The symptom of pain is likely to be one of the most common reasons for an individual to seek assistance for health care. Pain is a very subjective and a highly individualized experience. No other person can experience the same sensation of pain, except the person having it at the time. Therefore, pain is what the person says it is, and, exists whenever the person says it does. A cardinal rule to keep in mind when caring for patients with pain is that all pain is real, regardless of the cause(even when the cause remains unknown). Verification of pain is based simply on the patient’s indication of its presence.Two basic categories of pain are considered to exist: acute pain and chronic pain.
**Acute pain is a common occurrence, usually of a recent onset and most often associated with a specific injury. It is generally thought that acute pain indicates some degree of damage has occurred within the body which often require some form of treatment or intervention. As healing progresses with an organic disease or injury,the pain subsides and gradually disappears.
** Chronic pain, on the other hand, is often defined as pain that lasts for six months or longer. Chronic pain persists beyond the healing time and frequently cannot be attributed to a specific cause or injury. The onset is not well-defined, and response to treatment or interventions directed at its cause are often variable and poor.
Assessment of Pain
The sensation of pain may be influenced by a variety of different factors. Any one of the various factors may increase or decrease the patient’s perception of pain,increase or decrease tolerance for pain, and even produce a particular set of unique behavioral responses. Most important is to keep in mind that only the patient is experiencing the pain, and, therefore, only the patient can rate the degree of pain present. Therefore, ask the patient to rate the pain on a verbal or numerical scale(e.g., none, slight, moderate, severe, very severe: or, 0 to 10, where 0=none and10=worst possible pain). It may be helpful to have the patient describe previous episodes of pain and compare this episode to others. Other information may be
obtained with the following guideline used to assess the patient’s pain:
Assess the characteristics of the pain (sharp, dull, throbbing, etc.)
Severity of pain
Quality, location, duration, rhythmicity of pain
Tolerance for pain
Harmful effects of pain on patient’s recovery
Strategies the patient believes help in pain relief
Concerns the patient has about the pain
Assess the patient’s behavior responses to the pain
Determine if the pain is acute or chronic
Observe for behavioral responses
Physiological responses (changes in blood pressure, pulse, respiratory rate etc.)
Verbal statements and vocal responses1-24
Facial expressions and body movements
Alterations in response to the environment
Adaptation of physiological or behavioral responses
Effect on ability to communicate and carry out usual activities of daily living
Assess factors that influence responses to pain
Ethnic and cultural factors
Previous pain experience
Meaning of the pain experience
Patient’s response to pain relief strategies
Assess for allergic responses to any medications
There are a variety of interventions available for pain management and relief.Administration of analgesics is one frequently used method. Medication is most effective when the dose and interval between doses are individualized to meet the patient’s need. Before administering any medication, always as certain any history of allergies. It is best to administer analgesics before the pain reaches a severe or intense level. If the patient’s pain is expected to occur around-the-clock, a regular around-the-clock schedule may be indicated. Waiting for the intensity of the pain to reach severe levels before the patient requests pain medication is defeating the purpose of comfort and may result in a higher dose to achieve pain relief. When a“preventive approach” with regular dosing is used, a smaller dose may be required to relieve mild pain or to prevent the occurrence of pain. By being aware of the patient’s need for pain relief over a twenty-four hour period, less medication may actually be needed. In addition to more effective pain relief, side effects, such as sedation and constipation, may be avoided. The patient is less likely to experience extreme peaks of severe pain and spends less time in pain.
**Are there any situations when with holding pain medication is considered appropriate and strongly advised? This may be the case when the patient has sustained a head injury. It is important to continually assess the patient’s level of consciousness and orientation along with the ability to respond to verbal commands. These parameters are indications of the higher functions controlled in the cranial cavity. When there is a head injury, swelling or bleeding in the brain may impair the ability to verbally respond and may result in increased drowsiness and depressed respirations. The patient needs to be awakened frequently, even during sleeping periods to assess the level of consciousness. Administering pain medication that is a central nervous system depressant can further complicate the patient’s condition.
Whenever possible and appropriate, local applications of cold to a local painful part may also be considered as an adjunct therapy. This approach is an under used, but highly effective, method of pain relief. Cold relieves pain faster and the effect often lasts longer. Local application of cold does not necessarily cause muscle contractions. It may slow the conduction of impulses that maintain muscle tone and promote muscle relaxation. Thus, cold is indicated to reduce bleeding and swelling of new injuries, but may also be continued for pain relief. However, use care to avoid injury to the tissues.
