1. Chapter 28 Wound Care

2. Terms: Wound Abrasion Contusion Incision Laceration Penetrating wound
Puncture wound
Skin Tear

3. Types of wounds: Intentional Open Closed Clean Clean-contaminated
Infected/dirty
Chronic
Partial thickness
Full thickness

4. Pressure ulcers:
Also known as decubitus ulcers, bedsores, pressure sores
Causes: pressure, friction and shearing

5. Persons at risk: Confined to bed or chair
Need some or total help to move
Loss of B/B control
Poor nutrition and fluid balance
Altered mental awareness
Problems with sensing pain/pressure
Obese or very thin
Older
Circulatory problems

6. Sites: Usually occur over a bony spot Called pressure points
In obese, can occur where there is
skin to skin contact
In persons who are bedridden, sores
can develop on the ears
epidermal stripping

7. Stages of pressure ulcers:
Stage I

8. Stage II

9. Stage III

10. Stage IV

12. Surgical Wounds

13. Surgical Drains

14. Circulatory Ulcers: Venous

15. Circulatory Ulcers: Arterial

16. Prevention of Circulatory Ulcers:
Do not sit with legs crossed
Do not dress in tight clothes
Keep feet clean and dry, dry well between toes
Do not scrub or rub skin during bath
Linens dry and wrinkle free
Avoid injury to legs and feet
Make sure shoes fit properly
Keep pressure off heels and other bony areas
Observe legs and feet, report any skin breaks or color changes

17. Wound assessment: Location of each wound
Size and depth (the nurse does this, you may assist)
Appearance: area around it is red/warm to touch/swollen, sutures/staples intact, wound edges closed/separated
Drainage present COA
Wound photography

18. Wound Healing: Inflammatory Phase (first 3 days)
Proliferative Phase (days 3-21)
Maturation Phase (day 21 on)
Primary intention
Secondary intention
Tertiary intention

19. Complications:
Infections
Bleeding
Evisceration
Dehiscence
Gangrene

21. Factors that affect wound healing:
Circulatory disease
Age
Smoking
Diabetes
Certain medications (blood thinners)
Nutrition (especially protein)
Type of wound and treatment
Antibiotics
Weakened immune system

22. Prevention of skin breakdown and injury:
Heel and elbow protectors
Bed cradle
Turning and positioning
Wrinkle free linens
Be careful when moving a person
Prevent friction and shearing when turning
Make sure skin is completely dry when bathing
Do good perineal care
Apply lotion to dry skin as directed by care plan
Do not massage over pressure points
Keep heels off the bed
Reposition frequently in chair, encourage patient to shift weight
Report any skin conditions immediately

23. Other prevention techniques
Special beds/mattresses
Special chair cushions
Protective barrier cream

24. Wound Drainage
Serous
Sanguineous
Serosanguineous
Purulent

25. Treatment of wounds: Dressing changes: Dry dressing Wet to dry Packing
Duoderm
Gauze, non-adherent gauze
Tegaderm (transparent)
Sterile vs. clean
Purposes of dressings

26. Others: Montgomery ties Breast binder Single and double T binders
Abdominal binder
Ace wrap
TED Hose

27. Guidelines for applying:
Binders: Make sure there is firm even pressure over the area, snug, but not impeding circulation or breathing. Secure any pins to point away from the wound.
With Ace wraps, make sure they are snug, but not too tight and they are secured.
See pages 575,576
Always wash your hands, change any wraps/binders that become soiled.
Anything with blood or body fluids (such as dressings) need to be put in biohazard.
CNAS can apply a simple dry dressing (like basic first aide), but the nurse does all complicated dressing changes. You may assist. Be careful when removing tape (like after a blood draw).

28. Other treatments Ointments Irrigation Debridement Wound vac
CNAS can apply NON-MEDICATED protective barrier cream in most facilities. Check with your facility. Do NOT apply any type of medicated ointment or powder!

29. A final word…..
You will see some bad wounds during the course of your career. Some will have a very bad odor, lots of drainage, or be very deep (where you can see bone, muscle, etc).
You have to keep your emotions in check. Do not talk about the wound negatively in front of the person. They need to feel accepted and not worry about what people think of their wounds. Also, don’t run down the facility they came from in front of the patient (it is the nursing home’s, surgeon’s or hospital’s fault).