intentional wounds

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Fundamental of Nursing I Prepared by: Shady Shafeek Dowarah

جمــــهوريــة العــــراق

والبحث العلمي اليـليم العـعــوزارة الت

ياءــــنبأة وارث الــــامعـج

لتمريضية اـلـك

Republic of Iraq بسم الله الرحمن الرحيم

Ministry of Higher Education and Scientific Research

University of Warith Al-anbiya'a

College of Nursing

After completing this lecture the students will be able to:

1. Describe wounds and identify the common types of wounds.

2. Define pressure ulcer and identify clients at risk for developing pressure ulcers.

3. Describe the four stages of pressure ulcer development.

4. Discuss the processes involved in wound healing.

5. Differentiate primary, secondary, and tertiary wound healing.

6. Identify factors that affect wound healing.

7. Describe the principles of wound assessment and care.

8. Identify nursing diagnoses associated with impaired skin integrity.

9. Identify essential aspects of planning care to maintain skin integrity and promote

wound healing.

The skin is the body’s first line of defense, protecting the underlying structures from

invasion by organisms. Important nursing functions are maintaining skin integrity

and promoting wound healing. Impaired skin integrity, such as wound, may occur as

a result of trauma, surgery, and other invasive procedures. The potential for skin

breakdown and eventual pressure ulcer formation also exists whenever factor such

as prolonged pressure, constant irritation of the skin, and immobility are present.

Nurse plays a major role in maintaining the patient’s skin integrity, in identifying

risk factors that predispose a patient to a break in integrity, in intervening to prevent

or reduce a patient’s risk for impaired skin integrity, and in providing specific

wound care when breaks in integrity arise. A wound: is a break or disruption in the normal integrity of the skin, mucous

membrane, and body tissue.

1. Intentional wounds: occurs during treatment or therapy, under aseptic conditions

(e.g., surgical incision and venipuncture).

2. Unintentional wounds: result from unexpected trauma, or accident created in an

unsterile environment and therefore poses a greater risk of infection.

1. Open wound: occurs from intentional or unintentional trauma. The skin surface is

broken, providing a portal of entry for microorganisms. Examples include incisions

and abrasions.

2. Closed wound: damage of soft tissue and under lining structures while the skin

remains intact, may involve internal injury and hemorrhage. Result from a blow,

force, or strain caused by trauma such as a fall, an assault, or a motor vehicle crash.

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1. Incision: Open wound; deep or shallow; caused by sharp instrument (e.g., knife or

scalpel), once the edges have been sealed together as a part of treatment or healing,

the incision becomes a closed wound.

2. Contusion: Closed wound caused from a blunt instrument, skin appears ecchymotic

(bruised) because of damaged blood vessels.

3. Abrasion: Open wound involving the skin caused by surface scrape, either

unintentional (e.g., scraped knee from a fall) or intentional (e.g., dermal abrasion to

remove pockmarks).

4. Puncture: Open wound, caused by penetration of the skin and often the underlying

tissues by a sharp instrument, either intentional or unintentional.

5. Laceration: Open wound, edges are often jagged, tissues torn apart, often from

accidents (e.g., with machinery).

6. Penetrating wound: Open wound caused by penetrating of the skin and the

underlying tissues, usually unintentional (e.g., from a bullet or metal fragments).

1. Clean wounds: are uninfected wounds in which there is minimal inflammation and

the respiratory, gastrointestinal, genital, and urinary tracts are not entered. Clean

wounds are primarily closed wounds.

2. Clean-contaminated wounds: are intentional wounds e.g., surgical wounds in

which the respiratory, gastrointestinal, genital or urinary tract has been entered. Such

wounds show no evidence of infection.

3. Contaminated wounds: include open, fresh, accidental and surgical wounds

involving a major break in sterile technique or a large amount of spillage from the

gastrointestinal tract. Contaminated wounds show evidence of inflammation.

4. Dirty or infected wounds: include wounds containing dead tissue and wounds with

evidence of a clinical infection, such as purulent drainage.

1. Superficial wound: (e.g., first degree burn), involves loss of only the epidermis

layer (e.g., a superficial excoriation caused by friction); may take several days to a

week to heal.

