Chapter 28 Wound Care

Chapter 28 Wound Care

Chapter 28 Wound CareTerms:WoundAbrasionContusionIncisionLacerationPenetrating woundPuncture woundSkin Tear

Types of wounds:IntentionalOpenClosedCleanClean-contaminatedContaminatedInfected/dirtyChronicPartial thicknessFull thickness

Pressure ulcers:Also known as decubitus ulcers, bedsores, pressure soresCauses: pressure, friction and shearing

Persons at risk:Confined to bed or chairNeed some or total help to moveLoss of B/B controlPoor nutrition and fluid balanceAltered mental awarenessProblems with sensing pain/pressureObese or very thinOlderCirculatory problems

Sites:Usually occur over a bony spotCalled pressure pointsIn obese, can occur where there isskin to skin contactIn persons who are bedridden, sores can develop on the ears epidermal stripping

Stages of pressure ulcers:Stage I

Stage II

Stage III

Stage IV

Surgical Wounds

Surgical Drains

Circulatory Ulcers: Venous

Circulatory Ulcers: Arterial

Prevention of Circulatory Ulcers:Do not sit with legs crossedDo not dress in tight clothesKeep feet clean and dry, dry well between toesDo not scrub or rub skin during bathLinens dry and wrinkle freeAvoid injury to legs and feetMake sure shoes fit properlyKeep pressure off heels and other bony areasObserve legs and feet, report any skin breaks or color changesWound assessment:Location of each woundSize and depth (the nurse does this, you may assist)Appearance: area around it is red/warm to touch/swollen, sutures/staples intact, wound edges closed/separatedDrainage present COAWound photography

Wound Healing:Inflammatory Phase (first 3 days)Proliferative Phase (days 3-21)Maturation Phase (day 21 on)

Primary intentionSecondary intentionTertiary intention Complications:InfectionsBleedingEviscerationDehiscenceGangrene

Factors that affect wound healing:Circulatory diseaseAgeSmokingDiabetesCertain medications (blood thinners)Nutrition (especially protein)Type of wound and treatmentAntibioticsWeakened immune system

Prevention of skin breakdown and injury:Heel and elbow protectors Bed cradleTurning and positioningWrinkle free linensBe careful when moving a personPrevent friction and shearing when turningMake sure skin is completely dry when bathingDo good perineal careApply lotion to dry skin as directed by care planDo not massage over pressure pointsKeep heels off the bedReposition frequently in chair, encourage patient to shift weightReport any skin conditions immediately

Other prevention techniquesSpecial beds/mattressesSpecial chair cushionsProtective barrier cream

Wound DrainageSerousSanguineousSerosanguineousPurulentTreatment of wounds:Dressing changes:Dry dressingWet to dryPackingDuodermGauze, non-adherent gauzeTegaderm (transparent)Sterile vs. cleanPurposes of dressings

Others: Montgomery tiesBreast binderSingle and double T bindersAbdominal binderAce wrapTED Hose

Guidelines for applying:Binders: Make sure there is firm even pressure over the area, snug, but not impeding circulation or breathing. Secure any pins to point away from the wound.With Ace wraps, make sure they are snug, but not too tight and they are secured.See pages 575,576Always wash your hands, change any wraps/binders that become soiled.Anything with blood or body fluids (such as dressings) need to be put in biohazard.CNAS can apply a simple dry dressing (like basic first aide), but the nurse does all complicated dressing changes. You may assist. Be careful when removing tape (like after a blood draw). Other treatmentsOintmentsIrrigationDebridementWound vac

CNAS can apply NON-MEDICATED protective barrier cream in most facilities. Check with your facility. Do NOT apply any type of medicated ointment or powder!

A final word..You will see some bad wounds during the course of your career. Some will have a very bad odor, lots of drainage, or be very deep (where you can see bone, muscle, etc).You have to keep your emotions in check. Do not talk about the wound negatively in front of the person. They need to feel accepted and not worry about what people think of their wounds. Also, dont run down the facility they came from in front of the patient (it is the nursing homes, surgeons or hospitals fault).