Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 35 Wound Care

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.  The skin is the body’s first line of defense.  A wound is a break in the skin or mucous membrane.  A wound is a portal of entry for microbes.  Infection is a major threat.  Wound care involves:  Preventing infection  Preventing further injury to the wound and nearby tissues  You must prevent skin injury and give good skin care to help prevent skin breakdown. Slide 2

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.  Common causes of wounds are:  Surgery  Trauma  Pressure ulcers from unrelieved pressure  Decreased blood flow through the arteries or veins  Nerve damage  Older and disabled persons are at great risk for skin breakdown.  The nurse uses the nursing process to keep the person’s skin healthy. Slide 3

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Types of Wounds  Wounds are described in the following ways:  Intentional wounds and unintentional wounds  Open and closed wounds  Clean wounds  Clean-contaminated wounds  Contaminated wounds  Infected wounds (dirty wound)  Chronic wounds  Partial- and full-thickness wounds Slide 4

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.  Wounds are also described by their causes:  Abrasion  Contusion  Incision  Laceration  Penetrating wound  Puncture wound  Ulcer Slide 5

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Skin Tears  A skin tear is a break or rip in the skin.  The hands, arms, and lower legs are common sites for skin tears.  Causes  Friction and shearing  Pulling or pressure on the skin  Falls or bumping a hand, arm, or leg on any hard surface  Holding the person’s arm or leg too tight  Tell the nurse at once if you cause or find a skin tear. Slide 6

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.  Persons at risk for skin tears:  Need moderate to total help in moving  Have poor nutrition  Have poor hydration  Have altered mental awareness  Are very thin  Careful and safe care helps prevent skin tears and further injury. Slide 7

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Circulatory (Vascular) Ulcers  Open sores on the lower legs or feet  Caused by decreased blood flow  Types  Venous ulcers  Arterial ulcers  Diabetic foot ulcers  Poor circulation can result in:  Pain  Open wounds  Edema  Infection and gangrene Slide 8

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Venous (Stasis) Ulcers  Open sores on the lower legs or feet caused by poor blood flow through the veins  The heels and inner aspect of the ankles are common sites.  Risk factors include:  History of blood clots or varicose veins  Decreased mobility  Obesity  Leg or foot surgery  Advanced age  Surgery on the bones and joints  Phlebitis (inflammation of a vein) Slide 9

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.  Prevention and treatment involve:  Follow the person’s care plan to prevent skin breakdown.  Prevent injury.  Handle, move, and transfer the person carefully and gently.  Persons at risk need professional foot care.  Drugs for infection and to decrease swelling  Medicated bandages and other wound care products  Devices used for pressure ulcers  Elastic stockings or elastic bandages Slide 10

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.  Elastic stockings (antiembolism stockings)  Exert pressure on the veins  Promote venous blood return to the heart  Help prevent venous ulcers and blood clots (thrombi) in leg veins  Thrombi  Can form in deep leg veins  Can break loose and travel in the bloodstream (embolus)  An embolus can lodge in a vein in the lungs (pulmonary embolus)  Elastic bandages  Have the same purpose as elastic stockings  Support and reduce swelling from injuries  Can be used to hold dressing in place Slide 11

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Arterial Ulcers  Open wounds on the lower legs or feet caused by poor arterial blood flow  Found between the toes, on top of the toes, and on the outer side of the ankle  Smoking is a risk factor.  Treatment involves:  Treating the disease causing the ulcer  Drugs and wound care  A walking and exercise program  Professional foot care Slide 12

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Diabetic Foot Ulcers  Open wounds on the foot caused by complications from diabetes  Diabetes can affect the nerves and blood vessels.  You need to:  Check the person’s feet every day.  Report any sign of a foot problem to the nurse at once.  Follow the care plan. Slide 13

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Wound Healing  The healing process has three phases:  Inflammatory phase (3 days)  Proliferative phase (day 3 to day 21)  Maturation phase (day 21 to 2 years)  Healing occurs in three ways:  First intention (primary intention, primary closure)  Second intention (secondary intention)  Third intention (delayed intention, tertiary intention) Slide 14

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.  Many factors affect healing and increase the risk of complications.  The type of wound  The person’s age, general health, nutrition, and lifestyle  Circulation  Drugs  Nutrition  Immune system changes  Complications include:  Infection  Dehiscence: separation of wound layers  Evisceration: dehiscence plus protrusion of abdominal organs Slide 15

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.  Wound appearance  Doctors and nurses observe the wound and its drainage.  You need to make certain observations when assisting with wound care.  Wound drainage is observed and measured.  Serous drainage is a clear, watery fluid.  Sanguineous drainage is bloody drainage.  Serosanguineous drainage is thin, watery drainage that is blood-tinged.  Purulent drainage is thick green, yellow, or brown drainage. Slide 16

