What are management of Wound Healing, Wound care, and pressure ulcer.
Wound Healing
Maintaining skin integrity is a primary responsibility of nursing personnel. Impaired skin integrity, such as wounds, may occur as a result of trauma or surgery. The potential for skin breakdown and eventual pressure ulcer formation also exists whenever factors such as prolonged pressure, constant irritation of the skin, and immobility are present. Nurses, through constant and timely observations and interventions, can prevent or minimize skin breakdown. Prevention, early intervention, and treatment programs are essential strategies to decrease the prevalence of pressure ulcers and pain related to inflammation and infection.
Wounds
The skin is the body’s largest organ and is the primary defense against infection. The body’s complex physiological processes promote skin and wound healing, restoring the function and structure of the skin. A disruption in the integrity of body tissue is called a wound.
Types of wound
Depending on the cause, site, and depth, a wound can lead from simple to severe one. Here, There are different types of wounds.
- Open or Closed
- Acute or Chronic
Open wounds : Are the wounds with exposed underlying tissue or organs and open to the outside environment, for example, penetrating wounds. On the other hand,
closed wounds: Are the wounds that occur without any exposure to the underlying tissue and organs.
When an injury is sustained, a complex set of responses is set in motion, and the body begins a three-phase process of wound healing: defensive (hemostasis and inflammatory), reconstructive (proliferative), and maturation.
The wound healing process is also defined as having four main phases. When this occurs, the defensive phase is considered two separate phases: hemostasis and inflammation. Regardless of how the healing process is defined, these phases overlap and can take months or years to complete. Understanding these physiological responses will assist the nurse in caring for clients with impaired skin integrity and promoting optimal wound healing.
Hemostasis Phase
Homeostasis A series of events designed to control blood loss, establish bacterial control, and seal the defect occurs when there is an injury. During hemostasis injured blood vessels constrict, and platelets gather to stop bleeding. Clots form a fibrin matrix that later provides a framework for cellular repair. The defensive phase occurs immediately after injury and lasts about 3 to 4 days.
Inflammatory Phase.
In the inflammatory stage damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and movement/migration of serum and white blood cells into the damaged tissues. This results in localized redness, edema, warmth, and throbbing.
Reconstructive (Proliferative) Phase
The reconstructive phase begins on the third or fourth day after injury and lasts 2 to 3 weeks. This phase contains the process of collagen deposition, angiogenesis, granulation tissue development, and wound contraction.
Fibroblasts, normally found in connective tissue, migrate into the wound because of various cellular mediators. They are the most important cells in this phase because they synthesize and secrete collagen. Collagen is the most abundant protein in the body and is the material of tissue repair. Initially, collagen is gel-like, but within several months it cross-links to form collagen fibrils and adds tensile strength to the wound. As the wound gains strength, the risk of wound separation or rupture is less likely. The wound can resist normal stress such as tension or twisting after 15 to 20 days. During this time, a raised ‘‘healing ridge’’ may be visible under the injury or suture line.
Angiogenesis, the formation of new blood vessels, begins within hours after the injury. The endothelial cells in preexisting vessels begin to produce enzymes that break down the basement membrane. The membrane opens, and new endothelial cells build a new vessel. These capillaries grow across the wound, increasing blood flow, which increases the supply of nutrients and oxygen needed for wound healing. Repair begins as granulation tissue, or new tissue, grows inward from surrounding healthy connective tissue. Granulation tissue is filled with new capillaries that are fragile and bleed easily, thus giving the healing area a red, translucent, granular appearance. As granulation tissue is formed, epithelialization, or growth of epithelial tissue, begins. Epithelial cells migrate into the wound from the wound margins.
Eventually, the migrating cells contact similar cells that have migrated from the outer edges. Contact stops migration.
The cells then begin to differentiate into the various cells that compose the different layers of the epidermis. Wound contraction is the final step of the reconstructive phase of wound healing. Contraction is noticeable 6 to 12 days after injury and is necessary for closure of all wounds.
