Wound Healing and Care Wound Healing and Care

ObjectivesObjectives Demonstrate use of four senses in observing skin/wounds (listening, looking, touching, smelling)

List ways to promote healing

Demonstrate routine care of wounds and surgical drains

ObjectivesObjectives Recognize signs/symptoms of inflammation

Demonstrate use of four senses in observing dressing over wound site

Demonstrate correct technique of changing clean and sterile dressings

Document and report care related to skin integrity

Anatomy of SkinAnatomy of Skin

The skin or integumentary system is the largestsystem of the body. Hair, nails, and skin glandsare a part of this organ system.

The skin is a thin, relatively, flat organ that is classified as a cutaneous membrane. It forms aprotective boundary between the internal environment of the body and the external environment.

Skin LayersSkin Layers

Three layers of the skin:

1. Epidermis2. Dermis3. Subcutaneous tissue

Diagram of the SkinDiagram of the Skin

EpidermisEpidermis

The outer skin layer that is in direct contact with the environment

The epidermis has five layers

Contains skin pigment (melanin) that gives color to the skin

Contains a water repellant protein called keratin

EpidermisEpidermis Cells in the epidermis constantly change and

regenerate (research suggests 35 days)

Injury to these cells may cause blisters &

calluses

DermisDermis Contains no skin cells

Composed of collagen (a tough fibrous protein layer), blood vessels, and nerve cells

70% of the dermis layer is collagen which is very important in wound healing

Dermis restores the physical properties of the skin and its structural integrity

DermisDermis

Provides mechanical strength of the skin

Provides a reservoir storage area for water and important electrolytes

Contains a specialized network of nerves and nerve endings for sensation of pain, pressure, touch, and temperature

DermisDermis

Hair follicles

Collagen makes the skin stretchable & elastic

Point of attachment for smooth and voluntary muscles

Subcutaneous LayerSubcutaneous Layer Is not part of the skin itself, but supplies the major blood vessels and nerves to the skin above

Loose spongy texture

Ideal site for rapid and relatively pain-free absorption of injected medications (subcutaneous injection)

Functions of the SkinFunctions of the Skin

Functions of the skin are crucial for

maintenance of homeostasis.

1.ProtectionBarrier against bacteria, foreign matter, dehydration, ultraviolet (UV) light

2. Sensation Sense organ

3. Movement without injury

4. Excretion Regulating the volume and chemical content of sweat

Functions of the SkinFunctions of the Skin

5. Vitamin D production Exposure of skin to UV light

6. Immunity Specialized cells that attack and destroy

pathogenic microorganisms

7. Temperature regulationHeat production and heat loss (shivering,

vasoconstriction, etc)

Wound - DefinitionWound - Definition

A break in the skin or mucous membrane;An alteration in the integrity of the skin and

underlying tissues.

Wound - CausesWound - Causes

Causes

1. Surgical incisions2. Trauma3. Pressure4. Shearing force5. Friction6. Poor circulation

Risk Factors for Risk Factors for Developing a WoundDeveloping a Wound

Broken skin Age (young or old) Nutritional Status Stress Hereditary Disease process (acute or chronic) Medical therapies - steroids, chemotherapy, radiation, diuretics

Type of WoundsType of Wounds1. Intentional - created for therapy

i.e., surgical

2. Unintentional - resulting from trauma i.e., fall

3. Open wound - skin or mucous membrane is broken

4. Closed wound - tissues are injured but the skin is not broken

Type of WoundsType of Wounds

5. Clean wound - not infected, usually intentional

6. Contaminated wound - high risk of infection usually unintentional

7. Infected wound - (dirty wound) contains bacteria; signs of infection

Type of WoundsType of Wounds8. Chronic wound - wound that does not heal easily; can be due to pressure or circulation

9.Partial-thickness wound - epidermis & dermis of the skin is broken (superficial)

10. Full-thickness wound - epidermis, dermis, subcutaneous tissue are involved and may

involve muscle and bone (penetrating)

Description of WoundsDescription of Wounds

Wounds can be described by cause:

1. Abrasion - scraping or rubbing away of the skin

2. Contusion - closed wound caused by a blow to the body

3. Incision - open wound with clean straight edges

Description of WoundsDescription of Wounds

4. Laceration – open wound with torn tissues and jagged edges

5. Penetrating wound – skin and underlying tissue are pierced

6. Puncture wound - open wound from a

sharp object

Skin TearsSkin Tears

Occur most frequently in the elderly due to skin changes in the elastic fibers in the dermis, increased fragility of blood vessels, changes in the membrane between the epidermis & dermis, & thickening of collagen

These changes cause the skin to age and the skin appears translucent, wrinkled, thin, dry, fragile & lacking tensile strength

Skin TearsSkin Tears Upper and lower extremities most common site

80% of skin tears occur on the arms and hands

Tears are caused by friction and shearing

Tears are painful and can lead to wound complications

Principles of Tissue Principles of Tissue HealingHealing

The body’s ability to handle tissue trauma is influenced by:

