Wound Care Management and Dressings PDF

Chapter 40 Wound Care Management and Dressings Copyright © 2020, Elsevier Inc. All rights reserved.  Dressings, Bandages, and Binders ˜ Correct use promotes wound healing. ˜ Must have knowledge of proper wound dressing techniques. ˜ Selection of d...

Chapter 40 Wound Care Management and Dressings Copyright © 2020, Elsevier Inc. All rights reserved.  Dressings, Bandages, and Binders ˜ Correct use promotes wound healing. ˜ Must have knowledge of proper wound dressing techniques. ˜ Selection of dressing Ø Based on characteristics of wound Ø Expected outcomes desired Ø Practicality and feasibility of dressing changes in the home setting Copyright © 2020, Elsevier Inc. All rights reserved. 2  Principles for Practice (1 of 2) ˜ Wound healing process Ø Hemostasis Ø Inflammation Ø Proliferation Ø Maturation ˜ TIME framework for assessment Ø Tissue Ø Inflammation/infection Ø Moisture Ø Edge Copyright © 2020, Elsevier Inc. All rights reserved. 3  Principles for Practice (2 of 2) ˜ Physiological wound environment principles ˜ Effective dressings ˜ Primary wound healing ˜ Secondary wound healing ˜ Dressing material to promote wound healing Copyright © 2020, Elsevier Inc. All rights reserved. 4  Person-Centred Care (1 of 2) ˜ Select dressings to achieve individual patient outcomes. ˜ Select dressings that help reduce pain; provide analgesic doses 30 minutes prior to dressing change. ˜ Accommodate different cultures and religious practices. Copyright © 2020, Elsevier Inc. All rights reserved. 5  Person-Centred Care (2 of 2) ˜ Use skin barriers as needed. ˜ Assess patient or caregiver knowledge of wound care. ˜ Assess and try to understand the different meanings of blood and wounds and how they affect patients. ˜ Provide for patient privacy. Copyright © 2020, Elsevier Inc. All rights reserved. 6  Evidence-Informed Practice ˜ Wound cleansing and irrigation using non- cytotoxic solutions with surfactants ˜ Comprehensive wound assessment ˜ Various dressing may be effective in reducing surgical site infection and preventing pressure injuries. Copyright © 2020, Elsevier Inc. All rights reserved. 7  Safety Guidelines (1 of 2) 1. Know the cause or type of wound. 2. Identify appropriate wound cleansing agents. 3. Know the expected amount and type of wound exudate or drainage. 4. Determine if wound drainage tubes are present to prevent their accidental dislocation when you remove the old dressing. Copyright © 2020, Elsevier Inc. All rights reserved. 8  Safety Guidelines (2 of 2) 5. Perform hand hygiene prior to and after a dressing change. 6. Use the appropriate type of gloves when changing a dressing. 7. Make sure that patients in the home setting know infection control principles. Copyright © 2020, Elsevier Inc. All rights reserved. 9  Applying a Dry Dressing Skill 40-1 ˜ Dry Ø Protect wound from injury, discomfort Ø Speed healing ˜ Damp-to-dry Ø Moistened gauze Copyright © 2020, Elsevier Inc. All rights reserved. 10 Skill 40-1 Applying a Dry Dressing ˜ Debriding products Ø Autolytic Ø Enzymatic ˜ Wound packing Ø Fills dead space to avoid potential of abscess ˜ Open wounds Copyright © 2020, Elsevier Inc. All rights reserved. 11  Skill 40-1 Delegation and Collaboration ˜ The nurse is responsible for wound assessments, care of acute new wounds, wound care requiring sterile technique and evaluation of wound healing. ˜ The nurse directs UCP about: Ø Any unique modifications of the dressing change such as special tape or taping techniques to secure the dressing Ø Reporting pain, fever, bleeding, or wound drainage to the nurse immediately Copyright © 2020, Elsevier Inc. All rights reserved. 12  Skill 40-1 Communication and Documentation ˜ Document appearance and size of wound, characteristics of drainage, presence of necrotic tissue, type of dressing applied, patient’s response to dressing change, and level of comfort. ˜ Document patient’s understanding through teach- back for effective dressing change. ˜ Report any unexpected appearance of wound drainage, accidental removal of drain, bright red bleeding, or evidence of wound dehiscence or evisceration. Copyright © 2020, Elsevier Inc. All rights reserved. 13  Skill 40-1 Special Considerations (1 of 2) ˜ Teaching Ø Explain expected wound appearance and risks of improper wound care. Ø Allow patient/caregiver to change dressing with and without supervision. ˜ Pediatric Ø If a play therapist is available, or other care provider/ family, plan in advance for their support to assist in keeping child cooperative during procedure. Copyright © 2020, Elsevier Inc. All rights reserved. 