1. Wound Care Chapter 5 Starts on page 100 Advanced Skills for Health Care Providers, Second Edition, Barbara Acello, 2007 Thompson Delmar

2. Objectives 1.Spell and define key terms 2.Identify the structures of the skin affected by Stage I, Stage II, Stage III, and Stage IV pressure ulcers 3.List at least seven systemic factors and seven local factors affecting wound healing

3. Objectives continued 4.Describe how to remove a dressing and observations to make of the underlying wound 5.Demonstrate how to cleanse a linear wound and a circular wound, and explain why you would clean a wound from the most clean to least clean areas 6.Define dressings and describe when each is used

4. Objectives continued 7.Demonstrate how to apply dressings to wounds with and without drains 8.State the indications for using transparent film dressings, hydrocolloid dressings, and wet-to-dry dressings 9.Demonstrate suture and staple removal

5. KNOW PROCEDURES:  Procedure 19 Changing a Clean Dressing  Procedure 21 Applying a Sterile Dressing  Procedure 23 Changing Wet-to-dry Dressing  Procedure 27 Removing Sutures  Procedure 28 Removing Staples

6. PCT 130 Wound Care Word Bank systemic local necrotic tissue purulent maceration granulation tissue cytotoxic (continued next slide)

7. Word Bank continued dressings hypoallergenic tape bandages Montgomery straps transparent film dressings hydrocolloid dressings interrupted sutures continuous sutures

8. Wound Observations to Report to the Nurse Redness Drainage, purulent & / or foul-smelling Heat Edema Increased pain or tenderness Fever » continued

9. Wound Observations to Report to the Nurse, continued. Edema of tissue around the wound Separation of wound edges Trauma or injury Maceration Bruising Frank bleeding

10. Infection Alert Nursing is both an art and a science. To change wound dressings, you must be proficient in both aspects. The art involves organizing your time and supplies, protecting the patient’s dignity (continued)

11. Infection Alert continued and privacy, and making the dressing change as painless as possible. The science involves preventing wound contamination or cross-contamination, thereby reducing the risk of infection.

12. “Rights” for dressing changes: Right patient Right dressing Right time Right treatment product Right amount / quantity Right environment Right technique Right documentation

13. THE SKIN Many different types of wounds:  Trauma  Accidental injuries  Burns  surgical incisions, and pressure ulcers

14. Cross-section of the skin

15. Layers of the skin Epidermis – the outer, protective layer Dermis – beneath the epidermis, it contains nerves, hair follicles, sweat glands, and oil glands Subcutaneous tissue - this layer is made up of fat and is a covering for muscles, tendons, and bone

16. Pressure Ulcers Pressure ulcers are classified by stage, as determined by the depth and degree of involvement of the underlying structures

17. Pressure Ulcers Stage I Stage I: nonblanchable erythema, note: with dark skin, look for discoloration, warmth, edema, induration, or hardness

18. Pressure Ulcers Stage II Stage II : partial-thickness skin loss involving epidermis, dermis, or both; ulcer is a superficial abrasion, blister,or shallow crater

19. Pressure Ulcers Stage III Stage III: full-thickness skin loss involving damage to or necrosis of subcutaneous tissue; deep crater

20. Pressure Ulcers Stage IV Stage IV: full-thickness skin loss with extensive destruction, tissue necrosis,or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule)

21. Pressure Ulcer Staging

22. FACTORS AFFECTING WOUND HEALING: SYSTEMIC & LOCAL A systemic condition or factor is something that affects the entire body, rather than its single individual parts. Systemic factors that affect wound healing are: age nutritional status body build presence or absence of chronic disease circulatory problems weakened immune system radiation therapy

23. FACTORS AFFECTING WOUND HEALING: SYSTEMIC & LOCAL, CONTINUED A local or localized condition or factor is one that affects only one system or body part. Many local factors affect wound healing. These include: moist wound environment infection necrotic tissue (tissue that is dead) foreign objects in the wound trauma edema pressure on the wound incontinence and presence of excretions contaminating the wound