Skin Wound Nursing Process Student PDF

ASSESSMENT EVALUATION IMPLEMENTATION DIAGNOSIS PLANNING APPLYING THE NURSING PROCESS TO WOUND CARE & PRESSURE INJURIES ASSESSMENT • Past medical history • Physical assessment • Wound assessment WOUND ASSESSMENT • Assess old dressing • Type of wound • Location • Nearest anatomical landmark •...

ASSESSMENT EVALUATION IMPLEMENTATION DIAGNOSIS PLANNING APPLYING THE NURSING PROCESS TO WOUND CARE & PRESSURE INJURIES ASSESSMENT • Past medical history • Physical assessment • Wound assessment WOUND ASSESSMENT • Assess old dressing • Type of wound • Location • Nearest anatomical landmark • Size • L x W x D in mm or cm • Note any tunneling • Edges • Approximated or not approximated • Sutures • Staples • Steri-strips • Describe any undermining WOUND MEASUREMENT https://academy.activheal.com/topic/tissue-type/ WOUND ASSESSMENT CONTINUED • Wound bed • Describe tissue present • Necrotic tissue/ eschar • Slough • Granulation tissue • Newly formed epithelial tissue WOUND ASSESSMENT CONTINUED • Drainage • Amount • Type • Serous • Serosanguinous • Sanguinos • Purulent WOUND ASSESSMENT CONTINUED • Types of drains • Open drains • Penrose • Closed drains • Chest tube • Jackson-Pratt • Hemovac • Document drainage from the drains WOUND ASSESSMENT CONTINUED • Periwound • Note color • Palpate • Pain • Signs of infection WOUND DOCUMENTATION PRACTICE Wound assessment • Type: • Location: • Size: • Edges: • Wound bed: • Drainage: • Periwound: • Pain: • Signs of infection: Before After DIAGNOSIS • NANDA Nursing Diagnoses • Risk for impaired skin integrity • Risk for infection • Impaired skin integrity • Disturbed body image • Deficient knowledge related to wound care PLANNING • Outcome identification and planning • Maintain skin integrity • Demonstrate self-care measures to prevent injury or promote wound healing • Demonstrate evidence of wound healing • Remain free from infection at the site of the wound • Demonstrate appropriate wound care measures before discharge IMPLEMENTATION • Nursing interventions • Prevent infection and further injury • Promote wound healing • Promote physical and emotional comfort • Consult a specialist if necessary (physician/WCON) • Perform wound care as ordered PRESSURE INJURY PREVENTION S A V E S K I N Skin assessment Beginning of shift Discharge or transfer Assess risk Braden scale Consider alternative risk factors Vigilant monitoring Around and under medical devices Apply protective barriers when appropriate Alleviate pressure Early mobility Promote physical activity Surface selection Select & apply appropriate surface Waffle mattress/seat cushion, low air loss mattress, etc Keep linen free from wrinkels Keep turning Reposition at least every 2 hours Use appropriate friction reducing sheets Use pillows and/or other devices to alleviate pressure Incontinence management Use absorbent pads & barrier creams to minimize moisture Provide routine pericare Keep skin clean and dry Nutrition and hydration Promote appropriate nutritional intake WOUND CARE NURSING INTERVENTIONS • Prevent infection and further injury • Hand washing • Keep patient’s skin clean and dry • Perineal care as needed • SAVE SKIN • Promote wound healing • Address factors that can contribute to poor healing • Ensure adequate nutrition and hydration • Management of comorbid health conditions • Promote physical and emotional comfort • Consult a specialist if necessary (physician/WCON) • Perform wound care as ordered • Specific and individualized for each patient • Based on provider’s orders • Follow manufacturer’s instructions for specific dressings • Example of step-by-step instructions in PPT WOUND CARE MANAGEMENT • Dressings • Several different types available • Main functions • Absorb drainage • Maintain moisture • Prevent infection • Protect the wound and surrounding skin • Provide physical, psychological, and aesthetic comfort WOUND CARE MANAGEMENT CONTINUED • Table 33-5: Examples of Wound Dressings/Products • Factors to consider when selecting a dressing • Wound condition • Amount of drainage • Need for debridement • Availability within the facility • Ease of use • Cost and insurance coverage WOUND CARE MANAGEMENT CONTINUED • Performing the dressing