O slideshow foi denunciado.
Seu SlideShare está sendo baixado. ×

Wound management.pptx

Próximos SlideShares
Pressure Sores
Pressure Sores
Carregando em…3

Confira estes a seguir

1 de 69 Anúncio

Mais Conteúdo rRelacionado

Semelhante a Wound management.pptx (20)

Mais de MohammedAbdela7 (20)


Mais recentes (20)

Wound management.pptx

  1. 1. Institute Of Health Science School Of Nursing and Midwifery Wound management By Muleta Kenate (AHN) 2/8/2023 By Mulata kenate 1
  2. 2. Brain storm Why we give care for patient with wound? 2/8/2023 By Mulata kenate 2
  3. 3. WOUND MANAGEMENT Presentation outline Objectives Introduction Wounds - Classification Comprehensive Assessment Possible nursing diagnoses Plan Implementation Evaluation Reference 2/8/2023 By Mulata kenate 3
  4. 4. Objectives Up on completion of this session students will able to  Identify types of wounds  Discuss current evidence-based standard wound management  Discuss Wound management strategies  Provide standardized nursing care for client with skin intact problem 2/8/2023 By Mulata kenate 4
  5. 5. Introduction • Wounds have substantial adverse impact on client’s quality of life and have a predictive risk with mortality. • Better understanding of the etiology of the wound and following the evidenced based management protocols can; – extremely improve client’s health outcomes and – lower the cost of the medical care. 2/8/2023 By Mulata kenate 5
  6. 6. Wounds - Classification • Intentional – results from planned treatment • Unintentional wounds- results from unexpected trauma…accident/ burns/ shooting • Open -skin broken, portal of entry • Closed – trauma from force, skin intact, soft tissue damage, internal injury, possible bleeding • Acute – goes through normal/timely healing process • Chronic – fails to go through normal stages of healing; no timely progress in healing 2/8/2023 By Mulata kenate 6
  7. 7. Wounds –Classification • Superficial • Penetrating • Perforating • Laceration • Puncture • Abrasion • Contusion • Clean • Contaminated • Infected • Colonized • Pressure Ulcers Stage I Stage II Stage III Stage IV 2/8/2023 By Mulata kenate 7
  8. 8. Types of Wounds Types of Wounds Pressure ulcers Diabetic ulcer Venous stasis ulcers Arterial ulcers Fungating wounds Surgical wounds Burn wound 2/8/2023 By Mulata kenate 8
  9. 9. Pressure Ulcers • A pressure ulcer is localized injury to the skin or underlying tissue usually over a bony prominence, because of unrelieved pressure and or in combination with shear and/or friction. • Pressure causes poor tissue perfusion and tissue damage can occur within 2 -6 hours. 2/8/2023 By Mulata kenate 9
  10. 10. Pressure Ulcers Stages 2/8/2023 By Mulata kenate 10
  11. 11. Pressure Ulcers Stages Stage -I Non-blanchable erythema • Intact skin with non-blanchable redness of a localized area usually over a bony prominence. • Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. • The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. • Category I may be difficult to detect in individuals with dark skin tones. 2/8/2023 By Mulata kenate 11
  12. 12. Stage -I Non-blanchable erythema 2/8/2023 By Mulata kenate 12
  13. 13. Pressure Ulcers Stages Stage-II Partial thickness • Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (yellow, tan, gray, green or brown). • May also present as an intact or open/ruptured serum-filled or sero- sanginous filled blister. • Presents as a shiny or dry shallow ulcer without slough or bruising. • This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis. 2/8/2023 By Mulata kenate 13
  14. 14. Stage-II Partial thickness 2/8/2023 By Mulata kenate 14
  15. 15. Pressure Ulcers Stages Stage-III Full thickness skin loss • Loss of epidermis & dermis with tissue loss extended to the subcutaneous fat. • Subcutaneous tissue may be visible but bone, tendon or muscle are not exposed. • Slough may be present but does not obscure the depth of tissue loss. • In contrast, areas of significant adiposity can develop extremely deep. 2/8/2023 By Mulata kenate 15
  16. 16. Stage-III Full thickness skin loss 2/8/2023 By Mulata kenate 16
  17. 17. Pressure Ulcers Stages Stage-IV Full thickness tissue loss • Full thickness tissue loss with exposed bone, tendon or muscle. • Partial slough or eschar may be present. • Often includes undermining and tunneling. • The depth of a Stage IV pressure ulcer varies by anatomical location. • The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. 2/8/2023 By Mulata kenate 17
