Nursing Care for Clients with Wounds Nursing Fundamentals- NURS B20

Wound Classifications Status of skin integrity –Open Wound –Closed Wound Cause –Intentional –Unintentional

Wound Classifications Severity of Injury –Superficial –Penetrating –Perforating Cleanliness –Wound Classifications 1- 4

Wound Classifications Descriptive Qualities –Laceration –Incision –Abrasion –Contusion

Healing by Primary and Secondary Intention Primary Intention Secondary Intention Delayed Closure Nutrition in Wound Healing

Complications in Wound Healing Hemorrhage Infections Dehiscence Evisceration Fistulas

Factors Influencing Wound Healing Age Nutritional status Obesity Extent of wound Tissue oxygenation Smoking Immune Status Chronic conditions Radiation Stress on wound

Assessment In emergency settings –Bleeding? –Foreign bodies or contamination? –Size of wound? –Need for protection of wound? –Need for tetanus antitoxin

Assessment Stable Setting –Wound appearance –Character of drainage Serous Sanguineous Serosanguineous Purulent

Assessment Stable setting –Drains Penrose Evacuator units –Jackson Pratt drains –Hemovac drains –Wound closures Sutures Steel staples Clear strips Wound glues

Drains and Wound Closures

Assessment Stable setting (continued) –Palpation of the wound –Pain –Wound Cultures

Nursing Diagnosis Impaired Skin Integrity Impaired Tissue Integrity Risk for Infection Pain Imbalanced Nutrition, Less than body requirements

Implementation Wound Management –Dressings Purpose of dressings Three layers of surgical dressings –Contact layer –Absorbent layer –Outer layer

Implementation Wound Management (continued) –Dressings Types of dressings –Gauze dressings –Wet to dry dressings –Nonadherent dressings –Self-adhesive transparent dressings –Hydrocolloid and hydrogel dressings

Implementation Wound Management (continued) –Dressings Changing a dressing Packing a wound Securing a dressing –Cleansing skin and drain sites Basic skin cleansing Irrigations

Cleaning a Wound

Securing A Dressing

Implementation Wound Management (continued) –Suture Care –Bandages and binders Provide extra protection and therapeutic benefits by: –Exerting pressure –Immobilizing a body part –Supporting a wound –Securing a splint –Securing dressings

Implementation Wound management (continued) –Principles of bandage and binder application: Position in normal anatomical alignment Prevent friction between/ against skin surfaces Apply bandages securely to prevent slippage Wrap extremities from distal to proximal Apply firmly with equal tension, avoid excess overlap Position knots, pins, ties away from the wound for sensitive skin areas

Implementation Wound management (continued) –Types of binders Breast Abdominal T-Binder Slings

Abdominal Binder

Implementation Wound management (continued) –Elastic Bandage (Ace wrap) Wider bandages for larger body parts Variety of turns to cover various body parts –Circular, spiral, figure of eight Evaluate distal circulation –At least q 4 hours –Note: »Color »Temperature »Pulses »Presence of Numbness

Types of Bandage Applications