The following chart outlines the various routes of administration of medications:
|Orally or by mouth: a solid or liquid medication is absorbed from the gastrointestinal tract|
|Sublingual: under the tongue and absorbed by mucous membranes|
|Inhalation: a gaseous or vaporous medication is inhaled and absorbed through the lungs|
|Topical: liquid or semi-solid creams or lotions that are rubbed on and absorbed through the skin|
|Dermal: patch applied to skin for absorbption|
|Rectal suppositories: suppositories are administered into the rectal cavity for absorption|
Every patient should be able to expect that he or she is receiving the correct medication for their condition.
* This requires the vial or bottle be checked carefully toassure that it is the correct medication before administering it. Unlabeled bottles or medications should not be used.
* The quality of the drug must be checked.
*don’t give a medication that has changed color, or consistency, or has an unusual odor, for this could indicate that the medication has deteriorated and is unsafe to use. The right dose or amount of the needed medication must be given. It is incumbent upon the care giver to carefully check the dosage and the amount being prepared. If a mathematical calculation is required, the math should be double checked and,optimally, checked with another person. *Use special care in converting from English to metric measurement systems.
* Finally, care must be taken that the correct patient gets the correct medication. If more than one person is being cared for at the same time, proper identification is mandatory.
|“Rights” of Administration of Medications|
|Right Drug||Right Dose||Right Route||Right Time||Right Patient|
Timing is especially important when administering a series of medications. Many drugs are therapeutic only when they reach and maintain a specific level in the blood.
It is best to be as consistent and close to that time interval as possible. Commonly ordered time intervals follow:
|Twice a day (b.i.d.)||6 am & 6 pm or 12md &12mn
06:00 & 18:00 hrs or 12:00 &00:00
|Three times a day (t.i.d.)||6 am, 2 pm, & 10 pm
06:00, 14:00, & 22;00 hrs
|Four times a day (q.i.d.)||6 am, 12 pm, 6 pm,&12am
06:00, 12:00, 18:00, & 24:00
Additionally, there is one more right, the right of refusal. If the patient is alert and oriented, he/she still has control over his/her body when mentally competent. The patient has the right to refuse medication or treatment of any kind. The care giver must be certain the patient is competent to refuse the care. If this is the case, the care giver should record that the medication (or procedure) was refused and the reason why. Consent from the patient should be obtained whenever feasible prior to any intervention. In some cases, the patient should write the refusal on the chart.
Equipment for Parenteral Injections:
Medication, in vial or bottle
Alcohol sponges and sterile gauze, band aids
Syringe (parts are the barrel and the plunger)
Needle, based upon type of injection planned:
intradermal – ½”, 25 gauge
subcutaneous – ½ to 1″, 25 to 23 gauge
intramuscular – 1 ½”, 20 gauge
Preparation of Medication:
Medications should be prepared immediately before administering them, but if the medication is stable, medications can be prepared up to ½ hour before administration if necessary. When the vial is removed from the storage locker, the label must be read carefully and the dosage or amount per ml noted appropriately and recorded in the chart.
Check medication as removed from storage.
Clean stopper with alcohol sponge.
Select a syringe that will hold the necessary amount of medication: If the syringe has pre attached needles, check to make sure the size and gauge are correct. If the needle is not correct or if the needle is not attached, select the correct needle and attach the needle according to manufacturers’ package directions.
Remove needle guard/cap.
Draw up air into syringe equal to dosage amount; for 1 ml of medication, draw up 1 ml of air, according to indicator markings on barrel of syringe.
Insert needle through the stopper into the bottle and inject air into vial. This increases pressure inside the bottle and makes it easier to draw out the medicine.
Slowly pull back plunger and draw the necessary amount of medicine into syringe.
Expel air from the syringe, if needed, by pointing the needle upwards and waiting for any air bubbles to rise to the top. Slowly expel air until a drop of liquid lies on the tip.
Exit from the vial, and protect needle from contamination and exposure until the injection is given. Prefilled syringes are available for some of the most commonly used parenteral
medications. When using prefilled syringes, check the medication already in the syringe. Discard any amount that will not be used and then proceed to give the injection.
