1. WOUND CARE Prepared By Dr. Nahed Saied Al Nagger Assistant Professor of Nursing 1430H.
-
Upload
moris-moore -
Category
Documents
-
view
219 -
download
2
Transcript of 1. WOUND CARE Prepared By Dr. Nahed Saied Al Nagger Assistant Professor of Nursing 1430H.
1
WOUND CARE
Prepared By
Dr. Nahed Saied Al NaggerAssistant Professor of Nursing
1430H
Intended Learning Outcomes Define wound. Identify classifications of wound. Recognize the difference between
sutures, staples and Steri-Strips. Describe wound healing process. List factors affecting wound healing. Determine complications of wound. Discuss nursing management of
wound in emergency and treatment settings.
Skin Integrity and Wound Care
Skin Structure: epidermis and dermis Function
An overview of wounds and open sores
What is the meaning of wound? A wound or open sore is a break in the
skinor mucous membrane, that is at high
risk for infection.
Wound Classification Skin integrity: open, closed, acute, chronic.
Cause: intentional, or unintentional.
Severity of injury: superficial, penetrating, or perforating.
Cleanliness: clean, contaminated, or infected.
Descriptive qualities (types): laceration, or abrasion.
Classifications of wounds (cont.)
Open wounds can be classified into a number
of different types, according to the object that
caused the wound.
Types of open wounds are: Incisions caused by a clean, sharp-
edged object such as a knife, a razor or a glass splinter.
Lacerations rough irregular wounds caused by crushing or ripping forces.
Abrasions ( grazes) a superficial wound in which the topmost layers of the skin are scraped off, often caused by a sliding fall into a rough surface.
continue
SKIN Laceration
Puncture wounds caused by an object puncturing the skin such as a nail or needle.
Penetration wounds caused by an object such as a knife entering the body.
Gunshot wounds caused by a bullet or similar projectile driving into or through the body, there may be two wounds:
One at the site of entry. One at the site of exit.Remember that: All gunshot wounds should be considered major
wounds.continue
Sores can be caused by a wide range of factors, but the most are caused by infection, so treating the infection is essential to healing. There are many types:
Pressure ulcers. Diabetic ulcers. Bedsore wounds.
Pressure Ulcers: Pathogenesis
Pressure intensity Pressure duration Tissue tolerance
What is a Pressure Ulcer ?
Any lesion caused by unrelieved pressure usually over a bony prominence that results in damage to underlying tissue
Mosby items and derived items © 2005 by Mosby, Inc.
SHEARING FORCES
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.
Pressure ulcer stages
Stage 1: epidermis; nonblanching erythema. Stage 2: epidermis/dermis; shallow opening; blisters. Stage 3: Subcutaneous
tissue/fascia Stage 4: fascia + bone, tendon,
muscle, cartilage
Systemic Factors that affect Wound Healing
Nutritional Status Vascular Status Metabolic Factors Immunological Factors Age Medications (Steroids, etc) Genetic
Pressure Ulcer StagingStage I
Pressure Ulcer Staging
Stage IDark Skin
Pressure Ulcer Staging
Stage II
Stage 2: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
Pressure Ulcer Staging
Stage II
Pressure Ulcer StagingStage II
Pressure Ulcer StagingStage IIIFull thickness skin loss
involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
Pressure Ulcer Staging
Stage III
Pressure Ulcer Staging
Stage IVFull thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint, capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers
Stage IV
Diabetic Ulcer
What does the surgeon use to close the surgical wound? Surgical wound will be closed in multiple layers, first close muscle layer and then skin layer.
1. Sutures
are what most people
call stitches.
2. Steri-Strips method (which look like tape strips) are placed across the wound to hold the skin edges together. It requires a closure with many small stitches of the layer immediately below skin.
continue
Contra-indications of Steri- Strip method
1. The time of surgery is extended.2. Patient have had previous surgery
in the area.3. Patient’s healing may be
compromised due to other health problems.4. Patient have any other health
concerns that would not make this type of closure the best
method.
Staples: are small metal clips that hold the wound closed. This method allows the surgeon to close the wound more rapidly. Surgeon is the best judge as to the type of closure appropriate for the surgical wound. A combination of wound closure techniques.
Staples
*Stages of Wound Healing Inflammation- (approx. 2-3 days) consists of a vascular and a cellular response acute and chronic inflammation (neutrophils,
cytokines, oxygen, platelets rush to the site).
Proliferation – (approx. 2-3 weeks) Begins at the time of injury Rebuilding begins with scaffolding of the skin Revascularization of the wound begins.
Maturation Stage- (Approx 2-3 years)
Depositing of scar tissue The body attempts to contract or close the wound (Wounds are only ever 80% healed)
Wound Repair (Healing)
Partial thickness: inflammatory response, epithelial proliferation and migration, reestablishment of epidermal layers
Full thickness: inflammatory phase, proliferative phase, and remodeling
Factors Influencing Wound Healing Nutrition. Tissue perfusion. Medical problems such as diabetes. Medications e.g., taking daily
steroids. Immune system disorder. Infection. Age. Genetic.
Is wound care different for a child?
Children's wounds heal very quickly and normally without problem.
Preventing child from itching the wound or touching the wound is very important.
If the child requires the use of a diaper, an additional measure to protect a surgical wound in that area is necessary.
Special bandage material that forms water tight protection for the wound will be used until the wound is healed.
Do all sutures dissolve?
There are many types of suture material, some of which are dissolvable and some are not.
