Skin Integrity And Wound Care

Front 1

What is the largest organ in the body?

Back 1

The Skin

Front 2

The Skin . . .

Back 2

Composes 1\6 of the total body weight. Is a protective barrier against disease-causing organisms. A sensory organ for pain, temperature, and touch. Can synthesize Vitamin D.

Front 3

What is one of the nurse's most important responsibilities?

Back 3

Skin care. Knowing the normal healing pattern helps the nurse to recognize alterations that require interventions.

Front 4

Dermal-epidermal Junction

Back 4

the membrane that separates the epidermis and the dermis.

Front 5

Stratum Corneum

Back 5

The thin, outermost layer of the epidermis. It has flattened, dead, keratinized cells. The cells originate from the basal layer.

Front 6

Basal layer

Back 6

The innermost layer. Cells in this layer divide, proliferate, and migrate toward the epidermal surface. After they reach the stratum corneum, they flatten and die. This constant movement ensures replacement of surface cells sloughed during normal desquamation or shedding.

Front 7

Dermis

Back 7

The inner layer of the skin, provides tensile strength, mechanical support, and protection to the underlying muscles, bones, and organs. It contains mostly connective tissue and few skin cells. Collagen, blood vessels, and nerves are found in this layer. Fibroblasts are the only distinct cell withing this layer.

Front 8

Stratum Lucidum

Back 8

Present where skin is thick, not where the skin is thin.

Front 9

Stratum Granulosum

Back 9

Only 1-5 cells thick; aids with keratin formation

Front 10

Stratum Spinosum

Back 10

Called the prickly layer; where cells flatten to migrate upward

Front 11

Stratum Germinativum/Basale

Back 11

Mitotically dividing, making new cells.

Front 12

Papillary Dermis

Back 12

Papillae that interlock with epidermal rete ridges; also contains capillary system

Front 13

Reticular Dermis

Back 13

Extensive vascular plexus, lymphatics, collagen

Front 14

Fascia and Muscle

Back 14

Well Vascularized, which makes it more sensitive to ischemia. Pressure damage usually begins here. Fascia and muscle do not regenerate when there is tissue death.

Front 15

Functions of the skin:

Back 15

Protection, heat regulation, sensory perception, excretion, synthesis of vitamin D., Expression of body image

Front 16

Neonate Skin

Back 16

More permeable 1st. and 2nd. weeks. Trouble with heat regulation.

Front 17

Adult Skin

Back 17

Normal cell turnover; time is 21 days for ages 18-25, at age 35, cell turnover is closer to 42 days.

Front 18

Elderly Skin

Back 18

Prolonged turnover time, thinning, decreased collagen, decreased rete ridges, sporadic melanin production, decreased SQ tissue, capillary fragility.

Front 19

Wound Healing

Back 19

Injury, Hemostasis, Inflammation, Proliferation, Maturation

Front 20

Inflammatory Wound Healing

Back 20

1) Immediate to 2-5 days

2) Bleeding stops (hemostasis)- constriction of the blood supply, platelets start to clot, formation of a scab.

3) Inflammation- opening of the blood supply, cleansing of the wound

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Proliferative Wound Healing

Back 21

1) 5 days to 3 weeks

2) Granulation- new collagen tissue is laid down, new capillaries fills in defect

3) Contraction- wound edges pull together

4) Epithelization- cells cross over the moist surface, cell travel about 3 cm from point of origin

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Maturation Wound Healing

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1) Collagen forms which increases tensile strength to wounds

2) Scar tissue is only 80 percent as strong as original tissue

3) 3 weeks to 2 years

Front 23

Pressure Ulcers

Back 23

A never event, expensive, Painful/harmful. Impaired skin integrity related to unrelieved, prolonged pressure. Localized injury to the skin and other underlying tissue, usually over a body prominence, as a result of pressure or pressure in combination with shear and/or friction. Found most commonly in the critically ill. Norton scale and Braden scale are risk assessment tools. The length of stay and the overall cost of healthcare increases when a client develops a pressure ulcer.

