Chapter 28 Wound Care

*Chapter 28Wound Care

Wound: is a break in the skin and mucous membrane. Wound is a portal entry for microbes. Wounds results from many different causes:

-surgical incisions-trauma: accident or violent act that injures skin, bones, internal organs.-Circulatory ulcers and pressure sores from decreased blood flow through the

arteries and veins1. Type of wounds: pg 583 BOX “FOCUS on OLDER Person”.

2. Pressure Ulcers(decubitus ulcer, bedsore): READ PAGES 585-590 Caused by unrelieved pressure. Occur over bony area. The body weight reduces blood supply to tissue. Pressure Sores are easier to prevent (reposition q 2 h ) than to heal.

A. Causes for pressure ulcers: Page 584 Box 28-1 prevent blood flow to tissue, and over bone prominence

A. Causes of pressure ulcers: -friction: scrape/rubbing of skin

-shearing /skin tears: is a break or rip of the skin. skin sticks to a surface and the deeper tissues move downward and the skin is ripped.

✥To prevent skin tears/shearing/friction:-lift and turn person in bed-linens are wrinkle free-keep nail short and smooth and do not wear rings with large stones.-poor repositioning

B. Person at Risk: (risk factors)•Confined to bed or chair •needed some or total help moving•loss of bladder/bowel control •poor nutrition•altered mental awareness •obese or very thin•circulatory problems•older

C. Stages of pressure ulcers: Page 586-587 First sign of pressure ulcer is pale skin or a reddened area.Stage 1: red or pale skin. The color does not return to normal.

Complains of pain, burning or tinglingStage 2: skin cracks, blisters or peelsStage 3: skin is gone and the underlying tissue are exposedStage 4: muscles and bone are exposed. Drainage likely

D. Prevention of Pressure Ulcers: it is easier to prevent a pressure sore than trying to heal the pressure sore!!!! Pg 588 box 28-3

-reposition every 2 hours-lift and turn when moving person-force fluids-encourage balance diet, proteins➚-use pillows/sheep skin -prevent skin to skin contact-keep linens clean, dry and free from wrinkles-never rub or massage reddened areas

E. Devices to prevent pressure ulcers: page 589-590-bed cradle-elbow protectors (made from foam or sheepskin)-heel elevators-flotation pads-eggcrate -like mattress-special beds-footboards

3. Circulatory ulcers: page 591 Open wound on the lower legs and feet caused by decrease in blood flow through the arteries or veins

◆Stasis ulcers: open wounds caused by poor blood return to the heart from the legs and feet. Valves in the legs veins do not close efficiently. Therefore the veins do not pump blood back to the heart normally. Fluid collects in the legs/feet. Elastic stocking are order by the doctor.

-black dead tissue(necrotic tissue) When is happens: debridement (removal of dead tissue)

◆Arterial Ulcers: open wound on the lower legs/feet caused by poor arterial blood flow. Feet/legs may feel cold and look blue or shiny. Painful at rest and usually worse at night.

4. Dressing for wounds: Read pgs 595-598 •protect the wounds from injury and microbes•absorb drainage•Remove dead tissue•provide an environment for wound healing

A. CNA never preform procedures that require sterile technique

B. Tape: Remember the older persons skin is thin and fragile. You must prevent skin tears. Extreme care is necessary when removing tape. •Tape extends several inches beyond each side. •Tape must not circle the entire body part due to swelling.

C. Read the delegation guidelines for applying dressings✥Nurse will always give drugs before a dressing change to help with the pain

D. Always follow care plan and standard precaution when helping with a dressing change

5. Type of wound drains