Bell Ringer T or F-Remodeling follows the inflammatory phase of wound healing and may last 6 months to 2 years. T or F- A stage III pressure ulcer may.

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Presentation transcript:

Bell Ringer T or F-Remodeling follows the inflammatory phase of wound healing and may last 6 months to 2 years. T or F- A stage III pressure ulcer may be accompanied by serous drainage or purulent drainage caused by a wound infection. T or F- Gastric sump tubes, which are double-lumen tubes, are used almost exclusively to remove fluid and gas from the stomach. T or F- Intestinally placed tubes may lead to dumping syndrome.

Chapter 28: Wound Care

Wounds Wound: damaged skin or soft tissue resulting from trauma Open wounds: mucous membrane is no longer intact- cause: accidental or intentional- surgical incision Closed wounds: no open mucous membrane- cause: blunt trauma or pressure See table 28-1 on page 634

Wound Repair Inflammation: physiologic defense occurring immediately after tissue injury, lasting 2 to 5 days Purpose: limit local damage, remove injured cells/debris, prepare wound for healing Signs and symptoms of inflammation: swelling, redness, warmth, pain, and decreased function

Wound Repair (cont’d) Proliferation: period during which new cells fill and seal a wound; it occurs 2 days to 3 weeks after inflammatory phase The integrity of skin and damaged tissue is restored by resolution, regeneration, and scar formation

Wound Repair (cont’d) Remodeling: period during which the wound undergoes changes and maturation Lasts 6 months to 2 years During remodeling, the wound contracts and the scar shrinks

Inflammatory Response Swelling Redness Warmth Pain Decreased function

Phagocytosis Neutrophils and monocytes(White blood cells) are primarily responsible for phagocytosis, which is a process by which these cells emigrate from blood vessels to consume pathogens, coagulated blood, and cellular debris.

Wound Healing First-intention healing: reparative process in which wound edges are directly next to each other Second-intention healing: wound edges are widely separated; time-consuming, complex reparative process Third-intention healing: deep wound edges brought together with some type of closure material, resulting in a broad, deep scar, may have extensive drainage and tissue debris

(A) First-intention healing. (B) Second-intention healing.   (C) Third-intention healing.

Wound Healing Factors Type of wound injury Expanse or depth of wound Circulation quality Amount of wound debris Presence of infection Client’s health status

Wound Healing Complications Undermining Slough Necrotic tissue

Wound Healing Complications Dehiscence-separation of wound edges Evisceration-separation of wound edges with protrusion of organs

Dressings Dressing purposes: Keeping wound clean Absorbing drainage Controlling bleeding Protecting wound from further injury Holding medication in place Maintaining a moist environment

Dressings (cont’d) Types of dressings: Gauze dressings: ideal for covering fresh wounds that are likely to bleed, or wounds that exude drainage Transparent dressings: used to cover peripheral and central IV insertion sites

Dressings (cont’d) Types of dressings (cont’d) Hydrocolloid dressings: keep wounds moist; moist wounds heal more quickly; new cells grow more rapidly in a wet environment Dressing changes: when a wound requires assessment or care

Question Which dressing is ideal for covering fresh wounds that are likely to bleed? a. Gauze b. Transparent c. Hydrocolloid d. Dressing

Answer a. Gauze Gauze dressing is used for covering fresh wounds. Transparent dressings are used to cover IV insertion sites. Hydrocolloid dressings keep wounds moist. Dressing changes are done when a wound requires assessment, care, or is saturated with drainage.

Wound Management Drains Open drains Closed drains

Vacuum assisted Closure Wound Management Vacuum assisted Closure Sutures; Staples

Wound Management (cont’d) Bandages and binders Purpose: hold dressings in place, especially if tape cannot be used or dressing is very large Support area around the wound or injury to reduce pain Limit movement in wound area to promote healing

Wound Management (cont’d) Binder application – Different types of binders Single T-binder Double T-binder

Roller bandage application A circular and spiral turn. A spiral-reverse turn. A figure-of-eight turn. A spica turn. (E) A recurrent turn.

Wound Management (cont’d) Debridement: removal of dead tissue Sharp debridement: using sterile scissors, forceps, etc. Enzymatic debridement: using chemical substances Autolytic debridement: natural physiologic process

Wound Management (cont’d) Debridement (cont’d): Mechanical debridement: physical removal of debris from a wound using wet-to-dry dressings, hydrotherapy, irrigation Commonly irrigated structures include: Wounds, eyes, ears, vagina

Question Which type of debridement breaks down and liquefies wound debris? a. Autolytic b. Sharp c. Mechanical d. Enzymatic

Answer d. Enzymatic Enzymatic debridement involves the use of topically applied chemical substances. Autolytic debridement allows the body’s enzymes to soften, liquefy, and release devitalized tissue. Sharp debridement is the removal of necrotic tissue with sterile scissors, forceps, or other instruments. Mechanical debridement involves physical removal of debris.

Heat and Cold Applying heat Provides warmth Promotes circulation Speeds healing Relieves muscle spasm Reduces pain

Heat and Cold cont. Applying cold Reduces fevers Prevents swelling Controls bleeding Relieves pain Numbs sensation

Wound Management (cont’d) Heat and cold applications Ice bag and ice collar Chemical packs Compresses Aquathermia pad Soaks and moist packs Therapeutic baths

Pressure Ulcers Also known as decubitus ulcers Appear over bony prominences of the sacrum, hips, heals, and places where pressure is unrelieved Risk factors include: Inactivity, immobility, malnutrition, emaciation Diaphoresis, incontinence, sedation Vascular disease, localized edema, dehydration

Pressure Ulcers (cont’d) Stages of pressure ulcers Stage I: intact but reddened skin Stage II: reddened skin accompanied by blistering or a skin tear Stage III: shallow skin crater that extends to the subcutaneous tissue Stage IV: deeply ulcerated, extending to muscle and bone; life threatening

Pressure sore stages. (A) Stage I. (B) Stage II. (C) Stage III Pressure sore stages. (A) Stage I. (B) Stage II. (C) Stage III. (D) Stage IV.

Pressure Ulcers (cont’d) Prevention of pressure ulcers Change client’s position frequently Avoid using plastic-covered pillows Use the lateral position for side-lying Massage bony prominences Use pressure-relieving devices Provide a balanced diet and adequate fluid intake