Transcript Chapter 28 Wound Care - Mount Vernon High School

Terms:
 Wound
 Abrasion
 Contusion
 Incision
 Laceration
 Penetrating wound
 Puncture wound
 Skin Tear
Types of wounds:
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Intentional
Open
Closed
Clean
Clean-contaminated
Contaminated
Infected/dirty
Chronic
Partial thickness
Full thickness
Pressure ulcers:
 Also known as decubitus ulcers, bedsores, pressure
sores
 Causes: pressure, friction and shearing
Persons at risk:
 Confined to bed or chair
 Need some or total help to move
 Loss of B/B control
 Poor nutrition and fluid balance
 Altered mental awareness
 Problems with sensing pain/pressure
 Obese or very thin
 Older
 Circulatory problems
Sites:
 Usually occur over a bony spot
 Called pressure points
 In obese, can occur where there is
skin to skin contact
 In persons who are bedridden, sores
can develop on the ears
 epidermal stripping
Stages of pressure ulcers:
 Stage I
 Stage II
 Stage III
 Stage IV
Surgical Wounds
Surgical Drains
Circulatory Ulcers: Venous
Circulatory Ulcers: Arterial
Prevention of Circulatory Ulcers:
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Do not sit with legs crossed
Do not dress in tight clothes
Keep feet clean and dry, dry well between toes
Do not scrub or rub skin during bath
Linens dry and wrinkle free
Avoid injury to legs and feet
Make sure shoes fit properly
Keep pressure off heels and other bony areas
Observe legs and feet, report any skin breaks or color
changes
Wound assessment:
 Location of each wound
 Size and depth (the nurse does this, you may assist)
 Appearance: area around it is red/warm to
touch/swollen, sutures/staples intact, wound edges
closed/separated
 Drainage present COA
 Wound photography
Wound Healing:
 Inflammatory Phase (first 3 days)
 Proliferative Phase (days 3-21)
 Maturation Phase (day 21 on)
 Primary intention
 Secondary intention
 Tertiary intention
Complications:
 Infections
 Bleeding
 Evisceration
 Dehiscence
 Gangrene
Factors that affect wound healing:
 Circulatory disease
 Age
 Smoking
 Diabetes
 Certain medications (blood thinners)
 Nutrition (especially protein)
 Type of wound and treatment
 Antibiotics
 Weakened immune system
Prevention of skin breakdown and
injury:
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Heel and elbow protectors
Bed cradle
Turning and positioning
Wrinkle free linens
Be careful when moving a person
Prevent friction and shearing when turning
Make sure skin is completely dry when bathing
Do good perineal care
Apply lotion to dry skin as directed by care plan
Do not massage over pressure points
Keep heels off the bed
Reposition frequently in chair, encourage patient to shift weight
Report any skin conditions immediately
Other prevention techniques
 Special beds/mattresses
 Special chair cushions
 Protective barrier cream
Wound Drainage
 Serous
 Sanguineous
 Serosanguineous
 Purulent
Treatment of wounds:
 Dressing changes:
 Dry dressing
 Wet to dry
 Packing
 Duoderm
 Gauze, non-adherent gauze
 Tegaderm (transparent)
 Sterile vs. clean
 Purposes of dressings
Others:
 Montgomery ties
 Breast binder
 Single and double T binders
 Abdominal binder
 Ace wrap
 TED Hose
Guidelines for applying:
 Binders: Make sure there is firm even pressure over the area,
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snug, but not impeding circulation or breathing. Secure any pins
to point away from the wound.
With Ace wraps, make sure they are snug, but not too tight and
they are secured.
See pages 575,576
Always wash your hands, change any wraps/binders that become
soiled.
Anything with blood or body fluids (such as dressings) need to
be put in biohazard.
CNAS can apply a simple dry dressing (like basic first aide), but
the nurse does all complicated dressing changes. You may assist.
Be careful when removing tape (like after a blood draw).
Other treatments
 Ointments
 Irrigation
 Debridement
 Wound vac
 CNAS can apply NON-MEDICATED protective barrier
cream in most facilities. Check with your facility. Do
NOT apply any type of medicated ointment or powder!
A final word…..
 You will see some bad wounds during the course of
your career. Some will have a very bad odor, lots of
drainage, or be very deep (where you can see bone,
muscle, etc).
 You have to keep your emotions in check. Do not talk
about the wound negatively in front of the person.
They need to feel accepted and not worry about what
people think of their wounds. Also, don’t run down the
facility they came from in front of the patient (it is the
nursing home’s, surgeon’s or hospital’s fault).