 November 2023 Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 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 Rebira W. ( AHN student)
1 November 2023 Rebira W. ( AHN student) 35  Reading assignment, read the following two points in details! Suture Dressing
Management… 1 November 2023 Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 38  Antibiotics should be used when there is an obvious wound infection  Signs of infection Erythema Cellulitis Swelling Purulent discharge
Irrigation 1 November 2023 Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 1 November 2023 44
Complications… 2. Late complications  Hyperthrophic scar  Keloid formation  Necrosis  Inflammatory infiltration  Abscesses  Foreign body containing abscesses Rebira W. ( AHN student) 1 November 2023 45
Managing Chronic Wounds Rebira W. ( AHN student)  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??????? Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 1 November 2023 52
Rebira W. ( AHN student) 1 November 2023 53
Rebira W. ( AHN student) Many other factors  Shear  Friction  Moisture  Infection 1 November 2023 54
Shear Rebira W. ( AHN student)  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… Rebira W. ( AHN student) 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 Rebira W. ( AHN student)  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 Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 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 Rebira W. ( AHN student) Perspiration Wound drainage Soaking during bathing Fecal and/or urinary incontinence Maceration 1 November 2023 60
Stages of Pressure Sores Rebira W. ( AHN student) 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 Rebira W. ( AHN student) . 1 November 2023 62
Stage II Partial thickness Rebira W. ( AHN student) 1 November 2023 63
Stage III Rebira W. ( AHN student) 1 November 2023 64
Stage IV Rebira W. ( AHN student) 1 November 2023 65
Unstageable Pressure Ulcer Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 1 November 2023 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 Rebira W.( AHN student) 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 Rebira W.( AHN student) 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 Rebira W.( AHN student) 71  Most common sites:  Sacrum =84%  Shoulder= 60%  Most prevalent stages:  Stage II=13(52%)  Stage I=12(48%)
Manage Pressure Rebira W. ( AHN student)  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… Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 1 November 2023 74
Causes  Peripheral neuropathy  Vascular disease  Trauma: acute-any injury to the foot or chronic – deformity  Decreased immune response  Delayed response to tissue injury Rebira W. ( AHN student) 1 November 2023 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 Rebira W. ( AHN student) 1 November 2023 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 Rebira W. ( AHN student) 1 November 2023 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 Rebira W. ( AHN student) 1 November 2023 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 Rebira W. ( AHN student) 1 November 2023 80
Hypertrophic Scars Rebira W. ( AHN student)  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 Rebira W. ( AHN student)  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… Rebira W. ( AHN student) 1 November 2023 83
NOTE Rebira W. ( AHN student)  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 84
Develop Nursing Care Plan (ADOPIE) 1 November 2023 Rebira W. ( AHN student) 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 Rebira W. ( AHN student) 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 86
1 November 2023 Rebira W. ( AHN student) 87 MAY GOD BLESS YOU!

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Wound Management Presentation by Rebira.pptx

  • 1.
    Institute of HealthScience 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
  • 2.
    Objectives Rebira W. (AHN student) 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
  • 3.
    Objectives Rebira W. (AHN student)  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
  • 4.
    Outlines Rebira W. (AHN student)  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
  • 5.
    Outlines Rebira W. (AHN student)  Pressure sores  Diabetic foot ulcers  Hypertrophic scars  Keloid scars  Develop nursing care plan  References 1 November 2023 5
  • 6.
    Anatomy of theIntegument  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
  • 7.
    Skin Layers Epidermis  Outermostlayer of skin, which is thin & avascular  Further divided into five structurally and functionally distinct layers  Corneum  Lucidum  Granulosum  Spinosum  Germinativum (basal layer) Stratum Rebira W. ( AHN student) 1 November 2023 7
  • 8.
    Skin Layers…  Theseseveral 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. Rebira W. ( AHN student) 1 November 2023 8
  • 9.
    Skin Layers… Rebira W.( AHN student) 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
  • 10.
    Skin Layers… Rebira W.( AHN student) 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
  • 11.
    Skin Layers Fascia  Superficialfascia 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 Rebira W. ( AHN student) 1 November 2023 11
  • 12.
    … Rebira W. (AHN student) 1 November 2023 12
  • 13.
    Age-Related Changes Rebira W.( AHN student)  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
  • 14.