Front 24

Pathogenesis of Pressure Ulcers

Back 24

Pressure intensity: Capillary Pressure, Tissue ischemia, Blanching

Pressure duration

Tissue Intolerance

Front 25

Pressure Intensity

Back 25

A classic research study identified capillary closing pressure as the minimal amount of pressure required to collapse a capillary.

Front 26

Tissue Ischemia

Back 26

When the pressure that is applied over a capillary exceeds the normal capillary pressure and the vessel is occluded for a prolonged period of time. If the patient has reduced sensation and cannot respond to the discomfort of the ischemia, tissue ischemia and tissue death occur. No blood flowing through.

Front 27

Blanching

Back 27

Seen when the normal red tones of the light-skinned client are absent. Darkly pigmented skin appears darker than surrounding tissue; may have purple/blue hue; may be warm as compared to surrounding tissue.

Front 28

Pressure Duration

Back 28

1. Low pressure over prolonged period of time

2. High-intensity pressure over short amount of time.

How to test: Apply fingertip pressure over reddened area - it will immediately blanch (turn lighter in color) and the pink/red color will return once you remove the localized pressure = reactive hyperemia (vasodilation- blood vessel expansion; an attempt to overcome the ischemic episode)

Front 29

Non-Blanching erythema

Back 29

There area does not blanch. This can be an indicator that deep tissue damage may have occurred.

Front 30

Tissue Intolerance

Back 30

Depends on the integrity of the tissue and the supporting structures. Factors such as friction, shear, and moisture predispose to pressure ulcers. The ability of the underlying blood vessels is the ability to redistribute blood flow and pressure. Systemic factors such as poor nutrition, increased age, and low BP will affect the tissue's tolerance to externally applied pressure.

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Risk Factors for Pressure Ulcers

Back 31

Aging, Impaired Sensory perception, impaired mobility, alteration in LOC, shear, friction, moisture.

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Shear

Back 32

The force exerted parallel to skin resulting from both gravity pushing down on the body and resistance (friction) between the client and a surface. The skin and subcutaneous tissue adhere to the surface and the layers of muscle and bones slide in the direction of body movement. Underlying capillaries are stretched, necrosis occurs deep within the tissue layers, damage occurs, undermining at the pressure point.

Ex. HOB elevated; the skeletal frame starts sliding down but the skin is stuck in the same place.

Front 33

Friction

Back 33

Mechanical force exerted when skin is dragged across a coarse surface such as bed lined. Affects the epidermis - denudes the skin - which means; the skin appears red and painful (Sheet burn).

Ex. Clients that are restless or have uncontrollable movements or those that are dragged across the bed rather than lifted during position changes.

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Moisture

Back 34

reduces the skin's resistance to other physical factors. Prolonged moisture softens the skin making it more susceptible to damage.

Ex. wound drainage, excessive perspiration, fecal/urinary incontinence.

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Stage I

Back 35

Changes in: Skin temperature (warmth or coolness), tissue consistency (firm or beefy feel), sensation (pain or itching).

Appearance: a defined area of persistent redness, blue, or purple.

No open lesion.

There is an observable alteration in the skin.

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Stage II

Back 36

Partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents as an abrasion, blister, or shallow crater.

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Stage III

Back 37

Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia (the flat band of tissue that separates layers and encloses muscles). The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

Front 38

Stage IV

Back 38

Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures such as tendons and joints. Undermining and sinus tracts may be present.

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Tissue Type of a Pressure Ulcer

Back 39

Granulation tissue- red, moist; healing

Slough- yellow, stringy

Eschar- black/brown; necrotic

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Wound Dimension Measurements

Back 40

Depth, Length, Width. Should include consistent measurements and you should always use the same system (inches or centimeters). This is done to show changes in size which indicate healing or progression or wound bed.

Width: measure left to right

Length: top to bottom

Depth: inside wound to outside urface

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Exudate

Back 41

Amount, color, consistency, odor. Serous, purulent, serosanguinous, sanguineous.

