Chapter003.wound care

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 3

Advanced Wound Care Skills

Chapter 3

Advanced Wound Care Skills


Function of the skinFunction of the skin

• Protect

• Regulate temperature

• Sensation

• Make Vitamins ( vitamin D )

• Excrete waste


Structure of SkinStructure of Skin

• I. Epidermis

• Outer layer of skin

• Skin pigment

• Glands-oil (sebaceous)

-sweat (sudorriferous)

• Protects from invading germs

• Protect from fluid loss


Structure con’tStructure con’t

• II. Dermis- Middle layer

• Lymph nodes

• Blood vessels

• Nerves

• III Subcutaneous/hypodermis- Fatty layer

• Provides warmth

• Source of energy

• Padding

•


Disorders of the skinDisorders of the skin

• Bacterial: acne, boils, impetigo, cellulitis

• Acne- pores blocks


• Viral: Herpes, shingles, warts, chicken pox

• Autoimmune: psoriasis- silvery white patches

• Eczema-dry, scaly


Disorders con’tDisorders con’t

• Parasites: Lice, scabies

• Systemic: diabetes, circulation problems

• Allergies: Hives (wheal)

• Trauma: cuts, scraps, bruising

• blister-vesicle scab-crust


Fungal: ring worm, yeast (athletes feet)


Treatment for skin disordersTreatment for skin disorders

• Ointments

• Dressing changes


Ways of Describing WoundsWays of Describing Wounds

• Open wounds: breaks in the skin

• Closed wounds: damage to tissues underneath intact skin

• Intentional wounds: planned surgical or medical interventions


Ways of Describing Wounds (cont.)Ways of Describing Wounds (cont.)

• Unintentional wounds: the result of accidents

• Acute wounds: expected to heal completely within a few days or weeks

• Chronic wounds: delayed in healing or may never heal completely


Intentional and Unintentional Wounds Intentional and Unintentional Wounds


ComplicationsComplications

• Pressure Sores/Decubitus Ulcers

• Stages:

– 1. skin red/pale

– 2. blistered, cracked, peeling

– 3. deep- muscle involvement

– 4. extreme- bone exposed


Three Common Pressure UlcersThree Common Pressure Ulcers

• Late-stage pressure ulcers

• Venous (stasis) ulcers

• Arterial ulcers


Circulation UlcersCirculation Ulcers

• Arterial

• - oxygenated blood doesn’t get to LE

• - common in diabetics

• - monitor pedal pulses

• -elevate feet

• Venous

– Deoxygenated blood can’t get back to heart

- Blood pulls

- Feet swell

- Use TED hose or SCD


To Help Prevent a Pressure Ulcer From FormingTo Help Prevent a Pressure Ulcer From Forming

• Reposition q 2 hours

• look for: red, hot, or painful areas over pressure points

• previously reddened areas that have turned white, pale, or shiny

• Provide good skin care.

• Toilet as needed

• Provide good perineal care.


To Help Prevent a Pressure Ulcer From Forming (cont)To Help Prevent a Pressure Ulcer From Forming (cont)

• Encourage exercise.

• Use lifts & lift sheets to prevent shearing

• Good nutrition and hydration.

• Use pressure-relieving devices.


QuestionQuestion

A gunshot wound is a(n):

A. Intentional Wound

B. Closed Wound

C. Chronic Wound

D. Unintentional Wound


AnswerAnswer

D. Unintentional Wound

Unintentional wounds are the result of an accident. Examples of unintentional wounds are those resulting from falls, motor vehicle crashes, and gun and knife violence.


Phases of Wound HealingPhases of Wound Healing

• Inflammatory phase: Begins immediately; area - hot, red, swollen &painful.

• Proliferative phase: Begins 2–3 days after injury & can last 2–3 weeks; scar tissue replaces the tissue.

• Remodeling phase: Final stage of healing, more collagen is secreted & wound strengthens; can last-6 months.


Three Types of Wound HealingThree Types of Wound Healing

• First-intention wound healing: an open wound is closed surgically w sutures/ staples ASAP

• Second-intention wound healing: a wound is kept clean but left alone to repair itself, wound closes on own

• Third-intention wound healing: the wound is left open for a period of time to make sure no infection occurs, then closed surgically w sutures/ staples


Factors That Affect Wound HealingFactors That Affect Wound Healing

1. Nutrition and hydration

2. Overall health status

3. Age

4. Wound condition


QuestionQuestion

Wound healing increases the body’s need for ___________ and _____________.

A. fat and carbohydrates

B. minerals and water

C. calories and protein

D. vitamins and supplements


AnswerAnswer

C. calories and protein

The body requires more protein and calories to assist with cell repair and healing.


