Wound Care Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Wound Care

Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

The skin is the body’s first line of defense.

You must prevent skin injury and give good skin care to help prevent skin breakdown.

Older and disabled persons are at great risk for skin breakdown.

A wound is a break in the skin or mucous membrane.

Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.Slide

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Common causes of wounds are:

Surgery

Trauma

Pressure ulcers from unrelieved pressure

Decreased blood flow through the arteries or veins

Nerve damage

The nurse uses the nursing process to keep the person’s skin healthy.


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TYPES OF WOUNDS

Wounds are described in the following ways:

Intentional wounds and unintentional wounds

Open and closed wounds

Clean wounds

Clean-contaminated wounds

Contaminated wounds

Infected wounds

Chronic wounds

Partial- and full-thickness wounds


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Wounds also are described by their cause:

Abrasion

Contusion

Incision

Laceration

Penetrating wound

Puncture wound


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SKIN TEARS

A skin tear is a break or rip in the skin.

The hands, arms, and lower legs are common sites for skin tears.

Causes

Friction and shearing

Pulling or pressure on the skin

Tell the nurse at once if you cause or find a skin tear.


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Persons at risk for skin tears:

Need moderate to total help in moving

Have poor nutrition

Have poor hydration

Have altered mental awareness

Are very thin

Careful and safe care helps prevent skin tears and further injury.


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PRESSURE ULCERS (DECUBITUS ULCERS, BED SORES, PRESSURE SORES) A pressure ulcer is an injury usually from unrelieved pressure. A pressure ulcer usually occurs over a bony prominence. Pressure, shearing, and friction are common causes. Risk factors include:

Breaks in the skin Poor circulation to an area Moisture Dry skin Irritation by urine and feces


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Persons at risk for pressure ulcers are those who:

Are bedfast or chairfast

Need some or total help in moving

Are agitated or have involuntary muscle movements

Have loss of bowel or bladder control

Are exposed to moisture

Have poor nutrition

Have poor fluid balance

Have lowered mental awareness

Have problems sensing pain or pressure

Have circulatory problems

Are older

Are obese or very thin


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Pressure ulcer stages

Stage 1: The skin is red in persons with light skin. The skin is red, blue, or purple in persons with dark skin.

Stage 2: Partial-thickness skin loss

Stage 3: Full-thickness skin loss

Stage 4: Muscle and bone are exposed and damaged.

Sites

Pressure ulcers usually occur over bony areas called pressure points.

The ears also are sites for pressure ulcers.

In obese people, pressure ulcers can occur in areas where skin has contact with skin.


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Stages


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Stages


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Prevention and treatment

Good nursing care, cleanliness, and skin care are essential.

The person at risk for pressure ulcers is placed on a surface that reduces or relieves pressure.

The doctor orders wound care products, drugs, treatments, and special equipment to promote healing.


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Protective devices are often used to prevent and treat pressure ulcers.

Bed cradles

Heel and elbow protectors

Heel and foot elevators

Gel- or fluid-filled pads and cushions

Eggcrate-type pads

Special beds

Pillows, trochanter rolls, foot boards, and other positioning devices

Report and record any signs of skin breakdown or pressure ulcers at once.


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VENOUS ULCERS (STASIS ULCERS)

Are open sores on the lower legs or feet caused by poor blood flow through the veins

The heels and inner aspect of the ankles are common sites.


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Risk factors include:

History of blood clots

History of varicose veins

Decreased mobility

Obesity

Leg or foot surgery

Advanced age

Surgery on the bones and joints

Phlebitis (inflammation of a vein)


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Prevention and treatment involve:

Follow the person’s care plan to prevent skin breakdown.

Prevent injury.

Handle, move, and transfer the person carefully and gently.

Persons at risk need professional foot care.

Drugs for infection and to decrease swelling

Medicated bandages and other wound care products

Devices used for pressure ulcers

Elastic stockings or elastic bandages

Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Slide 32

ARTERIAL ULCERS

Are open wounds on the lower legs or feet caused by poor arterial blood flow

Are found between the toes, on top of the toes, and on the outer side of the ankle

Smoking is a risk factor.

Treatment involves:

Treating the disease causing the ulcer

Drugs and wound care

A walking and exercise program

Professional foot care


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DIABETIC FOOT ULCER

Is an open wound on the foot caused by complications from diabetes

You need to:

Check the person’s feet every day

Report any sign of a foot problem to the nurse at once

Follow the care plan


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WOUND HEALING

The healing process has three phases:

Inflammatory phase (3 days)

Proliferative phase (day 3 to day 21)

Maturation phase (day 21 to 2 years)

Healing occurs in three ways:

First intention (primary intention, primary closure)

Second intention (secondary intention)

Third intention (delayed intention, tertiary intention)


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Many factors affect healing and increase the risk of complications.

The type of wound

The person’s age, general health, nutrition, and lifestyle

Circulation

Drugs

Nutrition

Immune system changes

Complications include:

Infection

Dehiscence

Evisceration


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Wound appearance

Doctors and nurses observe the wound and its drainage.

You need to make certain observations when assisting with wound care.

Wound drainage is observed and measured.

Serous drainage is a clear, watery fluid.

Sanguineous drainage is bloody drainage.

Serosanguineous drainage is thin, watery drainage that is blood-tinged.

Purulent drainage is thick, green, yellow, or brown drainage.


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Drainage must leave the wound for healing.

When large amounts of drainage are expected, the doctor inserts a drain.

Drainage is measured in three ways:

Noting the number and size of dressings with drainage

Weighing dressings before applying them to the wound

Dressings are then weighed after removal.

Measuring the amount of drainage in the collection container if closed drainage is used


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DRESSINGS

Wound dressings have many functions.

Protect wounds from injury and microbes

Absorb drainage

Remove dead tissue

Promote comfort

Cover unsightly wounds

Provide a moist environment for wound healing

Apply pressure (pressure dressings) to help control bleeding


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The following types of dressings are common:

Gauze

Non-adherent gauze

Transparent adhesive film

Dressings that contain special agents to promote wound healing

Dressings are wet or dry.

Dry dressing

Wet-to-dry dressing

Wet-to-wet dressing


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Securing dressings

Microbes can enter the wound and drainage can escape if the dressing is dislodged.

Tape and Montgomery ties are used to secure dressings.

Binders hold dressings in place.


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BINDERS Binders promote healing by:

Supporting wounds

Holding dressings in place

Preventing or reducing swelling

Promoting comfort

Preventing injury

An abdominal binder provides abdominal support and holds dressings in place.

A breast binder supports the breasts after surgery. T-binders secure dressings in place after rectal and

perineal surgeries.


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MEETING BASIC NEEDS The wound can affect the person’s basic needs.

The wound causes pain and discomfort.

Good nutrition is needed for healing.

Infection is always a threat.

Delayed healing and infection are risks for persons who: Are older or obese Have poor nutrition Have poor circulation and diabetes

Many factors affect safety and security needs.

Whatever the wound site or size, it affects function and body image.


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QUALITY OF LIFE

Residents have the right to care that promotes healthy skin and prevents skin breakdown.

Everyone must keep the person’s skin healthy.

Follow the person’s care plan.

Be very careful not to injure the skin during care.

Treat the person with dignity and respect.


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Wound Care Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Documents

affiliate of elsevier

skin injury

skin breakdown

skin tearsa skin tear

persons skin healthy

good skin care

pressure soresa pressure

common causes of wounds