Some medications are stored in ampules which are small glass containers. To break the ampule open, score the neck of the ampule with a razor blade, if not prescored. Then wrap the neck of the ampule with gauze and break at the neck.
Medication may then be drawn up into the syringe. Extra care must be taken to eliminate air from the syringe.
Subcutaneous injections, informally called “subQ” are usually given in the upper arm or outer aspect of the thigh, but other surfaces may be used. Caution must be used to avoid blood vessels and nerves. Having selected an area for the injection site,avoid a spot with open sores or wounds, skin irritation, scars, moles, tattoos, etc.
Cleanse the skin with alcohol. Begin in the center of the site and wipe in a circular motion outward from the center. Wipe off excess alcohol with a second sponge.
Grasp skin and “pinch” up to accumulate a well-defined roll of skin and to elevate the skin from underlying muscle.
Hold syringe like a dart, and insert needle at a 45 degree angle quickly and smoothly.
Using the left hand, hold the barrel of the syringe and with the right hand*, pull the plunger of the syringe back slightly to check the position of the needle, if a red flashback of blood occurs, the needle is in a blood vessel.
If needle is in blood vessel, draw back syringe slightly, insert in new direction and recheck position of the needle.
When needle is not in blood vessel, inject medication slowly and smoothly by pushing the plunger into the syringe.
Withdraw quickly and apply light pressure with a gauze sponge. Put a bandaid over the site to avoid leaking and blood on the patient’s clothes.
* The care giver can reverse the hand position if the care giver is left-handed.
The procedure for insulin administration for a diabetic patient is essentially the same as administering a subcutaneous injection. It is extremely important with insulin to double check the dosage needed and to coordinate this amount with the patient’s schedule based on blood and urine testing. If possible, double check the dosage drawn up with another health care provider or with the patient, if necessary.
When insulin is administered, the skin is NOT pinched up but held taut, and the needle of the insulin syringe is inserted at a 90 degree angle. After the insulin is injected, the needle is left in place for 30 to 60 seconds and then quickly withdrawn.
This is done to prevent insulin from leaking out of the injection site. If insulin does leak back out, the care giver should try to estimate the amount lost. This may change the patient’s reaction and necessitate another injection or other action.
If the health care provider is responsible for giving the insulin, the injection site should be rotated according to the patient’s plan. The site used must be noted in the record or on the site rotation chart if the patient uses one. If the patient is going to be exercising the area chosen for the injection immediately after the injection, it would be wise to choose another site. The increased activity in that area may increase the absorption of the insulin and result in an adverse reaction for the patient. For example, if the patient is scheduled to be walking a long distance or is planning to go jogging, it would not be wise to inject the insulin in the patient’s thigh but rather to use an abdominal or upper arm site. If the patient is able to administer his or her own insulin, let the patient do so. The patient may need assistance with some part of the procedure. It is appropriate for the health care provider to help as requested.
The most common site is in the upper outer quadrant of the buttock. The deltoid muscle (upper arm) is acceptable for small amounts (2 cc or less) of medications such as immunizations.
If using the gluteal muscles (buttocks), have the patient relax by turning their toes inward and taking their weight off the selected leg.
Clean the injection site with alcohol as with subcutaneous injections. Begin in the center of the site and wipe in a circular motion outward from the center. Wipe off excess alcohol with a second sponge.
Don’t grasp or pinch the skin.
Hold syringe (like a dart) at 90 degree angle (perpendicular) to the skin, and quickly and smoothly insert the needle.
Check position by drawing back on the plunger and watching for a red”flashback” of blood. If a flashback occurs, a blood vessel has been entered,withdraw the needle a little way and redirect the path. Recheck position, if no flashback occurs,
Inject the medication slowly and smoothly.
Withdraw quickly and apply light pressure with a gauze sponge. Put a bandaid over the site to avoid leaking and blood on the patient’s clothes
Intravenous Infusions or Injections
Intravenous infusions are commonly referred to by the abbreviation IV. Either an injection of an emergency drug or the administration of larger amounts of fluid may be rapidly accomplished via this route. The equipment and length of time differ but the technique for choosing a vein, inserting the needle and removing the needle is the same. A syringe or infusion set is required for administration. With an IVinfusion, stabilization of the needle and the IV tubing occurs while the fluid is running.
