👩‍⚕️Foundations of Nursing Practice Unit 14 – Wound Care and Skin Integrity

Key Concepts in Wound Care

• Involves a multidisciplinary approach including assessment, prevention, treatment, and patient education
• Aims to promote optimal wound healing and prevent complications such as infection or delayed healing
• Considers factors influencing wound healing (age, nutrition, underlying health conditions)
• Utilizes evidence-based practices and guidelines to ensure effective and standardized care
• Emphasizes the importance of proper documentation and communication among healthcare team members
• Requires knowledge of various wound dressings, their indications, and appropriate application techniques
• Incorporates pain management strategies to minimize patient discomfort during wound care procedures

Anatomy and Physiology of Skin

• Consists of three main layers: epidermis, dermis, and hypodermis (subcutaneous tissue)
• Epidermis serves as a protective barrier against external factors (UV radiation, microorganisms, chemicals)
  • Composed of keratinocytes that undergo constant renewal and replacement
  • Contains melanocytes responsible for skin pigmentation (melanin production)
• Dermis provides structural support and contains blood vessels, nerves, hair follicles, and sweat glands
  • Collagen and elastin fibers in the dermis contribute to skin strength and elasticity
• Hypodermis acts as an insulating layer and energy reserve, containing adipose tissue
• Skin performs vital functions (thermoregulation, sensation, vitamin D synthesis, immune defense)
• Maintains homeostasis by regulating body temperature and fluid balance
• Skin integrity is crucial for preventing infection and maintaining overall health

Types of Wounds and Their Characteristics

• Acute wounds result from sudden injury or trauma (lacerations, burns, surgical incisions)
  • Usually heal within an expected timeframe without complications
• Chronic wounds persist for an extended period and fail to progress through normal healing stages
  • Examples include pressure ulcers, diabetic foot ulcers, and venous leg ulcers
• Partial-thickness wounds involve damage to the epidermis and part of the dermis (superficial burns, abrasions)
• Full-thickness wounds extend through the epidermis and dermis, potentially affecting underlying tissues (deep lacerations, severe burns)
• Contaminated wounds contain bacteria or foreign material that can lead to infection
• Tunneling wounds have channels extending from the wound surface into deeper tissues
• Undermining wounds have a larger wound base than the visible surface opening

Wound Assessment Techniques

• Involves a systematic evaluation of wound characteristics and surrounding skin
• Assess wound location, size (length, width, depth), shape, and edges
• Evaluate wound bed for tissue type (granulation, slough, necrosis), color, and moisture level
• Measure wound exudate (drainage) quantity and describe its color and consistency
• Assess periwound skin for signs of inflammation, maceration, or induration
• Use wound assessment tools (ruler, wound tracing, photography) for accurate documentation
• Consider pain level, odor, and any signs of infection during assessment
• Reassess wounds regularly to monitor healing progress and identify potential complications

Wound Healing Process

• Occurs in four overlapping stages: hemostasis, inflammation, proliferation, and remodeling
• Hemostasis involves blood clotting to stop bleeding and form a protective fibrin clot
• Inflammation phase is characterized by increased blood flow, immune cell infiltration, and removal of debris
  • Macrophages play a key role in clearing bacteria and stimulating tissue repair
• Proliferation stage involves the formation of granulation tissue, angiogenesis (new blood vessel growth), and epithelialization (migration of keratinocytes across the wound surface)
• Remodeling phase involves the reorganization and strengthening of collagen fibers, leading to scar formation
• Factors affecting wound healing include age, nutritional status, comorbidities (diabetes, immunosuppression), and medication use
• Adequate nutrition, particularly protein, vitamin C, and zinc, is essential for optimal wound healing

Treatment and Management Strategies

• Goals include promoting healing, preventing infection, and minimizing pain and discomfort
• Cleanse wounds with sterile saline or appropriate wound cleansers to remove debris and bacteria
• Select appropriate wound dressings based on wound characteristics and healing stage
  • Hydrocolloid dressings maintain a moist environment and promote autolytic debridement
  • Alginate dressings absorb excess exudate and provide hemostasis in bleeding wounds
  • Foam dressings manage moderate to heavy exudate and protect against friction and shear
• Consider debridement techniques (surgical, enzymatic, autolytic) to remove necrotic tissue and promote healing
• Manage wound pain through proper dressing selection, analgesics, and non-pharmacological techniques (relaxation, distraction)
• Address underlying factors contributing to wound development or delayed healing (pressure relief, blood glucose control, venous insufficiency management)
• Collaborate with interdisciplinary team members (wound care specialists, nutritionists, physical therapists) for comprehensive care

Infection Control in Wound Care

• Adhere to aseptic technique during wound care procedures to minimize the risk of introducing bacteria
• Perform hand hygiene before and after wound care and use personal protective equipment (gloves, gowns, masks) as needed
• Disinfect wound care equipment and surfaces to prevent cross-contamination
• Assess wounds for signs of infection (increased pain, redness, swelling, purulent drainage, malodor)
• Obtain wound cultures if infection is suspected to guide antibiotic therapy
• Use topical antimicrobial agents (silver dressings, iodine) for infected or high-risk wounds
• Educate patients and caregivers on proper hand hygiene and wound care techniques to prevent infection
• Promptly report and document any signs of infection to the healthcare team for timely intervention

Patient Education and Self-Care

• Provide patients and caregivers with clear, understandable instructions on wound care and dressing changes
• Demonstrate proper wound care techniques and have patients or caregivers return the demonstration
• Educate on the importance of proper nutrition, hydration, and blood glucose control for wound healing
• Encourage patients to quit smoking, as smoking impairs wound healing and increases infection risk
• Teach patients to recognize signs of infection and when to seek medical attention
• Provide written instructions and educational materials for reference at home
• Emphasize the importance of regular follow-up appointments to monitor wound healing progress
• Address any concerns or barriers to self-care and provide resources for support (home health services, wound care clinics)
• Encourage patients to engage in activities that promote overall health and well-being (exercise, stress management)