Chapter 38 Wound Care Treatment of Pressure Injuries PDF

CHAPTER 38 WOUND CARE/TREATMENT OF PRESSURE INJURIES Audra Xenakis, DNP, RN Discuss and assess different types of wounds, Wounds treatment, and nurisng responsibilities Phy...

CHAPTER 38 WOUND CARE/TREATMENT OF PRESSURE INJURIES Audra Xenakis, DNP, RN Discuss and assess different types of wounds, Wounds treatment, and nurisng responsibilities Physiologic Describe physiologic process by which wounds heal Process and factors influencing wound healing Objectives Describe possible complications for wound healing Complications and appropriate nursing care for each Documentation Identify information to document concerning wounds  Where do Wounds Come from? Where do wounds come from? Class Group 1 Group 2 Class 1 82 95 Class 2 76 88 Class 3 84 90  Types of Wounds and the Healing Process Types of Wounds and the Healing Process Open Closed Risk of Infection Permanent damage  Closed Wounds-without break in skin Contusion/Bruise Hematoma Sprain Open Wounds-break in skin Incision Closed and Laceration Abrasion Open Puncture Penetrating Wounds Avulsion Ulceration Closed Wounds Contusion Hematoma Sprain Tissue injury Tissue injury with Twisting of joint partial damage to blood vessel, rupture of ligaments Normally seen on the skin Causes a mass like Causes swelling appearance. Open Wounds Incision Laceration ▪ Surgically made. Clean smooth edges ▪ Traumatic. Torn edges Open Wounds Abrasions Puncture ▪ Traumatic scraping away of the skin ▪ Made by sharp, pointed object through layers the skin or mucous membranes  Open Wounds Penetrating Avulsion ▪ Made by bullet, metal, or wound ▪ Tearing away of a structure or part, such fragment. Extends deep as a fingertip. Surgical or not Open Wounds Perforation Ulceration ▪ Internal organ/body cavity open ▪ Excavation of tissue from injury or necrosis  Open Wounds Perforation Crush ▪ Internal organ/body cavity tissue open ▪ Compressed tissue ▪ Due from infection or penetrating wound Wound Thickness Partial Thickness Full Thickness Superficial No dermal layer Heals more quickly except margins Fibrin clot Necrotic tissue must framework be removed for granulation fill Wound Thickness Healing Either by Regeneration, Replacement, or Combination Regeneration Replacement ▪ Body uses SAME type of cells to heal ▪ Body uses DIFFERENT types cells to heal ▪ Partial thickness wounds-same tissue ▪ Full thickness wounds-scar tissue ▪ Original function and strength remains ▪ Original function and strength may not remain ▪ Types of cells that can regenerate: ▪ Skin ▪ Types of cell that use replacement: ▪ Mucous m embranes ▪ Heart m uscle ▪ Bone ▪ Central spinal nerve cells ▪ Muscle ▪ Liver ▪ Kidney ▪ Lung Wounds may be... Clean Dirty ▪ Free of microorganisms ▪ Contains microorganisms ▪ Example causes: ▪ Example causes: ▪ Uncontam inated sharp objects ▪ Contam inated object ▪ Surgical procedure ▪ Infected wound What is the difference between crushing and penetrating wound? What is an example?  What is the difference between crushing and penetrating wound? What is an example? Crushing: Compressed car door tissue Penetrating: Opening -bullets made by bullet, metal, or wound fragment. Extends deep Phases of Wound Healing  Regardless of the cause... Three distinct phases wound healing 2 3 1 Inflammatory phase Proliferation phase Maturation phase Wound Healing: https://www.youtube.com/watch?v=RiKu9sgFizY Inflammation First stage of wound healing Phase of Begins after injury when wound is fresh Wound Last 3-4 days Healing Stage includes: Hemostasis: Constricts blood vessels Platelet clumping Fibrin formation Clot & Scab forms 48 hours epithelial tissue forms over wound Phagocytes remove debris & protect against infection Inflammation Phase of Wound Healing Edema to injured part Erythema (redness) resulting from the increased blood supply Heat or increased tem perature at the site Pain stem ming from pressure on nerve receptors Possible loss of function resulting from all these changes Clinical Signs of Inflammation Edema Erythema Warmth Pain Begins on 3-4 day & lasts 2 to 3 weeks Wound filled new connective tissue-scar begins to form Macrophages-clean wound of debris, stimulating Proliferation fibroblasts... causing collagen (protein in connective tissue) Stage of Capillary networks formed-provides oxygen/ nutrients...for Wound collagen & granulation tissue Healing Tissue is deep pink Full-thickness wound