Chapter 30 Wound Care All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of...

Chapter 30

Wound Care

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Skin and Wound Care

The skin is the body’s first line of defense. A wound is a break in the skin or mucous

membrane. A wound is a portal of entry for microbes.

Infection is a major threat. Wound care involves:

Preventing infection Preventing further injury to the wound and nearby

tissues You must prevent skin injury and give good

skin care to help prevent skin breakdown. 2All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Wounds

Common causes of wounds are: Surgery Trauma Pressure ulcers from unrelieved pressure Decreased blood flow through the arteries or veins Nerve damage

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

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

3All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

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 (dirty wound) Chronic wounds Partial- and full-thickness wounds


Types of Wounds (Cont’d)

Wounds are also described by their causes: Abrasion Contusion Incision Laceration Penetrating wound Puncture wound Ulcer


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 Falls or bumping a hand, arm, or leg on any hard

surface Holding the person’s arm or leg too tight

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


Risk Factors for Skin Tears

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.


Circulatory (Vascular) Ulcers

Open sores on the lower legs or feet Caused by decreased blood flow Types

Venous ulcers Arterial ulcers Diabetic foot ulcers

Poor circulation can result in: Pain Open wounds Edema Infection and gangrene


Venous (Stasis) Ulcers

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.

Risk factors include: History of blood clots or varicose veins Decreased mobility Obesity Hereditary Leg or foot surgery Advanced age Surgery on the bones and joints Phlebitis (inflammation of a vein)


Prevention and Treatment

Prevention and treatment involve: Follow the person’s care plan to prevent skin breakdown. Prevent injury. Do not bump the legs and feet. Elevate the extremities. Do not put pressure on heels or

calves 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 Compression stockings or elastic bandages


Treatment

Compression stockings (anti-embolism stockings) Exert pressure on the veins Promote venous blood return to the heart Help prevent venous ulcers and blood clots (thrombi) in leg veins

Thrombus Can form in deep leg veins Can break loose and travel in the bloodstream (embolus) An embolus can lodge in a vein in the lungs (pulmonary embolus)

Elastic bandages Have the same purpose as compression stockings Support and reduce swelling from injuries Can be used to hold dressing in place


Arterial Ulcers

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

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


Diabetic Foot Ulcers

Open wounds on the foot caused by complications from diabetes

Diabetes can affect the nerves and blood vessels.

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.


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)


Wound Healing & Complications

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: separation of wound layers Evisceration: dehiscence plus protrusion of abdominal organs


Wound Appearance & Drainage

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.


Drainage

Drainage must leave the wound for healing. When large amounts of drainage are expected,

the doctor inserts a drain. Drainage is measured in two 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


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.


Types of Dressings

The following types of dressings are common: Gauze Nonadherent gauze Transparent adhesive film Dressings that contain special agents to promote wound

healing • Hydrocolloids• Hydrogels

Negative-pressure dressings Dressings are wet or dry.

Dry dressing Wet-to-dry dressing Wet-to-wet dressing


Dressings (Cont’d)

Securing dressings Microbes can enter the wound and drainage can

escape if the dressing is dislodged. Tape and adherent wraps are used to secure

dressings. Binders hold dressings in place.

The nurse may ask you to assist with dressing changes. Some centers let you apply simple, dry, non-sterile

dressings to simple wounds.


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. 21All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Warm and Cold Applications

Promote healing and comfort Reduce tissue swelling Warm and cold have opposite effects on body

function. Doctors order heat and cold applications.


Heat Applications

Heat: Relieves pain Relaxes muscles Promotes healing Reduces tissue swelling Decreases joint stiffness

When heat is applied to the skin: Blood vessels in the area dilate. Blood flow increases. Tissues have more oxygen and nutrients for healing. Excess fluid is removed from the area faster. The skin is red and warm.


Complications

Complications High temperature can cause burns. Report pain, excessive redness, and blisters at once. When heat is applied too long, blood vessels constrict.

Persons at risk for complications include: Older and fair-skinned persons Persons with problems sensing heat and pain (nervous

system damage, loss of consciousness, circulatory disorders, confusion, some medications)

Persons with dementia Persons with metal implants


Moist and Dry Warm Applications

Moist and dry warm applications With a moist heat application, water is in contact with the

skin. Moist heat has greater and faster effects than dry heat

because water conducts heat. Moist heat applications include a warm compress, a warm

soak, a sitz bath, and warm packs. Some warm packs and the aquathermia pad (Aqua-K, K-

Pad) are dry heat applications. With a dry heat application, water is not in contact with the

skin. A dry application stays at the desired temperature longer. Dry heat does not penetrate as deeply as moist.


Cold Applications

Are often used to treat sprains and fractures Reduce pain, prevent swelling, and decrease

circulation and bleeding Cool the body when fever is present Have the opposite effect of heat Are useful right after an injury Have a numbing effect on the skin

This helps reduce or relieve pain in the part. Complications include pain, burns, blisters, and poor

circulation. When cold is applied for a long time, blood vessels dilate.


Moist & Dry Cold Applications

Persons at risk for complications include: Older and fair-skinned persons Persons with sensory impairments Persons with dementia

Moist cold applications: Penetrate deeper than dry ones Are not as cold as dry applications Include cold compresses and cold packs

Dry cold applications include: Ice bags, ice collars, and ice gloves

Cold packs can be moist or dry applications.


Cooling and Warming Blanket

Hyperthermia is a body temperature that is much higher than the person’s normal range. Lowering the person’s body temperature is

necessary.• Vital signs are checked often to prevent rapid or excess

cooling.

Hypothermia is a very low body temperature. A warming blanket is like a cooling blanket except

warm settings are used.• Vital signs are checked often to prevent rapid or excess

warming.


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.


Quality of Life

To promote quality of life: Follow the person’s care plan. Be very careful not to injure the skin during care. Treat the person with dignity and respect. Try to understand the person’s concern. Refer questions to the nurse. Remember the right to personal choice. Remember to explain procedures to residents. Protect the right to privacy. Provide a safe, comfortable setting.


Chapter 30 Wound Care All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of...

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