1. Chapter 33 Wound Care Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

2.  A wound is a break in the skin or mucous membrane.  Common causes are: Surgery Surgery Trauma Trauma Unrelieved pressure or friction Unrelieved pressure or friction Decreased blood flow through the arteries or veins Decreased blood flow through the arteries or veins Nerve damage Nerve damage  Infection is a major threat.  Wound care involves preventing: Infection and further injury to the wound and nearby tissues Infection and further injury to the wound and nearby tissues Blood loss and pain Blood loss and pain Slide 2 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Wound Care

3. Skin Tears  A skin tear is a break or rip in the outer layers of the skin.  The epidermis (top skin layer) separates from the underlying tissues.  The skin is “peeled back.”  The hands, arms, and lower legs are common sites for skin tears. Slide 3 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

4. Skin Tears (cont’d)  Skin tears are caused by:  Friction, 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  Removing tape or adhesives  Bathing, dressing, and other tasks  Pulling buttons and zippers across fragile skin  Jewelry—yours or the person’s  Long or jagged fingernails (yours or the person’s) and long or jagged toenails Slide 4 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

5.  Persons at risk for skin tears:  Need help 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 5 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Skin Tears (cont’d)

6. Circulatory Ulcers  Circulatory ulcers (vascular ulcers) are open sores on the lower legs or feet.  They are caused by decreased blood flow through the arteries or veins.  Persons with diseases affecting the blood vessels are at risk.  These wounds are painful and hard to heal.  You must help prevent skin breakdown on the legs and feet. Slide 6 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

7. Circulatory Ulcers (cont’d)  Venous ulcers (stasis ulcers) are open sores on lower legs or feet caused by poor blood flow.  These ulcers can develop when valves in the legs do not close well. The veins do not pump blood back to the heart in a normal way. The veins do not pump blood back to the heart in a normal way. Blood and fluid collect in the legs and feet. Blood and fluid collect in the legs and feet. The heels and inner aspect of the ankles are common sites for venous ulcers. The heels and inner aspect of the ankles are common sites for venous ulcers. They can occur from skin injury. They can occur from skin injury. They can occur without trauma. They can occur without trauma. Venous ulcers are painful and walking is difficult. Venous ulcers are painful and walking is difficult. Infection is a risk. Infection is a risk. Slide 7 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

8.  Risk factors for venous ulcers include: History of blood clots History of blood clots History of varicose veins History of varicose veins Decreased mobility Decreased mobility Obesity Obesity Leg or foot surgery Leg or foot surgery Advanced age Advanced age Surgery on the bones and joints Surgery on the bones and joints Phlebitis (inflammation of a vein) Phlebitis (inflammation of a vein) Slide 8 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Circulatory Ulcers (cont’d)

9.  To prevent venous ulcers: Follow the care plan to prevent skin breakdown. Follow the care plan to prevent skin breakdown. Prevent injury. Prevent injury. Move and transfer the person carefully and gently. Move and transfer the person carefully and gently.  To treat venous ulcers: Persons at risk need professional foot care. Persons at risk need professional foot care. The doctor may order drugs for infection and to decrease swelling. The doctor may order drugs for infection and to decrease swelling. Medicated bandages and other wound care products are often ordered. Medicated bandages and other wound care products are often ordered. Devices used for pressure ulcers are often ordered. Devices used for pressure ulcers are often ordered. The doctor may order elastic stockings or elastic bandages. The doctor may order elastic stockings or elastic bandages. Slide 9 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Circulatory Ulcers (cont’d)

10.  Arterial ulcers are open wounds on the lower legs or feet caused by poor arterial blood flow.  They are found between the toes, on top of the toes, and on the outer side of the ankle.  They are caused by diseases or injuries that decrease arterial blood flow to the legs and feet. High blood pressure High blood pressure Diabetes Diabetes Narrowed arteries from aging Narrowed arteries from aging Smoking is a risk factor. Smoking is a risk factor.  The doctor treats the disease causing the ulcer. Drugs, wound care, and a walking and exercise program are ordered. Drugs, wound care, and a walking and exercise program are ordered.  Professional foot care is important. Slide 10 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Circulatory Ulcers (cont’d)