Some of the suture material will dissolve once your wound is completely healed.
Is it painful to have sutures and staples removed? Removing either sutures or staples may be uncomfortable but should not be painful.
Obviously, the longer the wound the greater time it will take to remove your sutures or staples.
Removal of the closure material normally ranges from one to five minutes depending on the length of the wound and the number of sutures or staples to be removed.
Techniques for suture and staple removal
Complications of Wound Healing
Hemorrhage—shock Infection Dehiscence Evisceration Fistula formation
Disinfectant Solutions
Nursing Management for wound
Assessment
Skin: color, temperature, turgor, integrity
Risk for pressure ulcers: Norton and Braden scales (p.1495).
Nutritional status Exposure of skin to body fluids Pain
Assessment of Traumatic Wounds
Wounds: emergency setting Abrasions Lacerations Punctures
Appearance Amount of bleeding Size
Assessment of Wounds in a Stable Setting
Appearance: size, healing
Character of drainage: serous, sanguineous, serosanguineous, purulent (p.1494)
Drains
Wounds: Stable Setting
Closures: staples, sutures Palpation of wound Wound cultures: aerobic, anaerobic
Mosby items and derived items © 2005 by Mosby, Inc.
Nursing Diagnoses
Risk for infection Imbalanced nutrition: less than body
requirements Pain Impaired skin integrity Impaired tissue integrity
Mosby items and derived items © 2005 by Mosby, Inc.
Planning
Goals and outcomes Wound improvement within 2 weeks No further skin breakdown Increase in caloric intake by 10%
Setting priorities Continuity of care
Mosby items and derived items © 2005 by Mosby, Inc.
Implementation: Health Promotion
Prevention of pressure ulcers Skin care Positioning Use of support surfaces
Implementation: Acute Care
Management of wounds and pressure ulcers
Wound Management
Prevent and manage infection. Cleanse the wound. Remove nonviable tissue. Manage exudate. Protect the wound. Client education. Nutritional support.
Necrosis of the skin
Removal of dead epidermis and dermis
Normal fat at the base of a debrided wound of the heel
Silvaden
Silvadene Is an excellent antibacterial cream to apply to a wound after debridement. One must insure that an 1/8 inch to 1/4 inch coat is applied to help insure that the dressing doesn't absorb all the cream and allow the wound subsequently dry
out.
First Aid for Wounds
Control of bleeding. Cleansing. Application of topical growth factors. Protection.
Dressings
Purpose Types: gauze, wet-to-dry, Telfa,
transparent, hydrocolloid, hydrogel, foam, alginate
Changing or reinforcing dressings Packing a wound. Securing the dressing
Montgomery straps
Transparent dressing
hydrocolloid dressing absorbs drainage into its matrix
Hydrocolloids ( Duoderm)-
How is the wound bandaged? Immediately after surgery, the wound
will be covered with sterile bandages. Normally this first bandage, often referred to as the surgical dressing, will be removed the day after surgery.
The nurse will examine the wound to be sure that it looks as expected, another bandage may be applied.
Dressing Changes
Administer required analgesic Explain steps of procedure to client Gather all necessary supplies Prepare sterile field, as indicated Remove old dressing, assess area, and
provide necessary care using appropriate aseptic technique
Answer client’s questions and document care provided
Wound Care
Cleansing skin and drain sites Wound irrigations Suture/staple care and removal Drainage evacuation Comfort measures
Wound irrigations
Wound Care
Application of Bandages and Binders
Inspect underlying skin Cover exposed wounds Assess condition of dressings Assess skin of areas distal to bandage Use appropriate technique to apply
Patient Education
How should the patient care for the wound?
The most important aspect for the first 72 to 96 hours will be to keep the wound dry and clean.
Wound will be assessed each day by surgeon and nurses to be sure that it is progressing and that no signs of infection are present.
They will alert the patient to any concerns that they have about wound and give patient specific instructions regarding wound care.
Is it normal for the wound to itch?
A few days after surgery, patient may notice some itching near surgical wound.
Itching may be a sign of healing, but it may also be a result of the Steri-Strips or other tapes that have been used.
It is best to avoid itching the wound. If it becomes too much of a problem, the
surgeon or nurse may order medications by mouth or some topical cream to help make this more tolerable.
When the patient can take a shower?• Surgical team will make a determination
about when the patient can take a shower.
• In most cases, the patient can take a shower approximately 4 to 5 days after surgery.
• Normally baths are discouraged for the first couple of weeks due to difficulty getting in and out of a bathtub, as well as avoiding soaking the wound in bath water.
DECUBITUS IMPLEMENTATION
Institute measures to prevent decubiti Assess the nutritional status of the client
and provide adequate nutritional intake to promote tissue integrity
Monitor for an alteration in skin integrity Relieve or remove pressure on the skin Turn and reposition the immobile client
every 2 hours, or more frequently if necessary
Ambulate the client
Mosby items and derived items © 2005 by Mosby, Inc.
ASSESSMENT OF PRESSURE RELIEF
From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes, ed 6, Philadelphia: W.B. Saunders. Modified from Gaymar Industries, Inc., Orchard Park, NY.
DECUBITUS IMPLEMENTATION
Provide active and passive exercises every 8 hours
Keep the skin clean and dry and the sheets wrinkle-free
Apply moisture barrier as prescribed to protect the skin
Use assistive devices to prevent pressure such as alternating air pressure mattress or sheepskin padding
Apply medications or dressings to the wound as prescribed
Evaluation
Client care Client expectations
Thanks