Type of Injury & Repair. Wound Healing 10/6/2009. Complex and dynamic process. Wound location influences healing. Surgical Incisions.

Transcription

1 Wound Healing & Wound Healing Complex and dynamic process Results in restoration of anatomic continuity and function Need adequate nutrition, blood flow, and oxygen Type of Injury & Repair Surgical Incisions Clean, approximated wounds Heal with minimal synthesis of new tissue Minimal body resources used Burn wounds Stimulate massive response from all body systems to sustain life Require complete regeneration of tissue Type of Injury & Repair Wound location influences healing Perineal wounds High risk for infection Wounds over joints Increased scarring because of motion Wounds in the periphery Heal slowly and sometimes not at all because of decreased blood supply 1

2 Inflammatory Response Chemical Mediators released (histamine, kinins, and prostaglandin) Vasodilatation (hot, red) Chronic Inflammation if cause persists Increased capillary Permeability (edema, Pain) Clot & fibrin Mesh wall off area Prepare for healing Scar tissue Chemotaxis (WBC to area) Phagocytosis Irritated nerve endings (pain) Healing Regeneration Resolution Diagnostics WBC elevated (4 10,000 normal) Neutrophils first responders, large numbers called segmented (segs) If high demand, immature neutrophils are released by bone marrow called banded (bands) When banded neutrophils are present it is referred to as a shift to the left (bacterial infection) Monocytes long lived cell important in healing and plays a role in encapsulating debris that is too large for tissue macrophages (tubercle bacillus) Lymphocytes (T cell and Ab Ag immunity) controlled by adrenocortical hormones. Eosinophils & Basophils histamine and heparin released during inflammation eosinophil release is specific to allergen antibody complex A patient with an open abdominal wound has a complete blood cell (CBC) count and white blood cell (WBC) differential, which indicates a shift to the left. The nurse will anticipate that the next collaborative intervention will be to 1. redress the wound with wet to dry to dressings. 2. obtain wound cultures. 3. start antibiotic therapy. 4. continue to monitor the wound for purulent drainage. Care Reduce Inflammation ASA Anti inflammatory, analgesia, and antipyretic, reduces platelet adhesion NSAID Anti inflammatory, inflammatory analgesia, and antipyretic ASA & NSAID Precautions: check for allergy, may cause irritation and ulcers in the stomach Do NOT use ASA for children because the combination of ASA and a viral infection contributes to the development of Reye s syndrome, a complication that involves the brain and liver 2

3 Care Reduce Inflammation Glucocorticoids Steroidal anti inflammatory Benefits Decrease capillary permeability; reduces the number of leukocytes and mast cells at the site, decreasing the release of histamine i and prostaglandins, and blocks the immune response. Side Effects, especially long term use Atrophy of lymph tissue & reduce numbers of WBCs; increased tissue breakdown with decreased protein synthesis and tissue regeneration, leading to osteoporosis, muscle wasting, and/or thinning and breakdown of skin & mucosa (stomach ulcer); delayed healing, retention of Na and H2O leading to HTN and edema. Wound Healing Process in which skin, with a loss in integrity, becomes closed or healed Healing Primary Intention Edges of wound are held close together and the wound is clean (stitches, staples, steri strips) p) Tertiary Intention Healing by primary intention after wound closure Contaminated wounds, increased risk of infection, left open until they are free of debris then sutured. Second Intention Large break in tissue, more inflammation, a longer healing period and more scar tissue Left open rather than closed with sutures. (pressure ulcers, abrasions) Heals by the spread of granulation tissue from the base of the wound (venous leg ulcers) A patient with massive trauma to the leg has a 7 cm by 10 cm full thickness leg wound with extensive skeletal muscle damage and wide, irregular wound edges. The nurse will teach the patient that 1. all of the damaged tissue will regenerate if infection does not occur. 2. most of the skin and skeletal muscle will be replaced by connective tissue. 3. the skin will regenerate to cover the injury but the muscle will not be replaced. 4. complete regeneration of skin and muscle tissue will take several months. 3

4 Healing Promote Healing Youth Good nutrition: protein, vitamins i A & C Adequate Hgb Good circulation Clean wound Delay Healing Advanced age Poor nutrition, dehydration Anemia Circulatory disease Infection, foreign material, insulin deficit Systemic response Inflammation S/S Edema Fever Leukocytosis Shift to the left Pain Loss of function Interventions RICE (edema subsides in 72 hours) Rest, ice, compression, elevation (soft tissue injury) Treat temp > 102 Diet: high in vitamin C, protein, calories, and fluid A patient with a systemic bacterial infection has goose pimples, feels cold, and has a shaking chill. At this stage of the febrile response, the nurse would expect to find 1. skin flushing. 2. rising body temperature. 3. decreasing blood pressure. 4.muscle cramps. Nursing Diagnoses Ineffective Peripheral Tissue Perfusion related to edema amb numbness/tingling (paresthesias), CRT>3, skin cool/hot, pain, periph pulse +1/3 Edema may restrict blood vessels and entrap nerves 4

5 Goal/Outcomes Goal: pt will have adequate tissue perfusion Outcomes: usual skin color, pulses distal to wound, skin warm, no n/t, pain controlled Interventions Assessment: Injury wounds: CSM (circulation, sensation, & movement); if edema, measure circumference, use skin marker for accurate serial measurements. RICE Ice vasoconstriction to decrease edema Compression and elevation decrease edema Edematous tissue at risk for breaking down Keep skin lubricated and protect from injury Interventions self care Teach RICE Teach how to use heat/ice Dressing changes Distal to proximal s/s of infection Change in color, pulse, and pain Incisions Assess every shift Dressings drainage and odor Normal wound appears pink and swelling Protect from further trauma nd external pressure Protect wound from stretching and pulling forces Dressings aseptic technique Gauze dressings on primary intention wounds Drains: assess volume and character of fluid 5

