1. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 1 Chapter 21 Assisting With Wound Care

2. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 2 A BREAKDOWN OF SKIN TISSUE THAT OCCURS WHEN BLOOD FLOW TO AN AREA IS INTERRUPTED. ALSO CALLED A PRESSURE ULCER, PRESSURE SORE, OR BEDSORE

3. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 3 PRESSURE ULCERS  Causes  Pressure, friction, and shearing  Breaks in the skin  Poor circulation to an area  Moisture  Dry skin  Irritation by urine and feces  Age  Friction scrapes the skin.

4. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 4  LYING OR SITTING TOO LONG IN ONE POSITION – CAUSES PRESSURE OVER BONY PROMINENCES  WRINKLES IN CLOTHING OR BED LINEN  POOR NUTRITION  SHEARING – WHEN THE SKIN STICKS TO THE SURFACE AND THE DEEPER TISSUE MOVE DOWNWARD (WHEN THE PERSON SLIDES DOWN IN BED)

5. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 5  Signs of pressure ulcers  The first sign is pale skin or a reddened area.  Stages of pressure ulcers Stage 1 Stage 1  The skin is red. The color does not return to normal when the skin is relieved of pressure. The skin is intact. Stage 2 Stage 2  The skin cracks, blisters, or peels. There may be a shallow crater. Stage 3 Stage 3  The skin is gone. Underlying tissues are exposed. The exposed tissue is damaged. There may be drainage from the area. Stage 4 Stage 4  Muscle and bone are exposed and damaged. Drainage is likely.

6. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 6 IN STAGE 1 THE SKIN IS RED AND MAY BE WARM TO THE TOUCH. THE COLOR DOES NOT RETURN TO NORMAL WHEN THE SKIN IS RELIEVED OF PRESSURE ON DARK COLORED SKIN THE AREA MAY APPEAR DARK BLUE OR PURPLISH

7. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 7  GENTLY MASSAGE OUTSIDE OF THE REDDENED AREA  KEEP AREA AROUND THE BREAKDOWN CLEAN AND DRY  RELIEVE ALL PRESSURE OVER THE AFFECTED AREA  ENCOURAGE NUTRITIOUS DIET AND ADEQUATE FLUIDS  NURSE MAY APPLY A PROTECTIVE COVERING

8. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 8 IN STAGE 2 THE SKIN CRACKS, BLISTERS, OR PEELS. DESTRUCTION OF THE EPIDERMIS AND PARTIAL DESTRUCTION OF THE DERMIS MAY LOOK LIKE AN ABRASION, BLISTER, OR SHALLOW CRATER

9. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 9  REMOVE THE PRESSURE  GENTLY MASSAGE AROUND THE OUTSIDE OF THE AFFECTED AREA  MAKE SURE YOU NOTIFY THE NURSE

10. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 10 IN STAGE 3 THE LAYERS OF SKIN HAVE BEEN DESTROYED AND A DEEP CRATER HAS FORMED. YOU MAY SEE MUSCLES AND TENDONS.

11. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 11  ASSIST IN KEEPING THE AREA AFFECTED CLEAN  ASSIST WITH DRESSING CHANGES  MAY REQUIRE SURGICAL TREATMENT  ASSIST WITH THE USE OF PRESSURE - RELIEVING DEVICES ( SPECIALTY MATTRESS, BED, OR CUSHIONS )

12. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 12 A STAGE 4 ULCER HAS DEEP TISSUE INVOLVEMENT EXPOSING MUSCLE AND BONE THERE MAY BE TUNNELING OF THE WOUND

13. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 13  ASSIST WITH DRESSING CHANGES  MAY REQUIRE SURGICAL TREATMENT

14. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 14 SKIN TEARS  Skin tears are caused by:  Friction and shearing  Pulling on the skin  Pressure on the skin  Tell the nurse at once if you cause or find a skin tear.

15. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 15  To prevent skin tears:  Keep the person’s and your fingernails short and smoothly filed  Do not wear rings or bracelets  Follow the care plan  Follow safety rules to lift, move, position, transfer, bathe, and dress the person  Prevent shearing and friction  Use an assist device to move the person in bed

16. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 16 CIRCULATORY ULCERS  Poor circulation can lead to:  Pain  Open wounds  Swelling of tissues (edema)  Infection and gangrene Gangrene is a condition in which tissue dies. Gangrene is a condition in which tissue dies.

17. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 17  Stasis ulcers (venous ulcers)  The heels and inner aspect of the ankles are common sites.  Arterial ulcers  Are found: Between the toes Between the toes On top of the toes On top of the toes On the outer side of the ankles On the outer side of the ankles On the heels for persons on bedrest On the heels for persons on bedrest  These ulcers can occur from shoes that fit poorly.

18. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 18  Prevention and treatment  Follow the person’s care plan.  Elastic stockings and elastic bandages promote circulation. Applying elastic stockings (NNAAP)* Applying elastic stockings (NNAAP)* Applying elastic bandages* Applying elastic bandages*

19. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 19 DRESSINGS  Wound dressings:  Protect wounds from injury and microbes  Absorb drainage  Remove dead tissue  Promote comfort  Provide a moist environment for wound healing

20. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 20  Securing dressings  Dressings are secured and held in place by: Adhesive tape Adhesive tape Paper and plastic tape Paper and plastic tape Elastic tape Elastic tape Montgomery ties Montgomery ties Binders Binders

21. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 21  Applying dry non-sterile dressings*  Meet fluid and elimination needs before you begin.  Collect needed equipment and supplies.  Control your nonverbal communication.  Remove dressings so the person cannot see the soiled side.  Do not force the person to look at the wound.  Remove tape by pulling it toward the wound.  Remove dressings gently.  Report and record your observations.

22. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 22 BINDERS  Binders promote healing by:  Supporting wounds and holding dressings in place  Reducing or preventing swelling  Promoting comfort  Preventing injury  Types of binders  Straight abdominal binders  Breast binders  T-binders

23. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 23 HEAT AND COLD APPLICATIONS  Heat and cold applications  Promote healing and comfort  Reduce tissue swelling  Heat applications  Heat applications are often used: For musculoskeletal injuries or problems For musculoskeletal injuries or problems To relieve pain, relax muscles, and decrease joint stiffness To relieve pain, relax muscles, and decrease joint stiffness To promote healing and reduce tissue swelling To promote healing and reduce tissue swelling  High temperatures can cause burns.

24. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 24  Persons at risk for complications are: Older and fair-skinned people Older and fair-skinned people Persons with problems sensing heat or pain Persons with problems sensing heat or pain Persons with dementia Persons with dementia Persons with metal implants Persons with metal implants  Moist and dry heat applications.

25. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 25  Cold applications  Reduce pain  Prevent swelling  Decrease circulation and bleeding  Complications include pain, burns, and blisters.  Persons at risk for complications include: Older and fair-skinned persons Older and fair-skinned persons Persons with mental or sensory impairments Persons with mental or sensory impairments  Moist and Dry cold applications