Wound cars and wound healing
Integumentary System: Objective Overview
Purpose and Function of the Skin (Tyerman & Cobbett, 2023)
Barrier from Bacterial Invasion: Protects against pathogens.
Cushion Against External Pressures: Absorbs shock and prevents injury.
Fluid, Temperature, and Immune Regulator: Maintains homeostasis.
Provides Sensory Information: Affects defensive responses to environmental stimuli.
Alterations in Skin Integrity: Can impair skin function.
Factors Supporting Healthy Skin
Adequate Blood Supply: Essential for nourishment and healing.
Adequate Nutrition: Requirement for skin repair and maintenance.
Adequate Moisture: Prevents dryness and promotes healing.
Sufficient Removal of Wastes: Flushes out toxins.
Proper pH: Ideal skin pH < 5.0 (approximately 4.7).
Ability to Heal (Immunity): Immune response is crucial for skin integrity.
Absence of Injury-Inducing Forces: Prevention of trauma promotes skin health.
Factors that Delay Wound Healing
Skin Damage Factors
Irritants: Sweat, urine, feces, chemicals can damage skin integrity.
Duration of Exposure: Longer exposure correlates with increased damage.
Frequency of Exposure: More frequent exposure exacerbates damage.
Stages of Wound Healing
Hemostasis: Formation of a clot to prevent blood loss.
Inflammation: Increased blood flow to deliver immune cells, nutrients, and oxygen.
Proliferation: Includes re-epithelialization, angiogenesis, and collagen synthesis.
Maturation: Remodeling of collagen, vascular maturity, and scar tissue formation.
Wound Management Approach
Proper Classification of Wounds: Types include surgical, pressure injuries, traumatic, diabetic ulcers - the root cause must be identified.
Assessment: Understand expected healing timelines for different wound types.
Identification and Removal of Inhibiting Factors: Necessary for effective healing.
Non-Pharmacological Interventions: Includes preventative strategies.
Pain Management: Increased pain can indicate infection; manage effectively.
Optimizing the Local Wound Environment: Create conditions that promote healing.
Documentation and Assessment of Wounds
Describe Wound Characteristics: Reference Perry and Potter (2019 pp. 1051-1052).
Healing vs. Non-Healing States: Assess wound bed characterization to determine state.
Expected Healing Rates: - Primary Intention: Closure in 1-2 days, full by 30 days. - Secondary Intention: 20-40% reduction in 4 weeks.
Skin Regeneration Limitations: New skin is not as strong as original skin.
Inflammation vs. Infection: Critical to correctly diagnose.
Thorough Assessment Techniques: Visual inspection is insufficient; tactile and olfactory assessments are vital.
Wound Bed Assessment Terminology
Granulating: Presence of new tissue.
Epithelializing: New skin formation.
Slough: Non-viable tissue that must be managed.
Necrotic: Dead, non-viable tissue.
Wound Bed Assessment – Additional Terminology
Undermining: Tissue loss under the intact skin edges.
Tunneling: Deeper tissue loss creating channels beneath skin.
Measuring Wound Dimensions: Length, Width, Depth (L, W, D).
Wound Drainage Terminology
Types of Drainage: - Serous: Clear fluid. - Sero-sanguineous: Blood-tinged fluid. - Sanguineous: Dark red blood. - Purulent: Thick, often indicative of infection.
Amounts of Exudate Terminology
None Visible: No drainage.
Scant: Few dots, smears of fluid.
Small: Less than 25% of dressing covered.
Moderate: Approximately 50% of dressing covered.
Large: Saturates the entire dressing.
Purpose of Wound Care
Optimizing the Local Wound Environment- to promote heaing
Basic Components: - Wound Cleansing: Essential for preventing infection and promoting healing. - Debridement of Necrotic Tissue: Critical to expose healthy tissue and support healing. - Managing Bacterial Balance: Essential to prevent infection. - Controlling Moisture: Keeps the wound bed hydrated.
Wound Cleansing
Principles: Solutions must be nontoxic, hypoallergenic, and readily available.
Common Solutions: Include sterile normal saline, sterile water, potable tap water, and liquid antiseptics.
When Infection Is Suspected: Use solutions with surfactants or antiseptics (e.g., povidone-iodine).
Therapeutic Irrigation: Effective at 4-15 psi.
Pain Management: Essential during dressing changes; ensure pain management measures are in place.
Sterile Technique: Follow strict sterile procedure (clean to dirty approach).
Definition of Debridement
European Wound Management Association: "The act of removing necrotic material… to promote wound healing."
Types of Debridement: - Autolytic: Natural process using the body’s enzymes. - Deliberate Intervention: Performed by trained professionals.
Types of Debridement
Mechanical: Wet to dry dressings, irrigation.
Chemical: Destroys both healthy and dead tissue (e.g., bleach).
Enzymatic: Uses enzymes to break down necrotic tissue.
Surgical: Performed by a health professional using scalpel or scissors.
Biological: Use of maggots; concerns about the “yuck factor”.
Selection of Debridement Method
Ranking Based on Various Factors (1 is most desirable, 5 least desirable): - Speed: Surgical (1), Enzymatic (3), Autolytic (5), Biological (2), Mechanical (4). - Tissue: Enzymatic (1), Surgical (3), Biological (4), Autolytic (2), Mechanical (5). - Painful Wound: Mechanical (5), Surgical (2), Autolytic (1), Biological (3), Enzymatic (4). - Exudate Management: Surgical (1), Enzymatic (4), Autolytic (3), Biological (5), Mechanical (2). - Infection Management: Surgical (1), Enzymatic (4), Biological (5), Autolytic (2), Mechanical (3). - Cost: Mechanical (5), Enzymatic (2), Surgical (1), Biological (3), Autolytic (4).
