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Metro Community College Nursing Program Nancy Pares, RN, MSN.

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Presentation on theme: "Metro Community College Nursing Program Nancy Pares, RN, MSN."— Presentation transcript:

1 Metro Community College Nursing Program Nancy Pares, RN, MSN

2 Age Elders: less elastic, drier, circulation impairment longer regeneration Mobility Increased pressure leads to breakdown Nutrition Poor nutrition, less regeneration, dehydration leads to poor turgor, increase risk of infection

3 Sensation level – Increased risk for pressure and breakdown Impaired circulation – Decreased O2 supply impacts healing ability, vessel disease, smoking Medications – Side effects: itching, rashes Diabetes – Impairs inflammatory response from hypoglycemia; must maintain control of BS

4 Moisture – Leads to maceration Obesity – Less blood supply in adipose tissue Fever – Affects moisture and metabolic rate Infection – Impedes healing Lifestyle – Tanning, bathing, piercings

5 Based on length of time wound existed and the condition of the wound Open/closed – No breaks in skin vs. true break in skin Acute/chronic – Short vs. prolonged healing Clean/contaminated/infected – Uninfected vs. open traumatic vs. evidence of infection

6 Superficial Epidermis: friction, shearing, burns Partial Extend into dermis Full Extend into subcutaneous tissue Penetrating Involves internal organs

7 Serous: clear-straw colored, watery Clean wounds Sanguinous: bloody Deep wounds Serosanguinous: pale pink (mixed) New wounds Purulent: yellow or green tinged pus Purosanguinous: red tinged pus

8 Regeneration Same process regardless of injury or tissues When wound involves only epidermis No scar Primary intention Minimal scarring Clean, surgical incision; edges well approximated

9 Secondary intention Extensive tissue loss Wound not well approximated; heals from inner surface to outer; epithelial tissue may look like sign of infection Tertiary intention (delayed closure) Granulating tissue is brought together; initially wound heals by secondary intention then is sutured; moderate scarring

10 Inflammatory: cleansing stage lasts 1-5 days – Hemostasis; vasoconstriction, platelets arrive at site, clotting occurs – Inflammation: vasodilatation, phagocytosis, scab formation Proliferative: granulation stage lasts 5-21 days – Fibroblasts form a bed of collagen – Fills defects and produces new capillaries Maturation: epitheliazation, begins 2 nd or 3 rd wk – Contraction of wound edges; scar tissue formation; scar tissue is 80% strong as original tissue.

11 Hemorrhage Infection – 2-3 days in contaminated wound; 4-5 days post op Hematoma Dehiscence: likely during inflammatory phase Evisceration – Place sterile saline soaked 4x4 over area – Call MD or notify charge/ surgical emergency Fistula: abnormal passageway often from infection

12 Location – Anatomic terms Size – Length and width Appearance – Type, color (Red, yellow black), condition, Skin around the wound Drainage Patient pain

13 Cleansing and irrigation Use saline, dilute antimicrobial or commercially prepared cleansersno hydrogen peroxide, alcohol or iodine; gentle is best; hydrotherapy=debridement Caring for drainage devices : Vol 2

14 Sharp MD or PT at bedside or OR Mechanical Wet to dry dressing-used less Hydrotherapy Enzymatic Topical agent Autolysis Uses body out mechanisms

15 Gauze Transparent Clear, semi permeable, non absorbent, often used for IV sites Hydrocolloids/hydrogels Water loving particles that form a gel with exudate Absorption See page 840 table

16 Securing dressings – Tape, Montgomery straps Binders – See 34-6,7 Vol 2 Important Nursing interventions – Inspect skin, assess and change dressings as ordered – Always ACE wrap distal to proximal – Assess for circulatory impairment

17 Clients at risk – Very old or very young – Sensory impairment – Body areas: highly vascularfingers, hands, face Moist heat – Moisture amplifies the treatment; vasodilates, reduces muscle tension Dry heat – Use with great caution

18 Vasoconstriction – Decreases edema and inflammation – Acts as a local anesthetic – Slows bacterial growth – Used in the first 24 hrs following injury – R-est – I-ce – C-ompress – E-levate

19 Surgical asepsis Absence of all microorganisms Slightest break in technique=contamination Sterile object is only sterile when touched by another sterile object When in doubt….throw it out…. Place only sterile objects on a sterile field Sterile object or field that is out of visual range is contaminated

20 If exposed to air for a prolonged time=contaminated Sterile border =field plus 1 inch Do not reach over a sterile field Keep hands in front and above waist in field of vision Procedures which require sterile technique Injection preparation, catherizations


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