*Criteria for selecting a site: Choose the largest convenient vein just below a venous junction. If possible, select the antecubital fossa.
the inner aspect of the arm below the elbow. Veins here are large and usually easily accessible. This requires limitation of the affected arm’s movement so stay below the elbow crease for the patient’s comfort, if possible. The ankle and foot can be used in extreme emergencies but risk of infection increases, and should be avoided if possible.
*Checking the vein prior to IV insertion: Apply the tourniquet lightly above the selected site. Have patient periodically clench the fist of the arm which will be used for the IV site. The arm may be placed below heart level, if needed, to further fill the veins and aid in selecting an injection site.
Any solid material such as wood, solid plastic, etc., may be padded with foam or a towel to stabilize the arm and to increase patient comfort. The arm board is usually about 3-4 inches wide and 12-18 inches long. Place it under the arm and lightly restrain the arm before insertion. After insertion, secure the arm more firmly by wrapping the arm and the board with gauze at the wrist and the upper arm to prevent the elbow from bending. Check the pulse at the wrist to make sure that circulation is not impaired by the straps being too tight.
The average rate of flow for an IV infusion is 60 drops per minute; this can be faster for dehydrated patients or slower for elderly or cardiac patients, or to just keep the access open. Mechanical or equipment factors which affect the rate of flow include the control valve position and other settings. The diameter and length of the IV tubing, the height at which the IV fluid is held, and the size of the needle used also affect flow. Another influence on the rate of flow is the viscosity of fluid – the thicker the fluid, the slower the flow rate.
The drops per milliliter as counted in the drip chamber of an IV infusion set vary with the commercial manufacturer. Check the set directions or check the rate by counting the drops falling into the drip chamber for one minute. The formula uses the amount of IV solution specified to give, multiplied by the drops per milliliter of fluid, divided by the time period for the infusion. For example, the patient needs to have 1 liter (1000 ml)of 5% Dextrose in Water fluid infused in approximately 2 ½ hours. The administration set indicates that there are 10 drops in 1 ml. How many drops per minute are needed to infuse this liquid in that time?
|CALCULATING FLOW RATE|
|?? drops/min = total volume x drops/ml divided by total time in minutes
example: drops/min = 1000 ml x 10 drops/ml = 65 drops/min
Needle size: 2 ½ to 4″; #18 – 21 gauge needle (may use prepacked IVangiocatheters)
IV infusion set-tubing, drip chamber, flow gauge
IV pole or method to hold IV solution above patient’s head
Inform patient of procedure and purpose.
If possible, place the patient is semi-sitting position and adjust patient’s sleeve.
Position tourniquet (DO NOT TIGHTEN) under an upper arm, just above the elbow.
Connect IV materials, hang fluid receptacle on the pole.
Recheck bottle label for correct solution and recheck calculations.
Allow IV fluid to flow through system until liquid drips from the needle. This should remove air bubbles. Drain more fluid if necessary to remove more air bubbles.
Tighten clamp on fluid and lay sterile needle in or on a sterile surface until the arm is prepared.
Tighten the tourniquet.
Have patient open and close the fist. Palpate and note the site.
Cleanse the skin thoroughly, using an antiseptic, such as iodine prep andwashing from the center of the site outward in a circular motion. Use a second alcohol sponge to remove excess fluid. Use antiseptic at room temperature since a cold application could cause the vein to constrict and make insertion more difficult.
Use a thumb to apply tension to tissue and vein about 2 inches (5 cm)BELOW injection site.
Hold needle at 45 degree angle along side the vein wall, in the direction of insertion.
Pierce the skin
Decrease the angle of the needle until nearly parallel to the skin and still slightly to one side of the vein. Apply pressure in the same direction and pierce the vein.
If there is a backflow of blood through the needle the vein has been entered. Advance the needle slowly about 1 inch (2.5 cm).
Release the tourniquet. (At this point, if an injection is to be given, slowly depress the plunger and inject the medication. Some medications must be injected very slowly.)
Release the clamp (flow gauge).
Slide a gauze square (folded in half, if necessary) under the needle to hold it in the proper position.
Anchor the needle in place using narrow adhesive strips. Fasten a loop of tubing to the arm to prevent pulling on the needle.
Regulate the flow of the solution to the calculated rate.
When an IV is inserted, the written medication record should include the IV site, size of needle, type of solution infused, flow rate and amount of fluid actually given. Any other medications given through the IV should be carefully recorded. Finally, record whether there were any problems encountered and the patient’s reaction to the procedure.
