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ZALIANA BRAHIM WOUND CARE NURSE HOSPITAL MIRI

A wound is a disruption of continuity of skin or underlying tissues with or with out an opening onto the body surface.

Classification of wounds
1.

Acute wound - caused by trauma, animal bites, burns and surgical incisions
- generally managed by the surgical team

Classification of wounds
2. Chronic wound 3 basic types:

Pressure ulcers Lower extremity ulcers Skin tears

BURN

BURN

BURN

Principles of wound Care


1.

2.
3. 4.

5.

Relieving pain Correcting nutritional deficits Wound debridement Wound dressing Management of infection

Wound Management Nursing aspect


1.

Burns

2. Wound assessment 3. Wound care products

4. Nursing Process

1 Burn (Superficial)
- involves epidermis

- produce pain and redness - heal within a week - no scaring

2 Burn (Partial thickness)


- involves epidermis, superficial dermis - produce pain, redness, blister - heal within 2 to 3 weeks - minimal scaring

3 Burn (Full thickness)


- involves epidermis,

dermis, subcutaneous tissue - appear pale and white - no pain - require grafting

Burns
Rule of 9
- To estimate severity of burns

LUND and BROWDER Chart

Burns Nursing Management


Objectives
Prevention of shock 2. Prevention of infection 3. Prevention of contracture 4. Provision of psychotherapy
1.

Prevention of shock
1.

Sedation for pain and restlessness (morphine still


being the most effective drug except in respiratory burn) timely, proper documentation in pain score chart. Evaluate effectiveness of analgesics. Refer appropriately. DDA protocol in usage and recording to adhere to.

2. Use of colloids and crystalloids to combat shock (


resuscitation formulas) Strict and accurate Intake /Output chart recording

Prevention of shock
3. Administration of oral fluids

- small amount of 10-50 mls hourly of bland fluids (water,


glucose, plain ovaltine, barley water, orange juice, ribena etc)Accurate Intake and Output Chart

Burned patients are thirsty and if given too much to drink too quickly, they will vomit because of gastric dilatation and paralytic ileus.

Prevention of shock
4. Urinary output

Child 10mls / hour Adult 30mls /hour


Hourly urine output must be done and

accurately recorded
Inform Doctor for any decrease in urinary output

or presence of blood

Prevention of shock
5. Observations Hourly TPR, BP & SPO2
Temperature can be subnormal because the skin surfaces are destroyed and elevated subsequently when infection sets in. Pulse Rate, volume and regularity of pulse should be noted. Increase in pulse rate indicates over transfusion and acute gastric dilatation. Respiration observe for its depth and frequency and state of airway. Tracheostomy / intubation may be indicated for laryngeal edema, respiratory distress, restrict chest movement SPO2 Any decrease in SPO2 must be referred. Blood Pressure Any change must be referred. Can be over / under transfusion.

Prevention of shock
Restlessness - often an indication of under transfusion or can result from anoxia. Color and temperature of extremities - any coldness accompanied with any changes indicates circulation
impairment . Inform doctor immediately

Prevention of Infection
Infection control measures
1.

Staff
Barrier nursing Hand washing technique: prior & after.

2.
-

Visitors
Restriction- close family members only Hand washing prior to patient contact

3. -

Environmental measures Air conditioned room Temp 25-28C Bed linen Sterile linen for exposed method dressings Soiled linen removed immediately

4. 5.

Wound Care

Infection control measures

- swabs for C&S on admission Technique! - strict aseptic dressing technique

General personal hygiene


- promotion of independence - early mobilization - Encourage family support

6.

Nutrition
- High calorie &Protein - Supplementary feed eg. Enercal - Vitamin C, B complex, Iron

Major burns
- sips of water -NG tube - Enteral feeding

Maintain strict intake output chart

Prevention of contracture
Physio & Occupational Therapy
All joints into active & passive movements

Encourage exercises
Involve family in activities Need for JOBST Garment

JOBST GARMENT pressure garment

Provision of Psychotherapy
Psychotherapy
On admission reassurance (allay fear and anxiety) Adequate pain relief Social worker role Counselor role Family support Constructive diversional therapy

WOUND ASSESSMENT

WHY IS WOUND ASSESSMENT NECESSARY?


To enable prompt and appropriate wound

management Relieve the psychological burden of the person (and family members) with the wound To give appropriate health information and thus advice Cost saving

Wound Assessment
Location

Clinical appearance
Dimension Exudates

Wound edges
Surrounding skin Infection Pain Psychosocial implications

Location

Clinical appearance
- Degree of tissue loss - ? Black hardened, necrotic,

eschar, dry or moist


Sloughy wound

Necrotic (dead, dry issue)

Clinical appearance
Pus exudate Infected with heavy exudate

Exudate - Observe for color, consistency, amount & odor

Clinical appearance

Granulation

Clinical appearance

Epithilialising

Dimensions
Length Width

Depth

Wound Surrounding skin

Pain -Assessment

WOUND CARE PRODUCTS

Wound Care products


Hydrogel Hydrofibre /Alginates

Hydrocolloids

Today's market offers a vast selection of products, from simple gauzes to silvercontaining dressings to negative pressure therapies.

