WOUND CARE.pptx

7/26/2019 WOUND CARE.pptx

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WOUND

CARE

JPP


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JPP SKIN INTEGRITY

Intact skin refers to the presence ofnormal skin and skin layers

uninterrupted by wounds. The appearance of the skin and the

skin interity are in!uenced by internalfactors such as enetics" ae" and theunderlyin health of the indi#idual aswell as e$ternal factors such as acti#ity.


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%&YSI'('GY ') T&E SKIN

&ypodermis

Temperature reulation #ia #asodilation"

#asoconstriction" sweatin and shi#erin. *bsorption of some o$yen" carbon

dio$ide" fat soluble #itamins+ *" ," E andK- certain steroid hormones and some

to$ic substance Sensory reception for touch" temperature"

pain" pressure" and stretch.


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,ermis %rotects aainst blood loss.

Synthesis of piments and #itamin , Temperature reulation #ia #asodilation"

#asoconstriction" sweatin and shi#erin.

*bsorption of some o$yen" carbon dio$ide" fatsoluble #itamins+ *" ," E and K- certain steroidhormones and some to$ic substance

Elimination of wastes/ salts" water" and urea

Sensory reception for touch" temperature"pain" pressure" and stretch.


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Epidermis

%rotects aainst/ dehydration" mechanicalin0ury" pathoens" 12 liht" blood loss.

Synthesis of piments and #itamin ,

*bsorption of some o$yen" carbon dio$ide"fat soluble #itamins+ *" ," E and K- certain

steroid hormones and some to$ic substance Elimination of wastes/ salts" water" and urea

Sensory reception for touch" temperature"pain" pressure" and stretch.


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TY%ES ') 3'1N,S

INTENTI'N*(

'ccur durin therapy

E$. 'perations or #enipuncture.

1NINTENTI'N*(

*ccidental traumaE$. )ractured arm in anautomobile collision.


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TY%ES ') 3'1N,S

4('SE,

If the tissues are traumati5ed without a

break in the skin.

'%EN

3hen the skin or mucous membrane

surface is broken.


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TYPE CAUSE DESCRIPTION&CHARACTERISTICS

IN4ISI'N Sharp instrument 'pen wound deep or shallow

4'NT1SI'N 6low from a bluntinstrument

4losed wound skin appearsecchymotic +bruised- because of

damaed blood #essels.

*6R*SI'N Surface scrape" eitherunintentional orintentional

'pen wound in#ol#in the skin

%1N4T1RE %enetration of the skinand often the

underlyin tissues by asharp instrument "either intentional orunintentional

'pen wound

(*4ER*TI'N Tissues torn apart" oftenfrom accidents +e.."

with machinery-

'pen wound edes are often 0aed

%ENETR*TING 3'1N,

%enetration of the skinand the underlyintissues" usuallyunintentional +e.." froma bullet or metal

framents-

'pen wound


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TY%ES ') 3'1N,S

Incision


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TY%ES ') 3'1N,S


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TY%ES ') 3'1N,S


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TY%ES ') 3'1N,S

7wounds can also be described accordin tothe likelihood and deree of woundcontamination.

4(E*N 3'1N,S

4(E*N74'NT*8IN*TE, 3'1N,S

4'NT*8IN*TE, 3'1N,S

,IRTY 'R IN)E4TE, 3'1N,S


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TY%ES ') 3'1N,S

4(E*N 3'1N,S

1ninfected wounds in which minimalin!ammation is encountered

The respiratory" alimentary" enital" andurinary tracts are not entered.

%rimarily closed wounds.


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TY%ES ') 3'1N,S

4(E*N74'NT*8IN*TE, 3'1N,S

Surical wounds in which the

respiratory" alimentary" enital orurinary tract has been entered.

Such wounds show no e#idence of

infection.


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TY%ES ') 3'1N,S

4'NT*8IN*TE, 3'1N,S

Include open" fresh" accidental

wounds and surical woundsin#ol#in a ma0or break in steriletechni9ue or a lare amount of

spillae from the GI tract . Show e#idence of in!ammation.


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TY%ES ') 3'1N,S

,IRTY 'R IN)E4TE, 3'1N,S

Include wounds containin dead

tissue and wounds with e#idenceof a clinical infection" such as apurulent drainae.