closes with scarring Proliferation Stage of Healing Wound fills new connective tissue Macrophages-clean wound of debris, stimulating fibroblasts... causing collagen (protein in connective tissue) Capillary networks formed- provides oxygen/ nutrients...for collagen & granulation tissue Wound Health Maturation Final stage of healing; Begins 3 weeks after injury Macrophages refine collagen gives scar strength Scar slowly thins and lightens Scar finally is firm and inelastic  Abnormal shortening muscle tissue from scarring When occurs around joints Contracture Restrict joint extension Overproduction of collagen results in a thick raised scar Keloid Most common in dark pigmented skin Adhesions Fibrous bands holding tissues together normally separated Interferes with function of internal organs What are Adhesions? https://www.yout ube.com/watch? v=CQTjI_lG0GA  What is the difference between an abrasion, laceration, and a hematoma? What is the difference between an abrasion, laceration, and a hematoma? Abrasion: Traumatic -road rash scraping away of the skin layers Laceration: Traumatic.jJagged cut Torn edges Hematoma: Tissue pool of blood injury with pooling of blood under unbroken skin  Describe the difference between Inflammatory, Proliferation, and Maturation stages. Describe the difference between Inflammatory, Proliferation, and Maturation stages. Inflammation: Begins after injury, Last 3-4 days, Hemostasis, epithelial tissue forms, Phagocytes remove debris & protect against infection May have redness, swelling, warmth and slight pain Proliferation: Begins on 3-4 day & lasts 2 to 3 weeks, new connective tissue-scar begins to form, Macrophages-clean wound of debris, stimulating fibroblasts... causing collagen (protein in connective tissue), Capillary networks formed-provides oxygen/ nutrients...for collagen & granulation tissue Maturation: Final stage of healing; Begins 3 weeks after injury, refine collagen gives scar strength  Healing: Primary, Secondary, Tertiary Intentions Primary intention -surgery Partial-Full thickness Healing: Edges approximate (meet) Slight chance of infection Primary, Secondary intention Secondary, Partial-Full thickness Edges do not approximate Tertiary Fills with scar tissue Chance of infection Intentions Tertiary intention Full thickness Also known as delayed closure Delayed suturing of wound Suture after granulation tissue begins to form Example-Abdominal wound left open for drainage-later closed Healing by First Intention Edges approximate (meet) Slight chance of infection Healing by Second Intention Edges do not approximate Fills with scar tissue Chance of infection Healing by Third Intention Delayed closure- wound left open and then later sutured If granulation tissue is present & no s/s of infection are noted, wound is closed Ex: Surgical wound left open to drain then later closed High chance of infection Wound Healing ▪ https://www.youtube.co m/watch?v=0AIDCV9Myi Q What is the difference between primary, secondary, and tertiary intentions?  What is the difference between wounds healing primary, secondary, and tertiary intentions? Primary Partial-Full thickness Edges approximate (meet) Slight chance of infection Secondary Partial-Full thickness Edges do not approximate Fills with scar tissue Chance of infection Tertiary Full thickness Also known as delayed closure Delayed suturing of wound Suture after granulation tissue begins to form Example-Abdominal wound left open for drainage-later closed Factors Affecting Wound Healing Factors Affecting Wound Healing Age Peripheral vascular Decreased immune Children & adults heal disease (PVD) system function more quickly than elderly Impaired blood flow Antibodies & monocytes necessary wound healing Reduced liver Decreased lung Nutrition function function Proteins, carbohydrates, Impairs synthesis of blood Reduces oxygen needed lipids, vitamins, and factors to synthesize collagen & minerals needed epithelium for wound healing Factors Affecting Wound Healing Lifestyle Medications Not smoking & exercising Steroids & anti- regularly will heal more quickly inflammatories, heparin, and antineoplastic agents interfere with healing process Infection Chronic illnesses Slows healing process Diabetes, cardiovascular Bacterial infections often cause disease, immune system wound drainage-assess color, disorders may slow wound consistency, & odor healing  Wound Complications Hemorrhage Infection Complications