  18. 18. 2/8/2023 By Mulata kenate 18
  19. 19. P.U. Management Principles • Friction & Shear management, Use lift/turn sheets ,Maintaining Head of Bead at <30 degrees • Turn & Reposition frequently • Pressure reduction & pressure redistribution utilizing low air loss mattress with alternating pressure • Skin protection dressings over high risk areas. Pain management • Optimal Nutrition & Hydration management • Temperature : keeping skin cool, clean and dry • Off-loading of pressure areas e.g. heel protectors • Moisture barrier & skin protectant ointments 2/8/2023 By Mulata kenate 19
  20. 20. Diabetic/Neuropathic Ulcers • A diabetic or Neuropathic ulcer is defined as an injury causing loss of skin or tissue often on the feet due to lack of sensation (neuropathy). 2/8/2023 By Mulata kenate 20
  21. 21. Diabetic/Neuropathic Ulcers 2/8/2023 By Mulata kenate 21
  22. 22. Diabetic/Neuropathic Ulcers Causes • Damage to nerves - Neuropathy • Damage to blood vessels / Decreased circulation (PAD & PVD) • Decreased immune response • Delayed response to tissue injury • Deformity 2/8/2023 By Mulata kenate 22
  23. 23. Diabetic/Neuropathic Ulcers Neuropathy associated with Diabetes Mellitus can be classified as: – Sensory Neuropathy – Motor Neuropathy – Autonomic Neuropathy 2/8/2023 By Mulata kenate 23
  24. 24. Diabetic/Neuropathic Ulcers Sensory Neuropathy • The most common type of diabetic neuropathy, causes pain or loss of feeling in the toes, feet, legs, hands, and arms 2/8/2023 By Mulata kenate 24
  25. 25. Diabetic/Neuropathic Ulcers Motor Neuropathy • Leads to paralysis of the foot's • muscles resulting in muscle atrophy that • predispose patients with diabetes to plantar ulceration by increasing plantar pressures and shear forces. 2/8/2023 By Mulata kenate 25
  26. 26. Diabetic/Neuropathic Ulcers Autonomic Neuropathy • Increases the risk of neuropathic ulceration due to disturbances in sweating mechanisms, callus formation, and blood flow. • It also effects heart, blood vessels, digestive system, urinary tract, eyes, lungs & sex organs. 2/8/2023 By Mulata kenate 26
  27. 27. Diabetic/Neuropathic Ulcers Wagner Grading Scale Grade 1: Superficial Diabetic Ulcer Grade 2: Ulcer extension Involves ligament, tendon, joint capsule or fascia, – No abscess or Osteomyelitis Grade 3: Deep ulcer with abscess or Osteomyelitis Grade 4: Gangrene to portion of forefoot Grade 5: Extensive gangrene of foot 2/8/2023 By Mulata kenate 27
  28. 28. Diabetic/Neuropathic Ulcers Management Principles 1. Wound Infection prevention: Wound Culture 2. MRI to Rule Out Osteomyelitis 3. Ankle Brachial Index & Toe Pressures 4. Hemoglobin A1c 7% or below 5. Serial debridement to minimize callous 6. Off-Loading 2/8/2023 By Mulata kenate 28
  29. 29. Venous Stasis Ulcers Venous Hypertension Underlying Pathologic Mechanism for Chronic Venous Insufficiency (CVI) and Ulceration Causes: 1. Outflow Obstruction 2. Valvular incompetence 3. Muscle pump failure 2/8/2023 By Mulata kenate 29
  30. 30. Venous Stasis Ulcers 2/8/2023 By Mulata kenate 30
  31. 31. Venous Stasis Ulcers Clinical Signs & Symptoms • Edema | 1+ • Discoloration of skin • Venous Dermatitis • Marked Redness • Atrophies blanche • Varicose veins 2/8/2023 By Mulata kenate 31
  32. 32. Venous Stasis Ulcers Management Principles • Diagnostic Testing: Segmental Pressures, Duplex Imaging • Compression Therapy • Diuresis • Diet Modification: Sodium monitoring & lose weight • Life style Modification: Daily weights & physical activities 2/8/2023 By Mulata kenate 32
  33. 33. Arterial / Ischemic Ulcers • Arterial or ischemic ulcers, are caused by the poor blood circulation to the lower extremities; peripheral artery disease (PAD). • Inadequate supply of oxygenated blood leads to tissue ischemia and necrosis. 2/8/2023 By Mulata kenate 33
  34. 34. Arterial / Ischemic Ulcers 2/8/2023 By Mulata kenate 34
  35. 35. Arterial / Ischemic Ulcers Clinical Findings: • pain relief w/dependency, • loss of hair, • Atrophic, • shiny skin, • Muscle wasting of calf or thigh, • Trophic nail changes • Poor tissue perfusion, • Color changes, • Coldness of the foot, • Gangrene of toes, • Absence of palpable pulse, • Par aesthesia (numbness) • Pulse-lessness (absence of pulses below the occlusion) • Paralysis (sudden weakness in the limb) • Extremity cool to touch 2/8/2023 By Mulata kenate 35
