1. Chapter 5 Wound Care

2. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.2 Pressure Ulcers Serious complication of immobility –Implement a preventive care plan for high risk patients –A risk factor does not make ulcers inevitable; it is a “red flag” –Planning and implementing preventive care are essential nursing functions

3. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.3 Staging Pressure Ulcers Stage I Ulcers –Nonblanchable erythema of intact skin –Persons with dark skin, discoloration, warmth, edema, induration, or hardness may be at higher risk

4. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.4 Staging Pressure Ulcers Stage II Ulcers –Partial thickness skin loss –Ulcer is superficial and may look like an abrasion, blister, or shallow crater

5. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.5 Staging Pressure Ulcers Stage III Ulcers –Full thickness skin loss that may extend down to underlying fascia

6. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.6 Staging Pressure Ulcers Stage IV Ulcers –Full thickness skin loss with damage to muscle, bone, or supporting structures

7. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.7 Treatment Cart Keep clean and well-stocked Leave treatment cart in hallway when in use

8. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.8 Treatment Cart Make sure you have the right: –Patient –Product –Dressing –Amount/quantity in the right environment –Technique

9. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.9 Supplies for Dressing Change Dressings are gauze, film, or other substances that cover a wound –Some have adhesive backing –Some are affixed with tape Bandages hold dressings in place Avoid wrapping bandages tightly

10. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.10 Supplies for Dressing Change Montgomery straps hold dressings in place –Long strips of adhesive attached to the skin on either side of the wound Elastic mesh and tubular gauze may be used to cover dressings

11. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.11 Changing Dressings Use clean or sterile supplies Set up a clean, dry work surface Observe wound for size, depth, signs of infection, and healing progress

12. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.12 Changing Dressings Clean the wound with normal saline or a pH neutral cleanser After cleaning the wound, remove gloves, clean hands, and apply new gloves Apply treatment product Cover the wound with a dressing

13. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.13 Other Considerations Care for multiple wounds separately –Work from cleanest to the least clean –Wash your hands (or use an alcohol product) between wounds Apply new gloves before caring for each wound

14. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.14 Other Considerations Use sterile technique for wound irrigation Some wounds must be loosely packed after irrigation

15. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.15 Other Considerations Your bandage scissors are a potential source of cross contamination –Wash with soap and water after each use Position trash receptacle so that it will not contaminate clean supplies

16. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.16 Other Considerations Never bring floor stock bottles into patients’ rooms –Pour liquid into a plastic cup –Use an individual container for each patient, if possible

17. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.17 Wounds with Drains Drains eliminate fluids from the body Use sterile technique when caring for a drain Observe and report: –Drain is not intact or patent –Drain appears blocked, dislodged, or kinked –Drainage is eroding surrounding, healthy skin

18. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.18 Wounds with Drains Observe and report: –Drainage is purulent, cloudy, or foul smelling –Amount of drainage changes –Patient has fever, tachycardia, hypotension –Urinary output decreases

19. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.19 Wet to Dry Dressings Used for healing surgical incisions –Occasionally used for removing necrotic tissue from pressure ulcers This is a sterile procedure The dressing is damp when it is applied to the wound

20. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.20 Transparent Film and Hydrocolloid Dressings Transparent film dressings –Adhesive membranes of various thicknesses and sizes Hydrocolloid dressings –Materials such as gelatin and pectin

21. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.21 Transparent Film and Hydrocolloid Dressings Dressings promote a moist environment –Do not use on infected wounds Dressings should be changed in 3-7 days

22. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.22 Pin Care Metal pins may be used to hold the bone in place –Pins may protrude from the skin –Often attached to traction Pins must be kept clean to prevent infection

23. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.23 Pin Care Use sterile technique for pin care Report crusts at the insertion site –Loose pins –Signs and symptoms of infection

24. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.24 Removing Sutures and Staples Sutures and staples must be removed in 7 to 10 days –Depends on location of the wound and progress of healing Interrupted sutures –Each thread is tied off and knotted separately

25. Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.25 Removing Sutures and Staples Continuous sutures –A single thread is used to close an open area of skin Remove every other suture or staple and evaluate the area before continuing