1. Wound Care Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

2.  The skin is the body’s first line of defense.  You must prevent skin injury and give good skin care to help prevent skin breakdown.  Older and disabled persons are at great risk for skin breakdown.  A wound is a break in the skin or mucous membrane. Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 2

3.  Common causes of wounds are:  Surgery  Trauma  Pressure ulcers from unrelieved pressure  Decreased blood flow through the arteries or veins  Nerve damage  The nurse uses the nursing process to keep the person’s skin healthy. Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 3

4.  TYPES OF WOUNDS  Wounds are described in the following ways:  Intentional wounds and unintentional wounds  Open and closed wounds  Clean wounds  Clean-contaminated wounds  Contaminated wounds  Infected wounds  Chronic wounds  Partial- and full-thickness wounds Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 4

5.  Wounds also are described by their cause:  Abrasion  Contusion  Incision  Laceration  Penetrating wound  Puncture wound Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 5

6.  SKIN TEARS  A skin tear is a break or rip in the skin.  The hands, arms, and lower legs are common sites for skin tears.  Causes  Friction and shearing  Pulling or pressure on the skin  Tell the nurse at once if you cause or find a skin tear. Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 6

7.  Persons at risk for skin tears:  Need moderate to total help in moving  Have poor nutrition  Have poor hydration  Have altered mental awareness  Are very thin  Careful and safe care helps prevent skin tears and further injury. Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 7

8.  PRESSURE ULCERS (DECUBITUS ULCERS, BED SORES, PRESSURE SORES)  A pressure ulcer is an injury usually from unrelieved pressure.  A pressure ulcer usually occurs over a bony prominence.  Pressure, shearing, and friction are common causes.  Risk factors include:  Breaks in the skin  Poor circulation to an area  Moisture  Dry skin  Irritation by urine and feces Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 8

9.  Persons at risk for pressure ulcers are those who:  Are bedfast or chairfast  Need some or total help in moving  Are agitated or have involuntary muscle movements  Have loss of bowel or bladder control  Are exposed to moisture  Have poor nutrition  Have poor fluid balance  Have lowered mental awareness  Have problems sensing pain or pressure  Have circulatory problems  Are older  Are obese or very thin Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 9

10.  Pressure ulcer stages  Stage 1: The skin is red in persons with light skin. The skin is red, blue, or purple in persons with dark skin.  Stage 2: Partial-thickness skin loss  Stage 3: Full-thickness skin loss  Stage 4: Muscle and bone are exposed and damaged.  Sites  Pressure ulcers usually occur over bony areas called pressure points.  The ears also are sites for pressure ulcers.  In obese people, pressure ulcers can occur in areas where skin has contact with skin. Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 10

11. Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 11

12. Stages Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 12

13. Stages Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 13

19.  Prevention and treatment  Good nursing care, cleanliness, and skin care are essential.  The person at risk for pressure ulcers is placed on a surface that reduces or relieves pressure.  The doctor orders wound care products, drugs, treatments, and special equipment to promote healing. Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 19

20.  Protective devices are often used to prevent and treat pressure ulcers.  Bed cradles  Heel and elbow protectors  Heel and foot elevators  Gel- or fluid-filled pads and cushions  Eggcrate-type pads  Special beds  Pillows, trochanter rolls, foot boards, and other positioning devices  Report and record any signs of skin breakdown or pressure ulcers at once. Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 20

28.  VENOUS ULCERS (STASIS ULCERS)  Are open sores on the lower legs or feet caused by poor blood flow through the veins  The heels and inner aspect of the ankles are common sites. Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 28

31.  Risk factors include:  History of blood clots  History of varicose veins  Decreased mobility  Obesity  Leg or foot surgery  Advanced age  Surgery on the bones and joints  Phlebitis (inflammation of a vein) Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 31