change • First dressing change is usually done by the surgeon • Prepare for dressing change • Verify and check the order • Use 2 identifiers to ID the patient • Explain the procedure • Provide prescribed analgesic 30-45 minutes prior to dressing change • Gather supplies • Position and provide privacy • Perform thorough hand hygiene and don appropriate PPE WOUND CARE MANAGEMENT CONTINUED • Performing the dressing change continued • Remove the dressing carefully • Push-pull technique • Adhesive remover • Moisten area with saline if it is adhered to wound • Assess dressing before discarding according to facility policy • Cleanse the wound • Follow physician orders • Saline is usually the solution of choice • Commercially approved solutions may be available • Apply new dressing and secure in place TEACHING WOUND CARE AT HOME • Involve the patient and family • Educate patient on risk factors, prevention strategies, and S&S of infection • Emphasize good hand hygiene • Provide simple, easy-to-read instructions • May need referral for home health or outpatient wound care ADDITIONAL TECHNIQUES • Negative pressure wound therapy (NPWT) • Advantages • Stimulate cell proliferation • Improves blood flow and growth of new blood vessels • Removes excess fluid while providing a moist environment • Prevent infection • Contraindications • Active bleeding or exposed vessels • Necrotic tissue • Fistulas • Malignant wounds WOUND VAC Special Considerations for NPWT: • Devices should operate 24 hours a day and should not be stopped longer than 2 hours • If a patient has to take a bath, help disconnect them from their device and protect the dressing so it doesn’t get wet • Dressings are left in place and usually changed every 2 to 3 days • Monitor fluid level in container per orders but at least every shift – included in output calculation ADDITIONAL TECHNIQUES • Hyperbaric oxygen therapy • Pressurized chamber • 100% oxygen • Utilized for hard to heal wounds • Other uses • Carbon monoxide poisoning • Decompression sickness • Severe anemia ADDITIONAL TECHNIQUES Hot and cold therapy • Heat • Dilates the blood vessels and accelerates the inflammatory response to promote healing • Cold • Constricts blood vessels to reduce edema and muscle spasms • Rebound phenomenon • Develops when the maximum time of therapeutic effect in heat and cold applications is exceeded • If application of heat continues more than 30-45 min, congestion occurs and blood vessels react by constricting • Adaptation • Thermoreceptors react strongly after the first few seconds but continue to react more slowly over the next 30 min ADDITIONAL TECHNIQUES • Devices to apply heat therapy • Dry heat • Hot water bags • Electric heating pads • Hot packs • Moist heat • Warm moist compress • Sitz bath • Warm soaks ADDITIONAL TECHNIQUES • Devices to apply cold therapy • Ice bags • Cold packs • Cooling blankets • Cold compress • Special Considerations • Prevent injury from hot or cold therapy • Only use approved devices • Check device to ensure proper functioning • Consider the patient’s ability to feel heat/cold PRACTICE QUESTION Upon review of a postoperative client’s medication list, the nurse recognizes that which medication will delay the healing of the operative wound? A. Corticosteroid B. Antihypertensive C. Potassium supplement D. Laxative PRACTICE QUESTION The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take? A. Allow the wound and intestinal contents to remain open to air B. Pack the wound with gauze pads and apply dry sterile dressings C. Inform the client that this is an expected occurrence and not to worry D. Apply saline solution moistened gauze over the protruding area PRACTICE QUESTION A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? A. Notify the healthcare provider of the pain B. Assess the client's wound and vital signs C. Administer the prescribed analgesic D. Document the pain and vital signs REFERENCES Lynn, P. (2019). Taylor’s clinical nursing skills: A nursing process approach (5th ed.). Philadelphia, PA: Wolters Kluwer Heath. Taylor, C., Lynn, P. & Bartlett, J. (2019). Taylor: Fundamentals of nursing (9th ed.). Philadelphia, PA: Wolters Kluwer. THANK YOU! WHAT QUESTIONS DO YOU HAVE?