The edges of the wound are drawn together by the action of myofibroblasts, specialized cells that contain bundles of parallel fibers in their cytoplasm. These myofibroblasts bridge across a wound and then contract to pull the wound closed.
Maturation Phase
Maturation, the final stage of healing, begins about the 21st day and may continue for up to 2 years or more, depending on the depth and extent of the wound. During this phase, the scar tissue is remodeled (reshaped or reconstructed by collagen deposition and lysis and debridement of wound edges). Although the scar tissue continues to gain strength, it remains weaker than the tissue it replaces. Capillaries eventually disappear, leaving an avascular scar (a scar that is white because it lacks a blood supply).
Types of Healing
Tissue may heal by one of three methods, which are characterized by the degree of tissue loss.
Primary intention healing occurs in wounds that have minimal tissue loss and edges that are well approximated (closed). If there are no complications, such as infection, necrosis, or abnormal scar formation, wound healing occurs with minimal granulation tissue and scarring.
Secondary intention healing is seen in wounds with extensive tissue loss and wounds in which the edges cannot be approximated. The wound is left open, and granulation tissue gradually fills in the deficit. Repair time is longer, tissue replacement and scarring are greater, and the susceptibility to infection is increased because of the lack of an epidermal barrier to microorganisms.
Tertiary intention healing, also known as delayed or secondary closure, is indicated when primary closure of a wound is undesirable. Conditions in which healing by tertiary intention may occur include poor circulation or infection.
Suturing of the wound is delayed until the problems resolve and more favorable conditions exist for wound healing.
Kinds of Wound Drainage Chemical mediators released during the inflammatory response cause vascular changes and exudation of fluid and cells from blood vessels into tissues. Exudates may vary in composition but all have similar functions.
These functions include:
1. Dilution of toxins produced by bacteria and dying cells
2. Transport of leukocytes and plasma proteins, including antibodies, to the site
3. Transport of bacterial toxins, dead cells, debris, and other products of inflammation away from the site
The nature and amount of exudate vary depending on the tissue involved, the intensity and duration of the inflammation, and the presence of microorganisms. Serous exudate is composed primarily of serum (the clear portion of blood), is watery in appearance, and has a low protein count. This type of exudate is seen with mild
inflammation resulting in minimal capillary permeability changes and minimal protein molecule escape (example, seen in blister formation after a burn).
Purulent exudate is also called pus. It generally occurs with severe inflammation accompanied by infection.
Purulent exudate is thicker than serous exudate because of the presence of leukocytes (particularly neutrophils), liquefied dead tissue debris, and dead and living bacteria.
The process of pus formation is called suppuration, and bacteria that produce pus are referred to as pyogenic bacteria. Purulent exudates may vary in color (example, yellow, green, brown), depending on the causative organism.
Hemorrhagic exudate has a large component of red blood cells (RBCs) due to capillary damage, which allows RBCs to escape. This type of exudate is usually present with severe inflammation. The color of the exudate (bright red versus dark red) reflects whether the bleeding is fresh or old. Mixed types of exudates may also be seen, depending on the type of wound.
For example, a serosanguineous exudate is clear with some blood tinge and is seen with surgical incisions.
Factor Affect Wound Healing
Wound healing is dependent on multiple influences, both intrinsic and extrinsic. Wounds may fail to heal or may require a longer healing period when unfavorable conditions exist. Factors that may negatively influence healing include age, nutrition, oxygenation, smoking, drug therapy, and diseases such as diabetes. Such factors reduce local blood supply and therefore impair wound healing. Nutrition and diet can also have an impact on the healing process.
Hemorrhage
Some bleeding from a wound is normal during and immediately after initial trauma and surgery, but hemostasis usually occurs within a few minutes.