11.  Diabetic foot ulcers are open wounds on the feet caused by complications from diabetes.  Some diabetics have nerve and blood vessel damage. Both problems can lead to diabetic foot ulcers. Both problems can lead to diabetic foot ulcers. Infection and gangrene are risks. Infection and gangrene are risks. The affected part may need to be amputated to prevent the spread of gangrene. The affected part may need to be amputated to prevent the spread of gangrene.  You need to: Check the person’s feet every day. Check the person’s feet every day. Report any signs of a foot problem to the nurse at once. Report any signs of a foot problem to the nurse at once. Follow the care plan. Follow the care plan. Slide 11 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Circulatory Ulcers (cont’d)

12. Wound Healing  The healing process has three phases.  Inflammatory phase (3 days) Bleeding stops. Bleeding stops. A scab forms. A scab forms.  Proliferative phase (day 3 to day 21) Cells multiply to repair the wound. Cells multiply to repair the wound.  Maturation phase (day 21 to 2 years) The scar gains strength. The scar gains strength. Slide 12 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

13. Wound Healing (cont’d)  Healing occurs in three ways.  First intention (primary intention, primary closure) The wound is closed. The wound is closed.  Second intention (secondary intention) Wounds are cleaned and dead tissue removed. Wounds are cleaned and dead tissue removed. Wound edges are not brought together. Wound edges are not brought together. Infection is a great risk. Infection is a great risk.  Third intention (delayed intention, tertiary intention) The wound is left open and closed later. The wound is left open and closed later. Infection and poor circulation are common reasons. Infection and poor circulation are common reasons. Slide 13 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

14.  Many factors affect healing and the risk for complications.  Wound type  The person’s age, health, nutrition, and life-style  Circulation  Certain drugs  Immune system changes  Persons taking antibiotics Specific antibiotics kill specific pathogens. In doing so, other pathogens may grow and multiply. Specific antibiotics kill specific pathogens. In doing so, other pathogens may grow and multiply. Slide 14 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Wound Healing (cont’d)

15.  Complications include:  Hemorrhage and shock You cannot see internal hemorrhage. Shock, vomiting blood, coughing up blood, and loss of consciousness signal internal hemorrhage. You cannot see internal hemorrhage. Shock, vomiting blood, coughing up blood, and loss of consciousness signal internal hemorrhage. Common signs of external hemorrhage are bloody drainage and dressings soaked with blood. Common signs of external hemorrhage are bloody drainage and dressings soaked with blood. Hemorrhage and shock are emergencies. Alert the nurse at once. Hemorrhage and shock are emergencies. Alert the nurse at once.  Infection  Dehiscence and evisceration are surgical emergencies. Dehiscence is the separation of wound layers. Dehiscence is the separation of wound layers. Evisceration is the separation of the wound along with the protrusion of abdominal organs. Evisceration is the separation of the wound along with the protrusion of abdominal organs. The person often describes the sensation of the wound “popping open.” The person often describes the sensation of the wound “popping open.” Slide 15 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Wound Healing (cont’d)

16.  Wound appearance  Doctors and nurses observe the wound and its drainage.  You need to make certain observations when assisting with wound care.  Report and record your observations according to agency policy.  Wound drainage  Amount and type of drainage depend on: Wound size and site Wound size and site Bleeding and infection Bleeding and infection Slide 16 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Wound Healing (cont’d)

17.  Wound drainage is observed and measured.  Serous drainage—clear, watery fluid  Sanguineous drainage—bloody drainage  Serosanguineous drainage—thin, watery drainage that is blood-tinged  Purulent drainage—thick green, yellow, or brown Slide 17 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Wound Healing (cont’d)

18.  Drainage must leave the wound for healing.  When large amounts of drainage are expected, the doctor inserts a drain.  A Penrose drain is a rubber tube that drains onto a dressing. It is an open drain. It is an open drain. Microbes can enter the drain and wound. Microbes can enter the drain and wound.  Closed drainage systems prevent microbes from entering the wound. A drain is attached to suction. A drain is attached to suction. Slide 18 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Wound Healing (cont’d)

