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Nursing Fundamentals Chapter 28. Wounds. A break in the continuity of soft parts of body structures caused by violence or trauma to tissues Damaged skin or soft tissue. Wound. Called the Integumentary System The largest organ of the body Skin is necessary to : Protect against infection

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  1. Nursing Fundamentals Chapter 28 Wounds

  2. A break in the continuity of soft parts of body structures caused by violence or trauma to tissues Damaged skin or soft tissue Wound

  3. Called the Integumentary System The largest organ of the body Skin is necessary to: Protect against infection Protect against dehydration Regulates body temperature Collection of sensory information d/t nerve endings Skin

  4. Cuts Blows Poor circulation Strong chemicals Excessive heat or cold Such trauma produces 2 types of wounds Examples of tissue trauma

  5. Open – the surface of the skin or mucous membrane is no longer intact perhaps due to a surgeon that incises the tissue (to cut cleanly as with a sharp instrument) Closed – there is no opening in the skin or mucous membrane. These wounds occur more often from blunt trauma or pressure Open Wounds vs. Closed Wounds

  6. Open Wound- Abrasion

  7. Closed WoundContusion-Note Ecchymosis

  8. Regardless of the type of injury, the body immediately starts to heal the injury. The process of wound repair happens in 3 sequential phases: Inflammation Proliferation Remodeling Healing or wound repair

  9. The physiologic defense immediately after tissue injury This lasts approximately 2-5 days Inflammation

  10. To limit the local damage To remove injured cells and debris To prepare the wound for healing by sending protein, WBC’s to site to heal Purpose of inflammation

  11. First, local changes occur Blood vessels constrict to control blood loss and confine damage Then, blood vessels dilate to deliver platelets to form a loose clot Discomfort starts d/t the membranes of the damaged tissue release plasma and a chemical substance The person has the signs & symptoms of inflammation  Several stages of Inflammation

  12. Swelling Redness Warmth Pain Decreased function Signs & Symptoms of Inflammation

  13. Leukocytes and macrophages migrate to the site of injury The body then produces more and more WBC’s to go to the injury site Blood work can be obtained to check WBC levels 2nd step of inflammation

  14. Leukocytosis – increased production of WBC’s An increase in the WBCs, neutrophils and monocytes, suggest an inflammatory or even infectious process Neutrophils are responsible for phagocytosis. They consume pathogens, coagulated blood, and cellular debris. Neutrophils and monocytes clean the injured area ansd prepare the site for wound healing WBC – lab values

  15. Inflammation

  16. Period in which new cells fill and seal the wound This occurs 2 days to 3 weeks after the inflammatory phase It’s characterized by the formation of granulation tissue Repair depends on the type and extent of damage Proliferation

  17. This tissue is pink to red in color because of the extensive projections of capillaries in the area Granulation tissue grows from the wound margin toward the center This granulation skin is fragile and can be easily disrupted Fibroblasts produce collagen which is a tough, protein substance The adhesive strength of the wound increases Granulation Tissue

  18. The new blood vessels degenerate causing the previous pink color to regress At the end of the proliferative phase

  19. Resolution- process by which damaged cells recover and re-establish their normal function Regeneration – cell duplication Scar formation – replacement of damaged cells with fibrous tissue What happens in skin repairing(general)

  20. Period in which the wound undergoes changes and maturation, the wound contracts and the scar shrinks This follows the proliferative phase This phase can last 6 months – 2 years Remodeling

  21. The speed of wound repair and extent of a scar depends on whether the wound heals by 1st, 2nd or 3rd intention Wound Healing

  22. Keloids are a collection of collagen in one area over a scar Some people form keloids and some people do not Can be lasered off for cosmetic purposes Some scars form keloids

  23. Keloids Exuberant amounts of collagen giving rise to prominent raised scars Genetic

  24. This is a reparative process The wound edges are directly next to each other The space between the edges is so small, only a small amount of scar tissue forms This looks like most surgical wounds First Intention healing(easiest method of healing)

  25. First Intention Healing

  26. First Intention Healing

  27. The wound edges are widely separated, this leads to more time consuming and complex reparative process The granulation tissue between the widely spread edges, needs additional time to extend across the expanse of the wound Healing by 2nd intention takes even longer if body fluid or other debris is present Wound care must be done cautiously as to not disrupt the new granulation tissue and retarding the healing process Second Intention

  28. Second Intention Healing Gaping irregular Granulation epithelium wound grows over scar

  29. Second Intention Healing • Third intention healing occurs when the edges are surgically brought together later after healing has begun

  30. The wound edges are widely separated and are later brought together with some type of closure material This results in a broad, deep scar These wounds are deep and contain extensive drainage and tissue debris To speed healing, these wounds are packed with absorbent gauze and may even contain a drainage device Third intention

  31. Third Intention Wound Increased Granulation Late suturing with wide scar

  32. Third Intention Healing

  33. High protein helps What type of diet is needed for skin repair?

  34. Nutritional deficiencies Inadequate blood supply Corticosteroid drugs Infection Mechanical friction on wound Advanced age Diabetes Mellitus Anemia Factors that delay wound healing

  35. Primary goal of wound management is to re-approximate the tissue to restore its integrity Wound Management

  36. A wound caused by prolonged capillary compression that impairs circulation to the skin and underlying tissue Pressure Ulcer

  37. Pressure Points

  38. Causes

  39. Pressure Effect

  40. Stage 1 Stage 2 Stage 3 Stage 4 Pressure sores have 4 stages with obvious signs & symptoms

  41. Persistent redness Stage 1

  42. Stage 1

  43. Skin tear Stage 2

  44. Stage 2

  45. Shallow crater, drainage, relatively painless Stage 3

  46. Stage 3

  47. Deep ulceration down to muscle or bone Stage 4

  48. Stage 4

  49. Hip – stage 4 healing

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