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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
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