  36. 36. Arterial / Ischemic Ulcers Management Principles • Pain management • Vascular Surgery Referral for possible Revascularization • Hyperbaric Oxygen Therapy (HBOT) • If patient is not appropriate for surgical intervention • Keep the wounds clean, dry and free from infection • No compression !!! No Elastic or stretchable gauze rolls 2/8/2023 By Mulata kenate 36
  37. 37. Malignant / Fungating Wounds • A Fungating or Malignant wound occur when malignant cells invade the skin, blood and lymph vessels, and penetrate the epidermis. • This results in a loss of vascularity and therefore nourishment to the skin, leading to tissue death and necrosis. • The lesion might be the result of a primary cancer or a metastasis to the skin. • The term “Fungating” is utilized to describe a proliferative process in this types of wounds. 2/8/2023 By Mulata kenate 37
  38. 38. Malignant / Fungating Wounds 2/8/2023 By Mulata kenate 38
  39. 39. Malignant / Fungating Wounds Clinical Findings: • Malignant wounds are usually polymicrobic, containing both aerobic and anaerobic bacteria causing foul odor and purulent drainage from the tissue necrosis. • Anaerobic bacteria emit putrescine and cadaverine, which results in foul odors and some aerobic bacteria such as Proteus and Klebsiella can also produce foul odors. 2/8/2023 By Mulata kenate 39
  40. 40. Malignant / Fungating Wounds Management Principles: • Managing malignant wounds is frequently based on expert opinion and the experiences of the clinicians. • The assessment of a malignant wound requires clinician to gain insight into the patient’s perception of the wound and its consequent impact on his/her life. • Nursing care requires counseling skills and knowing how to provide care that is based on an awareness of and insight into the patients’ experience 2/8/2023 By Mulata kenate 40
  41. 41. Malignant / Fungating Wounds Management Principles: • Treatment selections should include those that provide – minimum side effects and maximum benefit to the client. • Establish goal of care Healing vs Palliation • Wound bed preparation will vary based on the goal. • If palliation is the goal, tissue debridement and management of bacterial overload is required to minimize odor and decrease risk of infection. 2/8/2023 By Mulata kenate 41
  42. 42. Malignant / Fungating Wounds Management Principles: • Negative pressure wound therapy (NPWT) for moderate to high exudating wounds. • Foul odor management • Charcoal based dressings to minimize odors. • Lavender oil soaked gauze for odor control & inflammation. • Metronidazole powder : Topical treatment to minimize odors • Pain management 2/8/2023 By Mulata kenate 42
  43. 43. Surgical Wounds • A surgical wound is defined as an incision or wound which is associated with a surgical procedure. • This includes surgically dehisced / disrupted wounds which fail to heal after a surgical procedure. 2/8/2023 By Mulata kenate 43
  44. 44. Surgical Wounds 2/8/2023 By Mulata kenate 44
  45. 45. Surgical Wounds There are (3) three methods of surgical closures to promote surgical wound healing: 1. Heal by Primary Intention 2. Heal by Secondary Intention 3. Heal by Tertiary Intention 2/8/2023 By Mulata kenate 45
  46. 46. Surgical Wounds Management Principles: • Keep surgical incision site clean and covered; away from external trauma. • Change dressings every other day. (QOD) • If noted, increased inflammation & drainage at the site, collect swab culture and send for DNA based Culture & Sensitivity (C&S) testing. 2/8/2023 By Mulata kenate 46
  47. 47. Surgical Wounds Management Principles: • Negative Pressure Wound Therapy (NPWT) • Xeroform gauze on incision sites. • Cleansing of incision site with antimicrobial solution with each dressing change. 2/8/2023 By Mulata kenate 47
  48. 48. Surgical Wounds Management Principles: • Client & family education about wound & treatment regimen. • Nurse to reinforce & reeducate client & family each visit. • Ordering appropriate wound care supplies in an enclosed container. • Having a copy of the recent Wound care orders available in the patient’s folder. • Document patient’s response to care regimen and progress. 2/8/2023 By Mulata kenate 48
  49. 49. Burn 2/8/2023 By Mulata kenate 49
  50. 50. Burn Initial Management: ABCDEs • Airway • Breathing • Circulation • Depth of Burn • Extent of Injury(s) • Pediatric (special) issues 2/8/2023 By Mulata kenate 50
  51. 51. Acute phase • Wound care and closure • Prevention or treatment of cxn including infection • Nutritional support. 2/8/2023 By Mulata kenate 51