2. Partial thickness: (e.g., second degree burn), involves loss of dermis and epidermis

layers; heal by regeneration, may take 2 to 3 weeks to heal.

3. Full thickness: (e.g., third degree burn), involving the dermis, epidermis,

subcutaneous tissue, and possibly muscle and bone; require connective tissue repair,

may take months or years to heal.

Is a wound with a localized area of tissue necrosis that tend to developing when soft

tissue is compressed between a bony prominence and an external surface for a

prolonged period of time.

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A. Friction and shearing: Friction is a force acting parallel to the skin surface. e.g.,

sheets rubbing against skin create friction. Shearing force is a combination of

friction and pressure. It occurs commonly when a client assumes a sitting position in

bed.

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B. Immobility and inactivity: Normally people move when they experience

discomfort due to pressure on an area of the body. Immobility e.g., paralysis, can

hinder a person’s ability to change positions independently and relieve the pressure,

even if the person can perceive the pressure.

C. Inadequate nutrition: Prolonged inadequate nutrition causes weight loss, muscle

atrophy, and the loss of subcutaneous tissue. These three conditions reduce the

amount of padding between the skin and the bones, thus increasing the risk of

pressure ulcer development. More specifically, inadequate intake of protein,

carbohydrates, fluids, zinc, and vitamin C contributes to pressure ulcer formation.

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D. Fecal and urinary incontinence: Moisture from incontinence promotes skin

maceration (tissue softened by prolonged wetting or soaking) and makes the

epidermis more easily eroded and susceptible to injury. Digestive enzymes in feces,

and urea in urine, also contribute to skin excoriation (loss of the superficial layers of

the skin). Any accumulation of secretions or excretions is irritating to the skin,

harbors microorganisms, and makes an individual prone to skin breakdown and

infection.

E. Decreased mental status: Individuals with a reduced level of awareness, e.g.,

unconscious, heavily sedated, or have dementia, are at risk for pressure ulcers

because they are less able to recognize and respond to pain associated with

prolonged pressure.

F. Diminished sensation: reduces a person’s ability to respond to trauma, to injurious

heat and cold, and to the tingling (“pins and needles”). And also impairs the body’s

ability to recognize and provide healing mechanisms for a wound.

G. Excessive body heat: An elevated body temperature increases the metabolic rate,

thus increasing the cells’ need for oxygen. Also severe infections with

accompanying elevated body temperatures may affect the body’s ability to deal with

the effects of tissue compression.

H. Advanced age: older person more prone to impaired skin integrity.

I. Chronic medical conditions: e.g., diabetes (D.M) and cardiovascular disease

(CVD) are risk factors for skin breakdown and delayed healing. These conditions

compromise oxygen delivery to tissues by poor perfusion and thus cause poor and

delayed healing and increase risk of pressure ulcer.

1) Stage I: erythema of intact skin.

2) Stage II: partial-thickness skin loss (abrasion, blister, or shallow crater) involving

the epidermis and possibly the dermis.

3) Stage III: full-thickness skin loss involving damage or necrosis of subcutaneous

tissue that may extend down to, but not through, underlying fascia. The ulcer

presents clinically as a deep crater with or without undermining of adjacent tissue.

4) Stage IV: full-thickness skin loss with tissue necrosis or damage to muscle, bone, or

supporting structures, such as a tendon or joint capsule.

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Stage 1 stage 2

Stage 3 stage 4

1) Primary intention healing: occurs where the tissue surfaces have been

approximated (closed) and there is minimal or no tissue loss; it is characterized by

the formation of minimal granulation tissue and scarring. Example: closed surgical

incision.

2) Secondary intention healing: seen in wound that is extensive and involves

considerable tissue loss, and in which the edges cannot or should not be

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approximated. The wound is left open, and granulation tissue gradually fills in the

deficit. Example pressure ulcer and burns.

3) Tertiary intention healing (delayed or secondary closure): seen in wounds with

poor circulation or infection. Wound suturing is delayed until the problems resolves

(edema, infection, or exudate to drain) example diabetic foot.

1. Defensive (inflammatory) phase: begins immediately after injury and lasts 3 to 6

days. Two major processes occur during this phase: hemostasis and phagocytosis.