Checking the IV for Complications
There are a number of reasons why a well-placed IV can fail such as mechanical problems or infiltration. For each of these situations there are symptoms and remedial actions that can be taken.Sources of Mechanical Failure Include:
Needle may clog due to clotting .
Needle may slip from position.
The equipment may have a kink in the tube or occlusion.Symptoms include:
* Swelling (edema) at the site.
*Fluid doesn’t not flow properly
Check tubing for kinking and gently straighten or remove obstruction.
Rotate needle slightly to see if the bevel is lying against the vein wall.
Gently move the arm of the patient to a new position.
Lower IV bottle below level of patient to check for blood
Flashback-this will demonstrate if needle is patent or clear.
If none of these suggestions work, stop the flow, remove needle and restart IV using a new, sterile needle.
Infiltration: (The needle becomes dislodged and is lying in tissue).Symptoms at the injection site include:
*Edema and blanching of skin
*Discomfort and pain
*IV fluid slows or stops flowing
Stop infusion and remove IV.
Fluid Overload: occurs when the patient receives an excessive amount offluid in a brief time. Symptoms may include a headache, flushed skin, rapid pulse, and the veins appear distended. When the blood pressure is checked,it is usually increased and may be accompanied by coughing, shortness of breath, and increased respirations.
*Stop the infusion immediately and raise patient to sitting position, if possible, to make breathing easier. Monitor the patient closely.
Thrombophlebitis: A clot with inflammation forms in a vein. This clot occludes, or closes, the vein and stops the IV flow. The clot may be at or above the infusion site. Symptoms include:1- tenderness and then 2-pain along the course of the vein. It maybe accompanied by 3-edema, 4-redness,5- and warmth at an injection site.
*Discontinue the IV. Apply cold compresses to relieve pain and inflammation at the site and follow later with warm compresses to stimulate circulation.
*Loosen adhesive tape and place a sterile gauze square over the needle site.
*Gently withdraw the needle and exert pressure on the needle site until blood has clotted.
*Place a clean gauze pad and secure with tape or a bandaid over site.
*Enter note in flowsheet and medical record.
Disposal of Needles and Equipment
Needles, syringes, and IV equipment should NOT be reused. Needles should not be recapped in order to guard against an inadvertent needle stick. Needles and syringes should be disposed of in an impermeable container, preferably one designed for the purpose, or if necessary, something such as a coffee can or a glass jar. The container should be labeled as containing contaminated needles and syringes. Used tubing, alcohol sponges, and other soft, non-sharp materials should be placed in a biohazard (red plastic) or labeled bag for proper disposal at a later time.
The skin is a barrier to the outside world protecting the body from infection, radiation, and extremes of temperature.
There are many types of wounds that can damage the skin including abrasions(a wound caused by rubbing or scraping the skin or a mucous membrane), lacerations( a wound produced by the tearing of body tissue, as distinguished from a cut or incision ), rupture injuries(tearing or disruption of tissue), punctures(the act of piercing or penetrating with a pointed object), and penetrating wounds(a wound with disruption of the body surface that extends into underlying tissue or into a body cavity).
Abrasion laceration puncture
Many wounds are superficial requiring local first aid including cleansing and dressing.
Some wounds are deeper and need medical attention to prevent infection and loss of function, due to damage to underlying structures like bone, muscle, tendon, arteries and nerves.
The purpose of medical care for wounds is to prevent complications and preserve function. While important, cosmetic results are not the primary consideration for wound repair.
Animal and human bites should always be seen by a medical professional because of the high rate of infection.
It is important to know a person’s tetanus immunization status (for example, has the person had a tetanus shot or booster vaccine in the last 5 years?) so that it can be updated with a tetanus booster if needed. The skin is a large sensory organ that interacts with the environment, and sends signals to the brain about touch, pain, vibration, and position.
There are two layers of skin that cover the body, the epidermis and dermis:
Epidermis: Is the outer layer of the skin.