Complications of Wound HealingComplications of Wound Healing

1. Infection

2. Hemorrhage

3. Hematoma

4. Dehiscence and evisceration


InfectionInfection


The First Sign of Hemorrhage The First Sign of Hemorrhage


Dehiscence and Evisceration Dehiscence and Evisceration


QuestionQuestion

Blood collected under the skin is known as:

A. Pus

B. Evisceration

C. Hematoma

D. Hemorrhage


AnswerAnswer

C. Hematoma

Hematoma is better known as a bruise. Blood collects under the tissue and can interfere with healing.


Interventions to Support Wound HealingInterventions to Support Wound Healing

1. Sutures and staples

2. Dressings and bandages

3. Drains (open and closed)


Sutures and StaplesSutures and Staples

• Subcuticular sutures: placed underneath the dermis

• Retention sutures: threaded through a rubber tube over a plastic bridge


Dressing PurposesDressing Purposes

• Keep wound clean

• Prevent infection

• Maintain a moist environment to assist wound healing

• Absorb wound drainage

• Treat infection

• Apply pressure to the wound (to prevent or control hemorrhage, bruising, or swelling)

• Remove necrotic (dead) tissue

• Protect the wound from further injury

• Protect the patient from becoming upset at the sight of the wound


Dressing changesDressing changes

• Dr orders tell you:

• type of drsg.

• what to clean with

• how often

• Dr may change 1st surgical drsg.


Drsg. Change guidelinesDrsg. Change guidelines

• Remove 1 layer @ a time

• Clean –clean to dirty

• Around drain- circular motion-inside to outside

• Down incision- middle-outside-outside


Reinforcing dressingReinforcing dressing

• When: first 24 hours p OR

• until Dr. orders drsg. change

• Why: may disturb clot or healing

• What: apply new clean drsg. over old

• mark and keep track of new bleeding


Abdominal Binder Abdominal Binder


Dressings and BandagesDressings and Bandages

Layers of dressings

• Contact layer

• Secondary layer

Bandages

• Abdominal binder

• Montgomery straps/ties


Transparent DressingTransparent Dressing


Types of drsg. changesTypes of drsg. changes

• Dry sterile drsg.

• Wet to dry

• Wound irrigation

• Central line

• Drainage tube


QuestionQuestion

Tell whether the following statement is true or false.

When applying a dressing, the contact layer is applied directly to the wound.

A. True

B. False


AnswerAnswer

A. True

The contact layer is against the wound and generally made of non-stick material or gel.


DrainsDrains

• Penrose drain

• Closed drainage systems

– Jackson-Pratt drain

– Hemovac drain


Penrose Drain Penrose Drain


Closed Drainage Systems Closed Drainage Systems


Wound CareWound Care

• Proper cleansing – clean to dirty

• Removal of sutures and staples

• Débridement: the removal of necrotic tissue


Cleaning an Incision SiteCleaning an Incision Site

Report it to the nurse immediately if:

• Edges are gaping-open b/t sutures or staples

• Sutures or staples rip out or are broken

• Excessive swelling along the incision line

• Excessive redness along the incision line

• Incision line hot to the touch


Cleaning an Incision Site (cont)Cleaning an Incision Site (cont)

• Purulent drainage or pus

Drainage has a foul odor

• Pt. c/o increased pain at wound site 2 to 3 days after the injury or surgery took place

• Fever occurs 24 hours or more after the injury or surgery

• Increased amt. of bloody drainage is seen on the wound dressing or in the wound drainage system


Different Types of Wound Drainage Different Types of Wound Drainage

• Serous: clear and watery-looking

• Sanguineous: bloody-looking

• Serosanguineous: pink and watery-looking

• Purulent: thick and ranging in color from dark yellow or green to creamy white


SuturesSutures

• Why?- close wounds

• decrease scars and infection

• Types: 1. absorbable

• absorb in 5-7

• used inside body

• 2. Nonabsorbable-skin

• head-3-5days

• arm, legs, hands- 7-10 days


Removing Sutures and Staples Removing Sutures and Staples


StaplesStaples

• Used for big wounds or areas that need strong sutures

• Left in 7-10 days


Butterflies/steri-stripsButterflies/steri-strips

• Adhesive strips put on wound after removal of sutures/staples


DocumentationDocumentation

• 10/15/10 2000 8 sutures removed from abd. Incision per Dr. Smith orders. Incision pink, edges well approximated, no drainage noted. Site cleaned with betadine and 4 steri-strips applied. Pt. tolerated without c/O. Notified S. Smith RN of incision. Instructed to allow steri-strips to fall off on own.-------------------------- M/ Fox PCT


Pin Care Pin Care


DébridementDébridement

• Sharp (surgical – to cut off)

• Mechanical

• Autolytic

• Enzymatic (chemical)

• Biological

• Vacuum-assisted closure (VAC) therapy


Vacuum-assisted (VAC) therapy Vacuum-assisted (VAC) therapy

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Chapter003.wound care