    Age… Rebira W. (AHN student)  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
  • 15.
    Physiology of theintegument  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 Rebira W. ( AHN student) 1 November 2023 15
  • 16.
    Introduction to Wound RebiraW. ( AHN student) 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
  • 17.
    Definition Rebira W. (AHN student) 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
  • 18.
    Rebira W. (AHN student) CLASSIFICATION OF WOUNDS 1 November 2023 18
  • 19.
    Based on theOrigin 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 Rebira W. ( AHN student) 1 November 2023 19
  • 20.
    Mechanical wounds Abrasions  Awound in which the surface layers of skin are scraped away.  Superficial part of the epidermal layer.  Good wound healing Rebira W. ( AHN student) 1 November 2023 20
  • 21.
    Mechanical… Puncture  An openingof skin, underlining tissue, or mucous membrane caused by a narrow, sharp, pointed object.  Prone to anaerobic infection & injury of big vessels & nerves Rebira W. ( AHN student) 1 November 2023 21
  • 22.
    Mechanical… Incision wound  Aclean separation of skin & tissue with smooth , even wound edges.  Sharp object  Best healing Cut wound  Sharp object + blunt additional force  Edge- uneven Rebira W. ( AHN student) 1 November 2023 22
  • 23.
    Mechanical… Laceration  Separation ofskin & 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 Rebira W. ( AHN student) 1 November 2023 23
  • 24.
    Wound Caused byRadiation Rebira W. ( AHN student) 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
  • 25.
    Wounds caused bythermal forces Rebira W. ( AHN student) 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
  • 26.
    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 Rebira W. ( AHN student) 1 November 2023 26
  • 27.
    Surgical… Rebira W. (AHN student)  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
  • 28.
    Surgical… Rebira W. (AHN student) 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
  • 29.
    SWI Risk Factors RebiraW. ( AHN student)  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
  • 30.
    Wound Healing Rebira W.( AHN student)  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
  • 31.
    Phases of WoundHealing 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% Rebira W. ( AHN student) 1 November 2023 31
  • 32.
    Clinical Types ofHealing 1 November 2023 Rebira W. ( AHN student) 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.
  • 33.
    Factors Affecting WoundHealing  Ischemia  Infection  Foreign body  Edema, elevated tissue pressure  Age and gender  Sex hormones  Stress  Ischemia  Disease  Obesity  Medication  Alcoholism and smoking  Immunocompromised condition  Nutrition Rebira W. ( AHN student) Local Factors Systemic Factors 1 November 2023 33
  • 34.
    General Principle ofWound 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 Rebira W. ( AHN student)
  • 35.
    1 November 2023 RebiraW. ( AHN student) 35  Reading assignment, read the following two points in details! Suture Dressing
  • 36.
    Management… 1 November 2023 RebiraW. ( AHN student) 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
  • 37.
    Management… 1 November 2023 RebiraW. ( AHN student) 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.
  • 38.
    Antibiotics 1 November 2023 RebiraW. ( AHN student) 38  Antibiotics should be used when there is an obvious wound infection  Signs of infection Erythema Cellulitis Swelling Purulent discharge
  • 39.
    Irrigation 1 November 2023 RebiraW. ( AHN student) 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.
  • 40.
    Management… 1 November 2023 RebiraW. ( AHN student) 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.
  • 41.
    Management… 1 November 2023 RebiraW. ( AHN student) 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.
  • 42.
    Management… 1 November 2023 RebiraW. ( AHN student) 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.
  • 43.
    … 1 November 2023 RebiraW. ( AHN student) 43  Failure to remove the sutures by 7 to 10 days after repair will result in a cosmetically inferior wound.
  • 44.
    Complications of woundhealing 1. Early complications  Seroma  Hematoma  Wound dehiscence & evisceration  Superficial wound infection  Deep wound infection  Mixed wound infection Rebira W. ( AHN student) 1 November 2023 44
  • 45.
    Complications… 2. Late complications Hyperthrophic scar  Keloid formation  Necrosis  Inflammatory infiltration  Abscesses  Foreign body containing abscesses Rebira W. ( AHN student) 1 November 2023 45
  • 46.
    Managing Chronic Wounds RebiraW. ( AHN student)  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
  • 47.
    Brainstorming??????? Rebira W. (AHN student) 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
  • 48.
