Nursing Aspect – Wound management
-
Upload
bbiesyg-usagi-tsukino -
Category
Documents
-
view
236 -
download
0
Transcript of Nursing Aspect – Wound management
-
7/30/2019 Nursing Aspect Wound management
1/54
ZALIANA BRAHIM
WOUND CARE NURSE
HOSPITAL MIRI
-
7/30/2019 Nursing Aspect Wound management
2/54
A wound is a disruption of continuity of skin
or underlying tissues with or with out anopening onto the body surface.
-
7/30/2019 Nursing Aspect Wound management
3/54
Classification of wounds
1. Acute wound- caused by trauma, animal bites, burns and surgical incisions- generally managed by the surgical team
-
7/30/2019 Nursing Aspect Wound management
4/54
Classification of wounds2. Chronic wound
3 basic types:
Pressure ulcers
Lower extremity ulcers Skin tears
-
7/30/2019 Nursing Aspect Wound management
5/54
BURN
-
7/30/2019 Nursing Aspect Wound management
6/54
BURN
-
7/30/2019 Nursing Aspect Wound management
7/54
BURN
-
7/30/2019 Nursing Aspect Wound management
8/54
Principles of wound Care
1. Relieving pain
2. Correcting nutritional deficits
3. Wound debridement
4. Wound dressing5. Management of infection
-
7/30/2019 Nursing Aspect Wound management
9/54
Wound Management Nursing
aspect
1. Burns
2. Wound assessment
3. Wound care products
4. Nursing Process
-
7/30/2019 Nursing Aspect Wound management
10/54
1 Burn (Superficial)
- involves epidermis
- produce pain and
redness- heal within a week
- no scaring
-
7/30/2019 Nursing Aspect Wound management
11/54
2 Burn (Partial thickness)- involves epidermis,
superficial dermis
- produce pain, redness,blister
- heal within 2 to 3 weeks
- minimal scaring
-
7/30/2019 Nursing Aspect Wound management
12/54
3 Burn (Full thickness)
- involves epidermis,
dermis, subcutaneous
tissue- appear pale and white
- no pain
- require grafting
-
7/30/2019 Nursing Aspect Wound management
13/54
Burns
Rule of 9
- To estimate
severity of burns
d h
-
7/30/2019 Nursing Aspect Wound management
14/54
LUND and BROWDER Chart
-
7/30/2019 Nursing Aspect Wound management
15/54
Burns Nursing ManagementObjectives
1. Prevention of shock2. Prevention of infection
3. Prevention of contracture
4. Provision of psychotherapy
-
7/30/2019 Nursing Aspect Wound management
16/54
Prevention of shock
1. Sedation for pain and restlessness (morphine stillbeing the most effective drug except in respiratory burn) timely, proper documentation in pain score chart. Evaluateeffectiveness of analgesics. Refer appropriately. DDA protocol inusage and recording to adhere to.
2. Use of colloids and crystalloids to combat shock (resuscitation formulas) Strict and accurate Intake /Output
chart recording
-
7/30/2019 Nursing Aspect Wound management
17/54
-
7/30/2019 Nursing Aspect Wound management
18/54
Prevention of shock
3. Administration of oral fluids
- small amount of 10-50 mls hourly of bland fluids (water,glucose, plain ovaltine, barley water, orange juice, ribena etc)-
Accurate Intake and Output Chart
Burned patients are thirsty and if given toomuch to drink too quickly, they will vomitbecause of gastric dilatation and paralyticileus.
-
7/30/2019 Nursing Aspect Wound management
19/54
Prevention of shock
4. Urinary output
Child 10mls / hour
Adult 30mls /hour
Hourly urine output must be done andaccurately recorded
Inform Doctor for any decrease in urinary outputor presence of blood
-
7/30/2019 Nursing Aspect Wound management
20/54
Prevention of shock
5. Observations Hourly TPR, BP & SPO2
Temperature can be subnormal because the skin surfaces aredestroyed and elevated subsequently when infection sets in.
Pulse Rate, volume and regularity of pulse should be noted.
Increase in pulse rate indicates over transfusion and acute gastricdilatation.
Respiration observe for its depth and frequency and state ofairway.
Tracheostomy / intubation may be indicated for laryngeal edema,
respiratory distress, restrict chest movementSPO2 Any decrease in SPO2 must be referred.
Blood Pressure Any change must be referred. Can be over /under transfusion.
-
7/30/2019 Nursing Aspect Wound management
21/54
Prevention of shock
Restlessness
- often an indication of under transfusion or can result from anoxia.
Color and temperature of extremities - any coldness accompanied with any changes indicates circulation
impairment . Inform doctor immediately
-
7/30/2019 Nursing Aspect Wound management
22/54
Infection control measures1. Staff Barrier nursing
- Hand washing technique: prior & after.
