Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 32 Wound Care Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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