Presentation on theme: "Wound care and Dressings PN 103. Types of Dressings Multiple types!!!!! -wounds depth -amount of drainage -location of the wound. -needs a MD/PA/NP order."— Presentation transcript:
Wound care and Dressings PN 103
Types of Dressings Multiple types!!!!! -wounds depth -amount of drainage -location of the wound. -needs a MD/PA/NP order -Follow protocol at your facility - some facilities have pre-written orders depending on the type of lesion.
Surgical incision- -Clean, well approximated edges, minimal drainage 1. Clean incision with wound cleanser 2. Dry, sterile dressing (DSD)
-Open incision, moderated drainage -packing with normal saline wet to dry dressing -gauze strips -Iodoform, Nu- gauze -Skin prep to surrounding skin -Cover with absorbent dressing -Exudry, ABD-abdominal dressing
Pr essure and stasis ulcers Wound bed applications -granulating tissue -usually nothing -non-granulating tissue -hydrating gels -Xerophorm/Vaseline gauze
Tape -paper -clothe (silk, Medipore) -steri-strips -Montgomery straps Wraps -gauze wraps (Kerlex -ace wraps -Coban Etc. -Surgiflex, Band net
Allergic reaction to the tape adhesive -blistering (tape burns) Avoid tape to fragile, thin skin if possible
Monitoring Wounds Frequency -returning from surgury -wounds appearance changes -Increased odor/purulent drainage -another care setting -each dressing change -Daily-acute care setting -On admission-long-term care facility -once a week there after
Signs of healing- -Decreased size of the wound -Decreased drainage - Increased epitheliazation from the edges to the center of the wound -scar
Signs of wound deterioration -Increased drainage/odor -Erythema - wound and surrounding skin -Pain -Increased size -Change in wound drainage color
Wound Evaluation- -Outcomes based of planning, nursing diagnosis's and goals -if goals are not reached -examine the nursing interventions and strategies, then reassess. -create new goals and modify interventions
Case Study A patients right heel ulcer is not healing. She is a resident in a long term care facility How can the care plan be changed to meet the goals of having the right heel ulcer heal with out signs of infection?
. Float heels when in bed. 2. Change the dressing regime. 3. Padded boots when in bed. 4. Elevate the feet as much as possible 5. Sitting up in the wheelchair with legs elevated only for meals. 6. Evaluate and measure right heel wound every 3 days x 2 then if healing, evaluate and measure weekly
Therapeutic High Protein Diet _Components 1. High protein -animal proteins -vegetable proteins (legumes, soy) -supplements (Ensure, Boost, Glucerna, Promod) 2. Vitamin and Mineral Supplements -leafy green vegetable, citrus fruit -multivitamin with minerals
3. Fluids/Hydration -1.5-2 liters fluid/day -avoid caffeine drinks -acts as a diuretic -encourage water!