14  Skill 40-1 Special Considerations (2 of 2) ˜ Gerontological Ø Prevent tape from contacting skin. Ø Patients may have delayed wound healing. ˜ Care in the Community Ø Provide education for patient and caregiver to increase confidence and ability for independent dressing changes. Ø Select dressings that can remain intact longer. Copyright © 2020, Elsevier Inc. All rights reserved. 15  Applying a Pressure Bandage Skill 40-2 ˜ Pressure bandages Ø Temporary treatment to control excessive, unanticipated bleeding Ø Stop blood flow and promote clotting ˜ Aseptic technique is secondary during an episode of acute bleeding. Copyright © 2020, Elsevier Inc. All rights reserved. 16  Skill 40-2 Delegation and Collaboration ˜ The task of applying a pressure dressing in an emergency situation cannot be delegated to UCP. ˜ If application requires more than one person, UCP can assist. ˜ The nurse directs UCP to: Ø Assist nurse as directed. Ø Observe pressure dressing during care activities; ensure that dressing remains in place with no visible bleeding from the site. Ø Observe underneath the patient for bleeding after the dressing has been applied. Copyright © 2020, Elsevier Inc. All rights reserved. 17  Skill 40-2 Communication and Documentation ˜ Document status of patient’s bleeding control, time bleeding was discovered, estimated blood loss, nursing interventions (including effectiveness of applied pressure bandage), apical and distal pulses, blood pressure, mental status, signs of restlessness, and need for health care provider to administer to patient without delay. ˜ Document assessment, application of pressure dressing, and patient response. Copyright © 2020, Elsevier Inc. All rights reserved. 18  Skill 40-2 Special Considerations (1 of 2) ˜ Teaching Ø Explain the need to monitor vital signs and for patient to remain quiet and stay in position to reduce bleeding. ˜ Pediatric Ø Child will calm down if care providers and family remain calm. Copyright © 2020, Elsevier Inc. All rights reserved. 19  Skill 40-2 Special Considerations (2 of 2) ˜ Gerontological Ø Patients are at increased risk for vascular and tissue changes distal to pressure dressing. ˜ Care in the Community Ø Provide instruction: applying pressure to control bleeding, calling 9-1-1, elevating extremity (if applicable). Ø Do not remove a penetrating object. Ø Positioning to elevate body part Copyright © 2020, Elsevier Inc. All rights reserved. 20  Quick Quiz! (1 of 2) A 52-year-old male just underwent a cardiac catheterization, and bleeding at the insertion site is noted. What action should the nurse take? A. Apply a colloid dressing. B. Coat the area with petroleum jelly. C. Secure a pressure bandage. D. Inject vitamin K at the site. Copyright © 2020, Elsevier Inc. All rights reserved. 21  Quick Quiz! (2 of 2) Answer: C. Secure a pressure bandage. Copyright © 2020, Elsevier Inc. All rights reserved. 22  Applying a Transparent Dressing Skill 40-3 ˜ Transparent film dressing Ø Clear, adherent polyurethane sheet Ø Prevents tissue dehydration and allows for rapid, effective healing by speeding epithelial cell growth Ø Preferred for intravenous (IV) catheter insertion site Copyright © 2020, Elsevier Inc. All rights reserved. 23  Skill 40-3 Delegation and Collaboration ˜ The assessment of the wound and care of a new acute wound cannot be delegated to an unregulated care provider (UCP). ˜ The nurse directs UCP about: Ø Reporting any signs of bleeding, drainage, infection, or poor wound healing immediately to the nurse Copyright © 2020, Elsevier Inc. All rights reserved. 24  Skill 40-3 Communication and Documentation ˜ Document appearance of wound, presence and characteristics of drainage, and presence of odour. Note patient response to dressing change. ˜ Report signs of infection to health care provider. Copyright © 2020, Elsevier Inc. All rights reserved. 25  Skill 40-3 Special Considerations (1 of 2) ˜ Teaching Ø Explain the need to change dressing if edges loosen; explain that fluid under dressing is not “pus”; it is the result of normal interaction of body fluids with the dressing. ˜ Pediatric Ø Adhesive may tear premature infant skin Ø Tell children: the longer the dressing is left on, the easier it is to remove. Copyright © 2020, Elsevier Inc. All rights reserved. 26  Skill 40-3 Special Considerations (2 of 2) ˜ Gerontological Ø Adhesive may tear older person skin ˜ Care in the Community Ø Wound may be cleaned in the shower with provider approval Ø Explore dressing types with patient, and recommend one that the patient can easily locate and finds easy to apply Copyright © 2020, Elsevier Inc. All rights reserved. 