Hemorrhage (persistent bleeding) is abnormal and may indicate a slipped surgical suture, a dislodged clot, or erosion of a blood vessel. Swelling in the area around the wound or affected body part and the presence of sanguineous drainage from the surgical drain may indicate internal bleeding. Other evidence of bleeding may include the signs and symptoms seen in hypovolemic shock (decreased blood pressure, rapid thread pulse, increased respiratory rate, diaphoresis, restlessness, and cool, clammy skin). A hematoma, a localized collection of blood underneath the tissues, may also be seen and appear as a reddish-blue swelling or mass.
External hemorrhaging is detected when the surgical dressing becomes saturated with sanguineous drainage. It is also important to assess the linen under the client’s wound site because it is possible for blood to seep out from under the sides of the dressing and pool
Age
Blood circulation and oxygen delivery to the wound, clotting, inflammatory response, and phagocytosis may be impaired in the very young and in older adults; thus, the risk of infection is greater. Rate of cell growth and epithelialization of open wounds is lower with advancing age, so wound healing is slowed. Nutrition A balanced diet with adequate amounts of protein, carbohydrates, fats, vitamins, and minerals is needed to increase the body’s resistance to pathogens and to decrease the susceptibility of skin and mucous membranes to infection and trauma. Surgery, severe wounds and infections, stress from burns and trauma, and preexisting nutritional deficits increase nutritional requirements.
Malnutrition reduces humoral and cell mediated factors, leading to immunocompromise, thus impairing wound healing and increasing the risk for infection. Obesity leads to fatty tissue, which has a decreased supply of blood vessels that impairs delivery of nutrients and other elements needed for healing; also, suturing of fatty tissue is more difficult, and complications such as dehiscence or evisceration with subsequent infection may occur.
Oxygenation Decreased arterial oxygen tension alters the synthesis of collagen and the formation of epithelial cells, causing wounds to heal more slowly. Reduced hemoglobin levels (anemia) decrease oxygen delivery to the tissues and interfere with tissue repair.
Smoking Functional hemoglobin levels decrease, impairing oxygenation to tissues.
Drug therapy Steroids reduce the inflammatory response and slow collagen synthesis. Anti-inflammatory drugs suppress protein synthesis, wound contraction, epithelialization, and inflammation. Prolonged antibiotic use, with development of resistant strains of bacteria, may increase the risk of superinfection.
Diabetes mellitus
Small-vessel disease (microvascular changes) can impair tissue perfusion and oxygen delivery. Hemoglobin in poorly controlled diabetes has an increased affinity for oxygen, allowing less to be released to the wound bed. Elevated blood glucose levels impair leukocyte function and phagocytosis. The high-glucose environment is an excellent medium for the growth of bacterial, fungal, and yeast infections. under the client. The risk for hemorrhage is greatest during the first 24 to 48 hours after surgery.
Infection
Bacterial wound contamination is one of the most common causes of altered wound healing. A wound can become infected with microorganisms preoperatively, intraoperatively, or postoperatively. During the preoperative period, the wound may become exposed to pathogens because of the manner in which the wound was inflicted, such as in traumatic injuries. Nicks or abrasions created during preoperative shaving may also be a source of pathogens.
The risk for intraoperative exposure to pathogens increases when the respiratory, gastrointestinal, genitourinary, and oropharyngeal tracts are opened.
If the amount of bacteria in the wound is sufficient or the client’s immune defenses are compromised, clinical infection may result and become apparent 2 to 11 days postoperatively. Infection slows healing by prolonging the inflammatory phase of healing, competing for nutrients, and producing chemicals and enzymes that are damaging to the tissues.
Dehiscence and Evisceration Wound healing may be disrupted by dehiscence, the partial or complete separation of the wound edges and the layers below the skin. Evisceration occurs when the client’s viscera protrude through the disrupted wound. Factors that may predispose a wound to dehiscence include obesity, poor nutrition, problems with suturing, excessive coughing, vomiting, straining, and infection. Wound dehiscence is most likely to occur 4 to 5 days postoperatively, before extensive collagen is deposited in the wound. It may be preceded by sudden straining, such as that associated with coughing,
sneezing, or sitting up in bed. Signs of impending dehiscence may include the sensation of ‘‘something giving way’’ and an increased flow of serosanguineous drainage on the wound dressing.