Front 42

Surrounding area of Pressure Ulcer

Back 42

Color, Temperature, Condition

Front 43

Acute Wound

Back 43

Wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity. Can be caused by trauma or surgical incision. These wounds are usually easily cleaned and repaired. The wound edges are clean and intact.

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Chronic Wound

Back 44

Wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity. Vascular compromise, chronic inflammation, or repetitive insults to tissue. These wounds need continued exposure to insult impedes wound healing.

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Primary intention

Back 45

wound that is closed. The causes can be a surgical incision or a wound that is sutured or stapled. Healing occurs by epithelialization. It heals quickly with minimal scar formation. There is little tissue loss. Approximated skin edges, low risk of infection, healing occurs quickly, inflammation subsides less than 24 hours, wound resurfacing between 4-7 days.

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Secondary intention

Back 46

Wound edges are not approximated. The causes can be pressure ulcers or surgical wounds that have lost tissue. The wound heals by granulation tissue formation, wound contraction, and epithelizlization. Signification tissue loss (burn, ulcer, laceration). Wound left open to develop scarring, greater risk of infection, may have loss of tissue function.

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Tertiary Intention

Back 47

The wound is left open for several days, then wound edges are approximated. The wounds are contaminated and require observation for signs of inflammation. Closure of wound is delayed until risk of infection is resolved.

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Wound Classification

Back 48

Skin Integrity: Open, closed, acute, chronic

Cause: intentional, unintentional

Severity: superficial, penetrating, perforating

cleanliness: clean, contaminated, infected, colonized

Description: laceration, abrasion, contusion

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Suture

Back 49

Threads or metal used to sew body tissues together.

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Staples

Back 50

Outer closure; less trauma to tissues; provide extra strength.

Front 51

Steri-Strips

Back 51

Tape Closures. Common. Remove every other staple then apply these before removing the rest of the staples.

Front 52

Penrose Drain

Back 52

Sutured into place, safety pin attached. This drain may lie under a dressing. At the time of placement, a pin or clip is placed through the drain to prevent it from slipping further in a wound. It is the MD's responsibility to pull or advance the drain.

Front 53

Hemovac/Jackson-Pratt (JP)

Back 53

Provides constant low self-suction. Exerts a constant low pressure as long as the suction device (bladder or bag) is fully compressed.

Front 54

Basic Skin Cleansing

Back 54

Cleanse from least contaminated to the surrounding skin. Use gentle friction when apply solutions. When irrigating, wallow solution to flow from least to most contaminated area.

Front 55

Wound Irrigations

Back 55

Requires sterile technique to remove wound debris. Always have syringe tip over but not in the drainage site. Fluid should flow directly into wound; not over contaminated area.

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Cleansing Surgical Wounds

Back 56

Cleanse form inside to out- or from clean to dirty. Use gentle friction to penetrate pores. When irrigating, allow solution to flow from clean to dirty.

Front 57

Nursing responsibility for surgical drain management

Back 57

Assess the number of drains present, measure of drainage, description of drainage (color, consistency, presence of clots), notification of medical staff if sudden decrease in output.

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Arterial wounds

Back 58

Punched out shape, tips of toes/over bony prominence, between toes, cool/pale legs/faint pulse.

Treatment: restore blood flow, local wound care

Front 59

Venous Ulcers

Back 59

Irregular, dry and shallow, edema, hypertension r/t hemosiderin.

Treatment: local wound care, compression to control edema.

Front 60

Diabetic Wounds

Back 60

Usually on feet, likely r/t neuropathy, foot deformity caused by osteopenia/fractures that cause collapse of midfoot. Loss of protective sensation.

Treatment: Glucose control, offloading, education, daily footcare/inspections

Front 61

Lymphedema

Back 61

Lymphatic system drains protein rich fluid from tissues and returns to venous system. Obstruction in flow causes swelling and massive edema. Skin folds can trap moisture, causing maceration/ulcer formation. Firm/fibrotic skin can put pressure on capillaries, obstructing blood flow.

Treatment: Decongestive therapy (type of massage), limb elevation, and compression.

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Complications of wound healing.