27  Applying a Hydrocolloid, Hydrogel, Foam, Alginate Dressing or Hydrofibre Dressing Skill 40-4 ˜ Hydrocolloid dressings Ø Elastomeric, adhesive, and gelling agents Ø Absorptive and hydrating Ø Forms gel that promotes moist environment, facilitates autolytic and enzymatic debridement Ø Diminishes pain Ø Protects wound and periwound skin Copyright © 2020, Elsevier Inc. All rights reserved. 28 Skill 40-4 Applying a Hydrocolloid, Hydrogel, Foam, Alginate Dressing or Hydrofibre Dressing ˜ Hydrogel dressings Ø Glycerin- or water-based Ø Promotes moist wound healing and autolysis Ø Nonadherent with absorptive properties Ø Cooling/soothing properties Copyright © 2020, Elsevier Inc. All rights reserved. 29  Skill 40-4 Applying a Hydrocolloid, Hydrogel, Foam, Alginate Dressing or Hydrofibre Dressing ˜ Polyurethane foam dressings Ø Foamed polymer sheets with small open cells that hold wound exudate away from the wound bed Ø Protect wound surface while maintaining a moist, insulated environment Copyright © 2020, Elsevier Inc. All rights reserved. 30  Skill 40-4 Applying a Hydrocolloid, Hydrogel, Foam, Alginate Dressing or Hydrofibre Dressing ˜ Alginate and hydrofibre dressings Ø Promote autolysis, granulation, epithelization Ø Calcium alginate material (seaweed) Ø Form a gel over the wound to contain exudate Copyright © 2020, Elsevier Inc. All rights reserved. 31  Quick Quiz! (1 of 2) When is the use of an alginate dressing contraindicated? A. Full-thickness wounds B. Necrotic, dry wounds C. Hip donor sites D. Draining wounds Copyright © 2020, Elsevier Inc. All rights reserved. 32  Quick Quiz! (2 of 2) Answer: B. Necrotic, dry wounds Copyright © 2020, Elsevier Inc. All rights reserved. 33  Skill 40-4 Delegation and Collaboration ˜ The task of applying a hydrocolloid, hydrogel, foam, or alginate dressing cannot be delegated to UCP. ˜ How will the nurse direct UCP in relation to assisting in caring for these patients? Copyright © 2020, Elsevier Inc. All rights reserved. 34  Skill 40-4 Communication and Documentation ˜ Document appearance of wound, colour, size, characteristics of drainage, response to dressing change, condition of periwound skin, and patient’s level of comfort. ˜ Graph surface area or volume if chronic. ˜ Document patient’s understanding through teach-back for proper wound dressing. ˜ Report to the health care provider immediately signs of infection, necrosis, or deteriorating wound status. Copyright © 2020, Elsevier Inc. All rights reserved. 35  Skill 40-4 Special Considerations (1 of 2) ˜ Teaching Ø Explain wound and dressing information; always use the same brand. ˜ Pediatric Ø Obtain patient cooperation or aid in holding the child. Ø Child will calm down if care providers and family remain calm. Ø Adhesive may tear premature infant skin. Ø Tell children: the longer the dressing is left on, the easier it is to remove. Copyright © 2020, Elsevier Inc. All rights reserved. 36  Skill 40-4 Special Considerations (2 of 2) ˜ Gerontological Ø Prevent tape from contacting skin. Ø Patients may have delayed wound healing. Ø Patients are at increased risk for vascular and tissue changes distal to pressure dressing. Ø Adhesive may tear older person’s skin. Copyright © 2020, Elsevier Inc. All rights reserved. 37  Applying Gauze and Elastic Bandages Procedural Guideline 40-1 ˜ Gauze and elastic bandages secure or wrap hard-to-cover body areas. ˜ Bandages are a secondary dressing. ˜ Select type of bandage turn and width on the basis of size and shape of body part. ˜ Place outer surface next to the skin and roll it around the surface to be covered. ˜ Apply even tension during application. Copyright © 2020, Elsevier Inc. All rights reserved. 38  Procedural Guideline 40-1 Delegation and Collaboration ˜ The task of applying an elastic bandage for compression cannot be delegated to UCP. ˜ The task of applying bandages to secure nonsterile dressings can be delegated to UCP. ˜ The nurse directs UCP by: Ø Explaining how to modify bandage application, as with special taping Ø Reviewing what to observe and report Copyright © 2020, Elsevier Inc. All rights reserved. 39  Applying an Abdominal Binder Procedural Guideline 40-2 ˜ Binders Ø Elastic or cotton Ø Abdominal Copyright © 2020, Elsevier Inc. All rights reserved. 40  Procedural Guideline 40-2 Delegation and Collaboration ˜ The task of applying a binder can be delegated to UCP, depending on employer policy. ˜ The nurse directs UCP about: Ø How to modify task such as special wrapping or securing method Ø Reporting patient’s complaint of pain, numbness, tingling, or difficulty breathing, or any changes in patient skin colour or temperature Copyright © 2020, Elsevier Inc. All rights reserved. 41