Wound Classification
Various terms are used to describe and classify wounds. Wounds are usually described based on their etiology, since the treatment for the wound varies depending on the underlying disease process. Wound classification systems describe the cause of the wound, status of skin integrity, extent of tissue damage, cleanliness of the wound, or descriptive qualities of the wound, such as color. Commonly used classification systems follow.
Cause of Wound
• Intentional wounds occur during treatment or therapy. These wounds are usually made under aseptic conditions.
Examples include surgical incisions and venipunctures.
• Unintentional wounds are unanticipated and are often the result of trauma or an accident. These wounds are created in an unsterile environment and therefore pose a greater risk of infection.
Cleanliness of Wound
This classification system ranks the wound according to its contamination by bacteria and risk for infection (Sussman & Bates-Jensen, 2005).
• Clean wounds are intentional wounds that were created under conditions in which no inflammation was encountered, and the respiratory, alimentary, genitourinary, and oropharyngeal tracts were not entered.
• Clean-contaminated wounds are intentional wounds that were created by entry into the alimentary, respiratory,
Nutrient Function in Wound Repair
Proteins
Amino acids Neovascularization, lymphocyte formation, fibroblast proliferation, collagen synthesis, wound remodeling, and cell-mediated responses (phagocytosis)
Albumin Osmotic equilibrium control and edema prevention Carbohydrates Cellular energy and protein sparing Fats Cellular energy, component of cell membrane, and prostaglandin production
Minerals
Copper Collagen cross-linking for scar strength Iron Collagen synthesis and enhanced leukocytic bacterial activity Zinc Cell proliferation and cell membrane stabilization
Vitamins
A Collagen synthesis and epithelialization Pyridoxine, riboflavin, thiamine. Antibody and white blood cell formation; cofactors of enzyme systems C Resistance to infection, collagen synthesis, and capillary formation and stabilization K Coagulation genitourinary, or oropharyngeal tract under controlled conditions.
• Contaminated wounds are open, traumatic wounds or intentional wounds in which there was a major break in aseptic technique, spillage from the gastrointestinal tract, or incision into infected urinary or biliary tracts. These wounds have acute non purulent inflammation present.
• Dirty and infected wounds are traumatic wounds with retained dead tissue or intentional wounds created in situations where purulent drainage was present.
Examples of classification systems that describe wound severity for different wound etiologies are the National Pressure
Ulcer Advisory Panel (NPUAP) method, discussed later in this chapter; the Wagner staging system; the partial-thickness and full-thickness skin loss criteria; and Marion Laboratories’ red/yellow/black (RYB) color system.
Wagner Ulcer Grade Classification.
The Wagner staging system measures the depth and infection in a wound, mainly the dysvascular foot. It is the primary assessment tool used to evaluate diabetic foot ulcers. The classification ranges from 0 to 5, with 0 identifying the predisposing factors that may lead to grades 1 to 3 (superficial ulcer, deep ulcer, abscess osteitis). Grades 4 and 5, respectively, describe gangrene of the forefoot and gangrene of the whole foot.
Classification by Thickness of Skin Loss.
The thickness classification system is based on the depth of the wound and is used for wounds whose etiology is other than pressure wounds, such as skin tears, donor sites, vascular ulcers, surgical wounds, or burns. Superficial epidermal (first degree) wounds are confined to the epidermis layer, which comprises the four outermost layers of skin. Partial-thickness (first- to second-degree) wounds involve the epidermis and upper dermis, the layer of skin beneath the epidermis. Deep (second-degree) wounds involve the epidermis and deep dermis. Full-thickness (third degree) wounds refer to skin loss that extends through the epidermis and the dermis and into subcutaneous fat and deeper structures. Fourth-degree wounds are deeper than full-thickness loss, extending into the muscle and bone.
The RYB Wound Classification System.
In 1988, the RYB classification system was introduced for use in conjunction with the other classification systems to assist the nurse in assessing the wound surface color. The three color system is a tool to direct treatment of open wounds, with each color corresponding to specific therapy needs.
