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22 Pages

Tissue wound

Course: NURSING 96:135, Spring 2010
School: University of Iowa
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Word Count: 1398

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Coursehero >> Iowa >> University of Iowa >> NURSING 96:135

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Healing Sue Wound Gardner, PhD, RN, CWCN College of Nursing The University of Iowa Objectives Relate phase of healing with specific wound characteristics Differentiate partial thickness & full thickness healing and primary vs. secondary healing Identify risk factors for impaired healing Describe care and local treatment of wounds. Objectives Use wound characteristics to select nursing interventions that support healing Debridement Cleansing Dressings Nutrition Protection Tissue Repair and Wound Healing Injured tissue heals by regeneration or by connective tissue repair Regeneration is limited to cells/tissues that can undergo mitosis Connective tissue repair occurs in primary and secondary wounds in three phases - Inflammatory phase - Proliferative phase - Remodeling phase Regeneration or Repair Determined by Level of tissue injury Capacity of tissue to regenerate itself Levels of Tissue Injury: Skin Partial thickness wound Full thickness wound Partial Thickness Wounds Injury to epidermal & superficial dermal layers Heal by regeneration of epithelial, endothelial & connective tissue Stage II pressure ulcers; 2nd degree burn Partial Thickness Wound Partial Thickness Burn Partial Thickness Wound Components of Partial Thickness Healing Initial inflammatory response Epithelial proliferation & migration (resurfacing) Reestablishment & differentiation of epidermal layers Partial Thickness Healing Partial Thickness Healing Resurfaced Healed New epithelium fragile Repigmentation occurs as normal function returns Healed = return of pigmentation Full Thickness Wound Injury extends to subcutaneous tissue, muscle & fascia Deeper structures DO NOT regenerate Heal by connective tissue repair & replacement with scar tissue Stage III & IV pressure ulcers Surgical incisions Full Thickness Wound Full Thickness Wound Full Thickness Wound Full Thickness Healing Phases of healing - Inflammation (includes vascular response) - Proliferation (reconstructive; fibroblastic; connective) - Remodeling (differentiation; maturation; plateau) Phases overlap Phases marked by characteristic features Inflammation Defensive reaction to tissue injury Increased blood flow & capillary permeability Platelets aggregate & form fibrin clot Platelets release growth factors Neutrophils & monocytes engulf bacteria & debris Inflammation Inflammation Mediated by inflammatory mediators - Interleukins - TNF - Arachidonic acid derivatives (prostaglandins) Defining characteristics - YOU KNOW THESE!!! Necrosis or infection prolongs this phase Inflammation & Purulent Exudate Proliferation Mediated by growth factors - PDGF - Fibroblast growth factor Angiogenesis - restores vasculature Matrix formation - replaces damaged tissue with collagen and elastin fibers Wound contraction - reduces size of defect Epithelization - resurfaces wound Proliferation Proliferation New capillary network Collagen matrix Wound contraction Proliferation Proliferation Wound resurfaces Epithelial Cells Migration Proliferation Differentiation Granulation tissue essential Remodeling Simultaneous processes of wound matrix breakdown & synthesis of new matrix Scar gains strength Maximum tensile strength = 80% Extends 2 years post injury Remodeling Surgical Incision Primary vs. Secondary Healing Primary Intention Healing: Surgical Incision Inflammation: 0 - 6 days - Clotting - Phagocytosis - Epithelial ridge forms Proliferation: 4 - 14 days - Collagen formation - Minimal wound contraction Remodeling (Maturation): 14 days - 2 yrs. - Collagen synthesis & lysis - Tensile strength increases (max 80%) - Scar flattens, whitens Primary Healing Risk Factors for ImpairedWound Healing Lack of substrates to support healing - Age - Malnutrition - Tissue ischemia - Hyperglycemia - Decreased immune function - Glucocorticoid steroids - Presence of debris &/or devitalized tissue Contamination Necrotic tissue - Infection Advanced age - slows healing Malnutrition - Low protein (Albumin < 3.0 gm/dl) - Inadequate calories (< 30 cals/kg/day) Tissue ischemia (TCO2 < 30 mm Hg) - Decreased macrophage activity - Decreased fibroblast activity Hyperglycemia - FBS > 150 mg/dl - Glycosylated Hemoglobin A1C > 7% Decreased immune function - Inadequate neutrophils &/or lymphotyes Glucocorticoids - Decreased lymphocytes Wound Assessment Comprehensive assessment - Patient history - Wound characteristics - Basis for treatment decisions Wound Characteristics Location Stage* Size Exudate Approximation of edges Type of tissue Periwound area Undermining Tunneling Pain - * pressure, diabetic foot, arterial ulcer, burns - Surgical incisions Location Identify by anatomical landmarks Left ischial tuberosity Stage of Injury Defines depth of tissue injury Eschar must be remove to accurately assess stage Stage I Nonblanchable erythema Stage II Superficial Epidermis denuded Stage II Stage III Full thickness Involves subcutaneous Extend to facia Deep crater Undermining