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,eree of woundcontamination


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,eree of woundcontamination


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TY%ES ') 3'1N,S

3ounds are also classi:ed by depth +tissuelayers in#ol#ed-

%*RTI*( T&I4KNESS 4on:ned to the skin" that is" the dermis

and epidermis.

&eal by reeneration.

)1(( T&I4KNESS In#ol#in the dermis" epidermis"

subcutaneous" and possibly muscle andbone.

Re9uire connecti#e tissue repair.


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3'1N, &E*(INGREGENER*TI'N

+RENE3*( ') TISS1ES-


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TY%ES ') 3'1N,

&E*(ING; %RI8*RY INTENTI'N &E*(ING %rimary union or :rst intention healin.

'ccurs where the tissue surfaces ha#ebeen appro$imated +closed- and there isminimal or no tissue loss.

4haracteri5ed by the formation of minimal

ranulation tissue and scarrin. E.." closed surical incision" the use of

tissue adhesi#e" a li9uid lue that can beused to seal clean lacerations.


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%RI8*RY INTENTI'N &E*(ING


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TY%ES ') 3'1N, &E*(ING

SE4'N,*RY INTENTI'N &E*(ING

* wound that is e$tensi#e and in#ol#esconsiderable tissue loss" and in which theedes cannot or should not beappro$imated

E.." pressure ulcer

,i


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%&*SES ') 3'1N,&E*(ING

IN)(*88*T'RY %&*SE

%R'(I)ER*TI2E %&*SE

8*T1R*TI'N 'R RE8',E(ING %&*SE


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IN)(*88*T'RY %&*SE

Initiated immediately after in0ury and lasts = to > days.

? ma0or processes occur durin this phase/ hemostasis andphaocytosis.

&emostasis

The cessation of bleedin

Results from #asoconstriction of the larer blood #essels inthe a


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IN)(*88*T'RY %&*SE *lso in#ol#es #ascular and cellular

responses intended to remo#e any foreinsubstances and dead and dyin tissues.

2ascular response

The blood supply to the woundincreases" brinin with it o$yen andnutrients needed in the healin

process. The area appears reddenedand edematous as a result.


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74ellular response

,urin cell miration" leukocytes +speci:cally"neutrophils- mo#e into the interstitial space.

These are replaced about ?@hours after in0ury bymacrophaes" which arise from the blood monocytes.

The macrophaes enulf microoranisms and cellulardebris by a process known as %&*G'4YT'SIS.

The macrophaes also secrete an anioenesis factor+*G)-" which stimulates the formation of epithelialbuds at the end of in0ured blood #essels.

The microcirculatory network that results sustains thehealin process and the wound durin its life.

This in!ammatory response is essential to healin"and measures that impair in!ammation" such assteroid medications" can place the healin process atrisk.


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%R'(I)ER*TI2E %&*SE Second phase in healin" e$tends from day = or @ to about day ?A

post in0ury.

)ibroblasts +connecti#e tissue cells-" which mirate into the woundstartin about ?@hours after in0ury" bein to synthesi5e collaen.;

4apillaries row across the wound" increasin the blood supply.

)ibroblasts mo#e from the bloodstream into the wound" depositin:brin.

*s the capillary network de#elops" the tissue becomes translucentred color +GR*N1(*TI'N TISS1E-.;

3hen the ranulation tissue matures" marinal epithelial cellsmirate to it" proliferatin o#er this connecti#e tissue base to :llthe wound. +E%IT&E(I*(IB*TI'N-

If the wound does not close by epitheliali5ation" the areabecomes co#ered with dried plasma proteins and dead cells.+ES4&*R-.;


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8*T1R*TI'N %&*SE

6eins about day ?A and can e$tend A or? years after the in0ury.

)ibroblast continue to synthesi5e collaen. The collaen :bers reorani5e into a more

orderly structure.;

The wound is remodeled and contracted.;

In some indi#iduals" particularly dark7skinned persons" an abnormal amount ofcollaen is laid down. This can result in ahypertrophic scar +KE('I,-


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KIN,S ') 3'1N, ,R*IN*GE

= 8*C'R TY%ES ') EXUDATE

SER'1S

%1R1(ENT

S*NG1INE'1S

+&E8'RR&*GI4-


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KIN,S ') 3'1N,,R*IN*GE

Serous e$udate

4onsists chie!y of serum

deri#ed from blood and theserous membranes of the body"such as the peritoneum.

