LEC-1-RLE-NCM-104.pdf

NCM COMMUNITY HEALTH NURSING (INDIVIDUAL AND FAMILY AS CLIENTS) RLE 104 08-15-24 DISCUSSED...

NCM COMMUNITY HEALTH NURSING (INDIVIDUAL AND FAMILY AS CLIENTS) RLE 104 08-15-24 DISCUSSED BY: MS. VASELIE BATUCAN WOUND CARE SKIN - First line of defense - Largest organ in the body SKIN INTEGRITY - Refers to skin health - A skin integrity issue might mean the skin is damaged, vulnerable to injury or unable to heal normally. - A pressure wound (also called a pressure sore, bed sore or pressure ulcer) is an injury to the skin OPEN WOUND and surrounding tissue. - Is when the skin or the mucous membrane - Intact skin refers to the presence of normal skin surface is broken and skin layers uninterrupted by wounds. WOUNDS The appearance of the skin and skin integrity are WOUNDS influenced by internal factors such as: - Can be described according to the likelihood and - Genetics degree of wound contamination - Age - Underlying health of the individual CLEAN WOUNDS - Activity (external factors) - Are uninfected wounds in which there is minimal inflammation and the respiratory, GENETICS AND HEREDITY gastrointestinal, genital, and urinary tracts are - Determine many aspects of a person’s skin, not entered. including skin color, sensitivity to sunlight, and allergies. CLEAN- CONTAMINATED WOUNDS - Are surgical wounds in which the respiratory, AGE gastrointestinal, genital, or urinary tract has been - Influence skin integrity in that the skin of both the entered. Such wounds show no evidence very young and the very old is more fragile and infection. susceptible to injury than that of most adults. Wounds tend to heal more rapidly in infants and CONTAMINATED WOUNDS children. - Include open, fresh, accidental wounds and surgical wounds involving a major break in sterile OTHER HEALTH CONDITIONS LIKE MANY CHRONIC technique or a large amount of spillage from the ILLNESSES gastrointestinal tract. - And their treatments affect skin integrity. People - NOTE: Contaminated wounds show evidence of with impaired peripheral arterial circulation may inflammation have skin on the legs that damages easily. DIRTY OR INFECTED WOUNDS TYPES OF WOUNDS - Include wounds containing dead tissue and INTENTIONAL TRAUMA wounds with evidence of a clinical infection, such - Occurs during therapy examples are operations as purulent drainage or venipunctures TYPES OF WOUND EXUDATE UNINTENTIONAL TRAUMA EXUDATE - Are accidental, for example, a person may - Is material, such as fluid and cells, that has fracture an arm in an automobile collision escaped from blood vessels during the inflammatory process and is deposited in tissue CLOSED WOUND or on tissue surfaces. - If the tissues are traumatized without a break in the skin 1. SEROUS EXUDATE - Consist chiefly of serum (the clear portion of the blood) derived from blood and the serous membranes of the body. sdyr 😊 1 NCM COMMUNITY HEALTH NURSING (INDIVIDUAL AND FAMILY AS CLIENTS) RLE 104 08-15-24 DISCUSSED BY: MS. VASELIE BATUCAN 2. PURULENT EXUDATE TERTIARY INTENTION - Is thicker than serous exudate because - Wound that are left open for 3-5 days to allow of the presence of pus, which consist of edema of infection to resolve or exudate to drain leukocytes, liquefied dead tissue debris, and are then closed with sutures, stapes, or and dead and living bacteria, varies in adhesive skin closures color (some acquiring tinges of blue, - This is also called delayed primary healing green, of yellow; color may depend on the causative organism) PHASES OF WOUND HEALING (PROCESS) - Formation is referred to as Suppuration INFLAMMATORY PHASE - begins immediately after injury and lasts 3 to 6 3. SANGUINEOUS EXUDATE days. - Consist of large amounts off red blood - Two major processes occur during this phase: cells, indicating damage to the hemostasis (cessation of blood) and capillaries that is severe enough to allow phagocytosis. Inflammatory response is the escape of red blood cells from essential for wound healing plasma. PROLIFERATIVE PHASE Puru-sanguineous - The second phase in healing - type of exudate that consists blood and pus - Extends from day 3 or 4 to about day 21 post injury. COMPLICATIONS OF WOUND HEALING - Fibroblast (connective tissue cells), which HEMORRHAGE (massive bleeding) migrate into the wound starting about 24 hours - Is abnormal. A dislodged clot, a slipped stitch, or after injury, begin to synthesize collagen. erosion of a blood