Mel's Wound Care Lecture Nov 2006

Front 1

Assessment of Wound Color:

Back 1

*RED: proliferative stage (healthy granulation tissue--protect)
*YELLOW: oozing purulent
*BLACK: debride

Front 2

Wound Assessment and Documentation: how to describe wound appearance

Back 2

* LOCATION: side of body, where it is in relation to something else
* SIZE: Length, Width, Depth
* EDGES: Color, defined, or uneven (like a scrape), closed/open
* COLOR: is it necrotic?
* SWELLING--gentle palpation; separation of wound edges; pain/tenderness

Front 3

Wound Assessment: Drainage-Type

Back 3

1) Serous: clear
2) Serosanguinous: bloody/pink
3) Purulent: yellow pus/green, thick foul smelling
*AMOUNT: fully saturated? 50% of dressing type, size of quarter? OB: how many pads saturated
* where is the wound/where are the stresses? ex: abdominal wounds sometimes have sinus pocket on each end

Front 4

Wound assessment: closure, drains

Back 4

*type of closure: staples, sutures--are they intact?
*nurse responsible for maintaining the patency of the draining system, measuring output, assessing type and color of drainage

Front 5

3 Types of Drains

Back 5

1) penrose drain: function by gravity and have an open end that drains onto the dressing
2) Jackson Pratt and 3) Hemovac are closed suction drainage systems that draws out exudate from wound with gentle suction--these are put in the wound in the OR

Front 6

Removing Sutures

Back 6

*cut as closely as possible to one side and then pull through--never pull exposed suture (contaminated) through skin.

Front 7

Purpose of Dressings

Back 7

Provides 1) warmth and moisture, 2) keeps the wound clean guarding against infection 3) protects the wound from further physical trauma/injury 4) homestasis-keeps fluid balance 5) Absorption of drainage
6) debridement 7) support (skin graph or ace bandage

Front 8

Purpose of Cleansing the Wound--types of solution

Back 8

* Remove debris and bacteria with as little trauma to the healthy tissue as possible
* common solutions: normal saline (isotonic), betadine (antiseptic), H2o2/ns (debridement), Acetic Acid (vinegar deodorizes), povidone iodine (antiseptic)

Front 9

Cleansing the Wound: basic principles

Back 9

Always going from the least contaminated to the most contaminated; solutions warmed to room or body temperature

Front 10

Common Types of Wound Dressings

Back 10

* Gauze, telpha (non-stick), wet-dry, transparent film (protection for elderly with frail skin), colloid (from seaweed-high in NACL), collagens/gel, polyurethane foams around tubes, tapes--always stick to eachother, never the skin

Front 11

PRESSURE ULCER: Stage 1

Back 11

intact skin: defined area of persistent redness, or red/blue/purple in darker skin tones

Front 12

PRESSURE ULCER: Stage 2

Back 12

Partial thickness involving the epidermis, dermis, or both (abrasions, blister, shallow crater)

Front 13

PRESSURE ULCER: Stage 3

Back 13

Full thickness involving damage of subcutaneous tissue, may extend to but not through fascia

Front 14

PRESSURE ULCER: Stage 4

Back 14

Full thickness with extensive damage to muscle, bone or supporting structures

Front 15

PRESSURE ULCER: Unstageable

Back 15

When eschar is present, ulcer cannot be staged

Front 16

Assessment of Pressure Ulcers: Braden Scale

Back 16

Braden and Norton Scales exist to predict risk of pressure ulcers and include factors such as: sensory perception, moisture, activity level, mobility, nutrition, friction and shear, mental condition, incontinence

Front 17

4 Debridement Methods

Back 17

1) Surgical, 2) Mechanical (wet-to-dry dressings, whirlpool,etc), 3) Enzymatic or chemical, 4) Autolytic (enhancing body's own enzymes)

Front 18

5 Purposes of Bandages and Binders (types: gauze and elastic)

Back 18

1) Pressure to support incision
2) Immobilization
3) Support
4) Decrease edema
5) Secure a splint

Front 19

Dressing Change 101

Back 19

* MD order specifying details
* Pain meds beforehand
* Wash hands, assemble equipment, assess for drains, remove old dressing with regular gloves
* Cleansing drain sites or wound with sterile gloves, care of sutures, patient teaching, securing dressing

Front 20

Basics of application of Roller Bandages

Back 20

* cover with pad before bandage
* bandage the part in a normal position
* non-constricting pressure (2 finger-widths underneath)
* equal tension on all turns
* no tape on skin

Front 21

Interventions to prevent pressure ulcers

Back 21

1) skin inspection
2) control incontinence
3) bathing
4) positioning, avoid pressure areas, support surfaces, movement/turning

Front 22

Moist wound healing: topicals

Back 22

1) enzymes
2) hydrogel
3) calcium alginate
MAINTAIN NUTRITION

Front 23

Vacuum Assisted Closure

Back 23

*use of negative pressure to encourage wound healing (used for acute and chronic wounds)

Front 24

Wound Categorization by cleanliness of wound

Back 24

1) clean: intentional wounds that were created; no inflammation, no contamination by respiratory, alimentary, genitourinary and oropharyngeal tracts
2) clean, contaminated: intentional wounds that were created by entry of one of the above tracts
3) contaminated: open, traumatic wounds or intentional wounds that there was a break in aseptic technique (e.g. spillage from GI tract),
4) dirty and infected: traumatic wounds with retained dead tissue or intentional wounds where purulent drainage is present

Front 25

Partial thickness wounds

Back 25

1st - 2nd degree wounds involveing the epidermis and upper dermis

Front 26

Full thickness wounds

Back 26

3rd degree: skin loss extends through the epidermis and dermis into subcutaneous fat and deeper structures

Front 27

Inflammatory Response

Back 27

Assessment: local heat, edema, pain, temporary loss of function, leukocytosis, exudate, tissue repair

Front 28

8 Factors that effect tissue repair

Back 28

1) age
2) nutrition
3) circulation & oxygenation--localized ischemia
4) drug therapy
5) diabetes
6) general health status
7) stress on the wound
8) smoking

Front 29

5 Complications of Wound Care

Back 29

1. infection
2. fistula
3. pain
4. anxiety/fear
5. body image change