(ooks watery and has few cells. E.." the !uid in a blister from aburn


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%urulent e$udate

Thicker than serous e$udate because of thepresence of pus.

%us 7 consist of leukocytes" li9ue:ed deadtissue debris" and dead and li#in bacteria.

S1%%1R*TI'N7 the process of pusformation

%Y'GENI4 6*4TERI*7 bacteria thatproduce pus. ;

2ary in color" some ac9uirin tines of blue"reen" or yellow.;


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Sanuineous +hemorrhaic- e$udate

4onsists of lare amounts of R64.;

E.." open wounds

8IDE, TY%ES ') ED1,*TES *RE')TEN '6SER2E,/

Serosanuineous7 consistin of clear and

blood7tined drainae. e.." surical incisions.; %urosanuineous7 consistin of pus and

blood.

E.." new wound that is infected.


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4'8%(I4*TI'NS ')3'1N, &E*(ING

6(EE,ING

+&E8'RR&*GE- IN)E4TI'N

,E&IS4EN4E +3IT&%'SSI6(E E2IS4ER*TI'N-


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4'8%(I4*TI'NS ')3'1N, &E*(ING

&emorrhae

8assi#e bleedin

8ay be caused by a disloded clot" aslipped stitch" or erosion of a blood #essel.

Internal hemorrhae

8ay be detected by swellin or distention in

the area of the wound and" possibly" bysanuineous drainae from a surical drain.

Hematoma7 a locali5ed collection of bloodunderneath the skin that may appear as areddish blue swellin +6R1ISE-


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4'8%(I4*TI'NS ')3'1N, &E*(ING

&emorrhae

The risk is reatest durin the

:rst @hours after surery.;

Is an emerency case.

Nursin responsibility/ thenurse should apply pressuredressins to the area and

monitor the clientFs #ital


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4'8%(I4*TI'NS ')3'1N, &E*(ING

IN)E4TI'N;

'ccurs when the microoranisms coloni5in the woundmultiply e$cessi#ely or in#ade tissues.;

Infection suested by the presence of a chane in woundcolor" pain" or drainae is con:rmed by performin aculture of the wound.

Se#ere infection

4auses fe#er and ele#ated 364 count.

4lients who are immunosuppressed are susceptible.; * wound can be infected with microoranisms at the time

of in0ury" durin surery" or postoperati#ely.

Surical infection is most likely to become apparent? to AA days postoperati#ely.


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4'8%(I4*TI'NS ')3'1N, &E*(ING

,E&IS4EN4E 3IT& %'SSI6(E E2IS4ER*TI'N ,ehiscence

is the partial or total rupturin of asutured wound.

usually in#ol#es an abdominal wound inwhich the layers below the skin also

separate. E#isceration

7 Is the protrusion of the internal #iscerathrouh an incision.


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4'8%(I4*TI'NS ')3'1N, &E*(ING

,E&IS4EN4E8ore likely to occur @ to days post operati#ely beforee$tensi#e collaen is deposited in the wound.

)actors that heihtens clientFs risk of wound dehiscence/

'besity

%oor nutrition

8ultiple trauma

)ailure of suturin

E$cessi#e couhin

2omitin

,ehydration

8ay be preceded by sudden strainin" such as couhin orsnee5in.


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4'8%(I4*TI'NS ')3'1N, &E*(ING

,E&IS4EN4E

Nursin responsibility

The wound should be 9uicklysupported by lare sterile dressinssoaked in sterile normal saline.

%lace the client in bed with knees bent

to decrease pull on the incision.The sureon must be noti:ed because

immediate surical repair of the areamay be necessary.


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)*4T'RS *))E4TING 3'1N,&E*(ING

*GE

N1TRITI'N*( ST*T1S

(I)ESTY(E

8E,I4*TI'NS


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N1RSING 8*N*GE8ENT

*ssessment

Skin interity

3ounds

1ntreated and Treated wounds.

1NTRE*TE, 3'1N,S

7seen shortly after an in0ury. e.." at thescene of an accident or in anemerency center.


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*ssessment/ 1ntreated 3ounds

7assess the si5e and se#erity of thewound

7inspect the wound for bleedin.;7inspect the wound for forein bodies7assess associated in0uries such asfractures" internal bleedin" spinal cordin0uries" or head trauma.

