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