Stage III Stage IV Full thickness Damage to muscle, bone or supporting structures Extensive tissue loss & necrosis Undermining/tunneling Unstageable Eschar cover Unable wound to assess depth of tissue damage Wound Healing Assessment Wound Size Measure length - maximum head to toe Measure width - maximum side to side Burn Wound Assessment Wound Healing Assessment Wound Depth Measure deepest point of wound Mark off at wound edge Wound Healing Assessment Tissue type - Necrotic Slough Granulation Epithelial Necrotic Tissue Devitalized tissue Black, brown, tan Adheres to wound bed or edges Firm or soft Slough Devitalized tissue Yellow or white Adheres to wound bed Forms strings, clumps May be mucinous Granulation Pink, beefy red Shiny, moist Granular appearance Epithelial New pink or shiny tissue (skin) Grows from edges or as islands on wound Surgical Incision Edges closely approximated Minimal gaps along incision line Epithelial ridge in 48 - 72 hrs. Abnormal Surgical Incision Inflammation signs - Erythema - Edema - Induration - Exudate - Pain Wound Healing Assessment Exudate - Type - Amount Exudate - type Serous - Thin, watery - Clear Serosanguineous - Serous or blood tinged - Watery, thin - Pale red or pink Purulent - Product of inflammation - pus - Concentrated with leukocytes - Yellow, tan or green - Opaque Exudate - Amount Heavy - bathed in fluid Moderate - saturated Light - wet None dry Wound Healing Assessment Tunneling / Undermining Occur in areas with more extensive tissue Create dead space Predispose to exudate accumulation Tunnel (Sinus tract) Extends from surface of wound through subcu & muscle Channel or pathway Not entirely visible Predispose to abscess formation Undermining Tissue destruction around wound perimeter Edges pulled away from wound base Creates cliff of skin Wound Healing Assessment Wound edges - Diffuse, indistinct - Attached, unattached - Rolled under - Calloused (hyperkeratosis) - Scared (fibrotic) Edges Optimal healing - Diffuse, indistinct - Attached Edges Rolled under (closed) Edge separated from surface of wound Epithelial migration impaired Must reestablish open edge surgically or with cauterization Wound Edges Scarred Scar tissue from previous injury Epithelial migration impaired Must reestablish viable wound edge Wound Healing Assessment Periwound surface - Maceration - Erythema - Induration - Edema - Ecchymotic Periwound Surface Maceration Softening of skin White or gray Hypopigmented Periwound Surface Signs of Infection - Erythema - Induration - Edema - Exudate - Pain Periwound Surface Eccymosis Hemorrhagic area under skin Irregular shape Greenish brown or yellow Wound Healing Assessment Pain - Intensity - Character Wound Healing Assessment Must consider patient history Must be documented Must be ongoing Nursing Interventions Goals Support tissue repair & regeneration Control etiology of tissue injury Nursing Interventions Maintain moist wound environment Remove debris Eliminate dead space Identify & eliminate infection Provide substrates for healing Prevent further injury Maintain Moist Environment Wound open to the air - Desiccates wound bed - Impairs healing Maintain Moist Environment Select dressing to Maintain moisture in wound Control exudate on surrounding skin Dressing Options Gauze Dressings Moisten with saline or wound gel Remoisten frequently Can be packed in cavities Impregnated Gauze Dressings Nonadherent Contain petrolatum Covering for incisions Exudate Absorbing Dressings Calcium alginates Foams Remove Debris Devitalized tissue harbors microorganisms Increases risk of infection Impairs growth of granulation tissue Types of Debris Adherent, devitalized tissue Surface contaminants Debridement Removes adherent tissue Methods of Debridement Sharp Enzymatic Autolytic Mechanical Methods of Debridement Wound Cleansing Remove surface contaminants Use noncytotoxic solution Avoid antiseptics Repeat with each dressing change Wound Cleansing: Whirlpool Wound Cleansing: Irrigation Irrigation Pressure 5 - 15 psi Identify & Eliminate Infection Identify signs of acute inflammation All chronic wounds are colonized Swab cultures valid if use correct technique Chronic wounds dont exhibit acute inflammation signs - Increased pain - Lack of healing DONT DO THIS This is the best evidenced-based technique Identify & Eliminate Infection Report signs of infection to physician Remove adherent debris Antibiotics - Topical - localized cellulitis - Systemic - extensive cellulitis or sepsis Eliminate Dead Space Tunnels/undermining Pack with dressing to remove exudate & bacteria Provide Substrates for Healing Protein - 1.25 - 1.5 gm/kg/day Calories - 30 - 35 calories/kg/day Vitamins - Multivitamin - Supplement for deficiencies as needed Prevent Further Injury Protect from pressure or trauma Avoid walking (foot ulcers) or sitting (pressure ulcers) on injured tissue Avoid exposure to extremes of heat/cold Provide Pressure Protection Pressure reducing bed/mattress Site specific pressure-reducing device Wound Healing Interventions: Patient Outcomes Closed wound Strong scar Return of function Baseline Assessment Size - 3.8 x 2.8 = 10.64 cm2 Exudate Amount - None Tissue Type - Necrotic tissue 107 Week 2 Week 8 Week 10 Week 12 Week 14 Week 16

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