7If the wound is contaminated withforein material" determine when the

client last had a tetanus to$oid in0ection.;


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Nursin Inter#entions

4ontrol se#ere bleedin by

a. *pplyin direct pressure o#er the wound

b. Ele#atin the in#ol#ed e$tremity.

%re#ent infection by

a. 4leaninH!ushin abrasionsHlacerations with water

b. 4o#erin the wound with a clean dressin" if possible+ a sterile dressin is preferred-.;

4ontrol swellin and pain by applyin ice o#er the wound

and surroundin tissues. If bleedin is se#ere or if internal bleedin is suspected"

and if emerency e9uipment is a#ailable" assess the clientfor sins ofshock.


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N1RSING 8*N*GE8ENT

TRE*TE, 3'1N,S

Sutured wounds

1sually assessed to determine the proress of

healin. These wounds may be inspected durin chanin

of a dressin.

If the wound itself cannot be directly inspected"the dressin is inspected and other data reardinthe wound +e.." the presence of pain-;

Nursin Responsibility7'bser#e its appearance" si5e"drainae" and the appearance of swellin" pain" andstatus of drains or tubes.


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N1RSING 8*N*GE8ENT

1nderminin7occurs when the wound reaches under the skin surface.

7The edes of the wound around an open center may be raw orappear healed but the underminin can result in a sinus tract ortunnel that e$tends the wound many centimeters beyond themain wound surface.

7to fully assess the si5e of the wound e$plore the underminedarea with a thin" !e$ible probe. 'nce the end of the tract isreached" ently raise the probe so that the bule created by the

end can be seen and its lenth measured on the skin surface.;7sinus tracts are often caused by infection and ha#e sini:cantdrainae.

7treatment/ antibiotics" irriation" surical incision to open anddrain the tract" or #acuum therapy for lare tracts.


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N1RSING 8*N*GE8ENT

,I*GN'SING

Risk for Impaired Skin

Interity

Impaired Skin Interity

Impaired Tissue InterityRisk for Infection

%ain


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N1RSING 8*N*GE8ENT

%(*NNING

The ma0or oals for clients at risk forimpaired skin interity are to maintainskin interity and to a#oid potentialassociated risks.

4lients with impaired skin interity need

to demonstrate proressi#e woundhealin and reain intact skin.

Include plannin for home care.


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N1RSING 8*N*GE8ENT

I8%(E8ENTING

Nursin inter#entions for maintaininskin interity and wound care in#ol#e

supportin wound healin

pre#entin pressure ulcer

treatin pressure ulcers

dressin and cleanin wounds

applyin heat and cold

supportin and immobili5in wounds


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Supportin

3ound&ealin


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Supportin wound healin;

'btainin sucient nutritionand !uids.

%re#entin wound infections%roper positionin ;


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Supportin wound healin;

%re#entin wound infections

? main aspects/

%re#entin microoranismsfrom enterin the wound

%re#entin the transmission of

blood borne pathoens to orfrom the client to others.


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%re#entin wound infections

G1I,E(INES/

7Standard %recautions

7%roper wound care


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Standard %recautions

3ear lo#es when touchin bloodand body !uids" mucous membranes"or non intact skin of all clients" and

when handlin items or surfacessoiled with blood or body !uids.

3ash hands thorouhly after

remo#in lo#es" and if contaminatedwith blood or body !uids.


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3ound care

3ash hands before and after carin forwounds

3ear lo#es" surical masks" and protecti#e

eyewear as appropriate if procedurescommonly cause droplets or splashin of bloodor body !uids +e.." wound irriation-

Touch an open or fresh surical wound only

when wearin sterile lo#es or usin a sterileinstrument.

Remo#e or chane dressins o#er closedwounds when they become wet.


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>Preventingressure ulcer>Treating

ressure ulcers


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Treatin %ressure 1lcers

7)ollow aency protocols and thephysicianFs orders.

7The RY6 color code

3ound care uide

This concept is based on the color of anopen wound7 red" yellow" or black

+RY6-. 'n this scheme" the oals of wound

care are to protect +co#er- red" cleanseyellow" and debride black.

T ti % 1l R d d


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Treatin %ressure 1lcers/ Red wound

7wounds in the late reeneration phase of tissuerepair.

