1. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 52: Patient Management: Integumentary System

2. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Wounds Definition of a wound Classified according to time patient has had wound –Acute wound –Chronic wound Classified according to depth of wound –Partial-thickness wounds –Full-thickness wounds

3. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Pressure Ulcer Definition Causes/high-risk patients –Immobile –Decreased circulation –Incontinent –Malnourished Staging of pressure ulcers

4. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question A patient has nonblanchable erythema of the coccyx. What stage pressure ulcer is this? A. Stage I B. Stage II C. Stage III D. Stage IV

5. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. Stage I Rationale: Nonblanchable erythema is consistent with a stage I pressure ulcer. All others are much deeper.

6. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Comparison of Leg Ulcers LocationWound margins ColorTreatment Venous stasis ulcers Medial aspect of lower leg Irregular; shallow craters Ruddy; hemosiderin staining Unna boot; multiple wrap dressing. Elevate above heart. Arterial ulcers Distal leg; medial malleoli and dorsal aspect of toes, foot Round, smooth; punched-out appearance Pale and cool to touch Occlusive dressing; dependent leg position increases flow. Surgery for revascularization. Diabetic foot ulcers Plantar aspect of foot, heels and metatarsals Nothing significant May be infected with exudate Moist environment. Débridement needed. Special shoes.

7. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins The Healing Process: Stages of Wound Healing See Figure 52-1.

8. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question A wound is red, with a shiny, beefy appearance; when touched, it bleeds easily. This wound is in what stage of healing? A. Injury B. Inflammatory C. Proliferative D. Maturational

9. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Proliferative Rationale: In the proliferative phase, the wound is growing new blood vessels; this accounts for the bleeding. New cells are being produced, giving the wound a red, beefy appearance. This wound is beyond the injury or initial phase, and there is no edema or exudate, so it cannot be the inflammatory phase. Scar tissue marks the maturational phase, and there is no information to indicate this.

10. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Methods of Wound Healing See Figure 52-2.

11. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Care of the Patient With a Wound ASSESSMENT Exact anatomical location –Photograph Sizing the wound –Length –Width –Depth –Undermining and tunneling ASSESSMENT Tissue type –Necrotic tissue –Slough –Granulation tissue Drainage Wound margins Drains or tubes Dressings Pain

12. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Solutions That Are Tissue Toxins H2O2 Povidone-iodine Acetic acid Sodium hypochlorite (Dakin’s solution)

13. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Wound VAC Systems

14. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Wound Drainage Types of drains –Penrose –Jackson-Pratt –Hemovac –Chest tubes Wound cleansers

15. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question A nurse is to cleanse a wound around a chest tube. The nurse could use all of the following cleansers to do this without destroying epithelial cells EXCEPT: A. Normal saline solution (NSS) B. Betadine (povidone-iodine) C. Bacitracin D. Neosporin

16. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. Betadine (povidone-iodine) Rationale: Betadine contains iodine, which destroys epithelial tissue. Normal saline solution (NSS) is the same tonicity as tissue and blood, so it is an excellent medium for cleansing a wound. Bacitracin and Neosporin are over-the-counter broad-spectrum antibiotics and can help with the healing process.

17. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Wound Dressings Wet-to-dry –No longer indicated unless changed q4h Calcium alginates Foam dressings Hydrocolloids Hydrogels Absorptive wound dressings Silver (Ag) dressings Bilayered dressings

18. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Culturing a Wound Done if there are signs/symptoms of an infection Cleansed and irrigated with NSS Necrotic tissue isn’t cultured 10 points of contact Zigzag pattern from 12 o’clock to 6 o’clock Over 100,000 organisms/mL = positive culture

19. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Care to Prevent Pressure Keep wound off the bed Turning and repositioning Specialty beds

20. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Pharmacological Management MEDICATIONS TO RELIEVE PAIN Premedication prior to dressing changes, cultures, and any painful procedures PCA Epidurals MEDICATIONS FOR THE WOUND Growth hormones Steroid creams Silver dressings

21. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Nutrition Nutritional assessment within first 48 hours Need all nutritional components: proteins, fats, carbohydrates, minerals, and vitamins Caloric intake increases to 35 to 40 kcal/kg/day Protein requirements increase to 1.5 to 2 g/kg/day Monitor serum albumin, total protein, and electrolytes to determine outcomes Daily weights, I & 0, and hydration status ongoing assessments