of Wound Healing Dehiscence Eviseration Hemorrhage Risk is greatest during first 48 hours after surgery IT IS AN EMERGENCY Monitor all surgial clients for hemorrhage This Photo by Unknown author is licensed under CC BY-NC. Hemorrhage Signs and symptoms of hemorrhage Increase pulse Diaphoresis, Sanguineous Swelling in the Decrease B/P rate & Restlessness cold, clammy drainage in wound area respirations skin surgical drain  When assessing a dressing always look and feel beneath the patient for pooled blood Can be caused by a slipped suture, clot, trauma to the site Hemorrhage Apply pressure using sterile towels, monitor VS, and notify MD HEMATOMA Tissue injury with pooling of blood under unbroken skin May appear as swelling that is bluish red May place pressure on blood vessels and obstruct blood flow to tissues Client may have increased temperature Wound Drainage Sanguineous Bloody Serosanguineous Pink/Orange Serous Yellow/clear Describe the difference between sanguineous, serous, and serosanguineous drainage.  Describe the difference between sanguineous, serous, and serosanguineous drainage. Sanguineous Bloody Serosanguineous Pink/Orange Serous Yellow/clear Infection Most common type of wound complication Wound may be infected during surgery or postoperatively. Traumatic wounds are more likely to become infected Localized infection is an abscess: an accumulation of pus from debris Complications from Infections ▪ Cellulitis- Inflammation of tissue surrounding with redness and induration (skin hardening) ▪ Fistula-abnormal passage formed between 2 internal organs ▪ Sinus-fistula leading from infected cavity to outside of body Signs and Symptoms Increased pain Redness Warmth tissues Purulent exudate (fluid containing cellular debris) Labs Culture and sensitivity Taken from the wound exudate (fluid/drainage) Determine what type of organism is growing and what ABX can treat WBC-Elevated Microorganisms Infection Discharge-White,yellow, pink, green Staphylococcus aureus E. Coli MRSA (methicillin-resistent staphococcus aureus) Pseudomonas aeruginosa Obtaining a Wound Culture Use sterile gloves Swirl distal end of culturette swab in the wound Avoid the edges! Send to lab ▪ Maintain strict asepsis when performing Best Way to wound care! Prevent ▪ Use Sterile instruments ▪ Meticulous hand washing Wound ▪ Sterile gloves Infection... ▪ Sterile dressings ▪ Refrain from talking while dressing Dehiscence & Evisceration Dehiscence – spontaneous opening of an incision. Evisceration – protrusion of an internal organ through the incision. Risk Factors for Greatest risk for wound Dehiscence dehiscence is on 4-5 post-op day...before extensive collagen has been built. Poor Mutiple Obesity Nutrition Trauma Excessive Strong Vomiting Coughing Sneezing Suture Dehydration Failure  Evisceration Can lead to necrosis Pt may say “I feel like of intestines or something just split overwhelming sepsis open” Can have an Usually occurs increase in suddenly serosanguineous drainage before Evisceration-Immediate Care Supine Immediately place in supine position Place Place large sterile dressings over the viscera Soak Soak the dressings in sterile normal saline Notify Notify the surgeon immediately Prepare Prepare the patient for return to surgery-NPO Describe signs and symptoms of hemorrhage. Describe signs and symptoms of hemorrhage. Decrease B/P Increase pulse rate & respirations Restlessness Diaphoresis, cold, clammy skin Swelling in the wound area Sanguineous drainage in surgical drain Describe signs and symptoms of an infected wound. Describe signs and symptoms of an infected wound. Purulent drainage Increased pain Redness Warmth tissues WBC-Elevated  What is the difference between dehiscence and evisceration? What is the difference between dehiscence and evisceration? Dehiscence: Opening of wound Evisceration: Organs protruding from open wound Client is experiencing wound dehiscence. What are the immediate actions to take? Client is experiencing wound dehiscence. What are the immediate actions to take? Place in supine position Place large sterile dressings over the viscera Soak the dressings in sterile normal saline Notify the surgeon immediately Prepare the patient for return to surgery-NPO  Treatment of Wounds: Wound Closures WHAT KIND OF BANDAGE DO YOU USE ON A DUCK THAT HAS AN INJURY?  