A. Hemostasis (the cessation of bleeding): results from vasoconstriction of the larger

blood vessels in the affected area, retraction (drawing back) of injured blood vessels,

the deposition of fibrin (connective tissue), and the formation of blood clots in the

area.

B. Phagocytosis: The blood supply to the wound increases, bringing with it oxygen and

nutrients needed in the healing process. The area appears reddened and edematous as

a result. The increased blood supply transports leukocytes (specifically, neutrophils)

to the interstitial space. These are replaced about 24 hours after injury by

macrophages. These macrophages engulf microorganisms and cellular debris by a

process known as phagocytosis. The macrophages also secrete an angiogenesis

factor, which stimulates the formation of epithelial buds at the end of injured blood

vessels. The increased blood supply also removes the "debris of the battle" which

includes dead cells, bacteria, and exudate or material and cells discharged from

blood vessels.

2. Reconstructive (proliferative) phase: the second stage begins on the 3th

or 4th

day

after injury and lasts for (2-3) weeks. This phase contain the process of collagen

deposition, angiogenesis (the formation of new blood vessels), granulation tissue

development, and wound contraction.

3. Maturation phase: final stage of healing begins on about day 21 and can extend to 2

years or more, depending on the depth and extent of the wound. During this phase

the scar tissue remodeled. Although the scar tissue continues to gain strength, it

remains weaker than the original tissue it replaces. Capillaries eventually disappear,

leaving a vascular scar (a scar that is white because it lacks a blood supply).

Characteristics of the individual such as age, nutritional status, lifestyle, and

medications influence the speed of wound healing.

Healthy children and adults often

heal more quickly than older adults, because the blood circulation and O2 delivery to

the wound, clotting, inflammatory response, and phagocytosis may be impaired in

the elderly; thus, the risk of infection is greater.

A. A balance diet with adequate amounts of protein, carbohydrates, lipids, vitamins

(e.g., A and C), and minerals (such as iron, zinc, and copper) is needed to increase

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the body's resistance to pathogens and decrease the susceptibility of skin and

mucous membranes to infection and trauma.

B. Malnutrition reduces humoral and cell mediated factors, leading to

immunocompromise, thus impairing wound healing and increasing infection risk.

C. Obese clients are at increased risk of wound infection and slower healing because

adipose tissue usually has a minimal blood supply that impairs delivery of nutrients

and other elements needed for healing; also, suturing of fatty tissue is more difficult.

D. Drying up of wound tissue (ells dehydrate and die in a dry environment).

E. Over hydration related to urinary and fecal incontinence can lead to impairing

wound healing and increasing the risk of infection (moisture increase in the pH of

the skin, thus results overgrowth of infectious agents).

A. People who exercise regularly tend to have good circulation and because blood

brings oxygen and nourishment to the wound, they are more likely to heal quickly.

B. Smoking reduces the amount of functional hemoglobin in the blood, thus reduces the

amount of oxygen in the tissue. (Decreased arterial oxygen alters the synthesis of

collagen and the formation of epithelial cells, causing wounds to heal more slowly).

result in

delayed healing.

A. Cardiovascular disease (CVD): increase the risk of delayed healing due to impaired

O2 delivery to tissues.

B. Anemia: decreased O2 delivery to the tissues and interfere with tissue repair.

C. diabetes mellitus (DM):

DM can impair tissue perfusion and oxygen delivery.

Elevated blood glucose impairs leukocyte function and phagocytosis.

The high glucose environment is an excellent medium for growth of bacteria, fungal,

and yeast infections.

D. Anti-inflammatory drugs (e.g., steroids and aspirin) and antineoplastic agents reduce

inflammatory response and slow collagen synthesis. Anti-inflammatory drugs

suppress protein synthesis, wound contraction, epithelialization, and inflammation.

E. Prolonged use of antibiotics, with development of resistant strain of bacteria, may

increase the risk of wound infection.

Assessing Untreated Wounds: 1. Assess the location (anatomical location of wound), and extent of tissue damage

(e.g., partial thickness or full thickness).

2. Size: measure the wound length, width, and depth (e.g., 5 inches suture line on

the right lower quadrant of the abdomen.

