Pressureulcerandwoundsextrahelp

NRB 121 Self Learning Module: Wound Assessment

Tracey J. Siegel MSN RN CWOCN CNE

Mrs. Siegel Says:

This may help you visualize pressure ulcers and other wounds!

Don’t print this up!Save paper!Watch this as a slide show! Then read the information in the notes section to help you better understand the nursing care of wounds!

Objectives:

Following this self directed Power Point, nursing students will be able to:

1. Describe the best practices to manage acute and chronic wounds.

2. Explain the role of the nurse when caring for acute and chronic wounds.

Why is this topic important to student nurses?

New RN graduates are responsible for the prediction, prevention and management of pressure ulcers in all settings. As our population gets older, understanding pressure ulcers and the care of all wounds is a priority!

Everything Old is New Again!

“Nature alone cures…nature heals the wound. What nursing has to do…is put the patient in the best condition for nature to act upon him.” Florence Nightingale

Assessment!

Often as nurses we get so wrapped up in the wound itself, we forget an important thing- we need to look at the whole patient….not just the hole in the patient!

Patient Assessment and Wound CarePatient Assessment and Wound Care

Subjective/Objective DataSubjective/Objective Data Remember, the client is more than the Remember, the client is more than the

wound- need to do a complete nursing wound- need to do a complete nursing historyhistory

Focus on: Nutrition, hydration, oxygen Focus on: Nutrition, hydration, oxygen and vascular status, immune state, other and vascular status, immune state, other illnessesillnesses

Contributing Factors: pressure, shear, Contributing Factors: pressure, shear, friction, impaired mobility friction, impaired mobility

Overall prognosis and/or client goalsOverall prognosis and/or client goals

AssessmentAssessment: Objective Data: Objective Data

Mechanical Mechanical stressorsstressors

EdemaEdema

Wound Wound temperaturetemperature

Cytotoxic agentsCytotoxic agents

Excess exudateExcess exudate

LocalLocalDry wound bed

Presence of devitalized tissue

Contaminated

Infection

Assessment!“…it must never be lost sight of

what observation is for. It is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort.”

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Partial-Thickness WoundsPartial-Thickness Wounds

• Tissue destruction Tissue destruction through the through the epidermis extending epidermis extending into but not through into but not through the dermisthe dermis

Heals by:Heals by:• EpithelializationEpithelialization• Contraction of Contraction of

wound marginswound margins

For example: Skin Tears, For example: Skin Tears, blisters, and Stage II blisters, and Stage II pressure ulcerspressure ulcers

SkinTear

Pressure Ulcer vs. Dermatitis

Which is which?

Stage III and Stage IV Pressure Ulcers vs. Full Thickness Wounds

All Stage III and IV PU are full thickness wounds but not all full thickness wounds are pressure ulcers!

Surgical, arterial, venous, and other wounds do not get staged…only pressure ulcers.

These wounds are classified as either partial or full thickness

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Full-Thickness WoundsFull-Thickness Wounds

Tissue destruction Tissue destruction extending through extending through the dermis to the dermis to involve involve subcutaneous subcutaneous tissue and possibly tissue and possibly muscle or bonemuscle or bone

Heals by:Heals by:GranulationGranulationWound ContractionWound ContractionEpithelializationEpithelialization

Clean dehised surgical wound

Clean granular Stage III or IV Pressure Ulcer

“ASSESSMENTS”

Anatomic Location-Age of wound

Size, Shape and Stage

Sinus Tracts Exudate Sepsis Surrounding Skin

Maceration Edges,

Epithelialization Necrotic Tissue Tissue Bed Status

Baranoski and Ayello (2007)

Assessment and Classification Assessment and Classification by Colorby Color

RED WOUNDRED WOUND YELLOW WOUNDYELLOW WOUND

If charting this wound- 60% slough40% red granulation tissue

Assessment and ClassificationAssessment and Classification by Color by Color

BLACK WOUNDBLACK WOUND BLACK WOUNDBLACK WOUND

Deep Tissue Injury- new classification of pressure ulcer

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Further description:Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

Deep Tissue Injury

MeasurementMeasurement

Undermining

L x W x D

Pain!

Depth

Sharp Debridement

What is wrong with this picture???

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Nursing Diagnosis and Goals

Impaired Skin Integrity

Altered Tissue Perfusion

???????????? Cure vs. Palliative

Care Pain Management Multidisciplinary

Approach

Moist Wound Healing is the current

Standard of CareEnhances angiogenesisEnhances epithelial cell migration↑ activity of fibroblasts, essential

for collagen formationPrevents dehydration and tissue

cooling

Assessment- Management

Wound care products are now classified by action and structure similar to medications-therefore just as all Beta Blockers or Penicillins act in a similar fashion- so do all hydrocolloids and calcium alginates!

It doesn’t matter what the brand name is- get to know wound care products by how they work in the wound environment!

Disadvantages to Gauze in Topical Therapy

Non research based therapy

More painful May impede

wound healing Increased risk for

infection Costly and labor

intensive

Transparent Dressings (Op Site®)First dressings developed to promote moist wound healing

Actions semi permeable membrane that

permits gaseous exchange but prevents bacterial invasion

Maintains moist wound environment

Supports autolytic debridement of dry eschar

Insulates and protects Indicated for partial thickness

wounds, prevention, and protection, secondary dressing

Contraindicated in fragile geriatric skin over skin tears

Hydrocolloids (Duoderm®) An occlusive moldable wafer

Actions Supports autolytic debridement Absorbs moderate exudate Protects and insulates wound Normal for exudate to look

yellow with a slight odor- doesn’t mean that wound is infected

Change q. 3-5 days Indicated for partial and full

thickness wounds with minimal exudate

Contraindications include infected diabetic ulcers

Hydrogel (Intrasite ®)Water or glycerin based gels, sheets or impregnated gauzes

Actions Supports autolytic debridement Rehydrates dry, desiccated

wounds Fills dead space as packing Limited absorptive action There are no contraindications for

gels Frequency of dressing changes

depends upon type Excellent for pain management as

they soothe and cool especially radiation burns and herpes zoster

Calcium Alginate (Sorbsan®)Highly absorbent sheets or ropes of “seaweed”

Actions Exudate absorption Wound packing Supports autolytic

debridement of yellow slough Contraindicated in dry eschar

and non draining wounds Change q. 2-4 days

Foams (Allevyn®)- “Sponges”

Actions Creates a moist wound environment Absorbs exudate Insulates wound Support autolytic debridement Contraindicated in dry eschar and non

draining wounds Can be used on all partial and full

thickness wounds Change q. 3-7 days

Enzyme Debriders (Santyl®)

Actions Selective debridement of

fibrin slough Digests nonviable

protein but is harmless to granulation tissue

Only works in moist environment and thick eschar must be scored

Daily or BID dressing

Vacuum Assisted Closure®

The application of negative pressure to remove wound exudate and stimulate the growth of granulation tissue

Indicated for full thickness wounds, grafts and flaps

I hope this helped you understand the role of the nurse when caring with patients with wounds!

See Mrs. Siegel if you have any questions or comments!

Reference

Baranoski, S., & Ayello, E. A. (2007). Wound care essentials (2nd ed.). New York: Lippincott, Williams & Wilkins.