2. Visitors- Restriction- close family members only- Hand washing prior to patient contact
3. Environmental measures
- Air conditioned room Temp 25-28C
- Bed linen- Sterile linen for exposed method dressings
- Soiled linen removed immediately
Prevention of Infection
-
7/30/2019 Nursing Aspect Wound management
23/54
4. Wound Care- swabs for C&S on admission Technique!- strict aseptic dressing technique
5. General personal hygiene- promotion of independence- early mobilization- Encourage family support
6. Nutrition
- High calorie &Protein- Supplementary feed eg. Enercal- Vitamin C, B complex, Iron
Major burns- sips of water
-NG tube- Enteral feeding
Maintain strict intake output chart
Infection control measures
-
7/30/2019 Nursing Aspect Wound management
24/54
Prevention of contracture
Physio & Occupational Therapy All joints into active & passive movements Encourage exercises
Involve family in activities
Need forJOBST Garment
-
7/30/2019 Nursing Aspect Wound management
25/54
JOBST GARMENTpressure
garment
-
7/30/2019 Nursing Aspect Wound management
26/54
Provision of PsychotherapyPsychotherapy On admission reassurance (allay fear and anxiety)
Adequate pain relief
Social worker role
Counselor role
Family support Constructive diversional therapy
-
7/30/2019 Nursing Aspect Wound management
27/54
WOUND ASSESSMENT
-
7/30/2019 Nursing Aspect Wound management
28/54
WHY IS WOUND ASSESSMENTNECESSARY?
To enable prompt and appropriate woundmanagement
Relieve the psychological burden of the person (andfamily members) with the wound
To give appropriate health information and thusadvice
Cost saving
-
7/30/2019 Nursing Aspect Wound management
29/54
Wound Assessment Location Clinical appearance
Dimension
ExudatesWound edges
Surrounding skin
Infection
Pain
Psychosocial implications
-
7/30/2019 Nursing Aspect Wound management
30/54
Location
Clinical appearance
-
7/30/2019 Nursing Aspect Wound management
31/54
Clinical appearance
- Degree of tissue loss
- ? Black hardened, necrotic,
eschar, dry or moist
Necrotic(dead, dry
issue)
Sloughy wound
Cli i l
-
7/30/2019 Nursing Aspect Wound management
32/54
Pusexudate
Exudate - Observe for color, consistency, amount & odor
Infected with heavy exudate
Clinical appearance
-
7/30/2019 Nursing Aspect Wound management
33/54
Clinical appearance
Granulation
-
7/30/2019 Nursing Aspect Wound management
34/54
Epithilialising
Clinical appearance
-
7/30/2019 Nursing Aspect Wound management
35/54
Dimensions
Length Width
Depth
-
7/30/2019 Nursing Aspect Wound management
36/54
Wound Surrounding skin
-
7/30/2019 Nursing Aspect Wound management
37/54
Pain -Assessment
-
7/30/2019 Nursing Aspect Wound management
38/54
WOUND CARE PRODUCTS
-
7/30/2019 Nursing Aspect Wound management
39/54
Wound Care products
Today's market offers avast selection ofproducts, from simplegauzes to silver-containing dressings tonegative pressuretherapies.
Hydrofibre/Alginates
Hydrogel
Hydrocolloids
Negativepressuretherapy
-
7/30/2019 Nursing Aspect Wound management
40/54
Selecting a Dressing
Consider the following general recommendations: Keep the wound moist (the standard rule)
- A moist wound heals twice as quickly as a dry one
Avoid standard wet-to-dry dressings
If it's wet, dry it; if it's dry, wet it.
- This means that a wound with heavy exudate will need a more absorptivedressing, such as a foam or alginate, while a dry wound will require rehydrationwith a hydrogel or an occlusive dressing, such as a hydrocolloid.
-
7/30/2019 Nursing Aspect Wound management
41/54
Types of dressing1. Alginates.
- Derived from seaweed, these highly absorptive dressingsare soft, nonwoven, and non-adhesive, and conform tothe shape of the wound.
- When in contact with drainage, they form a gel.Alginates are most useful for wounds with heavy exudate.
- Don't use them for dry or eschar-covered wounds,because they won't form a gel and may stick to the
wound, causing tissue trauma when you remove them
- Some contain silver, which has an antimicrobial action
- If a patient has a silver dressing, you may need toremove it before magnetic resonance imaging (MRI).
l
-
7/30/2019 Nursing Aspect Wound management
42/54
Cont Alginates
Alginates come in sheets that you can cut to size. They alsocome in rope form, which is especially good for areas of
undermining or tunneling. When using an alginate, you'll need to cover the wound
with a secondary dressing to hold the product in place andto protect the wound from outside contaminants. Leave the
alginate in place for one to three days, until it begins to geland shows evidence of breakthrough drainage.