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3. Inspect the wound for bleeding. The amount of bleeding varies according to the

type of wound and location. Penetrating wounds may cause internal bleeding.

4. Inspect the wound for foreign bodies (soil, broken glass, shreds of cloth).

5. Assess associated injuries such as fractures, internal bleeding, spinal cord

injuries, or head trauma.

6. If the wound is contaminated with foreign material, determine when the client

last had a tetanus toxoid injection. A tetanus immunization or booster may be

necessary.

Assessing treated wounds or sutured wounds: 1. Usually assessed to determine the progress of healing. These wounds may be

inspected during changing of a dressing.

2. Assess general appearance, size and status of drain or tubes: color of the wound

and surrounding area helps to determine the wound's present phase of healing.

Document amount, color, location, odor, and consistency of any drainage.

3. Assess pain: any pain or tenderness at the wound site should be notified and

documented.

4. Laboratory data:

Cultures of the wound drainage are used to determine the presence of infection

and to identify the causative organism. The sensitivity results list the antibiotics

that will effectively treat the infection.

An elevated WBCs count is indicative of an infectious process.

A decreased leukocyte count may indicate that the client is at increased risk for

developing an infection related to decreased defense mechanisms.

Hemoglobin (Hb) level below normal range indicates poor O2 delivery to the

tissues.

A decreased albumin, there are decreased resources of protein for wound healing.

for example 1. Impaired tissue integrity related to surgical incision as manifested by…..

2. Risk for infection related to malnutrition, decreased defense mechanisms.

3. Pain related to inflammation, infection as evidence by……

The goal focusing on promoting wound healing, preventing infections, and

educating the client.

1. Initiate emergency measures:

Slandered precautions are always implemented.

If hemorrhage is detected, sterile dressing and pressure should be applied to

stop the bleeding and elevated the effected extremity.

When dehiscence or evisceration occurs, the client should be instructed to

remain quiet and to avoid coughing or straining. Sterile dressing, soaked with

sterile normal saline should be used to cover the wound and abdominal

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contents. This will reduce the risk of bacterial contamination and drying of the

viscera. Notify the surgeon immediately and the client prepared for surgical

repair of the area.

Vital signs should be monitored frequently.

2. Cleanse the wound: the goal of cleansing the wound is to remove debris and

bacteria from the wound bed with as little trauma to the healthy granulation

tissue as possible. It is recommended that isotonic solutions such as normal

saline or lactated ringers be used to preserve healthy tissue. Commonly used

antiseptic agents such as povidone-iodine 10% hydrogen peroxide 3%, sodium

hypochlorite, and acetic acid are effective in destroying bacteria but at the

same time destroy fibroblasts and healthy granulation tissue.

The major principles to keep in mind when cleansing a wound are:

a. Use standard precautions at all times.

b. When using a swab or gauze to cleanse a wound, work from the clean area out

toward the dirtier area.

c. When irrigating a wound, warm the solution to room temperature, preferably

to body temperature, to prevent lowering of the tissue temperature. Be sure to

allow the irrigate to flow from the cleanest area to the contaminated area to

avoid spreading pathogens.

3. Provide suture care.

4. Dressing the wound: covering the wound with a sterile dressing, when the

first layer of dressing becomes saturated with blood, applies a second layer. Do

so without removing the first layer of dressing, because blood clots might be

disturbed, resulting in more bleeding.

The purposes of wound dressing are:

a. Provide moist environment and therefore enhance epithelialization.

b. Supporting healing by absorbing drainage.

c. Protect the wound from microbial invasion.

d. Promote homeostasis.

e. Provide thermal isolation of the wound.

f. Protect the wound from physical trauma and supporting the wound site.

5. Monitor drainage of wounds: when excessive drainage accumulates in the

wound, tissue healing is delayed. To facilitate drainage of any excess fluid, a

tube or drain should be inserted.

6. Control swelling and pain: by applying ice over the wound and surrounding

tissues.

7. Checking bandages, binders, and slings: bandages and binders are applied

over wound dressing sites to secure, immobilize, or support a body part; to

hold a dressing in place; or to prevent or minimize swelling of a body part.

evaluate the clients achievement of the goals establishes during

the planning phase.

intentional wounds

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