Wound CareChapter 5

Starts on page 100

Advanced Skills for Health Care Providers, Second Edition,

Barbara Acello, 2007 Thompson Delmar

Objectives

1. Spell and define key terms

2. Identify the structures of the skin affected by Stage I, Stage II, Stage III, and Stage IV pressure ulcers

3. List at least seven systemic factors and seven local factors affecting wound healing

Objectives continued

4. Describe how to remove a dressing and observations to make of the underlying wound

5. Demonstrate how to cleanse a linear wound and a circular wound, and explain why you would clean a wound from the most clean to least clean areas

6. Define dressings and describe when each is used

Objectives continued

7. Demonstrate how to apply dressings to wounds with and without drains

8. State the indications for using transparent film dressings, hydrocolloid dressings, and wet-to-dry dressings

9. Demonstrate suture and staple removal

KNOW PROCEDURES:

Procedure 19 Changing a Clean DressingProcedure 21 Applying a Sterile DressingProcedure 23 Changing Wet-to-dry

DressingProcedure 27 Removing SuturesProcedure 28 Removing Staples

PCT 130 Wound Care Word Bank

systemiclocalnecrotic tissuepurulentmacerationgranulation tissuecytotoxic (continued next slide)

Word Bank continued

dressingshypoallergenic tapebandagesMontgomery strapstransparent film dressingshydrocolloid dressingsinterrupted suturescontinuous sutures

Wound Observations to Report to the Nurse

• Redness• Drainage, purulent & / or foul-smelling• Heat• Edema• Increased pain or tenderness• Fever

» continued

Wound Observations to Report to the Nurse, continued.

• Edema of tissue around the wound

• Separation of wound edges

• Trauma or injury

• Maceration

• Bruising

• Frank bleeding

Infection Alert

Nursing is both an art and a science. To change wound dressings, you must be proficient in both aspects. The art involves organizing your time and supplies, protecting the patient’s dignity

(continued)

Infection Alert continued

and privacy, and making the dressing change as painless as possible.

The science involves preventing wound contamination or cross-contamination, thereby reducing the risk of infection.

“Rights” for dressing changes:

• Right patient• Right dressing• Right time• Right treatment product• Right amount / quantity• Right environment• Right technique• Right documentation

THE SKIN

Many different types of wounds:

TraumaAccidental injuriesBurnssurgical incisions, and pressure ulcers

Cross-section of the skin

Layers of the skin

• Epidermis – the outer, protective layer

• Dermis – beneath the epidermis, it contains nerves, hair follicles, sweat glands, and oil glands

• Subcutaneous tissue - this layer is made up of fat and is a covering for muscles, tendons, and bone

Pressure Ulcers

Pressure ulcers are classified by stage, as

determined by the depth and degree of

involvement of the underlying structures

Pressure Ulcers Stage I

Stage I: nonblanchable erythema, note: with

dark skin, look for discoloration, warmth,

edema, induration, or hardness

Pressure Ulcers Stage II

Stage II : partial-thickness skin loss involving

epidermis, dermis, or both; ulcer is a

superficial abrasion, blister,or shallow crater

Pressure Ulcers Stage III

Stage III: full-thickness skin loss involving

damage to or necrosis of subcutaneous

tissue; deep crater

Pressure Ulcers Stage IV

Stage IV: full-thickness skin loss with extensive destruction, tissue necrosis,or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule)

Pressure Ulcer Staging

FACTORS AFFECTING WOUND HEALING: SYSTEMIC & LOCAL

A systemic condition or factor is something that affects the entire body, rather than its single individual parts. Systemic factors that affect wound healing are:

• age• nutritional status• body build• presence or absence of chronic disease• circulatory problems• weakened immune system• radiation therapy

FACTORS AFFECTING WOUND HEALING:SYSTEMIC & LOCAL, CONTINUED

A local or localized condition or factor is one that affects only one system or body part. Many local factors affect wound healing. These include:

• moist wound environment• infection• necrotic tissue (tissue that is dead)• foreign objects in the wound• trauma• edema• pressure on the wound• incontinence and presence of excretions contaminating

the wound