Throughly irrigate the wound with sterile normal salinesolution before reapplying the alginate.
-
7/30/2019 Nursing Aspect Wound management
43/54
Types of dressing2. Foams.
- Typically polyurethane-based, this type of dressing isnon-adhesive and comes in various sizes, shapes, anddegrees of thickness.
- foam dressings provide thermal insulation and help
keep the wound moist.- They may be used as a primary or secondary dressing, topromote autolytic debridement, and to inhibit hyper-granulation.
- When using a foam dressing, make sure it's one to two
inches larger than the wound; you can leave it in place forup to seven days.
-
7/30/2019 Nursing Aspect Wound management
44/54
Types of dressing3. Hydrocolloids.
Hydrocolloid dressings contain hydrophilic colloidal particles in anadhesive compound laminated to a flexible wafer. Like foams, theycome in numerous sizes, shapes, and levels of thickness.
- Hydrocolloids have minimal absorptive capabilities.- They help keep the wound moist and promote
autolysis of necrotic areas.
- Don't use them on wounds that are infected or have heavyexudate.
- To avoid damaging fragile skin by removing the dressings toofrequently, keep them in place for as long as possible, but nolonger than seven days.
-
7/30/2019 Nursing Aspect Wound management
45/54
Types of dressing4. Hydrogels.
- Available as gels, sheets, or gauze impregnatedwith various percentages of water,
- Hydrogels are hydrophilic polymers with few
absorptive properties.- Theyadd moisture to the wound bed and arenon-adherent, and they're used mainly for dryand minimally exudative
-
7/30/2019 Nursing Aspect Wound management
46/54
Type of Dressing
5. Hydrofiber Hydrofiber Wound Dressing is indicated for:
- Management of exuding wounds including leg ulcers, pressure ulcers anddiabetic ulcers, surgical wounds, partial thickness burns, and traumatic wounds
Why choose Hydrofiber Wound Dressing?
- Absorbs and retains exudate and harmful components- Locks exudate in the dressing
- Conforms to the wound surface, thereby reducing dead space
- Does not damage tender, granulating wound tissue or healthy tissuesurrounding exudating wounds during dressing changes
- Absorbs wound f luid and creates a soft gel
- Aids in autolytic debridement (removal of nonviable tissue from the wound)- Removes without leaving residue or causing trauma to wound
- Manages painful wounds
Negative Pressure Wound therapy (NPWT)
-
7/30/2019 Nursing Aspect Wound management
47/54
- This is an option for treating wounds that are draining
heavily, failing to heal, or healing slowly.- NPWT applies sub-atmospheric pressure to the woundthrough the use of special foam dressings occlusively sealedand connected to a pump and collection chamber. - NPWT isuseful in removing exudates and debris, promoting blood
flow, hastening tissue granulation, and encouraging thecontracture of wound edges.
- It's especially helpful in treating deep, cavernous wounds.
- The foam fills in dead space, and this can enhance closure of
tunneling and undermined areas.
Negative Pressure Wound therapy (NPWT) vacuum assisted closure
-
7/30/2019 Nursing Aspect Wound management
48/54
Debride the wound first
Before you apply the dressing of choice, make sure that
nonviable tissue, such as slough, eschar, and fibrin,have been debrided.
Eschar that's dry, hard, and stable need not beremoved, however, unless signs of infection are
presentredness, pus, fluctuance (bogginess ormushiness), wound edge separation with drainage
Whenever you suspect infection, refer to doctor incharge; wound cultures and/or antimicrobial therapymay be indicated.
Taking wound swab for C&S properly please!!!
-
7/30/2019 Nursing Aspect Wound management
49/54
Nursing Process
-
7/30/2019 Nursing Aspect Wound management
50/54
Document what you have observed Location
Clinical appearance
Dimension
Exudates
Wound edges Surrounding skin
Infection
Pain
Psychosocial implications
-
7/30/2019 Nursing Aspect Wound management
51/54
Identify Nursing Problems
1. Risk of hypovolemic shock/ Risk of deficit fluid volume
2. Risk of infection due to impaired skin/tissue integrity
3. Risk of 2 infection superimposed on the primary wound
4. Risk of imbalanced nutrition: less than the body requirement
5. Pain
6. Hypothermia
7. Hyperthermia
8. Altered body image
9. Altered sleeping pattern
10. Deficient knowledge regarding condition, prognosis, treatment, self
care and discharge needs
-
7/30/2019 Nursing Aspect Wound management
52/54
Evaluation Is the wound getting better?
Draw the wound size
Take photos
Collectionfor case
presentation
-
7/30/2019 Nursing Aspect Wound management
53/54
Any Question?
-
7/30/2019 Nursing Aspect Wound management
54/54