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Wound Care Basics

Wound Care Basics. Wound Care Overview. Layers of skins Epidermis Dermis Subcutaneous tissue Types of Wounds Surgical Diabetic Pressure Venous Stasis Traumatic Arterial Classifications Wagner University Of Texas PUSH tool (pressure wounds) Wound Care Goals Nutrition Circulation

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Wound Care Basics

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  1. Wound Care Basics

  2. Wound Care Overview Layers of skins Epidermis Dermis Subcutaneous tissue Types of Wounds Surgical Diabetic Pressure Venous Stasis Traumatic Arterial Classifications Wagner University Of Texas PUSH tool (pressure wounds) Wound Care Goals Nutrition Circulation Pain management Treatment Topical Dressings Negative Pressure Treatment

  3. ● Protects from dehydration, infection, & moisture loss ● Consists of 4 - 5 layers (or strata), depending on location ● Made up of epithelial tissue/produces Vit. D & cytokines ● Regenerated/Repairs itself every 2 to 4 weeks ● Non-vascularized Epidermis ● Contains nerves, connective tissue, collagen, & elastin ● Inflammatory reactions originate here (trauma/infection) ● Contain nerves that sense heat, cold, pressure, & pain ● Very vascularized Dermis Subcutaneous tissue ● Supports dermis and epidermis ● Can vary in depth (depending on location) ● Made up of adipose tissue, connective tissue, & blood vessels ● Functions include storing fat & temperature regulation

  4. Types of Wounds

  5. Types of Wounds Surgical Wounds Source: www.medscape.com

  6. Types of Wounds Diabetic Wounds Source: www.medscape.com

  7. Types of Wounds Pressure Wounds Source: www.medscape.com

  8. Types of Wounds Venous Stasis Wounds Source: www.medscape.com

  9. Types of Wounds Arterial Wounds Source: www.medscape.com

  10. Types of Wounds As most trauma wounds can be very graphic, they were not added here as most nurses viewing this presentation were not in that niche. Trauma Wounds

  11. Wound Classification Systems PUSH Tool • Wound size (greatest length x greatest width = wound surface area) • Exudate amount (estimate as light, moderate or heavy after removal of the dressing) • Tissue type (closed/resurfaced, epithelial tissue, granulation tissue, slough, necrotic tissue/eschar) Swezey, L. (2015, November 19). Wound Assessment Tools: A Basic Introduction to PUSH, NPUAP and Wagner. Retrieved April 12, 2018, from http://www.woundsource.com/blog/wound-assessment-tools-basic-introduction-push-npuap-and-wagner Moses, S. (2015, November 13). University of Texas Diabetic Wound Classification. Retrieved April 12, 2018, from https://fpnotebook.com/Surgery/Exam/UnvrstyOfTxsDbtcWndClsfctn.htm The NPUAP and the EPUAP (European Pressure Ulcer Advisory Panel) • International standard used anywhere in the world • Classifies wounds by tissue appearance and involvement & wound depth • Also tracks wound tunneling The University Of Texas Wound Assessment Tool • Uses stages to document ischemia and infection • Uses grading to document wound depth and tissue involvement

  12. Wound Goals • Nutrition • Additional protein, electrolytes, etc. needed to repair • Moisture/Temp control • Moist wounds (dry wounds slows healing) • Warmer wounds facilitate healing (cool temps slows/stops healing) • Pain Management • Medicate BEFORE handling the patient & their wounds • Comorbidity management • i.e. diabetes/circulation decrease healing time

  13. Ideal Wound Treatment • Manage/reduce exudate • Waste removal promotes healing • Maintains moist environment • Dry wounds don’t heal • Protects the wound from infection • Promoted wound bed integrity • Dressings must be neutral • Not disturb wound bed • Not cause allergic reactions or cause pain • Easy to apply

  14. Wound Treatments • Negative pressure wound treatment • Generally for deeper, irregular wound • Hyperbaric therapy • Promotes oxygenation of wounds/ Used in conjunction with other treatments • Hydrogels • Used with dry wounds w/ eschar / for low to no exudate wounds / contain water or glycerine • Hydrocolloids • Good for low to moderate exudate absorption/promote wound moisture • Alginates • Contain sodium or calcium salts / needs moist wounds to work / highly absorbant • Collagen • Provides healing by placing matrix that can promote new tissue growth • Grafting • Replaces damaged skin with donor sites or biomaterial • Debridement • Physical, chemical, or enzymatic removal of dead tissue

  15. Wound Treatments Negative Pressure Wound Treatment Bariatric Treatment Hydrogels Hydrocolloid Treatment Alginate Treatment

  16. Research Baranoski, Sharon, and Elizabeth Ayello. Wound Care Essentials : Practice Principles, Wolters Kluwer Health, 2015. ProQuest EbookCentral, https://ebookcentral.proquest.com/lib/pensu/detail.action?docID=4786219. L. D., Stacy, K. M., & Lough, M. E. (2018). Critical care nursing: diagnosis and management. Maryland Heights, MO: Elsevier Moon, K. (n.d.). Clinical Guidelines (Nursing) Wound Care. Retrieved April 10, 2018, from tps://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Wound_care/#Defs Oliverio, J., Gero, E., Whitacre, K., & Rankin, J. (2016). Wound Care Algorithm: Diagnosis and Treatment. Wound Care Journal,29(2), 65-72. Retrieved April 11, 2018. • You can find many more free templates on the Presentation Magazine website www.presentationmagazine.com

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