7they need to be protected to a#oid disturbance toreeneratin tissue.

7Nursin responsibility

a. entle cleansin

b. a#oid the use of dry au5e or wet to drydressins

c. apply topical antimicrobial aent

d. apply appropriate dressin

e. chane the dressin as infre9uently aspossible.


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Treatin %ressure 1lcers /Yellow wounds

7characteri5ed primarily by li9uid to semi7li9uidJslouh that is often accompanied by purulentdrainae.

7wounds are cleanse to remo#e non#iable tissue.7methods used/

*pplyin wet7to7damp dressins

Irriatin the wound

1sin absorbent dressin materials Topical antimicrobial


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Treatin %ressure 1lcers/ 6lack wounds

7wounds that are co#ered with thick necrotic tissue" oreschar.

7re9uire debridement+ remo#al of necrotic material- thismust occur before the wound can heal.

@ di


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dressing and cleaning wounds


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,RESSING 3'1N,S

,ressins are applied for the followinpurposes/

To protect the wound from mechanical in0ury

8icrobial contamination

To pro#ide or maintain hih humidity of thewound

To pro#ide thermal insulation

To absorb drainae or debride a wound or both

To pre#ent hemorrhae

To splint or immobili5e the wound site and

thereby facilitate healin and pre#ent in0ury.


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TY%ES ') ,RESSING

The type of dressin used depends on

The location" si5e and type of the wound

The amount of e$udate

3hether the wound re9uires debridementor is infected

)re9uency of dressin chane" ease or

diculty of dressin application and cost.

TY%ES ') 3'1N,


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TY%ES ') 3'1N,,RESSINGS

DRESSING DESCRIPTION PURPOSE EXAMPLESTransparentadhesi#e tapesHwound barriers

*dhesi#e plastic"semipermeable"nonabsorbentdressins allowe$chane of

o$yen betweenthe atmosphereand wound bed.

They areimpermeable tobacteria and water.

To pro#ideprotectionaainstcontaminationand friction to

maintain a cleanmoist surfacethat facilitatescellularmiration topro#ideinsulation by

pre#entin !uide#aporationand to facilitatewoundassessment.

'p7Site"Teaderm"6ioclusi#e


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TY%ES ') 3'1N, ,RESSINGS

DRESSING DESCRIPTION PURPOSE EXAMPLES

Imprenated nonadherent dressin

3o#en ornonwo#en cottonor syntheticmaterials are

imprenated withpetrolatum"saline" 5inc7saline"antimicrobials" orother aents.Re9uiresecondary

dressins tosecure them inplace" retainmoisture" andpro#ide woundprotection.

To co#er" soothe"and protectpartial7and full7thickness wounds

without e$udate

*daptic" 4arrasyn"Deroform


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&ydrocolloids 3aterproofadhesi#e wafers"pastes" orpowders.

3afers"desinedto be worn for upto L days" consistof two layers. Theinner adhesi#elayer has particlesthat absorbe$udate and forma hydrated elo#er the woundthe outer :lmpro#ides a seal.

To absorbe$udate toproduce a moisten#ironment that

facilitates healinbut does notcause macerationof surroundinskin to protectthe wound frombacterialcontamination"forein debris"and urine orfeces and topre#ent shearin.

,uo,erm"4omfeel"

Teasorb" restore"Replicare


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DRESSING DESCRIPTION

PURPOSE EXAMPLES

&ydroels Glycerin orwater7based

non7adhesi#e0ellylikesheets"ranules" orels are

o$yenpermeable"unlessco#ered by aplastic :lm.8ay re9uire

secondary

To li9uefynecrotic tissue

or slouh"rehydrate thewound bed"and :ll indead space.

*9uasorb"elasto7el"

#iilon


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DRESSING DESCRIPTION PURPOSE EXAMPLES%olyurethanefoams

Nonadherenthydrocolloiddressins theseneed to ha#etheir edes

taped down orsealed. Re9uiresecondarydressins toobtain anocclusi#e

en#ironment.Surroundinskin must beprotected topre#entmaceration

To absorb lihtto moderateamounts ofe$udate todebride wounds

(yofoam"alle#yn"#iifoam"!e$5an


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E$udateabsorbers+alinates-

Nonadherentdressins ofpowder" beadsor ranules"ropes" sheets"or pasteconform to thewound surfaceand absorb up

to ?M timestheir weiht ine$udatere9uire asecondarydressin

To pro#ide amoist woundsurface byinteractin withe$udate to forma elatinousmass to absorbe$udate toeliminate dead

space or packwounds and tosupportdebridement.