Back 62

Hemorrhage- bleeding from wound site (internal or external)

Infection- purulent drainage

Dehiscence- separation of wound edges

Evisceration- protusion of visceral organs

Fistula- abnormal passage

Front 63

Hemorrhage

Back 63

Bleeding from a wound site is normal immediately after the initial trauma. Hemostatis (clotting) occurs within several minutes unless large blood vessels are involved or the client has a clotting disorder.

Treatment: elevate and apply pressure.

Front 64

Internal Hemorrhage

Back 64

Unobservable.

Ex. surgical clip slips off a bleeding vessel.

If a surgical drain is placed, the internal bleeding could be detected if the amount of drainage suddenly increased above the expected amount. The nurse should also assess for distention or swelling of the affected body part.

Front 65

Hematoma

Back 65

A localized collection of blood underneath the tissues may appear as a swelling, change in color, sensation, or warmth. It can be very dangerous when located near a major blood vessel because it may obstruct blood flow.

Front 66

External Hemorrhage

Back 66

Obvious. usually the dressing will be saturated with bloody drainage. The risk is greatest during the first 24-48 hours post-op.

Front 67

Wound infection

Back 67

the 2nd. most common nosocomial infection. CDC says a wound is infected if purulent material drains from it - even if a culture is not taken or has negative results. Bacterial wound infection inhibits wound healing. A contaminated or traumatic wound may show signs of infection within 2-3 days. A surgical wound will usually show signs around 4-5th day.

Signs and Symptoms: fever, tenderness and pain at wound site; elevated WBC; wound edges inflamed; purulent drainage.

Front 68

Dehiscence

Back 68

the partial or total separation of wound layers. Those with poor nutritional status, infection, and obesity increase risk. Usually occurs with sudden strain - coughing, vomiting, sitting up in bed. The patient may complain that something has give way. There is an increasse in serosanguineous drainage from wound.

Treatment: splint the area to support healing tissues and to increase intraabdominal pressure (use a pillow)

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Evisceration

Back 69

Total separation of wound layers with protusion of visceral organs through a wound opening. This is an emergency and requires immediate surgical intervention. Nurse covers organs with sterile towels soaked in sterile saline to reduce bacterial invasion and to keep organs moist. Keep patient at NPO, observe for shock and prepare for emergency surgery.

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Fistula

Back 70

An abnormal passage between two organs or between an organ and outside the body. Most result of poor wound healing or a complication of disease (Chron's), trauma, infection, radiation, and disease/cancer prevent tissue layers from closing properly - a fistula tract forms. Chronic drainage through fistulas may predispose to skin breakdown.

Front 71

Calories

Back 71

Support cellular activity for wound healing. Surgical patient requires at least 1500 kcal/day for nutritional maintenance; enough to maintain Positive Nitrogen Balance.

Front 72

Vitamin A

Back 72

Epithelialization, wound closure; can reverse negative effects of steroids on wound healing.

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Vitamin C

Back 73

Needed for synthesis of collagen, capillary wall integrity, and fibroblast function

Front 74

Protein

Back 74

Needed for wound remodeling; needs are increased - enough to maintain positive nitrogen balance. Patient can lose a s much as 50 g protein per day from an open, weeping wound. Measuring serum albumin levels are good predictors for malnutrition (prealbumin levels reflect what has been ingested, what has been absorbed, digested, and metabolized).

Front 75

Zinc

Back 75

Trace element. Needed for protein synthesis and collagen formation.

Front 76

Fluids

Back 76

Essential for cell function (need 6-8 glass / day) - water is best!

Front 77

Tissue Perfusion

Back 77

Oxygen fuels the cellular functions needed for healing' oxygen requirements depend on the phase of wound healing. Clients with reduced circulation - shock or PVD- diabetes- are at risk for poor tissue perfusion.

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Infection

Back 78

Prolongs the healing process and may lead to additional tissue destruction.

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Age

Back 79

Increased age affects all phases of wound healing.

Vascular changes- impaired circulation to wound

Reduced liver function- alters synthesis of clotting factors.

Slowed inflammatory response.

Reduced formation of antibodies and lymphocytes.