vessel may cause severe bleeding MATURATION PHASE - Begins on about day 21 and can extend 1-2 years INFECTION after injury. - Occurs when the microorganisms colonizing the - Fibroblast continue to synthesize collagen wound multiply excessively or invade tissues FCATORS AFFECTING WOUND HEALING DEHISCENCE DEVELOPMENTAL CONSIDERATIONS - Is the partial or total rupturing of a sutured - Healthy children and adults often heal more wound, usually involves an abdominal wound in quickly than older adults, who are more likely to which the layers below the skin also separate have chronic diseases that hinder healing EVISCERATION NUTRITION - Is the protrusion of the internal viscera through - Malnourished clients may require time to improve an incision their nutritional status before surgery, if this is possible. Obese clients are at increased risk of TYPES OF WOUND HEALING (CHARACTERISTICS) wound infection and slower healing because PRIMARY INTENTION adipose tissues usually have a minimal blood - Healing occurs where the tissue surfaces have supply been approximated (closed) and there is minimal or no tissue loss; it is characterized by LIFESTYLE the formation of minimal granulation and - People who exercise regularly tend to have good scarring (Example: is a closed surgical incision, circulation and because blood brings oxygen and tissue adhesive, a liquid glue that can be used) nourishment to the wound, they are more likely to heal quickly. SECONDARY INTENTION HEALING - A wound that is extensive and involves FACTORS INHIBITING WOUND HEALING IN OLDER ADULTS considerable tissue loss, and in which the edges - Vascular changes associated with aging, such cannot or should not be approximated (ex: as atherosclerosis and atrophy of capillaries in pressure ulcer) the skin, can impair blood flow to the wound. sdyr 😊 2 NCM COMMUNITY HEALTH NURSING (INDIVIDUAL AND FAMILY AS CLIENTS) RLE 104 08-15-24 DISCUSSED BY: MS. VASELIE BATUCAN - Collagen tissue is less flexible, which increases 2. IMMOBILITY the risk of damage from pressure, friction, and - Refers to a reduction in the amount and shearing. control of movement that a person has. - Scar tissue is less elastic. 3. INADEQUATE NUTRITION - Causes weight loss, muscle atrophy, - Changes in the immune system may reduce the and the loss of subcutaneous tissue formation of the antibodies and monocytes necessary for wound healing. 4. MOISTURE FROM INCONTINENCE - Promotes skin maceration (softening - Nutritional deficiencies may reduce the and breaking down of skin resulting numbers of red blood cells and leukocytes, thus from prolonged exposure to moisture) impeding the delivery of oxygen and the - And skin excoriation (area loss of the inflammatory response essential for wound superficial layers of the skin; also known healing. Oxygen is needed for the synthesis of as denuded area) collagen and the formation of new epithelial cells. 5. DECREASED MENTAL STATUS - Having diabetes or cardiovascular disease - Are at risk for pressure ulcers because increases the risk of delayed healing due to they are less able to recognize and impaired oxygen delivery to these tissues. respond to pain associated with - Cell renewal is slower, leading to delayed prolonged pressure healing. 6. DIMINISHED SENSATION DEPTHS OF WOUND - Also impairs the body’s ability to Wounds, excluding pressure ulcers and burns, are recognize and provide healing classified by depth, that is, the tissue layers involved in the mechanisms for a wound wound. 7. ADVANCED AGE PARTIAL THICKNESS - Brings about several changes in the skin - Confined to the skin, that is, the dermis and and its supporting structures, making epidermis the older person more prone to - Heal by regeneration impaired skin integrity. FULL THICKNESS 8. OTHER FACTORS - Involving the dermis, epidermis, subcutaneous - Poor lifting and transferring techniques tissue, and possibly muscles and bones - Incorrect positioning - Require connective tissue repair - hard support surfaces - incorrect application of pressure PRESSURE ULCER ETIOLOGY STAGES OF PRESSURE ULCER - Ischemia (a deficiency in the blood supply to the STAGE 1: PRESSURE INJURY LIGHTLY PIGMENTED tissue) - skin is unbroken and reddened, but does not blanch RISK FACTORS: 1. FRICTION AND SHEARING STAGE 2: PRESSURE INJURY - A force acting parallel to the skin - partial-thickness skin loss surface. - Shearing force is a combination of STAGE 3: WITH EPIBOLE