- comprised of epithelial cells
- 0.04mm thick
- regenerated every 2-4weeks, subject to an individual’s age and friction forces applied to the skin
- receives nutrients from the dermis below
- comprised of 4 to 5 layers depending on the body location
Dermis: Is the middle layer of the skin and is approximately 0.5mm thick subject to anatomical site
- made up of two layers
- is very vascular
- contains nerves, connective tissue, collagen, elastin and specialized cells such as fibroblasts and mast cells
- responsible for inflammatory reactions which occur in response to trauma and infection
- receptors for heat, cold, pain, pressure, itch and tickle
Hypodermis: Is the inner most layer of the skin and is referred to as the subcutaneous layer
- supports the dermis and epidermis
- varies in thickness and depth
- comprised of adipose tissue, connective tissue and blood vessels
- the function is to store lipids, protect underlying organs, provide insulation and regulate temperature
Skin Appendages: Includes Sweat glands, hair, nails and sebaceous glands which are all considered epidermal appendages.
All patients with wounds will have their wounds appropriately assessed by nursing staff within 24hours of recognition with timely referrals to stomal therapy(The stomal therapist is responsible for helping patients adjust to living with either a permanent or temporary stoma be it a colostomy, ileostomy or urostomy. This role includes pre-operative counselling, immediate post-operative care and education and follow-up assessment and counselling following patient discharge) where appropriate.
Considerations for assessment
- Granulating: healthy red tissue which is deposited during the repair process, presents as pinkish/red coloured moist tissue and comprises of newly formed collagen, elastin and capillary networks. The tissue is well vascularised and bleeds easily
- Epithelializing: process by which the wound surface is covered by new epithelium, this begins when the wound has filled with granulation tissue. The tissue is pink, almost white, and only occurs on top of healthy granulation tissue
- Sloughy: the presence of devitalized yellowish tissue. Is formed by an accumulation of dead cells. Must not be confused with pus
- Necrotic: wound containing dead tissue. It may appear hard dry and black. Dead connective tissue may appear grey. The presence of dead tissue in a wound prevents healing
- Hypergranulating: granulation tissue grows above the wound margin. This occurs when the proliferative phase of healing is prolonged usually as a result of bacterial imbalance or irritant forces
- ‘Assessment and evaluation of the healing rate and treatment modalities are important components of wound care. All wounds require a two-dimensional assessment of the wound opening and a three- dimensional assessment of any cavity or tracking’:
- Two-dimensional measures– use a paper tape to measure the length and width in millimetres. The circumference of the wound is traced if the wound edges are not even – often required for chronic wounds.
- Three -dimensional measures– the wound depth is measured using a dampened cotton tip applicator
- Healthy wound edges present as advancing pink epithelium growing over mature granulated tissue.
- Colour – pink edges indicate growth of new tissue; dusky edges indicate hypoxia; and erythema indicates physiological inflammatory response or cellulitis
- Raised – wound edges (where the wound margin is elevated above the surrounding tissue) may indicate pressure, trauma or malignant changes
- Rolled -wound edges (rolled down towards the wound bed) may indicate wound stagnation or wound chronicity
- Contraction – wound edges are coming together, signs of healing
- Sensation – increased pain or the absence of sensation should be noted
- Is produced by all acute and chronic wounds (to a greater or lesser extent) as part of the natural healing process. It plays an essential part in the healing process in that it:
- Contains nutrients, energy and growth factors for metabolising cells
- Contains high quantities of white blood cells
- Cleanses the wound
- Maintains a moist environment
- Promotes epithelialisation
- It is important to asses and document the type, amount and odour of exudate to identify any changes.
- Too much exudate leads to maceration and degradation of skin while too little can result in the wound bed drying out. It may become more viscous and odorous in infected wounds.
- The exudate may be:
|Serous||Clear, straw coloured||Thin, watery||Normal. An increase may be indicative of infection|
|Haemoserous||Clear, pink||Thin, watery||Normal|
|Sanguinous||Red||Thin, watery||Trauma to blood vessels infection contains pyogenic|
|Purulent||Yellow, grey, green||Thick||organisms and other inflammatory cells|
- Wound infection may be defined as the presence of bacteria or other organisms,which lead to a host reaction. A host reaction can present with one or a combination of the following local and systemic clinical indicators:
- Local indicators
- Redness (erythema or cellulitis) around the wound
- Increased amounts of exudate
- Change in exudates colour
- Localised pain
- Localised heat
- Delayed or abnormal healing
- Wound breakdown
- Systemic indicators
- Increased systemic temperature
- General malaise
- Increased leucocyte count
If any of the above clinical indicators are present medical review should be instigated and an Microscopy & Culture Wound Swab (MCS) should be considered
Types of Wounds throughout RCH
1-Acute Surgical Wounds
A clean cut with a sharp instrument which cuts or punctures the skin deliberately during a surgical procedure. Acute surgical wounds normally proceed through an orderly and timely reparative process resulting in sustained restoration of anatomic and functional integrity. If an acute wound fails to heal within six weeks, it can become a chronic wound.