Negative pressure therapy

Selecting a Dressing
Consider the following general recommendations:

Keep the wound moist (the standard rule)


- A moist wound heals twice as quickly as a dry one

Avoid standard wet-to-dry dressings If it's wet, dry it; if it's dry, wet it.
- This means that a wound with heavy exudate will need a more absorptive dressing, such as a foam or alginate, while a dry wound will require rehydration with a hydrogel or an occlusive dressing, such as a hydrocolloid.

Types of dressing
1.

Alginates. - Derived from seaweed, these highly absorptive dressings are soft, nonwoven, and non-adhesive, and conform to the shape of the wound. - When in contact with drainage, they form a gel. Alginates are most useful for wounds with heavy exudate. - Don't use them for dry or eschar-covered wounds, because they won't form a gel and may stick to the wound, causing tissue trauma when you remove them - Some contain silver, which has an antimicrobial action - If a patient has a silver dressing, you may need to remove it before magnetic resonance imaging (MRI).

Cont Alginates Alginates come in sheets that you can cut to size. They also come in rope form, which is especially good for areas of undermining or tunneling. When using an alginate, you'll need to cover the wound with a secondary dressing to hold the product in place and to protect the wound from outside contaminants. Leave the alginate in place for one to three days, until it begins to gel and shows evidence of breakthrough drainage. Throughly irrigate the wound with sterile normal saline solution before reapplying the alginate.

Types of dressing
2.

Foams. - Typically polyurethane-based, this type of dressing is non-adhesive and comes in various sizes, shapes, and degrees of thickness. - foam dressings provide thermal insulation and help keep the wound moist. - They may be used as a primary or secondary dressing, to promote autolytic debridement, and to inhibit hypergranulation. - When using a foam dressing, make sure it's one to two inches larger than the wound; you can leave it in place for up to seven days.

Types of dressing
3. Hydrocolloids.
Hydrocolloid dressings contain hydrophilic colloidal particles in an

adhesive compound laminated to a flexible wafer. Like foams, they come in numerous sizes, shapes, and levels of thickness.

- Hydrocolloids have minimal absorptive capabilities.

- They help keep the wound moist and promote autolysis of necrotic areas. - Don't use them on wounds that are infected or have heavy exudate. - To avoid damaging fragile skin by removing the dressings too frequently, keep them in place for as long as possible, but no longer than seven days.

Types of dressing
4. Hydrogels.

- Available as gels, sheets, or gauze impregnated with various percentages of water, - Hydrogels are hydrophilic polymers with few absorptive properties. - They add moisture to the wound bed and are non-adherent, and they're used mainly for dry and minimally exudative

Type of Dressing
5. Hydrofiber

Hydrofiber Wound Dressing is indicated for:


- Management of exuding wounds including leg ulcers, pressure ulcers and diabetic ulcers, surgical wounds, partial thickness burns, and traumatic wounds

Why choose Hydrofiber Wound Dressing? - Absorbs and retains exudate and harmful components - Locks exudate in the dressing - Conforms to the wound surface, thereby reducing dead space - Does not damage tender, granulating wound tissue or healthy tissue surrounding exudating wounds during dressing changes - Absorbs wound fluid and creates a soft gel - Aids in autolytic debridement (removal of nonviable tissue from the wound) - Removes without leaving residue or causing trauma to wound - Manages painful wounds

Negative Pressure Wound therapy (NPWT) vacuum assisted closure

- This is an option for treating wounds that are draining heavily, failing to heal, or healing slowly. - NPWT applies sub-atmospheric pressure to the wound through the use of special foam dressings occlusively sealed and connected to a pump and collection chamber. - NPWT is useful in removing exudates and debris, promoting blood flow, hastening tissue granulation, and encouraging the contracture of wound edges. - It's especially helpful in treating deep, cavernous wounds. - The foam fills in dead space, and this can enhance closure of tunneling and undermined areas.

Debride the wound first Before you apply the dressing of choice, make sure that nonviable tissue, such as slough, eschar, and fibrin, have been debrided. Eschar that's dry, hard, and stable need not be removed, however, unless signs of infection are presentredness, pus, fluctuance (bogginess or mushiness), wound edge separation with drainage Whenever you suspect infection, refer to doctor in charge; wound cultures and/or antimicrobial therapy may be indicated.
Taking wound swab for C&S properly please!!!

Nursing Process

Document what you have observed


Location Clinical appearance

Dimension
Exudates Wound edges

Surrounding skin
Infection Pain

Psychosocial implications

Identify Nursing Problems


Risk of hypovolemic shock/ Risk of deficit fluid volume 2. Risk of infection due to impaired skin/tissue integrity 3. Risk of 2 infection superimposed on the primary wound 4. Risk of imbalanced nutrition: less than the body requirement 5. Pain 6. Hypothermia 7. Hyperthermia 8. Altered body image 9. Altered sleeping pattern 10. Deficient knowledge regarding condition, prognosis, treatment, self care and discharge needs
1.

Evaluation Is the wound getting better? Draw the wound size

Take photos

Collection for case presentation

Any Question?

Thank You.