friction and pressure. It occurs - the edges of the skin surrounding the injury roll commonly when a client assumes a under the rolled tissue sitting position in bed. In this position, the body tend to slide downward towards STAGE 4: PRESSURE INJURY the foot of the bed - full-thickness skin loss sdyr 😊 3 NCM COMMUNITY HEALTH NURSING (INDIVIDUAL AND FAMILY AS CLIENTS) RLE 104 08-15-24 DISCUSSED BY: MS. VASELIE BATUCAN UNSTAGEABLE / UNCLASSIFIED: capillary refill when gently pressed with a finger - full-thickness skin loss, the full extent of the injury or thumb. cannot be determined due to slough or eschar - Inspect pressure areas for abrasions and SUSPECTED DEEP TISSUE PRESSURE INJURY excoriations. Abrasions can occur when skin rubs - injury-depth unknown against a sheet. Excoriations can occur when the - dark area of discolored intact skin due to skin has prolonged contact with body secretions damage of underlying tissue. or excretions or with dampness in skinfolds. PRESSURE ULCER RISK ASSESSMENT TOOLS - Palpate the surface temperature of the skin over Several risk assessment tools are available that provide the pressure areas (warm your hands first). nurses with systematic means of identifying clients for Normally, the temperature is the same as that of high risk of pressure ulcer development. The tool chosen the surrounding skin. Increased temperature is for use should include data collection in the area of abnormal and may be due to inflammation. immobility, incontinence, nutrition, and level of consciousness. - Palpate over bony prominences and dependent body areas for the presence of edema, which BRADENS SCALE feels spongy or boggy. NORTONS PRESSURE AREA RISK ASSESSMENT FORM (SCORING SYSTEM) ASSESSING COMMON PRESSURE SITES - Ensure the lighting is good, preferably natural or fluorescent, because incandescent lights can create a transilluminating effect. - Regulate the environment before beginning the assessment so that the room is neither too hot nor too cold. Heat can cause the skin to flush; cold can cause the skin to blanch or become cyanotic. - Inspect pressure areas for discoloration. This can be caused by impaired blood circulation to the area. The pressure areas should have brisk sdyr 😊 4 NCM COMMUNITY HEALTH NURSING (INDIVIDUAL AND FAMILY AS CLIENTS) RLE 104 08-15-24 DISCUSSED BY: MS. VASELIE BATUCAN ASESSMENT TO SKIN INTEGRITY PREVENTING INFECTION Particular attention is paid to skin condition in areas most - There are two main aspects to controlling wound likely to break down: infection: - Skinfolds (under the breast) - Preventing microorganisms form - In areas that are frequently moist (perineum) entering the wound - Areas receiving extensive pressure (bony - Preventing the transmission of prominences) bloodborne pathogens to or from the client to others. ASSESSMENT OF WOUNDS Assess it as treated or untreated POSITIONING - Clients must be positioned to keep pressure off UNTREATED WOUNDS the wound (sometimes referred to as off- - Usually are seen shortly after an injury (e.g. at the loading) scene of an accident or in a emergency center) GUIDELINES FOR PREVENTING INFECTION AND THE TREATED WOUND TRANSMISSION OF VLOODBORNE PATHOGENS - Sutured wounds, are usually assessed to STANDARD PRECAUTIONS determine the progress of healing - Wear gloves when touching blood and bloody fluids, mucous membranes, or nonintact skin of Undermining – wound reaches under the skin surface all clients, and when handling items or surfaces soiled with blood or body fluids. PRESSURE ULCERS - Cleanse hands thoroughly if contaminated with - Location of the ulcer, related to a bony blood or body fluids and after removing gloves prominence - Size of ulcer in centimeters. Measure greatest WOUND CARE length, width, and depth. To measure depth, - Cleanse hands before and after caring for insert a sterile applicator swab at the deepest wounds part of the wound, and then measure it again with - Wear gloves, masks, and protective eyewear as a measuring guide. appropriate if procedures commonly cause - Presence of undermining or sinus tracts, droplets or splashing of blood or bodily fluids (e.g. location described by position on the face of a wound irrigation) clock, 12 o’clock as the client’s head. - Touch an open or fresh surgical wound only when - Stage of the ulcer wearing sterile gloves or using a sterile - Color of the wound bed and location of necrosis instrument (dead