DUCK TAPE! Wound Closures Sutures and staples Silver wire clips Large retention sutures Steri-Strips Dermabond Sutures Hold the edges of the wounds together until it can heal Suture that are used to attach tissues beneath the skin are absorbed and not removed Made from silk, cotton, linen, wire, nylon, or Dacron Retention Sutures Used to take some of the pressure off other sutures Wound does not pull open as it is healing Usually used after abdominal surgeries in patients who are overweight or who may suffer from a distention of the abdomen due to swelling or disease Steri-Strips Small reinforced adhesive strips that hold the wound edges together Often applied after sutures/staples are removed Staples Hold edges of the wound together Removed after 7-14 days Dermabond (Surgical Adhesive) Noninvasive glue Provides a seal without needing a dressing Used in place of sutures. Comes off in 7-10 days. Do not use on mucous membranes. https://www.youtube.com/watch?v=64z0fFFMrfM https://www.youtube.com/watch?v=_M_rDhPVIMY https://www.youtube.com/watch?v=C5m0CYCt59E What is the difference between routine sutures and retention sutures? What is the difference between routine sutures and retention sutures? Retention sutures are used to take some of the pressure off other sutures Wound does not pull open as it is healing Usually used after abdominal surgeries in patients who are overweight or who may suffer from a distention of the abdomen due to swelling or disease  Open Wound Classifications Open Wound Classifications Red wounds Yellow wounds Black wounds  Open Wound Classification- Red Clean, ready to heal Protect the wound! Open Wound Classification- Yellow Layer of yellow fibrous debris or exudate Sloughing Natural shedding of dead tissue May cause drainage Needs to be cleaned often Dressing needs to absorb drainage Watch for infection!! Open Wound Classification- Black Needs debridement (removal of unhealthy tissue) Eschar-Dead tissue Won’t heal until debrided Wound Drains Drains and Drainage Devices Provide an exit blood/fluids accumulated during the inflammatory process Passive-Drain-Penrose Active- Hemovac, Devol, and Jackson-Pratt Active Versus Passive Drains Active Passive ▪ Uses suction ▪ No suction ▪ Attached to a suction collection device ▪ Works by increased pressure inside wound ▪ Works by compressing device ▪ Drains by gravity ▪ Types: ▪ Type: ▪ Jackson-Pratt (JP drain) ▪ Penrose Drain ▪ Hemovac ▪ Davol Active Drains-Jackson-Pratt, Hemovac, Davol Jackson Pratt Hemovac Davol Passive Drain-Penrose Passive- Penrose https://www.youtube.com/watch?v=DeC3JAO-MSM https://www.youtube.com/watch?v=xDv1D2c8eLY NURSING CARE FOR DRAINS Empty drains Every end of shift When ½ to 2/3 full Do not wait until it is full...suction will not work Compress to facilitate suctioning Document Intake and Output every shift Clean spout and plug with alcohol swab What is the primary difference between an active and passive drain? What is the primary difference between an active and passive drain? Active uses active suction (compressing drain) Passive uses gravity Name a passive drainage system. Name active drainage systems.  Name a passive drainage system. Name active drainage systems. Passive: Penrose drain Active: Hemovac, Davol, Jackson Pratt (JP) drains What are essential nursing tasks when caring for a drain?  What are essential nursing tasks when caring for a drain? Empty Drain- at the end of every shift Empty when ½ to 2/3 full Do not wait until it is full...suction will not work Compress to facilitate suctioning Document Intake and Output every shift Clean spout and plug with alcohol swab Debridement  Debridement Removing necrotic tissue- healing can occur Sharp Debridement-Provider May be performed with scissors, scapel, forceps Use sepsis cellulitis Wound may bleed after Can be painful Enzymatic Debridement-Nurse Using an enzyme to liquefy dead tissue Placed in wound then dressing placed over Useful uninfected wounds Sharp Debridement-Provider https://www.youtube.com/watch?v=7ewnTy8jKbw Enzymatic Debridement https://www.youtube.com/watch?v=t0_Sp2qqiAg Debridement Mechanical Debridement Physical removal debris Types: Irrigation or hydrotherapy Whirlpool or ultrasound mist Microscopic bubbles, sound waves Wet to dry dressing. Tissue sticks to dressing Cells are pulled off Not recommended any longer Debridement Autolytic Debridement Longer process Uses body’s own enzymes break down the tissue Use on small, uninfected wound- Dressings that promote moist environment — hydrogels, hydrocolloids, transparent films — support moisture retention and assist in debridement Debridement Chemical Debridement Use when necrotic is not responding to other trxt Dakin solution (bleach and peroxide) or sterile maggots  Dressings Sonic is making a drink in honor of Temple music department...what would the name of the department be?  