Red wounds are the color of normal granulation tissue and are in the proliferative phase of wound repair. These wounds need to be protected and kept moist and clean.
Yellow wounds have either fibrinous slough or purulent exudate from bacteria. These wounds need to be cleansed of the purulent exudate, and nonviable slough needs to be removed. Black wounds contain necrotic tissue (eschar).
Eschar may be either black, gray, brown, or tan. These wounds need debridement, which is the removal of nonviable necrotic tissue. Mixed-color wounds often occur. The rule for treatment is to treat the worst color first. For example, a red and black wound would be debrided first, and then moisture and protection would be provided for the red portion.
ASSESSMENT
When it comes to wound care, the nurse is confronted with wounds that are extremely diverse. According to Doughty (2007), accurate assessment of wound healing is a critical component of effective wound management because it drives topical therapy and signals progress or problems in the healing process. The wound may have occurred traumatically just before the client presents to the emergency room, or the Hair shaft Sebaceous (oil) gland Hair follicle Nerve Sweat pore Sensory nerve ending for touch Epidermis Dermis Subcutaneous fatty tissue (hypodermis) Vein Artery.
Impaired Skin Integrity Resulting from Abuse
A woman presents to your clinic with multiple bruises on her breasts, thighs, and abdomen; fresh abrasions on her hands and knees, with gravel mixed in; and two puncture wounds on her left shoulder blade, surrounded by streaks of blue ink. Her injuries are highly suggestive of abuse, especially the puncture wounds, because these could not have been self-inflicted.
How do you feel about caring for this client? What are the skin care priorities? What other issues should be addressed with this client once her wounds have been evaluated and any immediate physical needs attended to? What are the procedures for reporting suspected abuse at your clinical agency?
A. Bruise, also known as a contusion, results from damage to the soft tissues and blood vessels, which causes bleeding beneath the skin surface. A bruise in a light-skinned individual will change from red to purple to greenish yellow before fading; in a dark-skinned person, the bruise will first look dark red then darker red, brown, or purple, and slowly fade.
B. Abrasion, also known as a scrape or rug burn, results when the outer layer of skin is scraped or rubbed away. Exposure of nerve endings makes this type of wound painful, and the presence of debris from the scraped surface (rug fibers, gravel, sand) makes abrasions highly susceptible to infection.
C. Laceration, cut, or incision is caused by sharp objects such as knives or glass or from trauma due to a strike from a blunt object that opens the skin, such as a base ball bat. If the wound is deep, the cut may bleed profusely; if nerve endings are exposed, it may also be painful.
D. Avulsion results when the skin or tissue is torn away from the body, either partially or completely. The bleeding and pain will depend on the depth of tissue affected.
E. Puncture results when the skin is pierced by a sharp object such as a pencil, nail, or bullet. If a piece of the object remains in the skin, or if there is little bleeding due to the depth and location of the puncture, infection is likely.
Wound may be a slow-healing chronic ulcer. Despite all this diversity, the nurse should approach assessment of the wound in a systematic manner, evaluating the wound’s stage in the healing process. The nurse also needs to show sensitivity to the client’s pain and tolerance levels during assessment and must always follow Standard Precautions to prevent the transfer of pathogens. Basic criteria for wound assessment follow.
Health History.
The health history is conducted to elicit information regarding medical conditions or disease processes that are often associated with delayed or disrupted healing, such as cardiovascular disease, diabetes, renal failure, immunosuppression, gastrointestinal disorders, collagen disorders, malignancy, septic shock, trauma, infection, liver disease, pulmonary disease, musculoskeletal disease, and depression and psychosis.
It is important to obtain the data in chronological order: when and how the wound occurred, the initial location and size, and all associated symptoms, such as pain and itching.
The history should include aggravating and alleviating factors, such as radiation at the site of the wound, which can influence the healing process. The nurse should document allergies to tape, latex, medications, or other substances. An assessment of the client’s nutritional status should evaluate albumin and pre albumin levels, the client’s weight trend, and the client’s current nutrient intake (Doughty, 2007).
