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Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 3
Advanced Wound Care Skills
Chapter 3
Advanced Wound Care Skills
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Function of the skinFunction of the skin
• Protect
• Regulate temperature
• Sensation
• Make Vitamins ( vitamin D )
• Excrete waste
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Structure of SkinStructure of Skin
• I. Epidermis
• Outer layer of skin
• Skin pigment
• Glands-oil (sebaceous)
-sweat (sudorriferous)
• Protects from invading germs
• Protect from fluid loss
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Structure con’tStructure con’t
• II. Dermis- Middle layer
• Lymph nodes
• Blood vessels
• Nerves
• III Subcutaneous/hypodermis- Fatty layer
• Provides warmth
• Source of energy
• Padding
•
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Disorders of the skinDisorders of the skin
• Bacterial: acne, boils, impetigo, cellulitis
• Acne- pores blocks
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• Viral: Herpes, shingles, warts, chicken pox
• Autoimmune: psoriasis- silvery white patches
• Eczema-dry, scaly
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Disorders con’tDisorders con’t
• Parasites: Lice, scabies
• Systemic: diabetes, circulation problems
• Allergies: Hives (wheal)
• Trauma: cuts, scraps, bruising
• blister-vesicle scab-crust
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Fungal: ring worm, yeast (athletes feet)
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Treatment for skin disordersTreatment for skin disorders
• Ointments
• Dressing changes
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Ways of Describing WoundsWays of Describing Wounds
• Open wounds: breaks in the skin
• Closed wounds: damage to tissues underneath intact skin
• Intentional wounds: planned surgical or medical interventions
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Ways of Describing Wounds (cont.)Ways of Describing Wounds (cont.)
• Unintentional wounds: the result of accidents
• Acute wounds: expected to heal completely within a few days or weeks
• Chronic wounds: delayed in healing or may never heal completely
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Intentional and Unintentional Wounds Intentional and Unintentional Wounds
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ComplicationsComplications
• Pressure Sores/Decubitus Ulcers
• Stages:
– 1. skin red/pale
– 2. blistered, cracked, peeling
– 3. deep- muscle involvement
– 4. extreme- bone exposed
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Three Common Pressure UlcersThree Common Pressure Ulcers
• Late-stage pressure ulcers
• Venous (stasis) ulcers
• Arterial ulcers
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Circulation UlcersCirculation Ulcers
• Arterial
• - oxygenated blood doesn’t get to LE
• - common in diabetics
• - monitor pedal pulses
• -elevate feet
• Venous
– Deoxygenated blood can’t get back to heart
- Blood pulls
- Feet swell
- Use TED hose or SCD
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To Help Prevent a Pressure Ulcer From FormingTo Help Prevent a Pressure Ulcer From Forming
• Reposition q 2 hours
• look for: red, hot, or painful areas over pressure points
• previously reddened areas that have turned white, pale, or shiny
• Provide good skin care.
• Toilet as needed
• Provide good perineal care.
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To Help Prevent a Pressure Ulcer From Forming (cont)To Help Prevent a Pressure Ulcer From Forming (cont)
• Encourage exercise.
• Use lifts & lift sheets to prevent shearing
• Good nutrition and hydration.
• Use pressure-relieving devices.
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QuestionQuestion
A gunshot wound is a(n):
A. Intentional Wound
B. Closed Wound
C. Chronic Wound
D. Unintentional Wound
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AnswerAnswer
D. Unintentional Wound
Unintentional wounds are the result of an accident. Examples of unintentional wounds are those resulting from falls, motor vehicle crashes, and gun and knife violence.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Phases of Wound HealingPhases of Wound Healing
• Inflammatory phase: Begins immediately; area - hot, red, swollen &painful.
• Proliferative phase: Begins 2–3 days after injury & can last 2–3 weeks; scar tissue replaces the tissue.
• Remodeling phase: Final stage of healing, more collagen is secreted & wound strengthens; can last-6 months.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Three Types of Wound HealingThree Types of Wound Healing
• First-intention wound healing: an open wound is closed surgically w sutures/ staples ASAP
• Second-intention wound healing: a wound is kept clean but left alone to repair itself, wound closes on own
• Third-intention wound healing: the wound is left open for a period of time to make sure no infection occurs, then closed surgically w sutures/ staples
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Factors That Affect Wound HealingFactors That Affect Wound Healing
1. Nutrition and hydration
2. Overall health status
3. Age
4. Wound condition
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
QuestionQuestion
Wound healing increases the body’s need for ___________ and _____________.
A. fat and carbohydrates
B. minerals and water
C. calories and protein
D. vitamins and supplements
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AnswerAnswer
C. calories and protein
The body requires more protein and calories to assist with cell repair and healing.