Sonic is making a drink in honor of Temple music department...what would the name of the department be? Temple College Band-Aid! Purpose Protective coverings placed over wounds Prevent microorganisms from entering the wound Absorb drainage Control bleeding Support and stabilize tissues Reduce discomfort Gauze Absorbent Material Used for wet-to damp dressings Varies sizes Sizes vary: 2X2 4X4 4X8 Kerlex Fluff Gauze Absorbent Material Used for wet-to damp dressings Non-Adherent Gauze Shiny, coated gauze Doesn't stick to wound Good choice for fragile skin Causes less trauma when removed Example: Telfa Abdominal Pads Used to cover gauze Hold the dressing in place Line goes on the outside  Occlusive Dressings Wounds heal faster when kept moist Occlusive dressings keep wound moist while protecting from contamination Used for chronic or hard-to-heal wounds Transparent Film Dressing Clean wounds without drainage or infection! Can be used to hold other dressings in place/IV In place for 3-7 days Example: Tegaderm Hydrocolloid Not for use on infected wounds! Keeps moist wounds moist Don’t use on heavily draining wounds In place 3-5 days Facilitates autolytic debridement Provides thermal insulation Example: DuoDERM Hydrogel Dressings What does non-adherent mean? Why is this important? What does non-adherent mean? Why is this important? Does not adhere (stick) to wound. Good for fragile skin Less painful Shiny, coated gauze Causes less trauma when removed  Name a dressing that encourages a wound to remain moist? What if wound is infected or large amount of drainage? Name a dressing that encourages a wound to remain moist? What if wound is infected or large amount of drainage? Hydrocolloid aids moisture Do not use if infected-occlusive dressing Mrs. Bone's New Bicycle Mrs. Bone Accident  tissue injury with bruise: tissue injury traumatic scraping damage to blood normally seen on the away of skin layers vessel. Causes skin a mass like appearance Mrs. Bone's List of Wounds tearing away of traumatic torn excavation of structure or part, edges tissue from injury such as a fingertip or necrosis Mrs. Bone's List of Wounds ▪ Abrasion-hand Contusion-head ▪ Ulceration-foot Deep Laceration ▪ Avulsion-fingertip to her abdomen Hematoma-knee  Mrs. Bone Walking in Hallway ▪ Mrs. Bones has surgery, including repair to her lacerated abdominal area. She is ambulating in the hallway and says "Help help! Something has just split open!" ▪ What do you think may have happened? What is she now at risk for? Mrs. Bone Walking in Hallway ▪ Mrs. Bones has surgery, including repair to her lacerated abdominal area. She is ambulating in the hallway and says "Help! HELP! Something has just split open!" ▪ What positions should you immediately place Mrs. Bones in? ▪ Sit her up straight on the couch? Mrs. Bone Walking in Hallway ▪ Mrs. Bones has surgery, including repair to her lacerated abdominal area. She is ambulating in the hallway and says "Help help! Something has just split open!" ▪ What positions should you immediately place Mrs. Bones in? ▪ Tell her to call Mr. Bones? Mrs. Bone Walking in Hallway ▪ Mrs. Bones has surgery, including repair to her lacerated abdominal area. She is ambulating in the hallway and says "Help help! Something has just split open!" ▪ What positions should you immediately place Mrs. Bones in? ▪ Tell her to place her hands over her abdomen to keep her intestines inside? Mrs. Bone Walking in Hallway ▪ Mrs. Bones has surgery, including repair to her lacerated abdominal area. She is ambulating in the hallway and says "Help help! Something has just split open!" ▪ What positions should you immediately place Mrs. Bones in? ▪ Immediately place her in a supine position. Mrs. Bone Post-Op Care ▪ Monitoring Mrs. Bone's vital signs and conditions, which one of the following would be most concerning? ▪ Paleness, rising pulse rate, lowering blood pressure ▪ Oriented, rising pulse, normal blood pressure ▪ Pain, normal pulse, rising blood pressure ▪ Laughing, normal pulse, normal blood pressure Mrs. Bone Post-Op Care ▪ Assessing Mrs. Bone's wound, you notice red granulation