    Pressure Sores Rebira W.( AHN student) 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
  • 49.
    Etiology of PressureUlcers Rebira W. ( AHN student) 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
  • 50.
    Pressure Rebira W. (AHN student) 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
  • 51.
    Time-Pressure Rebira W. (AHN student) 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
  • 52.
    Bony Prominences  Sacrum Coccyx  Ischial tuberosities  Greater trochanters  Elbows  Heels  Scapulae  Occipital bone  Sternum  Ribs  Iliac crests  Patellae  Lateral malleoli  Medial malleoli Rebira W. ( AHN student) 1 November 2023 52
  • 53.
    Rebira W. (AHN student) 1 November 2023 53
  • 54.
    Rebira W. (AHN student) Many other factors  Shear  Friction  Moisture  Infection 1 November 2023 54
  • 55.
    Shear Rebira W. (AHN student)  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
  • 56.
    Shear… Rebira W. (AHN student) 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
  • 57.
    Shear & Friction RebiraW. ( AHN student)  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
  • 58.
    Friction Rebira W. (AHN student) 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
  • 59.
    Excessive Moisture Rebira W.( AHN student) 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
  • 60.
    Causes of Moisture RebiraW. ( AHN student) Perspiration Wound drainage Soaking during bathing Fecal and/or urinary incontinence Maceration 1 November 2023 60
  • 61.
    Stages of PressureSores Rebira W. ( AHN student) 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
  • 62.
    Stage I Rebira W.( AHN student) . 1 November 2023 62
  • 63.
    Stage II Partialthickness Rebira W. ( AHN student) 1 November 2023 63
  • 64.
    Stage III Rebira W.( AHN student) 1 November 2023 64
  • 65.
    Stage IV Rebira W.( AHN student) 1 November 2023 65
  • 66.
    Unstageable Pressure Ulcer RebiraW. ( AHN student) 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
  • 67.
    Unstageable Rebira W. (AHN student) 1 November 2023 67
  • 68.
    Evidence/Research 12 November 2023 RebiraW.( 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%
  • 69.
    … 12 November 2023 RebiraW.( AHN student) 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%
  • 70.
    … 12 November 2023 RebiraW.( AHN student) 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
  • 71.
    … 12 November 2023 RebiraW.( AHN student) 71  Most common sites:  Sacrum =84%  Shoulder= 60%  Most prevalent stages:  Stage II=13(52%)  Stage I=12(48%)
  • 72.
    Manage Pressure Rebira W.( AHN student)  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
  • 73.
    Manage Pressure Cont’d… RebiraW. ( AHN student) 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
  • 74.
    Support Surfaces Rebira W.( AHN student) 1 November 2023 74
  • 75.
    Causes  Peripheral neuropathy Vascular disease  Trauma: acute-any injury to the foot or chronic – deformity  Decreased immune response  Delayed response to tissue injury Rebira W. ( AHN student) 1 November 2023 76
  • 76.
    Wagner Grading System Grade1: 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 Rebira W. ( AHN student) 1 November 2023 77
  • 77.
    Treatment of FootUlcers 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 Rebira W. ( AHN student) 1 November 2023 78
  • 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 Rebira W. ( AHN student) 1 November 2023 79
  • 79.
    Prevention of FootUlcer 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 Rebira W. ( AHN student) 1 November 2023 80
  • 80.
    Hypertrophic Scars Rebira W.( AHN student)  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
  • 81.
    Keloids Scars Rebira W.( AHN student)  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
  • 82.
    Keloids… Rebira W. (AHN student) 1 November 2023 83
  • 83.
    NOTE Rebira W. (AHN student)  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 84
  • 84.
    Develop Nursing CarePlan (ADOPIE) 1 November 2023 Rebira W. ( AHN student) 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
  • 85.
    References Rebira W. (AHN student) 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 86
  • 86.
    1 November 2023 RebiraW. ( AHN student) 87 MAY GOD BLESS YOU!

Editor's Notes

  • #50  Many other factors—primarily shear, friction, excessive moisture, and possibly infection—interact to mechanically damage soft tissue
  • #61  Fecal incontinence exposes the skin to bacteria in the stool and adds the risk of infection. When a patient is incontinent of both urine and stool, the urea from the urine reacts chemically with the stool and causes further damage.