A personal and social history and a functional ability assessment are done to determine the client’s ability to provide self-care and to identify support systems present in the home. A risk assessment tool, such as the Braden or Norton scale to assess the risk for pressure ulcers, is a part of the history.
Physical Examination
Although the focus of the assessment will be to accurately describe and/or stage the wound, the physical effects of any existing concurrent condition are evaluated. Three common types of ulcers include:
Vascular ulcers: Evaluate the skin, nails, hair, color, capillary refill, temperature, pulses, edema of the extremity, and hemosiderin (an iron pigment that is a product of RBC hemolysis) in the peri ulcer area.
Arterial ulcers: Evaluate for weak or absent pulses, thin skin, and lack of hair on the affected extremity.
Neuropathic ulcers: Use the Wagner staging system, previously discussed, to evaluate diabetic ulcers.
Wound Assessment
The following discussion will describe how to assess a wound, documenting location and size and noting length, width, and depth in centimeters. The appearance of the wound bed and surrounding skin is assessed for sinus tracts, undermining, tunneling, exudate, drainage, necrotic tissue, and signs of infection. Some agencies may require a photograph of the wound on admission and documentation of the client’s response to therapy.
Location
Assessment begins with a description of the anatomical location of the wound; for example, ‘‘5-inch suture line on the right lower quadrant of the abdomen.’’ This task often becomes difficult if the client has multiple wounds close to each other, as is common in burn or multiple-trauma victims.
Types of Burns
A. Superficial epidermal (first-degree burn): Injury to the epidermis; skin is red, dry, and painful.
B. Deep (second-degree burn): Injury to the epidermis and upper layers of the dermis; skin is red, is moist or has dry blisters, and is extremely painful; exudate and swelling usually occur.
C. Full-thickness (third-degree burn): Injury to the epidermis, dermis, and subcutaneous tissue; skin is dry, pearly white to charred, inelastic, and leathery.
The length (head to toe), width (side to side), and depth of a wound are measured in centimeters. Single-use measurement guides (tape measures) often come with dressing supplies. To determine the depth of a wound, insert a sterile cotton swab into the deepest point of the wound and mark it at the skin surface level. Then the swab can be measured and the wound depth in centimeters can be documented. Tunneling, also called undermining, can be measured by using a cotton swab to gently probe the wound margins. If tunneling is noted, the location and depth are documented.
For clarity in describing the location of the tunneling, refer to the tunnel location using the hands of the clock as a guide, with 12 o’clock pointing at the client’s head. Example: ‘‘Tunneling occurs at 1 o’clock and its depth is 2 cm.’’
For extremely irregularly shaped wounds, the wound edges can be traced on a plastic surface. A plastic bag or piece of plastic sheeting folded in half is placed on the wound, and the wound margins are traced. The side of the plastic that has been placed against the skin is cut off and discarded. The rest of the plastic can be placed in the chart.
General Appearance and Drainage
A general description of the color of the wound and surrounding area helps determine the wound’s present phase of healing. Gently palpate the edges of the wound for swelling.
Document the amount, color, location, odor, and consistency of any drainage.
Nurses who care for the client in the home must demonstrate the need for skilled nursing services by accurately describing all wounds. Document a clear, concise, and accurate picture of the client’s wound: size, depth, and location of the wound; nature of drainage; condition and appearance of surrounding skin; and specific individualized instructions for treatment. For example, for Medicare to reimburse for nursing care, the care must be reasonable, be necessary, and reflect a plan of care appropriate for the client’s diagnosis, prognosis, and rehabilitative potential.
Pain
Document and notify the prescribing practitioner of any pain or tenderness at the wound site. Pain may indicate infection or bleeding. It is normal to experience pain at the incision site of a surgical wound for approximately 3 days. If there is any sudden increase in pain accompanied by changes in the appearance of the wound, be sure to notify the prescribing practitioner immediately.