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Complications of Wound HealingComplications of Wound Healing
1. Infection
2. Hemorrhage
3. Hematoma
4. Dehiscence and evisceration
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InfectionInfection
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The First Sign of Hemorrhage The First Sign of Hemorrhage
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Dehiscence and Evisceration Dehiscence and Evisceration
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QuestionQuestion
Blood collected under the skin is known as:
A. Pus
B. Evisceration
C. Hematoma
D. Hemorrhage
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AnswerAnswer
C. Hematoma
Hematoma is better known as a bruise. Blood collects under the tissue and can interfere with healing.
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Interventions to Support Wound HealingInterventions to Support Wound Healing
1. Sutures and staples
2. Dressings and bandages
3. Drains (open and closed)
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Sutures and StaplesSutures and Staples
• Subcuticular sutures: placed underneath the dermis
• Retention sutures: threaded through a rubber tube over a plastic bridge
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Dressing PurposesDressing Purposes
• Keep wound clean
• Prevent infection
• Maintain a moist environment to assist wound healing
• Absorb wound drainage
• Treat infection
• Apply pressure to the wound (to prevent or control hemorrhage, bruising, or swelling)
• Remove necrotic (dead) tissue
• Protect the wound from further injury
• Protect the patient from becoming upset at the sight of the wound
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Dressing changesDressing changes
• Dr orders tell you:
• type of drsg.
• what to clean with
• how often
• Dr may change 1st surgical drsg.
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Drsg. Change guidelinesDrsg. Change guidelines
• Remove 1 layer @ a time
• Clean –clean to dirty
• Around drain- circular motion-inside to outside
• Down incision- middle-outside-outside
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Reinforcing dressingReinforcing dressing
• When: first 24 hours p OR
• until Dr. orders drsg. change
• Why: may disturb clot or healing
• What: apply new clean drsg. over old
• mark and keep track of new bleeding
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Abdominal Binder Abdominal Binder
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Dressings and BandagesDressings and Bandages
Layers of dressings
• Contact layer
• Secondary layer
Bandages
• Abdominal binder
• Montgomery straps/ties
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Transparent DressingTransparent Dressing
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Types of drsg. changesTypes of drsg. changes
• Dry sterile drsg.
• Wet to dry
• Wound irrigation
• Central line
• Drainage tube
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QuestionQuestion
Tell whether the following statement is true or false.
When applying a dressing, the contact layer is applied directly to the wound.
A. True
B. False
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
AnswerAnswer
A. True
The contact layer is against the wound and generally made of non-stick material or gel.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
DrainsDrains
• Penrose drain
• Closed drainage systems
– Jackson-Pratt drain
– Hemovac drain
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Penrose Drain Penrose Drain
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Closed Drainage Systems Closed Drainage Systems
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Wound CareWound Care
• Proper cleansing – clean to dirty
• Removal of sutures and staples
• Débridement: the removal of necrotic tissue
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Cleaning an Incision SiteCleaning an Incision Site
Report it to the nurse immediately if:
• Edges are gaping-open b/t sutures or staples
• Sutures or staples rip out or are broken
• Excessive swelling along the incision line
• Excessive redness along the incision line
• Incision line hot to the touch
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Cleaning an Incision Site (cont)Cleaning an Incision Site (cont)
• Purulent drainage or pus
Drainage has a foul odor
• Pt. c/o increased pain at wound site 2 to 3 days after the injury or surgery took place
• Fever occurs 24 hours or more after the injury or surgery
• Increased amt. of bloody drainage is seen on the wound dressing or in the wound drainage system
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Different Types of Wound Drainage Different Types of Wound Drainage
• Serous: clear and watery-looking
• Sanguineous: bloody-looking
• Serosanguineous: pink and watery-looking
• Purulent: thick and ranging in color from dark yellow or green to creamy white
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SuturesSutures
• Why?- close wounds
• decrease scars and infection
• Types: 1. absorbable
• absorb in 5-7
• used inside body
• 2. Nonabsorbable-skin
• head-3-5days
• arm, legs, hands- 7-10 days
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Removing Sutures and Staples Removing Sutures and Staples
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StaplesStaples
• Used for big wounds or areas that need strong sutures
• Left in 7-10 days
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Butterflies/steri-stripsButterflies/steri-strips
• Adhesive strips put on wound after removal of sutures/staples
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DocumentationDocumentation
• 10/15/10 2000 8 sutures removed from abd. Incision per Dr. Smith orders. Incision pink, edges well approximated, no drainage noted. Site cleaned with betadine and 4 steri-strips applied. Pt. tolerated without c/O. Notified S. Smith RN of incision. Instructed to allow steri-strips to fall off on own.-------------------------- M/ Fox PCT
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Pin Care Pin Care
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DébridementDébridement
• Sharp (surgical – to cut off)
• Mechanical
• Autolytic
• Enzymatic (chemical)
• Biological
• Vacuum-assisted closure (VAC) therapy
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Vacuum-assisted (VAC) therapy Vacuum-assisted (VAC) therapy