19.  Drainage is measured in three ways.  Weigh dressings before applying them. The weight of each new dressing is noted. The weight of each new dressing is noted. Dressings are weighed after removal. Dressings are weighed after removal. Dry dressing weight is subtracted from the wet dressing weight. Dry dressing weight is subtracted from the wet dressing weight.  Note the number and size of dressings with drainage. The amount and kind of drainage on each dressing is noted. The amount and kind of drainage on each dressing is noted.  Measure the amount of drainage in the collection container if closed drainage is used. Slide 19 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Wound Healing (cont’d)

20. 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 20 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

21. Dressings (cont’d)  Dressing type and size depend on many factors.  The type of wound  Wound size and site  Amount of drainage  Infection  The dressing’s function  The frequency of dressing changes  The doctor and nurse choose the dressing for each wound. Slide 21 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

22.  Dressings are described by the material used and how applied.  The following are common: Gauze—absorbs drainage and moisture Gauze—absorbs drainage and moisture Non-adherent gauze—gauze dressing with non-stick surface Non-adherent gauze—gauze dressing with non-stick surface Transparent adhesive film—allows wound observation Transparent adhesive film—allows wound observation  Some dressings contain special agents to promote wound healing.  Dressings are wet or dry. Dry dressing Dry dressing Wet-to-damp dressing Wet-to-damp dressing Wet-to-wet dressing Wet-to-wet dressing Slide 22 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Dressings (cont’d)

23.  Dressings must be secured over wounds or 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. Binders hold dressings in place. Adhesive tape sticks well to the skin. Adhesive tape sticks well to the skin. Paper, plastic, and cloth tapes usually do not cause allergic reactions. Paper, plastic, and cloth tapes usually do not cause allergic reactions. Elastic tape allows movement of the body part. Elastic tape allows movement of the body part. Slide 23 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Dressings (cont’d)

24. Montgomery ties are used for large dressings and frequent dressing changes. Montgomery ties are used for large dressings and frequent dressing changes.  A wound may need 2 or 3 Montgomery ties on each side.  They have adhesive strips and cloth ties.  When in place, the strips are placed on both sides of the dressing and the ties are secured over the dressing.  They protect the skin from frequent tape application and removal.  You may assist the nurse with dressing changes.  Some agencies let you apply simple, dry, non-sterile dressings to simple wounds. Slide 24 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Dressings (cont’d)

25. Binders and Compression Garments  Binders are applied to the abdomen, chest, or perineal areas.  Binders promote healing by:  Supporting wounds  Holding dressings in place  Preventing or reducing swelling  Promoting comfort  Preventing injury Slide 25 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

26. Binders and Compression Garments (cont’d)  Common binders include:  Abdominal binder—provides abdominal support and holds dressings in place  Breast binder—supports the breasts after surgery  Compression garments are commonly worn after plastic surgery. They help:  Reduce swelling  Prevent fluid build-up at the surgical site  Hold skin against the body  Achieve the desired shape Slide 26 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

27. Heat and Cold Applications  Heat and cold applications  Promote healing  Promote comfort  Reduce tissue swelling Slide 27 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

28.  The wound causes pain and discomfort.  Allow pain drugs to take effect before giving care.  Good nutrition is needed for healing.  Pain and discomfort and also odors from wound drainage can affect appetite.  Infection is always a threat.  Delayed healing and infection are risks for persons who:  Are older or obese  Have poor nutrition  Have poor circulation or diabetes Slide 28 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Meeting Basic Needs

29.  Many factors affect safety and security needs.  The person fears scarring, disfigurement, delayed healing, and infection.  Medical bills are other concerns.  Victims of violence have many other concerns.  Future attacks, finding and convicting the attacker, and fear for family members are common concerns.  Whatever the wound site or size, it affects function and body image.  Love and belonging and self-esteem needs are affected.  Adjustment may be hard and rehabilitation necessary. Slide 29 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Meeting Basic Needs (cont’d)