tissue) or eschar - Remove or change dressings over closed wounds - Condition of the wound margins when they become wet - Integrity of the surrounding skin - Clinical signs of infection such ads redness, PRACTICE GUIDELINES FOR TREATING PRESSURE ULCERS warmth, swelling, pain, odor, and exudate (note - Minimize direct pressure on the ulcer. Reposition color of exudate) the client at least every 2 hours. Make a schedule, and record the position changes on the client’s SUPPORTING WOUND HEALING chart. Provide devices to minimize or float MOIST WOUND HEALING pressure areas - The dressing and frequency of changes should - Clean the pressure ulcer with every dressing support moist wound bed conditions change. The method of cleansing depends on the stage of the ulcer, products available, and NUTRITION AND FLUIDS agency protocol. - Clients should be assisted to take in at least - Clean and dress the ulcer using surgical asepsis. 2,500 mL of fluids a day unless conditions contraindicate Never use alcohol or hydrogen peroxide because this amount. Vitamins or minerals enhance wound healing, they are cytotoxic to tissue beds adequate amounts are extremely important. - If the pressure ulcer is infected, obtain a sample of the drainage for culture and sensitivity to antibiotic agents - Teach the client to move frequently, even if only slightly, to relieve pressure sdyr 😊 5 NCM COMMUNITY HEALTH NURSING (INDIVIDUAL AND FAMILY AS CLIENTS) RLE 104 08-15-24 DISCUSSED BY: MS. VASELIE BATUCAN - Provide range of motion (ROM) exercises and DRESSING WOUNDS mobility as the client’s condition permits. Dressings are applied for the following purposes: - To protect the wound from mechanical injury TREATING PRESSURE ULCERS - To protect the wound from microbial RYB COLOR CODE contamination - This concept is based on the color of an open - To provide or maintain moist wound healing wound: red, yellow, or black (RYB) rather than the - To provide thermal insulation depth or size of the wound. On this scheme, the - To absorb drainage or debride a wound or both goals of wound care are to protect (cover) red, - To prevent hemorrhage (when applied as a (cleanse) yellow, and (debride) black. pressure dressing or with elastic bandages) - To splint or immobilize the wound site and RED (cover) thereby facilitate healing and prevent injury - Wounds that are red are usually in the late regeneration phase of tissue repair (i.e. TYPES OF DRESSING developing granulation tissue). They need to be The type of dressing usually depends on: protected to avoid disturbance to regenerating a. The location, size, and type of the wound tissue. b. The amount of exudate c. Whether the wound requires debridement or is A nurse protects red wounds by: infected - Gentle cleansing (i.e., use of noncytotoxic wound d. Such considerations as frequency of dressing cleanser applied without pressure): change, ease or difficulty of dressing application - Protecting peri-wound skin with alcohol-free or cost barrier film: - Filling dead space with hydrogel or alginate TYPES OF DRESSING: - Covering with an appropriate dressing such as TRANSPARENT DRESSING transparent film, hydrocolloid dressing, or a clear - Applied to wounds including ulcerated or burned absorbent acrylic dressing skin areas - Changing the dressing as infrequently as possible HYDROCOLLOID DRESSING - They are frequently used for pressure ulcers YELLOW WOUNDS (cleanse) - Characterized primarily by liquid to semiliquid SECURE DRESSING “slough” that is often accompanied by purulent - The nurse tapes the dressing over the wound, drainage or previous infection. ensuring that the dressing covers the entire wound and does not become dislodged BLACK WOUNDS (debridement) - Covered with thick necrotic tissue, or eschar. MONTGOMERY STRAPS Requires debridement (removal of necrotic - (tie tapes) are used for wounds requiring material) frequent dressing changes. These straps prevent skin irritation and discomfort caused by 4 types of debridement: removing the adhesive each time the dressing is 1. SHARP DEBRIDEMENT changed - A scalpel or scissors is used to separate and remove dead tissue The correct type of tape must be selected for the purpose. 