Extent of damage, i.e. skin intact or brokenPerson’s state of health, i.e. nutritional statusBody’s response to traumaHealing is promoted when wound is free of foreign bodies and bacteria

Phases of Wound HealingPhases of Wound Healing

Inflammatory or Defensive Stage

Starts when skin integrity is impaired and continues from 4 - 6 days

Homeostasis - blood vessels constrict, platelets stop bleeding forming clots to

scabs

Inflammatory response - increased blood flow and vascular permeability causing redness & edema

Phases of Wound HealingPhases of Wound Healing

Inflammatory or Defensive Stage

White blood cells - arrive & clean cell of debris

Epithelial cells - move to base of wound margins for 48 hours

Phases of Wound HealingPhases of Wound Healing

Proliferative or Reconstruction Stage

Closure begins on day 3 or 4 & continues for 2 - 3 weeks

Fibroblasts with vitamin C & B for repair

Collagen - provides strength and structure

Epithelial cells - duplicate damaged cells

Phases of Wound HealingPhases of Wound Healing

Maturation Stage

Final stage of healing & may last for 1 year as the scar strengthens

Cleaning a WoundCleaning a Wound

Types of Wound HealingTypes of Wound Healing Primary intention - Incision edges of a clean surgical incision remain close, tissue loss is minimal & skin quickly regenerates

Secondary intention - Open wound with tissue loss and jagged edges, there is a gap between the edges, granulation tissue gradually fills in the area of defect with scar tissue

Types of Wound HealingTypes of Wound Healing

Tertiary intentionSometimes called delayed intention or closureSurgical wounds are left open 3 - 5 days & then

stapled or sutured closed

Wound HealingWound HealingInfluencing FactorsInfluencing Factors

Age Nutrition Obesity Extent of wound Wound stress Circulating oxygen Smoking Drugs Chronic diseases Infection (local/systemic)

Signs & Symptoms of Signs & Symptoms of InfectionInfection

1. Erythema and edema

2. Painful and tender

3. Drainage & odor - tan, cream, green, yellow

4. Fever

5. Fatigue

Signs & Symptoms of Infection

6. Rash

7. Change in WBC

8. Loss of appetite

9. Mucous membrane sores

10. Elderly: confused, agitated, incontinent

Wound DrainageWound DrainageThe exudate deposited in or on tissue

surfaces during inflammatory & destructive phases of healing.

Drainage must leave the wound for healing to occur

Trapped drainage can lead to infection and other complications

Types of Wound DrainageTypes of Wound Drainage

1. Serous drainage Clear, watery fluid

2. Sanguineous drainage Bloody drainage

Large amount - suspect hemorrhage Bright drainage - indicates fresh bleeding

Darker drainage - indicates older bleeding

Types of Wound DrainageTypes of Wound Drainage

3. Serosanguineous drainage

Thin watery drainage that is blood tinged

4. Purulent drainage

Thick green, yellow, or brown drainage

DrainsDrains

When large amounts of drainage are expected, the physician inserts a drain to aid

in healing. drainage systems can be opened or closed.

Penrose drainAn open drain that drains exudate onto the dressing; no suture; safety pin prevents slippage into the wound; drains by gravity

DrainsDrainsHemovac

Closed suction drainage, sutured in place

Jackson-PrattClosed suction drainage, sutured

T-tubeClosed drainage, sutured; drains by gravity

DrainsDrains Keep drainage tubes free of kinks

Drainage collection reservoir is emptied every eight hours and when 1/2 to 1/3 full

Drainage volume decreases 2 - 3 days after insertion

Report any purulence, foul odor, redness around insertion site, bleeding

HemovacHemovac

Jackson - PrattJackson - Pratt

T - TubeT - Tube

Measuring DrainageMeasuring Drainage

Note the number and size of dressings with drainage (describe amount)

Weighing dressing before and after removal

Measuring the amount of drainage in the collection receptacle

Record on I&O form

Wound ComplicationsWound Complications Hemorrhage

May be internal or external

Shock Low or falling blood pressure; rapid, weak pulse; rapid respirations; skin - cold, moist, and pale; restless; confusion; loss of consciousness

Infection

DehiscenceSeparation of wound layers, usually abdominal, caused by wound stress (coughing, vomiting, abdominal distention); surgical emergency

Wound ComplicationsWound Complications

EviscerationSeparation of wound with protrusion

of abdominal organs, surgical emergency, cover with normal saline sterile dressings, notify RN immediately

FistulaAn abnormal tube-like passage from a normal cavity or tube to a free surface or to another cavity

Wound ObservationsWound Observations Wound location

May have multiple wounds from surgery or trauma

Wound size and depth Measure in centimeters

Size - measure from top to bottom, side to sideDepth - use a sterile swab into the depth of the open wound, RN supervision

Wound appearanceRed, swollen, area around wound warm to touch, sutures, staples - intact or broken

Wound ObservationsWound Observations

Drainage COCA (Color, Odor, Consistency, Amount)

Drains

Odor of wound

Surrounding skin Intact, color, swollen

PainReview facility’s pain assessment tool