,ebrisan"Sorbsan"Kaltostat"*liderm


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*%%(YING 3'1N,

,RESSINGS

*%%(YING 3'1N,


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*%%(YING 3'1N,,RESSINGS

%repare materials to be needed

E$plain to the client what you are oin to do" why is itnecessary" and how heHshe can cooperate.

3ash hands and obser#e appropriate infection control

procedures. %ro#ide for client pri#acy. *ssist client to a comfortable

position in which the wound can be readily e$posed.

*pply clean lo#es and remo#e the e$istin dressin"discardin it accordinly.

Thorouhly clean the skin area around the wound. %ut on lo#es .

4lean the skin well but ently with normal saline or a mildcleansin aent. *lways rinse the ad0acent skin wellbefore applyin a dressin

*%%(YING 3'1N,


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*%%(YING 3'1N,,RESSINGS

7clean the wound if indicated. %ut on cleanH sterile lo#es in accordance with

aency practice.

4lean the wound with the prescribed solution.

,ry the surroundin skin with dry au5e.

7assess the wound

7apply the wound barrier.

)ollow the manufacturerFs instruction.;

Remo#e and dispose of lo#es.

7assess and chane the dressin as indicated

7document the dressin chane and the clientFs

response.


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SE41RING,RESSINGS


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SE41RING ,RESSINGS

The correct type of tape must be selectedfor the purpose.

Elastic tape can pro#ide pressure

Nonallerenic tape is used when a clientis alleric to other tape.


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SE41RING ,RESSINGS

STE%S T' )'(('3/

%lace the tape so that the dressin cannot befolded back to e$pose the wound. %lace strips at

the ends of the dressin" and space tapes e#enlyin the middle.

Ensure that the tape is lon and wide enouh toadhere to se#eral inches of skin on each side ofthe dressin" but not so lon or wide that the

tape loosens with acti#ity.

%lace the tape in the opposite direction from thebody action" for e$ample" across a body 0oint orcrease" not lenthwise.


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4(E*NING 3'1N,S


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4(E*NING 3'1N,S

In#ol#es the remo#al of debris +i.e."forein materials" e$cess slouh"necrotic tissue" bacteria" and othermicrooranisms.

The choices of cleanin methoddepend larely on aency protocol and

the physicianFs preference


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4(E*NING 3'1N,S

1se solutions such as isotonic saline ortap water to clean or irriate wounds. Ifantimicrobial solutions are used" make

sure they are well diluted. 3hen possible" warm the solution to body

temperature before use.;

If the wound is rossly contaminated byforein material" bacteria" slouh" ornecrotic tissue" clean the wound at e#erydressin chane.;


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4(E*NING 3'1N,S

If the wound is clean" has little e$udate"and re#eals healthy ranulation tissue"a#oid repeated cleanin.;

1se au5e s9uares. *#oid usin cottonballs and other products that shed :bersonto the wound surface.;

4lean super:cial noninfected wounds byirriatin them with normal saline.

To retain wound moisture" a#oid dryin awound after cleanin it.


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4(E*NING 3'1N,S

&old cleanin spones with forceps orwith a sterile lo#ed hand.

4lean from the wound in an outwarddirection to a#oid transferrinoranisms from the surroundin skininto the wound.

4onsider not cleanin the wound at allif it appears to be clean.


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3'1N, IRRIG*TI'N *N,

%*4KING


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3'1N, IRRIG*TI'N *N, %*4KING

IRRIG*TI'N+(*2*GE-

Is the washin or !ushin out of an area.

Sterile techni9ue is re9uired for a wound

irriation because there is a break in the skininterity.

Irriation pressures should rane from @ to Apound per s9uare inch +psi-.

6elow @ psi" the irriation may not bee


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3'1N, IRRIG*TI'N *N, %*4KING

Gau5e %ackin

1sin the wet to damp techni9ue

has been used to pack wounds fordebridement.

G G '


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IRRIG*TING * 3'1N,

%repare materials to be needed

E$plain to the client what you are oin todo" why is it necessary" and how heHshe

can cooperate. 3ash hands and obser#e appropriate

infection control procedures.

