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Unit 9 Wound Care and Sterile Technique

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1 Unit 9 Wound Care and Sterile Technique
Metro Community College Nursing Program Nancy Pares, RN, MSN

2 Factors that influence wound healing
Age Elders: less elastic, drier, circulation impairment longer regeneration Mobility Increased pressure leads to breakdown Nutrition Poor nutrition, less regeneration, dehydration leads to poor turgor, increase risk of infection

3 Factors affecting skin integrity con’t
Sensation level Increased risk for pressure and breakdown Impaired circulation Decreased O2 supply impacts healing ability, vessel disease, smoking Medications Side effects: itching, rashes Diabetes Impairs inflammatory response from hypoglycemia; must maintain control of BS

4 Factors cont Moisture Obesity Fever Infection Lifestyle
Leads to maceration Obesity Less blood supply in adipose tissue Fever Affects moisture and metabolic rate Infection Impedes healing Lifestyle Tanning, bathing, piercings

5 Classification of wounds
Based on length of time wound existed and the condition of the wound Open/closed No breaks in skin vs. true break in skin Acute/chronic Short vs. prolonged healing Clean/contaminated/infected Uninfected vs. open traumatic vs. evidence of infection

6 Classification cont Superficial Partial Full Penetrating
Epidermis: friction, shearing, burns Partial Extend into dermis Full Extend into subcutaneous tissue Penetrating Involves internal organs

7 Wound drainage Serous: clear-straw colored, watery Sanguinous: bloody
Clean wounds Sanguinous: bloody Deep wounds Serosanguinous: pale pink (mixed) New wounds Purulent: yellow or green tinged pus Purosanguinous: red tinged pus

8 Wound healing process Regeneration Primary intention
Same process regardless of injury or tissues When wound involves only epidermis No scar Primary intention Minimal scarring Clean, surgical incision; edges well approximated

9 Wound healing Secondary intention Tertiary intention (delayed closure)
Extensive tissue loss Wound not well approximated; heals from inner surface to outer; epithelial tissue may look like sign of infection Tertiary intention (delayed closure) Granulating tissue is brought together; initially wound heals by secondary intention then is sutured; moderate scarring

10 Wound healing stages Inflammatory: cleansing stage lasts 1-5 days
Hemostasis; vasoconstriction, platelets arrive at site, clotting occurs Inflammation: vasodilatation, phagocytosis, scab formation Proliferative: granulation stage lasts days Fibroblasts form a bed of collagen Fills defects and produces new capillaries Maturation: epitheliazation, begins 2nd or 3rd wk Contraction of wound edges; scar tissue formation; scar tissue is 80% strong as original tissue.

11 Complications of wound healing
Hemorrhage Infection 2-3 days in contaminated wound; 4-5 days post op Hematoma Dehiscence: likely during inflammatory phase Evisceration Place sterile saline soaked 4x4 over area Call MD or notify charge/ surgical emergency Fistula: abnormal passageway often from infection

12 Nursing Assessment Location Size Appearance Skin around the wound
Anatomic terms Size Length and width Appearance Type, color (Red, yellow black), condition, Skin around the wound Drainage Patient pain

13 Nursing interventions related to wound care
Cleansing and irrigation Use saline, dilute antimicrobial or commercially prepared cleansers—no hydrogen peroxide, alcohol or iodine; gentle is best; hydrotherapy=debridement Caring for drainage devices : Vol 2

14 Debridement Sharp Mechanical Enzymatic Autolysis
MD or PT at bedside or OR Mechanical Wet to dry dressing-used less Hydrotherapy Enzymatic Topical agent Autolysis Uses body out mechanisms

15 Applying wound dressings
Gauze Transparent Clear, semi permeable, non absorbent, often used for IV sites Hydrocolloids/hydrogels Water loving particles that form a gel with exudate Absorption See page 840 table

16 Supporting and immobilizing
Securing dressings Tape, Montgomery straps Binders See 34-6,7 Vol 2 Important Nursing interventions Inspect skin, assess and change dressings as ordered Always ACE wrap distal to proximal Assess for circulatory impairment

17 Heat and Cold Therapy Clients at risk Moist heat Dry heat
Very old or very young Sensory impairment Body areas: highly vascular—fingers, hands, face Moist heat Moisture amplifies the treatment; vasodilates, reduces muscle tension Dry heat Use with great caution

18 Cold therapy Vasoconstriction Decreases edema and inflammation
Acts as a local anesthetic Slows bacterial growth Used in the first 24 hrs following injury R-est I-ce C-ompress E-levate

19 Sterile Technique Surgical asepsis Absence of all microorganisms
Slightest break in technique=contamination Sterile object is only sterile when touched by another sterile object When in doubt….throw it out…. Place only sterile objects on a sterile field Sterile object or field that is out of visual range is contaminated

20 Sterile technique con’t
If exposed to air for a prolonged time=contaminated Sterile border =field plus 1 inch Do not reach over a sterile field Keep hands in front and above waist in field of vision Procedures which require sterile technique Injection preparation , catherizations

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