  52. 52. Blister • In the pre-hospital setting, there is no hurry to remove blisters. • Leaving the blister intact initially is less painful and requires fewer dressing changes. • The blister will either break on its own, or the fluid will be reabsorbed. 2/8/2023 By Mulata kenate 52
  53. 53. Blisters break on their own Upper arm burn day 1 day 2 Burn “looks worse” the next day because of blisters breaking and oozing 2/8/2023 By Mulata kenate 53
  54. 54. Debride blister using simple instruments 2/8/2023 By Mulata kenate 54
  55. 55. Medic debriding blister 2/8/2023 By Mulata kenate 55
  56. 56. Before and after debridement • Removing the blister leaves a weeping, very tender wound, that requires much care. 2/8/2023 By Mulata kenate 56
  57. 57. Silver sulfadiazene 2/8/2023 By Mulata kenate 57
  58. 58. Rehabilitation phase • Prevention of scar and contracture • Physical, occupational and vocational rehabilitation • Psychological counseling 2/8/2023 By Mulata kenate 58
  59. 59. Complication • Immediate – shock pain Dehydration _ Infection Late. Scar Failure to heal Contracture 2/8/2023 By Mulata kenate 59
  60. 60. Comprehensive Assessment • Health History : Allergies, Smoking, Medications etc. • Duration of Ulceration: Current & Previous treatments • Diabetes Management: Hemoglobin A1c,RBS • Foot & Shoe Exam: Deformity, Improper shoes , Circulation / Pedal • Pulses, Skin Color, Temperature, Neuropathy, Callous • Mobility Status: Ambulatory, Wheelchair, Walker etc. • Nutrition: Pre-Albumin, Vitamin D, Vitamin C 2/8/2023 By Mulata kenate 60
  61. 61. Comprehensive Assessment • Location of wound : Plantar | Lateral or Medial aspect • Duration of Ulceration: When ulcer was first discovered • Grading of Ulcer: Wagner grading scale • Drainage or Odor: Type of drainage and odor; if any • Wound edges: Calloused | Pink & soft | Rolled • Presence of Pain: Assessing sensory loss 2/8/2023 By Mulata kenate 61
  62. 62. Possible nursing diagnoses • Imbalanced nutrition, less than body requirements, related to hyper metabolism as evidenced by wt loss • Impaired skin integrity related to injury as evidenced by physical examination • Impaired physical mobility related to joint contractures as evidenced by physical examination. 2/8/2023 By Mulata kenate 62
  63. 63. Possible nursing diagnoses • Deficient knowledge about the course of wound care & treatment as evidenced by patient verbalization • Ineffective airway clearance related to effects of smoke inhalation as evidenced by difficulty of breathing. 2/8/2023 By Mulata kenate 63
  64. 64. Outcome Identification and Planning • The goals of care for clients with wounds generally focus on – Promoting wound healing, – Preventing infection, and – Educating the client 2/8/2023 By Mulata kenate 64
  65. 65. Nursing Implementation • Initiate Emergency Measures • Prevention • Cleanse the Wound – Use Standard Precautions at all times • Dressing the Wound • Monitor Drainage of Wounds • Provide Suture Care • Checking Bandages, Binders, and Slings 2/8/2023 By Mulata kenate 65
  66. 66. Prevention 2/8/2023 By Mulata kenate 66
  67. 67. Evaluation • The client should be free of infection, with no evidence of fever, redness, or exudate. WBC and VS should be within normal range within one week. • The wound should exhibit beefy red granulation tissue, and the wound edges should be contracting 1 week after admission. 2/8/2023 By Mulata kenate 67
  68. 68. Reference 1. .Armstrong, D. G., Boulton, A. J. M., & Bus, S. A. (2017). Diabetic foot ulcers and their recurrence. New England Journal of Medicine, 376(24), 2367-2375. https://arizonaprimo.hosted.exli 2. Sue C. DeLaune, MN, RN, C Fundamentals.of.Nursing.3HAXAP-1 3. 2020 Wound Care Study Guide line 4. Pressure ulcer staging. (2013). www.npuap.org 5. Home Health Potentially Avoidable Event Measures (2013). Centers for Medicare & Medicaid Services. www.cms.gov. 6. Management of the wounds. (2014). www.woundcarenurses.org 7. Ferrell BA, Josephson K, Norvid P, Alcorn H. Pressure ulcers among patients admitted to home care. J Am Geriatr Soc 2000; 48(9):1042-1047. 8. Bergquist S. Subscales, subscores, or summative score: evaluating the contribution of Braden Scale itemsfor predicting pressure ulcer risk in older adults receiving home health care. J Wound Ostomy Continence Nurs 2001; 28(6):279-289. 9. Gorecki C, Brown JM, Nelson EA, Briggs M, Schoonhoven L, Dealey C et al. Impact of pressure ulcers on quality of life in older patients: a systematic review. J Am Geriatr Soc 2009; 57(7):1175-1183 2/8/2023 By Mulata kenate 68
  69. 69. 2/8/2023 By Mulata kenate 69