Managing Bacterial Balance
Five Levels of Involvement: 1. Contamination 2. Colonization 3. Local Infection 4. Spreading Infection 5. Systemic Infection
Regular Reassessment: Reassessing the wound environment is critical to minimize infection risk and promote healing.
Skills and Nursing Interventions
Specific Nursing Interventions
Daily Skin Assessment: Identify risks to skin integrity using tools like the Braden Scale.
Ensure Adequate Nutrition: Vital for healing.
Maintain Dry Bed Linens: Prevents moisture-associated skin damage.
Apply Moisturizers: Approved products to minimize pH changes.
Reduce Shear and Irritation: Use appropriate linen and clothing.
Encourage Mobilization: Increases blood flow.
Turn Bed-Bound Clients Frequently: At least every 2 hours.
Stress Management: Enhances immunity; consider stress reduction programs.
Smoking Cessation: Improves blood flow and healing capacity.
Types of Wounds
Acute Wounds: Generally heal quickly, with no underlying healing defect.
Chronic Wounds: Slow to heal, often requiring specialized care and interventions.
Stages of Wound Healing
Inflammatory Stage: - Redness, heat, pain, swelling, and loss of function. - Vessels constrict to prevent blood loss. - Platelets form clots; WBCs arrive to fight infection.
Proliferative Stage: - Begins 2-3 days after injury. - Characterized by fibroblast activity and collagen formation.
Maturation Stage: - Tissue remodels, enhancing tensile strength. - May take months to years.
Types of Wound Healing
Primary Intention: Wound edges are pulled together; fast healing; minimal scarring.
Secondary Intention: Wound edges are not approximated; heals through granulation; longer healing time.
Tertiary Intention: Wound left open for days then closed; more complications; larger scars.
Goals of Care Based on Wound Type
Intact Skin: Preventative plans and interventions.
Healing Wound: Client must have physical capacity to heal and proper resources should be implemented.
Non-Healing Wound: Education and intervention directed toward improving choices that affect healing.
Non-Healable Wound: Focus on palliative goals: pain management, infection control, and care stabilization.
Selection of the Best Dressing
Dependent on: - Wound characteristics (tissue type, exudate type and amount). - Presence of infection and clinical situation.
Five Rules for Dressing Selection: 1. Categorization: Understand dressings' characteristics and compare. 2. Selection: Opt for the safest and most effective dressing. 3. Change: Modify dressing based on assessments rather than routine. 4. Evolution: Adjust dressing protocols as the wound heals through various phases. 5. Practice: Hands-on experience enhances understanding of dressing efficacy.
Wound Care Product Categories
Overview
Products categorized based on behavior and healing process contributions.
Wound Cleansers
Facilitate non-traumatic removal of exudate and contaminants; saline is recommended.
Dressing Types
Hydro gels: Hydrate and assist with autolytic debridement.
Moisture Retentive Dressings: Retain moisture and support healing.
Absorbent Dressings: Absorb excess exudate while keeping the wound moist.
Antimicrobial Dressings: Control bacterial burden and reduce infection risk.
Collagen Dressings: Useful in chronic wounds; re-balances wound environment.
Odor Control Dressings: Improve quality of life by managing odor.
Documentation Standards
Use a detailed wound assessment record.
Be specific in documentation; avoid vague observations.
Track changes, interventions, and patient responses.
Gerontological Considerations
Skin Changes with Age: - Thinning skin - Reduced elasticity and moisture - Increased fragility and potential for injury - Delayed healing due to blood flow and growth factors.
Wound Assessment in Non-Caucasian Individuals
Requires knowledge of variations in clinical manifestations.
Rashes and symptoms may need palpation to assess accurately.
Wound Complications
Infection: Symptoms include purulent drainage, pain, redness, and elevated temperature.
Biofilms: Amorphous structures delaying healing; require debridement.
Hemorrhage: Excessive blood loss may lead to shock; check under clients.
Dehiscence: Separation of wound edges; early signs include sero-sanguineous drainage increase.
Evisceration: Emergency where internal organs are exposed; cover with sterile gauze and prepare for transport.
Psychosocial Impact of Wounds
Encourage verbalization of feelings.
Promote self-care as tolerated.
Explore non-adherence reasons or lifestyle factors affecting healing.
Wound Swabs
Reassess Non-Healing Wounds
Consider holistic assessment factors (nutrition, circulation).
Consult interdisciplinary approaches for comprehensive care.
Monitor skin integrity; implement interventions for healing.
Document all assessments, interventions, and responses.
Adjust goals of care in collaboration with the healthcare team where needed.
Practical Nurse’s Role
Implement principles to promote healing and minimize negative outcomes, focusing on nutrition and proper care routines.
Recommended Readings
Lewis (2023): Chapter on wound healing factors and management strategies.
Perry & Potter (2020): Clinical skills regarding wound assessment and management techniques.
Orsted (2018): On wound infection factors, inflammation, and biofilms.
References for Further Reading: As cited throughout the guide, including works by Elsevier, authors Lewis, Perry, Potter, and Orsted.