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.  Drainage must leave the wound for healing.  When large amounts of drainage are expected, the doctor inserts a drain.  Drainage is measured in three ways:  Noting the number and size of dressings with drainage  Weighing dressings before applying them to the wound Dressings are then weighed after removal. Dressings are then weighed after removal.  Measuring the amount of drainage in the collection container if closed drainage is used Slide 17

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Dressings  Wound dressings have many functions.  Protect wounds from injury and microbes.  Absorb drainage.  Remove dead tissue.  Promote comfort.  Cover unsightly wounds.  Provide a moist environment for wound healing.  Apply pressure (pressure dressings) to help control bleeding. Slide 18

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.  The following types of dressings are common:  Gauze  Non-adherent gauze  Transparent adhesive film  Dressings that contain special agents to promote wound healing  Dressings are wet or dry.  Dry dressing  Wet-to-dry dressing  Wet-to-wet dressing Slide 19

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.  Securing dressings  Microbes can enter the wound and drainage can escape if the dressing is dislodged.  Tape and Montgomery ties are used to secure dressings.  Binders hold dressings in place.  The nurse may ask you to assist with dressing changes.  Some centers let you apply simple, dry, non-sterile dressings to simple wounds. Slide 20

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Binders  Binders promote healing by:  Supporting wounds  Holding dressings in place  Preventing or reducing swelling  Promoting comfort  Preventing injury  An abdominal binder provides abdominal support and holds dressings in place.  A breast binder supports the breasts after surgery.  T-binders secure dressings in place after rectal and perineal surgeries. Slide 21

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Heat and Cold Applications  Promote healing and comfort  Reduce tissue swelling  Heat and cold have opposite effects on body function.  Doctors order heat and cold applications. Slide 22

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Heat Applications  Heat:  Relieves pain  Relaxes muscles  Promotes healing  Reduces tissue swelling  Decreases joint stiffness  When heat is applied to the skin:  Blood vessels in the area dilate.  Blood flow increases.  Tissues have more oxygen and nutrients for healing.  Excess fluid is removed from the area faster.  The skin is red and warm. Slide 23

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.  Complications  High temperature can cause burns.  Report pain, excessive redness, and blisters at once.  When heat is applied too long, blood vessels constrict.  Persons at risk for complications include:  Older and fair-skinned persons  Persons with problems sensing heat and pain (nervous system damage, loss of consciousness, circulatory disorders, confusion, some medications)  Persons with dementia  Persons with metal implants Slide 24

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.  Moist and dry heat applications  With a moist heat application, water is in contact with the skin.  Moist heat has greater and faster effects than dry heat because water conducts heat.  Moist heat applications include a hot compress, a hot soak, a sitz bath, and hot packs.  Some hot packs and the aquathermia pad (Aqua-K, K-Pad) are dry heat applications.  With a dry heat application, water is not in contact with the skin.  A dry application stays at the desired temperature longer.  Dry heat does not penetrate as deeply as moist. Slide 25

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Cold Applications  Are often used to treat sprains and fractures  Reduce pain, prevent swelling, and decrease circulation and bleeding  Cool the body when fever is present  Have the opposite effect of heat  Are useful right after an injury  Have a numbing effect on the skin  This helps reduce or relieve pain in the part.  Complications include pain, burns, blisters, and poor circulation.  When cold is applied for a long time, blood vessels dilate. Slide 26

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.  Persons at risk for complications include:  Older and fair-skinned persons  Persons with sensory impairments  Persons with dementia  Moist cold applications:  Penetrate deeper than dry ones  Are not as cold as dry applications  Include cold compresses and cold packs  Dry cold applications include:  Ice bags, ice collars, and ice gloves  Cold packs can be moist or dry applications. Slide 27

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Cooling and Warming Blanket  Hyperthermia is a body temperature that is much higher than the person’s normal range.  Lowering the person’s body temperature is necessary. Vital signs are checked often to prevent rapid or excess cooling. Vital signs are checked often to prevent rapid or excess cooling.  Hypothermia is a very low body temperature.  A warming blanket is like a cooling blanket except warm settings are used. Vital signs are checked often to prevent rapid or excess warming. Vital signs are checked often to prevent rapid or excess warming. Slide 28

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Meeting Basic Needs  The wound can affect the person’s basic needs.  The wound causes pain and discomfort.  Good nutrition is needed for healing.  Infection is always a threat.  Delayed healing and infection are risks for persons who:  Are older or obese  Have poor nutrition  Have poor circulation and diabetes  Many factors affect safety and security needs.  Whatever the wound site or size, it affects function and body image. Slide 29

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Quality of Life  To promote quality of life:  Follow the person’s care plan.  Be very careful not to injure the skin during care.  Treat the person with dignity and respect.  Try to understand the person’s concern.  Refer questions to the nurse.  Remember the right to personal choice.  Remember to explain procedures to residents.  Protect the right to privacy.  Provide a safe, comfortable setting. Slide 30