%ro#ide for client pri#acy.

IRRIG*TING * 3'1N,


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IRRIG*TING * 3'1N,

%repare the client

*ssist the client to a position in which theirriatin solution will !ow by ra#ity from theupper end of the wound to the lower end and intothe basin.

%lace the waterproof drape o#er the client andthe bed.

%ut on lo#es and remo#e and discard old

dressin If indicated" clean the wound.

*ssess the wound and drainae

Remo#e and discard clean lo#es

IRRIG*TING * 3'1N,


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IRRIG*TING * 3'1N,

%repare the e9uipment

Irriate the wound.

Instill a steady stream of irriatin solutioninto the wound. 8ake sure all areas of thewound is irriated.

If usin a catheter" insert the catheter into

the wound until resistance is met. 4ontinue irriatin until the solution

becomes clear.

,ry the area around the wound

IRRIG*TING * 3'1N,


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IRRIG*TING * 3'1N,

*ssess and dress the wound.

,ocument the irriation and theclientFs response.


98/112


99/112

Al!ing Heat and "old

&E*T *N, 4'(, *%%(I4*TI'NS


100/112

&E*T *N, 4'(, *%%(I4*TI'NS

(ocal e


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&E*T *N, 4'(, *%%(I4*TI'NS

4old can decrease blood !ow to thewound" thereby inhibitin healin.

In traumatic in0ury cold compress

decreases bleedin by constrictinblood #essels" decreases edema byreducin capillary permeability.

4ontraindications to the use


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4o a d ca o s o e useof heat and cold

1se of heat

The :rst ?@h after traumatic in0ury.+increases bleedin and swellin-

*cti#e hemorrhae

Nonin!ammatory edema + increasescapillary permeability-

(ocali5ed malinant tumor+metastases- Skin disorder that causes redness or

blisters

4ontraindications to the use


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of heat and cold

1se of cold

'pen wounds7 increase tissue damaeby decreasin blood !ow to an open

wound

Impaired circulation7 further impairnourishment of the tissues and cause

tissue damae.


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suorting andimmobili#ing

wounds

S1%%'RTING *N, I88'6I(IBING3'1N,S


105/112

3'1N,S

6andaes and binders ser#e #ariouspurposes/

Supportin a wound

Immobili5in a wound

*pplyin pressure

Securin a dressin

Retainin warmth

S1%%'RTING *N, I88'6I(IBING


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S1 ' G ' G3'1N,S

Inspect and palpate the area for swellin

Inspect for the presence of and status of wounds

Note the presence of drainae

Inspect and palpate for ade9uacy of circulation *sk the client about any pain e$perienced.

*ssess the ability of the client to reapply thebandae or binder when needed.

*ssess the capabilities of the client reardinacti#ities of daily li#in and assess the assistancere9uired durin the con#alescent period.


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HOME CARE PLANNING

Teachin/ &ome 4are


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Teachin/ &ome 4are

8aintainin intact skin ,iscuss relationship between ade9uate

nutrition and healthy skin.

,emonstrate appropriate positions for pressurerelief

Establish a turnin or repositionin schedule.

,emonstrate application of appropriate skin

protection aents and de#ices Instruct to report persistent reddened areas.

Identify potential sources of skin trauma andmeans of a#oidance.

Teachin/ &ome 4are


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Teachin/ &ome 4are

%romotin wound healin

,iscuss relationship between ade9uatenutrition and healthy skin.

Instruct in wound assessment andpro#ide mechanism for documentin.

Emphasi5e principles of asepsis" esp.

hand washin and proper methods ofhandlin used dressins.

Teachin/ &ome 4are


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Teachin/ &ome 4are

%ro#ide information about sins ofwound infection and othercomplications to report.

Reinforce appropriate aspects ofpressure ulcer pre#ention.

,emonstrate wound care techni9ues

such as wound cleansin and dressinchanin.

,iscuss pain control measures" ifneeded.

&ome care considerations


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&ome care considerations

3ound care

%erform appropriate client teachin forpromotin wound healin and maintenance

of healthy skin. Instruct the client and family on where to

obtain needed supplies. 6e sensiti#e to thecost of dressins.

Instruct in proper disposal of contaminateddressins.

2erify how the client may bathe with thewound.


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Thank youO

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