2. MECHANICAL DEBRIDEMENT The nurse follows these steps: - Is accomplished though scrubbing - Place the tape so that the dressing cannot be force or damp-to-damp dressings folded back to expose the wound. Place strips at 3. CHEMICAL DEBRIDEMENT the ends of the dressing, and space tapes evenly - Collagenase enzyme agents such as at the middle papain- urea are currently most recommended for this use - Ensure that the tape is long enough and wide 4. AUTOLYTIC DEBRIDEMENT enough to adhere several inches of the skin on - Dressings such as hydrocolloid and each side of the dressing, but not too long or wide clear absorbent acrylic dressings trap that the tape loosens with activity. the wound drainage against eschar sdyr 😊 6 NCM COMMUNITY HEALTH NURSING (INDIVIDUAL AND FAMILY AS CLIENTS) RLE 104 08-15-24 DISCUSSED BY: MS. VASELIE BATUCAN - Place the tape in the opposite direction form the contaminating debris and reduces body action, for example, across a body joint or bacterial colonization crease, not lengthwise. - Avoid drying a wound after cleaning it CLEANING WOUNDS - Rationale: this helps retain wound - Follow standard precautions for personal moisture protection. Wear gloves, gown, goggles, and mask as indicated - Hold cleaning sponges with forceps or with a sterile gloved hand - Use solutions such as isotonic saline or wound cleansers to clean or irrigate wounds. If - Clean from the wound in an outward direction to antimicrobial solutions are used, make sure they avoid transferring organisms from the are well diluted surrounding skin into the wound - Microwave healing of liquids to be used on the - Consider not cleaning the wound at all if it wound is not recommended. When possible, appears to be clean warm the solution to body temperature before use. PROCEDUE: WOUND CARE - Rationale: this prevents lowering the 1. Introduce self and identify the patient wound temperature which slows the 2. Inform the patient the purpose of the procedure healing process. Microwave healing and the benefits of the procedure could cause the solution to become too 3. Get the consent of the patient hot. 4. Perform hand hygiene 5. Gather the materials for wound care - If a wound is grossly contaminated by foreign 6. Provide privacy material, bacteria, slough, or necrotic tissue, 7. Position the patient in a comfortable position clean the wound at every dressing change exposing only the area to be treated - Rationale: foreign bodies and 8. Wear clean gloves devitalized tissue act as a focus for 9. Remove adhesives and dispose soiled dressing infection and can delay healing on a cuffed plastic bag within your reach 10. Assess the wounds for appearance, location, type - If a wound is clean, has little exudate, and reveals size odor, and amount of exudates healthy granulation tissue, avoid repeated 11. Wash the wound and dry the skin around the cleaning. wound - Rationale: unnecessary cleaning can 12. Remove clean gloves delay wound healing by traumatizing 13. Prepare materials (cotton balls, gauze, sterile newly produced, delicate tissues, gloves and adhesives) use picking forceps reducing the surface temperature of the 14. Don sterile gloves wound, and removing exudate, which 15. Clean the wounds using your gloved hands. itself may have bactericidal properties Apply betadine using appropriate stokes and discard each swab - Use gauze squares or nonwoven swabs that do a. Circular stroke not shed fibers. Avoid using cotton balls and other b. Top to bottom stroke products that shed fibers onto the wound surface c. Inward to outward stroke - Rationale: the fibers become 16. Dry the skin around the wound, not on the wound embedded in the granulation tissue and 17. Apply dressing, over the wound can act as foci for infection. They may 18. Secure the dressing with tapes and adhesives, also stimulate “foreign body” reactions, long and wide enough to support the dressing prolonging the inflammatory phase of 19. Dispose all the materials used, then remove the healing and delaying the healing gloves and dispose them process 20. Perform hand hygiene 21. Document the procedure and assessment - Clean the superficial noninfected wounds by findings irrigating them with normal saline. SAMPLE DOCUMENTATION: - Rationale: the hydraulic pressure of an 6/5/15 15:30 Midline abdominal wound around 7cm with irrigating stream of fluid dislodges intact sutures except for center 3cm, open area with sdyr 😊 7 NCM COMMUNITY HEALTH NURSING (INDIVIDUAL AND FAMILY AS CLIENTS) RLE 104 08-15-24 DISCUSSED BY: MS. VASELIE BATUCAN moderate amt. thin serous drainage. Irrigated with NS until clear. Redressed using sterile technique N. Jamaghani, RN sdyr 😊 8