Chapter 28 Wound Care

Terms: Wound Abrasion Contusion Incision Laceration Penetrating wound Puncture wound Skin Tear

Types of wounds: Intentional Open Closed Clean Clean-contaminated Infected/dirty Chronic Partial thickness Full thickness

Pressure ulcers: Also known as decubitus ulcers, bedsores, pressure sores Causes: pressure, friction and shearing

Persons at risk: Confined to bed or chair Need some or total help to move Loss of B/B control Poor nutrition and fluid balance Altered mental awareness Problems with sensing pain/pressure Obese or very thin Older Circulatory problems

Sites: Usually occur over a bony spot Called pressure points In obese, can occur where there is skin to skin contact In persons who are bedridden, sores can develop on the ears epidermal stripping

Stages of pressure ulcers: Stage I

Stage II

Stage III

Stage IV

Surgical Wounds

Surgical Drains

Circulatory Ulcers: Venous

Circulatory Ulcers: Arterial

Prevention of Circulatory Ulcers: Do not sit with legs crossed Do not dress in tight clothes Keep feet clean and dry, dry well between toes Do not scrub or rub skin during bath Linens dry and wrinkle free Avoid injury to legs and feet Make sure shoes fit properly Keep pressure off heels and other bony areas Observe legs and feet, report any skin breaks or color changes

Wound assessment: Location of each wound Size and depth (the nurse does this, you may assist) Appearance: area around it is red/warm to touch/swollen, sutures/staples intact, wound edges closed/separated Drainage present COA Wound photography

Wound Healing: Inflammatory Phase (first 3 days) Proliferative Phase (days 3-21) Maturation Phase (day 21 on) Primary intention Secondary intention Tertiary intention

Complications: Infections Bleeding Evisceration Dehiscence Gangrene

Factors that affect wound healing: Circulatory disease Age Smoking Diabetes Certain medications (blood thinners) Nutrition (especially protein) Type of wound and treatment Antibiotics Weakened immune system

Prevention of skin breakdown and injury: Heel and elbow protectors Bed cradle Turning and positioning Wrinkle free linens Be careful when moving a person Prevent friction and shearing when turning Make sure skin is completely dry when bathing Do good perineal care Apply lotion to dry skin as directed by care plan Do not massage over pressure points Keep heels off the bed Reposition frequently in chair, encourage patient to shift weight Report any skin conditions immediately

Other prevention techniques Special beds/mattresses Special chair cushions Protective barrier cream

Wound Drainage Serous Sanguineous Serosanguineous Purulent

Treatment of wounds: Dressing changes: Dry dressing Wet to dry Packing Duoderm Gauze, non-adherent gauze Tegaderm (transparent) Sterile vs. clean Purposes of dressings

Others: Montgomery ties Breast binder Single and double T binders Abdominal binder Ace wrap TED Hose

Guidelines for applying: Binders: Make sure there is firm even pressure over the area, snug, but not impeding circulation or breathing. Secure any pins to point away from the wound. With Ace wraps, make sure they are snug, but not too tight and they are secured. See pages 575,576 Always wash your hands, change any wraps/binders that become soiled. Anything with blood or body fluids (such as dressings) need to be put in biohazard. CNAS can apply a simple dry dressing (like basic first aide), but the nurse does all complicated dressing changes. You may assist. Be careful when removing tape (like after a blood draw).

Other treatments Ointments Irrigation Debridement Wound vac CNAS can apply NON-MEDICATED protective barrier cream in most facilities. Check with your facility. Do NOT apply any type of medicated ointment or powder!

A final word….. You will see some bad wounds during the course of your career. Some will have a very bad odor, lots of drainage, or be very deep (where you can see bone, muscle, etc). You have to keep your emotions in check. Do not talk about the wound negatively in front of the person. They need to feel accepted and not worry about what people think of their wounds. Also, don’t run down the facility they came from in front of the patient (it is the nursing home’s, surgeon’s or hospital’s fault).