Week 7 Nursing Flashcards
Wounds
▪ A wound is a break or disruption in the normal integrity of the skin and tissues.
▪ There are two (2) main classification of wounds;
Surgical (planned invasive therapy)
Non-surgical (unexpected trauma)
Wounds can also be classified as:
Acute (usually heal within 6 weeks)
Chronic (take longer than 3 months)
Wound Classification
▪ Wound classification systems describe the cause of the wound, cleanliness of the wound, thickness of tissue loss and colour.
* Intentionality of the wound
* Cleanliness of the wound
* Thickness of skin or tissue loss
▪ Multiple classification systems can be used to describe a wound, especially a complex or chronic wound.
▪ Specialist wound care nurses are available to help classify wounds and determine an appropriate wound management regime.
Phases of Wound Healing
▪ Inflammatory Phase
* Begins at the time of injury and lasts 3-6 days.
* Haemostasis and inflammation occurs.
▪ Proliferative Phase
* Begins from day 2-3 for approximately 2-3 weeks.
* Granulation tissue production and wound closure.
▪ Maturation Phase
* Begins from around day 21, last 6 to 12 months or more.
* Collagen remodelling occurs to increase strength.
Types of Wound Healing
▪ Primary Intention Healing
– Tissue surfaces are closed and there is minimal tissue loss (e.g. surgical incision). Wound edges are easily opposed.
▪ Secondary Intention Healing
– Extensive wound and considerable tissue loss (e.g. pressure ulcers). Wound heals through process of granulation.
▪ Tertiary Intention Healing
– Wounds left open for 3-5 days (e.g. traumatic wounds and abscess drainage). Primary intention closure is then attempted.
Factors Affecting Wound Healing
▪ Local Factors
– Pressure
– Desiccation
– Maceration
– Trauma
– Oedema
– Infection
– Foreign Bodies
– Necrosis
▪ Systemic Factors
– Age
– Oxygenation and Circulation
– Nutritional Status
– Medication and General Health
– Glucose Control
– Immunosuppression
– Smoking
– Connective Tissues Disorders
Tissue
▪ Necrosis
▪ Eschar
▪ Slough
▪ Granulation
Infection & Inflammation
▪ Infection
– Increased pain
– Delayed healing
– Purulent discharge
– Green appearance
– Malodorous
▪ Inflammation
– Pain surrounding wound
– Erythema
– Hot on palpation
– Peri-wound breakdown
Moisture
▪ Dry Wounds
– Scab formation
– Delayed healing
– Wound contraction
▪ Moist Wounds
– Optimal environment
– Minimal scarring
▪ Wet Wounds
– Altered fluid balance
– Maceration of skin
– Damage to tissues
Edge of Wound
▪ Desiccation
– Excessive dryness
▪ Maceration
– Excessive moisture
▪ Undermining
– Rolling of wound edges
Types of Wound Exudate
▪ Referred to as exudate due to exudation (movement) of fluid and cells from the vascular space into the wound.
▪ Wound exudate occurs during the defensive phase:
– Dilution of toxins produced by bacteria and dying cells
– Transport of leukocytes and plasma proteins
– Removal of bacterial toxins, dead cells and debris
▪ Serous exudate is composed primarily of serum and is watery in appearance and has a low protein count and is yellow in colour.
▪ Purulent exudate is also called pus and is thick, tenacious and is yellow or green in colour and contains dead pathogens and cells debris.
▪ Haemorrhagic exudate has a large component of red blood cells and is usually bright red in colour.
Aseptic technique
- Surgical site infections (SSI) common postoperative HAI
- Use of Aseptic Non Touch Technique (ANTT) reduces the risk of SSI
- Correct hand hygiene is essential
- Hands or equipment must not come into contact with ‘key-site’ (wound)
- Non-touch technique
- Follow organisational procedures (wound field concept or clean and dirty area)
Moist Wound Healing
▪ Decreased dehydration and cell death
▪ Increased angiogenesis
▪ Increased reepithelialisation
▪ Enhanced autolytic debridement of wound
▪ Decreased pain
▪ Improved cosmesis
Intestinal Stomas
Gastrointestinal
▪ A stoma is an opening onto the abdominal wall to allow evacuation of faecal material.
– Colostomy
– Ileostomy
▪ Stomas can be permanent or temporary depending on the reason the bowel was diverted.
Renal
▪ Ureters are resected from the bladder and anastomosed to a resected part of the ileum.
– Ileal conduit / urostomy
Indications
▪ Colostomy/Ileostomy
– Bowel obstruction
– Trauma (burns)
– Ischaemic bowel
– Perforated bowel
– Infection
– Inflammatory bowel disease (severe)
– Diverticulitis
– Colorectal cancer
– Congenital birth defects
– Temporary (post-surgery)
▪ Ileal Conduit
– Bladder cancer requiring a cystectomy
– Traumatic bladder injury
– Severe intractable incontinence
– Neurogenic bladder threatening kidney function
Ostomy Appliances
▪ Ostomy pouch or ostomy appliance is the preferred term
– 1 piece / 2 piece appliance
– Drainable / closed
– Disposable / reusable
– Stoma and wound nurses
– Outreach services
