-
Nursing Care for Clients with Wounds
Nursing Fundamentals-
NURS B20
-
Wound Classifications
Status of skin integrity
Open Wound
Closed Wound
Cause
Intentional
Unintentional
-
Wound Classifications
Severity of Injury
Superficial
Penetrating
Perforating
Cleanliness
Wound Classifications 1- 4
-
Wound Classifications
Descriptive Qualities
Laceration
Incision
Abrasion
Contusion
-
Healing by Primary and Secondary Intention
Primary IntentionSecondary IntentionDelayed ClosureNutrition in
Wound Healing
-
Complications in Wound Healing
HemorrhageInfectionsDehiscenceEviscerationFistulas
-
Factors Influencing Wound Healing
AgeNutritional statusObesityExtent of woundTissue
oxygenationSmokingImmune StatusChronic conditionsRadiationStress on
wound
-
Assessment
In emergency settings
Bleeding?
Foreign bodies or contamination?
Size of wound?
Need for protection of wound?
Need for tetanus antitoxin
-
Assessment
Stable Setting
Wound appearance
Character of drainage
Serous
Sanguineous
Serosanguineous
Purulent
-
Assessment
Stable setting
Drains
Penrose
Evacuator units
Jackson Pratt drains
Hemovac drains
Wound closures
Sutures
Steel staples
Clear strips
Wound glues
-
Drains and Wound Closures
-
Assessment
Stable setting (continued)
Palpation of the wound
Pain
Wound Cultures
-
Nursing Diagnosis
Impaired Skin IntegrityImpaired Tissue IntegrityRisk for
InfectionPainImbalanced Nutrition, Less than body requirements
-
Implementation
Wound Management
Dressings
Purpose of dressings
Three layers of surgical dressings
Contact layer
Absorbent layer
Outer layer
-
Implementation
Wound Management (continued)
Dressings
Types of dressings
Gauze dressings
Wet to dry dressings
Nonadherent dressings
Self-adhesive transparent dressings
Hydrocolloid and hydrogel dressings
-
Implementation
Wound Management (continued)
Dressings
Changing a dressing
Packing a wound
Securing a dressing
Cleansing skin and drain sites
Basic skin cleansing
Irrigations
-
Cleaning a Wound
-
Securing A Dressing
-
Implementation
Wound Management (continued)
Suture Care
Bandages and binders
Provide extra protection and therapeutic benefits by:
Exerting pressure
Immobilizing a body part
Supporting a wound
Securing a splint
Securing dressings
-
Implementation
Wound management (continued)
Principles of bandage and binder application:
Position in normal anatomical alignment
Prevent friction between/ against skin surfaces
Apply bandages securely to prevent slippage
Wrap extremities from distal to proximal
Apply firmly with equal tension, avoid excess overlap
Position knots, pins, ties away from the wound for sensitive
skin areas
-
Implementation
Wound management (continued)
Types of binders
Breast
Abdominal
T-Binder
Slings
-
Abdominal Binder
-
Implementation
Wound management (continued)
Elastic Bandage (Ace wrap)
Wider bandages for larger body parts
Variety of turns to cover various body parts
Circular, spiral, figure of eight
Evaluate distal circulation
At least q 4 hours
Note:
Color
Temperature
Pulses
Presence of Numbness
-
Types of Bandage Applications