32.  Prevention and treatment involve:  Follow the person’s care plan to prevent skin breakdown.  Prevent injury.  Handle, move, and transfer the person carefully and gently.  Persons at risk need professional foot care.  Drugs for infection and to decrease swelling  Medicated bandages and other wound care products  Devices used for pressure ulcers  Elastic stockings or elastic bandages Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 32

37.  ARTERIAL ULCERS  Are open wounds on the lower legs or feet caused by poor arterial blood flow  Are found between the toes, on top of the toes, and on the outer side of the ankle  Smoking is a risk factor.  Treatment involves:  Treating the disease causing the ulcer  Drugs and wound care  A walking and exercise program  Professional foot care Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 37

39.  DIABETIC FOOT ULCER  Is an open wound on the foot caused by complications from diabetes  You need to:  Check the person’s feet every day  Report any sign of a foot problem to the nurse at once  Follow the care plan Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 39

40.  WOUND HEALING  The healing process has three phases:  Inflammatory phase (3 days)  Proliferative phase (day 3 to day 21)  Maturation phase (day 21 to 2 years)  Healing occurs in three ways:  First intention (primary intention, primary closure)  Second intention (secondary intention)  Third intention (delayed intention, tertiary intention) Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 40

41.  Many factors affect healing and increase the risk of complications.  The type of wound  The person’s age, general health, nutrition, and lifestyle  Circulation  Drugs  Nutrition  Immune system changes  Complications include:  Infection  Dehiscence  Evisceration Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 41

42.  Wound appearance  Doctors and nurses observe the wound and its drainage.  You need to make certain observations when assisting with wound care.  Wound drainage is observed and measured.  Serous drainage is a clear, watery fluid.  Sanguineous drainage is bloody drainage.  Serosanguineous drainage is thin, watery drainage that is blood-tinged.  Purulent drainage is thick, green, yellow, or brown drainage. Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 42

43.  Drainage must leave the wound for healing.  When large amounts of drainage are expected, the doctor inserts a drain.  Drainage is measured in three ways:  Noting the number and size of dressings with drainage  Weighing dressings before applying them to the wound  Dressings are then weighed after removal.  Measuring the amount of drainage in the collection container if closed drainage is used Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 43

44.  DRESSINGS  Wound dressings have many functions.  Protect wounds from injury and microbes  Absorb drainage  Remove dead tissue  Promote comfort  Cover unsightly wounds  Provide a moist environment for wound healing  Apply pressure (pressure dressings) to help control bleeding Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 44

45.  The following types of dressings are common:  Gauze  Non-adherent gauze  Transparent adhesive film  Dressings that contain special agents to promote wound healing  Dressings are wet or dry.  Dry dressing  Wet-to-dry dressing  Wet-to-wet dressing Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 45

46.  Securing dressings  Microbes can enter the wound and drainage can escape if the dressing is dislodged.  Tape and Montgomery ties are used to secure dressings.  Binders hold dressings in place. Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 46

47.  BINDERS  Binders promote healing by:  Supporting wounds  Holding dressings in place  Preventing or reducing swelling  Promoting comfort  Preventing injury  An abdominal binder provides abdominal support and holds dressings in place.  A breast binder supports the breasts after surgery.  T-binders secure dressings in place after rectal and perineal surgeries. Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 47

48.  MEETING BASIC NEEDS  The wound can affect the person’s basic needs.  The wound causes pain and discomfort.  Good nutrition is needed for healing.  Infection is always a threat.  Delayed healing and infection are risks for persons who:  Are older or obese  Have poor nutrition  Have poor circulation and diabetes  Many factors affect safety and security needs.  Whatever the wound site or size, it affects function and body image. Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 48

49.  QUALITY OF LIFE  Residents have the right to care that promotes healthy skin and prevents skin breakdown.  Everyone must keep the person’s skin healthy.  Follow the person’s care plan.  Be very careful not to injure the skin during care.  Treat the person with dignity and respect. Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 49