6 Sutures Removal: 4 7 days Control scarring (face) 7 10 days Other areas days Hand and foot, areas of mobility Wound Disruption Dehiscence Suture line opens, previously intact (cough, sneeze) Highest risk: granulation phase of healing; 5 th post op day to 3 weeks. Evisceration Wound opens Exposure of internal organs Cover organs with sterile moist dressing Call MD Prepare for surgery Open Wounds Assessment Pain, size of wound, measure depth of wound using a cotton swab, wound location, color, exudate, granulation tissue (red, shiny, and bumpy), redness beyond wound edges, odor, fever (systemic sign), condition of surrounding skin Diagnositics Hemoglobin, hematocrit, albumin, WBCs Indicate degree of nutritional impairment Delayed healing correlates with low serum albumin Pressure ulcers If untreated, a pressure sore can progress from a small irritated but unbroken skin patch to a potentially life threatening wound involving extensive tissue death and infection. 6

7 Staging Pressure Ulcers Stage I: A reddened area on the skin that, when pressed, is "non blanchable" (does not turn white). a pressure ulcer is starting to develop. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. i Stage III: The skin breakdown now looks like a crater where there is damage to the tissue below the skin. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone. Unstageable if slough (yellow grey necrotic tissue) or eschar is present A patient is admitted to the hospital with an infected pressure ulcer on the left buttock. The pressure ulcer is 5 cm long by 2.5 cm wide and is 1.5 cm deep. The base of the wound is yellow and involves subcutaneous tissue. The nurse classifies the pressure ulcer as stage 1. I. 2. II. 3. III. 4. IV. Core Measures Nursing skin assessment is a priority Hospital Reimbursement and Nursing No reimbursement for wounds (pressure ulcers) that occur during hospitalization ti (nosocomial) 7

8 Evidence Based Practice Braden Scale reduce the incidence of nosocomial pressure ulcers by 40-60%. reduce the severity of nosocomial pressure ulcers reduce the cost of care by decreasing the inappropriate use of specialty beds reduce the cost of care by avoiding the excess hospital days associated with the complication of nosocomial pressure ulcers Scoring Based on 6 categories Sensory perception, moisture, activity, mobility, nutrition, friction & shear Score of 23 is no risk ik Score is at risk Score moderate risk Score high risk Score < 9 very high risk Diagnosis Impaired skin integrity r/t delayed wound healing secondary to impaired circulation, to infection, or to malnutrition amb Goal: decrease wound size in 3 weeks Outcomes: no odor from wound, less drainage from wound, no s/s of infection Planning & Implementation Document wound assessments q shift Wound care as prescribed by HCP Anticipate Antibiotic administration if an infection is present (Wound C & S) Collaborate with the wound care or ostomy nurse Many wounds heal slowly. Encourage patients to become active in the wound care regimen 8

9 General Care Issues No massage reddened or body prominences Minimize amount of linens and pads No Do-Nut type devices Maintain good hydration Dry moist skin Ulcer Care Keep ulcer bed moist Cleanse with nontoxic solutions Debride Use adhesive membrane, ointment, or wound dressing Keep the wound bed moist it and the surrounding tissues dry Nursing Interventions Prevention: Frequent turning Offer bedpan/urinal and glass of water when turning Manage moisture, nutrition, and friction & shear Use absorbent pads or diapers that wick and hold moisture. Pressure reduction support surface if bed or chair bound 9

10 Manage Friction & Shear Elevate HOB no more than 30 degrees Use trapeze Use lift sheet Promote Healing Increase protein Increase calories (carbohydrates) to spare proteins Use MVI, need vitamin A, C, & E Consult Dietician Protect elbows and heels Pressure Relieving Surfaces Use if: Patient has intractable pain Severe pain exacerbated by turning Low air loss beds are not a substitute for turning The charge nurse observes a new graduate performing a dressing change on a stage III sacral pressure ulcer. Which action by the new graduate indicates a need for further education about pressure ulcer care? 1. The new graduate uses a hydrocolloid dressing (DuoDerm) to cover the ulcer. 2. The new graduate inserts a sterile cotton tipped applicator into the pressure ulcer. 3. The new graduate irrigates the pressure ulcer with a 30 ml syringe using sterile saline. 4. The new graduate cleans the ulcer with a sterile dressing soaked in half strength peroxide. 10

11 Documentation Nursing assessment & documentation Granulation tissue is filling in the gap It appears moist and pink or red in color 1 day post op expect wound to be red and warm around the edges signifies healing Prevention Granulation tissue is fragile and easily broken down by microorganisms or stress on the tissue. 5 days to 3 weeks. Because of fragility of tissue at risk for dehiscence The nurse has just received change of shift report about the following four patients. Which patient will the nurse assess first? 1. The newly admitted patient with a stage IV pressure ulcer on the coccyx. 2. The patient who has been receiving immunosuppressant medications and has a temperature of 102 F. 3. The patient who has multiple black wounds on the feet and ankles. 4. The patient who needs to be medicated with multiple analgesics prior to a scheduled dressing change. 11