tissue. What would be your response? ▪ Tissue is about to become infected ▪ Tissue is about to hemorrhage ▪ Tissue is infected ▪ Tissue is healing Mrs. Bone Post-Op Care ▪ You are caring for Mrs. Bone during her Post- Op care. You know she is most at risk for hemorrhage during what timeframe? ▪ First 24 hours ▪ First 48 hours ▪ First 72 hours ▪ First 96 hours  Mrs. Bone Post-Op Care ▪ Mrs. Bones' Provider noted an infection in her wound and is going to perform a sharp debridement. What education will you share with Mrs. Bones? ▪ You will be performing the procedure ▪ An enzymatic solution will be applied to her wound ▪ A Dakin solution will be used ▪ Wound may bleed afterwards Securing dressings  Dressing may be secured with: Tape, stretch roller gauze Stretch gauze- (Conform, Kerlix, Kling) Mesh netting Elastic bandage Montgomery straps Binders Securing a Dressing Elastic tape or bandages provide pressure Stretch gauze and mesh netting allow movement Montgomery straps allow changing dressing without removing tape  Montgomery straps Used for frequent dressing changes Adheres to each side of the wound and dressing is “tied” on. Tape Application Types of Tape Silk Paper Cloth Do not apply Over broken or irritated skin Removing Pull parallel to skin surface TOWARDS the wound Check for allergies! Tape Application Place tape To adhere to intact skin Tape should be Long and wide enough to adhere firmly to intact skin Placed ends of the dressing Place tape Opposite to body action in the wound location. Across a joint or crease Turn tape Under the end, leaving a tab for easy removal Correct tape across a joint or crease Allows for movement  Clean Dressing Change https://www.youtube.com/watch?v=otHmSV8nC9s Binders Decreases tension around wound or suture line Adds comfort Holds abdominal dressing in place Made of elastic and velcro Applies pressure to site Negative Pressure Wound Therapy Vacuum Assisted Closure (WOUND VAC) Suction device creates negative pressure drawing edges together Stretches cells increasing cell and tissue growth Removes fluid from wound Increases blood flow-increases oxygen and nutrients to wound Keeps wound moist Negative Pressure Wound Therapy Dressing changes: Infected wound- every 12-24 hours Clean wound- 3 times a week Do not use: Bleeding, exposed organs, exposed blood vessels or nerves, malignant tissue Mrs. Bone Walking in Hallway ▪ Mrs. Bones says, I am scared my wound is going to open up again. She asks if there is anything she can use to decrease tension around her incision and increase her comfort. You consider what type of support? Mrs. Bone Post-Op Care ▪ Following Mrs. Bones debridement, she is to have frequent dressing changes. To decrease tape irritation by frequent removal and applications, what dressing could you consider using?  Mrs. Bone Post-Op Care ▪ Mrs. Bone is being seen at her 6 week post- op appointment. You notice her surgery scar is thick, raised with dark pigmentation. Your findings reveal ▪ Normal healing-all scars look this way ▪ Keloid has formed ▪ Concerned wound is about to open up ▪ Wound is infected Mrs. Bone Has Healed and Ready to Go Shopping for a New Bicycle What is the purpose of an abdominal binder? What is the purpose of an abdominal binder? Decreases tension around wound or suture line Holds abdominal dressing in place Made of elastic and velcro Applies pressure to site  You are to remove a dressing. What direction should you pull to remove the tape from the old dressing? You are to remove a dressing. What direction should you pull to remove the tape from the old dressing? Parallel to skin towards the wound  What is the difference between a Montgomery Strap and another type of dressing? What is the difference between a Montgomery Strap and another type of dressing? Used for frequent dressing changes Adheres to each side of the wound and dressing is “tied” on.  Treatment of Pressure Injuries or Vascular Ulcers What bandage is worn by most card players?  