Nursing Care for Clients with Wounds Chapter 48 PDF

10/4/2023 Nursing Care for Clients with Wounds Chapter 48 Nursing Fundamentals- NURS B...

10/4/2023 Nursing Care for Clients with Wounds Chapter 48 Nursing Fundamentals- NURS B40 1 Scientific Knowledge Base Skin ◦ Epidermis ◦ Top layer of skin ◦ Dermis ◦ Inner layer of skin ◦ Collagen ◦ Dermal–epidermal junction ◦ Separates dermis and epidermis 2 2 Severity of Injury ◦Superficial ◦Penetrating ◦Perforating Cleanliness ◦Wound Classifications 1- 4 3 3 1  10/4/2023 Wound descriptors Descriptive Qualities ◦Laceration ◦Incision ◦Abrasion ◦Contusion ◦Pressure wounds 4 4 Scientific Knowledge Base Pressure injuries ◦ Pressure ulcer, decubitus ulcer, or bed sore Pathogenesis ◦ Pressure intensity ◦ Tissue ischemia ◦ Blanching ◦ Pressure duration ◦ Tissue tolerance 5 5 Scientific Knowledge Base (3 of 9) Risk factors for pressure ulcer development ◦ Impaired sensory perception ◦ Impaired mobility ◦ Alteration in LOC ◦ Shear ◦ Friction ◦ Moisture 6 6 2  10/4/2023 Scientific Knowledge Base (4 of 9) Classification of pressure injuries ◦ Stage 1: Non-blanchable erythema of intact skin ◦ Stage 2: Partial-thickness skin loss with exposed dermis ◦ Stage 3: Full-thickness skin loss ◦ Stage 4: Full-thickness skin and tissue loss ◦ Unstageable pressure injury: Full-thickness skin and tissue loss obscured by slough or eschar ◦ Deep-tissue pressure injury: Localized area of non- blanchable dark discoloration, or epidermal separation with dark wound bed or blood-filled blister 7 7 Pressure Injury staging 8 8 Wound Classifications Wounds Status of skin integrity ◦ Open Wound ◦ Closed Wound Cause ◦ Intentional ◦ Unintentional 9 9 3  10/4/2023 Scientific Knowledge Base Medical device-related pressure injures Table 48.1 pg 1324 Medical adhesive-related skin injury Wound classifications: onset and duration of healing Table 48.2 pg 1325 ◦ Process of wound healing (next slide) ◦ Wound repair ◦ Partial-thickness wound repair ◦ Full-thickness wound repair 10 10 Process of wound healing Primary Intention Secondary Intention Tertiary intention/ Delayed Closure 11 11 Wound Classified By Color Assessment pg 1326 12 12 4  10/4/2023 Full-Thickness wound repair Hemostasis: minimize blood loss Inflammatory phase Proliferative and new tissue formation phase Remodeling and maturation 13 13 Complications of wound healing ◦Hemorrhage ◦Infection ◦Types of wound drainage Table 48.3 p 1327 ◦Dehiscence ◦Evisceration 14 14 Nursing Knowledge Base Prediction and prevention of pressure injuries ◦ Risk assessment ◦ Braden Scale the most widely used tool, see Table 48.5 page1329 ◦ Economic consequences of pressure injuries Factors influencing pressure injury formation and wound healing ◦ Nutrition: Table 48.6 p 1330 ◦ Tissue perfusion ◦ Infection ◦ Age ◦ Psychosocial impact of wounds 15 15 5  10/4/2023 Nursing Process Assessment ◦Environment: what in the environment may have contributed ◦Skin: minimum of once per shift 16 16 Nursing Process 17 17 Assessment ◦Wounds and pressure injuries ◦Predictive measures: assess risk ◦Mobility ◦Nutritional status: screening within 24 hours, weight, oral health ◦Body fluids: urine, bile, stool, purulent drainage (moderate risk). Gastric and pancreatic drainage (highest risk for breakdown) ◦Pain: decrease pain increased mobility 18 18 6  10/4/2023 Assessment ◦Surgical and traumatic wounds ◦ Emergency setting ◦ Stable setting ◦ Wound appearance ◦ Character of wound drainage: (next slide) ◦ Palpation of wound ◦ Drains ◦ Wound closures ◦ Wound cultures ◦Psychosocial 19 19 Characteristics of Drainage ◦note amt, color, odor and consistency ◦Serous ◦Sanguineous ◦Serosanguineous ◦Purulent 20 20 Drains ◦Penrose Fig 48.10 ◦Evacuator units ◦Jackson Pratt drains Fig 48.11 ◦Hemovac drains 21 21 7  10/4/2023 Wound Closures Staples Sutures Wound adhesives 22 22 Nursing Diagnosis/Pt Problems Analysis and nursing diagnosis ◦ Examples ◦ Risk for Infection ◦ Acute or Chronic Pain ◦ Impaired Mobility ◦ Impaired Peripheral Tissue Perfusion 23 23 Implementation ◦ Nutrition ◦ Prevention of pressure injuries ◦ Topical skin care and incontinence management ◦ Positioning ◦ Support surfaces (therapeutic beds and mattresses) Table 48.9 p1343-44 24 24 8  10/4/2023 Implementation Implementation: acute care ◦First aid for wounds ◦Hemostasis ◦Cleaning ◦Management of pressure injuries 25 25 Implementation Implementation: acute care ◦Wound management ◦Debridement ◦Protection ◦Nutritional status 26 26 Implementation ◦ Dressings ◦ Purposes of dressings ◦ Types of dressings ◦ Changing dressings ◦ Packing a wound ◦ Negative-pressure wound therapy ◦ Securing dressings 27 27 9  10/4/2023 Cleaning a Wound ◦ Comfort measures ◦ Cleaning skin and drain sites ◦ Basic skin cleaning: least contaminated first ◦ (pg 1352) ◦ Irrigation ◦ Skin closures: ◦ Binders ◦ Slings ◦ Roll bandage application 28 28 Heat and Cold Therapy Review handout in syllabus r/t heat and cold therapies In addition- read pgs 1354-1358 See Tables 48.11 and 48.12 Know what happens physiologically with each type of therapy and know specific examples of when the therapies are used effectively. 29 29 Safety Guidelines for Nursing Skills Follow proper aseptic technique. Routinely assess for risks of pressure injuries. Inspect skin daily. Use approaches to minimize friction and shear. History of previous skin damage and chronic diseases, especially vascular disease and diabetes, increase a patient’s risk for pressure injury development and impede wound healing. 30 30 10