A stressful event caused by either a mechanical or a chemical injury resulting in tissue damage. Depending on its level, trauma can have serious short-term and long-term consequences.
Injuries to tissues caused by heat, friction, electricity, radiation, or chemicals. Burns may be caused by even a brief encounter with heat greater than 120°F (49°C). The source of this heat may be the sun , hot liquids, steam, fire, electricity, friction (causing rug burns and rope burns), and chemicals (causing a caustic burn upon contact).
Fail to heal in an orderly and timely manner. The chronic wound environment is different to the acute wound environment. The clinical signs of chronic wounds may include:
* Non viable wound tissue (slough and/or necrosis)
* Lack of healthy granulation tissue (wound tissue may bepale, greyish and avascular(
*No reduction in wound size over time
* Recurrent wound breakdown
A localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, shear and/or friction, or a combination of these factors.
Invasion of wound tissue by and multiplication of pathogenic microorganisms, which may produce subsequent tissue injury and progress to overt disease through a variety of cellular or toxic mechanisms.
1-Phases of Wound Healing to consider
- Phase 1 – INFLAMMATORY PHASE (0-3 Days) the body’s normal response to injury. This phase activates vasodilatation leading to increased blood flow causing HEAT, REDNESS, PAIN, SWELLING, LOSS OF FUNCTION (e.g. arm swells and cannot bend). Wound ooze may be present and this is also a normal body response.
- Phase 2 – PROLIFERATIVE PHASE (3-24 Days) the time when the wound is healing. The body makes new blood vessels, which cover the surface of the wound. This phase includes reconstruction and epithelialisation. The wound will become smaller as it heals.
- Phase 3 – MATURATION PHASE (24-365 Days) the final phase of healing, when scar tissue is formed. The wound at this stage is still at risk and should be protected where possible.
2-Mechanisms of wound healing to consider
- Primary Intention; most clean surgical wounds and recent traumatic injuries are managed by primary closure. The edges of the wounds are approximated with steri strips, glue, sutures and/or staples. Minimal loss of tissue and scarring results.
- Delayed Primary Intention; is defined as the surgical closure of a wound 3 -5 days after the thorough cleansing or debridement of the wound bed. Used for 1. Traumatic wounds, 2. Contaminated surgical wounds.
- Secondary intention; occurs slowly by granulation, contraction and re-epithelialisation and results in scar formation. Commonly used for 1. Pressure Injuries 2. Leg ulcers 3. Dehisced wounds
- Skin Graft; removal of partial or full thickness segment of epidermis and dermis from its blood supply and transplanting it to another site to speed up healing and reduce the risk of infection.
- Flap; is a surgical relocation of skin and underlying structures to repair a wound
Requires the application of fluid to clean the wound and optimise the healing environment.
- Remove visible debris and devitalised tissue
- Remove dressing residue
- Remove excessive or dry crusting exudates
Method&Choice of dressing:
Irrigation is the preferred method for cleansing open wounds. This may be carried out utilising a syringe in order to produce gentle pressure – in order to loosen debris. Gauze swabs and cotton wool should be used with caution as can cause mechanical damage to new tissue and the shedding of fibres from gauze swabs/cotton wool delays healing.
A wound will require different management and treatment at various stages of healing. No dressing is suitable for all wounds; therefore frequent assessment of the wound is required. Considerations when choosing dressing products:
– Maintain a moist environment at the wound/dressing interface
– Be able to control (remove) excess exudates. A moist wound environment is good, a wet environment is not beneficial
– Not stick to the wound, shed fibres or cause trauma to the wound or surrounding tissue on removal
– Protect the wound from the outside environment& bacterial barrier
– Good adhesion to skin
– Aid debridement if there is necrotic or sloughy tissue in the wound (caution with ischaemic lesions)
– Keep the wound close to normal body temperature
– Conformable to body parts and doesn’t interfere with body function
– Diabetes – choose dressings which allow frequent inspection
– Non-flammable and non-toxic