What bandage is worn by most card players? Ace Bandages! Cleaning Ulcers or Pressure Injuries Clean at each dressing change Irrigate with syringe and water, saline, nontoxic cleanser Pressure of irrigation-do not damage new granulation Use 250-500 ml-include tunnels Observe and document Cover wound dressing according to characteristics Pressure Injuries Stages Stage 1 Stage 2 Stage 3 Stage 4 Protective Uninfected- Injury Chemical dressings- Use with drainage enzyme to transparent hydrocolloid (uninfected) debride film Protect against Dressing to Mechanical Protect from bacteria absorb debridement shearing forces drainage Hyperbaric Keep moist Keep moist oxygen Hydrogel drsg therapy Nursing Process Assessment Document the location and appearance of the wound daily During wound care: Amount of drainage on the wound Scant, small, moderate, large Color of the drainage Swelling Odor Pain Approximation (degree of closure) Warmth Signs of infection-fever, WBC, malaise Assessment Acute- 8 hours; chronic-24 hours Measuring Wound Weekly Length, width, and depth Use a ruler or disposable paper wound ruler Measure width and length at widest point Depth: use sterile cotton-tipped swab Also check for sinus tract  Assessment https://www.youtube.com/watch?v=fDsPwhBN0Z8 Planning Must have an order - change drsg or irrigate If ordered not to change-draw a circle with a pen around the drainage on the dressing Determine when last drsg change or irrigation Date/time/initial after drsg change If large amount of drainage, reinforce the dressing and notify the MD Implementation Sterile-touching open or fresh surgical wound Nonsterile-wound is closed Clean Water, Normal saline Antimicrobial cleaner If solution is refrigerated-bring to room temperature Cold solution lowers wound temperature Slows healing Implementation Evaluate patient (is pain med needed?) Gather supplies Wash hands, clean gloves Assess drainage on dressing Remove old dressing Loosen tape-Pull off tape toward the wound Wet the drg with NS if it sticks to wound Inspect wound Remove dirty gloves, wash hands Dressing Change Set up sterile field Clean wound- Saline or wound cleanser (not cold) Clean grossly infected wounds each change Do not use cotton balls-cotton fibers can embed Clean from center outward to avoid pulling microorganisms from skin to wound-do not use circular motion Irrigating a Wound Flushing out an area with liquid Physician order Sterile technique Large syringe with 20 gauge needle Spray wound with irrigation solution Hold 1 inch from wound Use back and forth motion Hold a basin underneath inferior portion to collect drainage Packing Wound Do not use on infected wounds Facilitates wound healing from the inside out, granulation tissue Wet to damp dressing Moist gauze is placed in the wound and changed before it dries out Performed every 4-6 hours Painful Suture & Staple Removal Sutures: Sterile technique Cut and pulled through the skin Inspect for intactness Staples: Removal requires a special instrument Steri-Strips applied after removal of sutures or staples Describe best technique when cleansing a wound. Describe best technique when cleansing a wound. Clean center outwards Do not use cotton balls Sterile for open wounds Do not use cold solutions Pull tape towards wound Document Wound Documentation VERY IMPORTANT Amount and color of drainage on old dressing Length, width, diameter/depth Color of wound Appearance of surrounding skin Type of dressing applied IS THE WOUND GETTING SMALLER?? Eye, Ear, & Vaginal Irrigations Eye, Ear, & Vaginal Irrigations Eye irrigations May be performed when injury is involved and debris or a caustic substance is present in the eye Ear irrigations Used to remove cerumen or foreign substances Vaginal irrigation May be ordered for infections or surgical preparation You are removing a dressing, and it begins to stick to the wound. What should you do?  You are removing a dressing, and it begins to stick to the wound. What should you do? Add normal saline to loosen the dressing Hot & Cold Applications Can be dry or moist Usually requires physician’s order Provides comfort and speeds healing process Hot Applications Relieve pain, Reduce reduce congestion, inflammation and relieve muscle swelling spasm Provide comfort, elevate body temperature Cold Applications For joint injuries or Decreases swelling areas requiring and pain decreased blood flow Used in the form of Decreases cellular compresses, ice bags, activity, leading to collars, or numbing hypothermia blanket Common Nursing Diagnosis for Patients with Wounds Risk for Impaired skin integrity infection: Related Disturbed body image related to mechanical factors: Inadequate factor (e.g., surgical related to injury primary defenses incision) (broken skin) Why couldn't the nurse use alcohol swabs on the patients? Why couldn't the nurse use alcohol swabs on the patients? He was under 21!