Collagen tissue less pliable- scar tissue less elastic.

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Psychosocial impacts of wounds

Back 80

The nurse must assess the client's psychological response to any wound. Body image changes may impose great stress and influence self-concept and sexuality. Presence of scars, drains, odor, prosthetic devices, etc.

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Nursing Diagnosis

Back 81

Impaired skin integrity, risk for infection, imbalanced nutrition (less than body requirements), impaired physical mobility, ineffective tissue perfusion.

Front 82

Topical Skin Care

Back 82

Avoid hot water, soaps, and alcohol-based lotions. Drying and alkaline residue inhibits normal flora. Clean skin, completely dry, moisturize without over-saturating; cornstarch is a dry lubricant and helps reduce friction. Control and Correct excessive perspiration, incontinence, and wound drainage - use absorbent pads and garments as last resort.

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Positioning Interventions

Back 83

Designed to reduce pressure and shearing forces to the skin. Turn or reposition every 2 hours. Use positioning devices to protect bony prominences. Lateral 30 degree position is recommended. Lift using draw sheet rather than pulling or sliding across mattress. Limit sitting to 2 hours or less - increases pressure on ischial tuberosities. Teach to shift weight every 15 mins. Use soft foam or gel cushions (do-nuts and rigid cushions are contraindicated because it decreases circulation to the area). Perform hyperemia test.

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Support Surfaces

Back 84

Therapeutic beds and mattresses. This do not alleviate the need for meticulous nursing care.

Front 85

Pressure-relieving

Back 85

Relieves the interface pressure below 32 mm Hg (capillary closing pressure)

Front 86

Pressure-reducing

Back 86

Reduce interface pressure but not necessarily below the capillary closing pressure.

Front 87

Low-air-loss system

Back 87

bed or overlay

Front 88

Foam

Back 88

Overlay or full mattress

Front 89

Static air

Back 89

Filled overlays

Front 90

Air-fluidized beds

Back 90

Kinetic therapy provides passive ROM and low-air-loss

Front 91

Stool/Urine Protection

Back 91

Barrier cream, fecal containment, frequent checking, good hygiene

Front 92

How often should you turn a patient?

Back 92

Every 2 hours

Front 93

Debridement

Back 93

The removal of necrotic tissue so that healthy tissue can regenerate. It rids the source of infection, enable visualization of the wound bed, provide clean base necessary for healing. Never use on heel ulcers or if they do not have edema, eryhthma, or drainage.

Front 94

Mechanical Debridement

Back 94

The use of wet to dry saline gauze dressing; a moistened gauze is placed inside the wound bed; allowed to dry thoroughly before the nurse pulls the gauze that has adhered to the tissue out of the wound. This is a non-selective method. You cannot distinguish between viable and non-viable. Not used often.

Front 95

Autolytic Debridement

Back 95

Transparent film or hydrocolloid dressings. Uses synthetic dressings over a wound to allow the eschar to be self-digested by the action of enzymes that are present in wound fluids.

Front 96

Chemical Debridement

Back 96

Topical preps; maggots. Can use topical enzymes; MD order required. The preparation either digests or dissolves the dead tissue.

Ex. Dakin's solution- breaks and loosens dead tissue (often used with wet-to-dry)

Front 97

Surgical Debridement

Back 97

Removal of nonviable tissue by using a scalpel, scissors, or other sharp instrument. Usually performed by MD. The quickest method of debridement is indicated when signs of cellulitis or sepsis.

Front 98

Wound irrigation

Back 98

High pressure irrigation and pulsatile high pressure lavage

Front 99

Purposes of wound dressings

Back 99

Protect wound from contamination, aiding hemostasis, absorbs drainage, debridement, wound support or splinting, to decrease client stress of visualization, thermal insulation, provide moist environment. The use of dressings requires and understanding of wound healing and the correct dressing selection can facilitate wound healing. The dressing type will depend on the assessment and the phase of wound healing.

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Principles of Dressing Selection

Back 100

Add moisture to a dry wound, absorb excess exudate from a wet wound, do not occlude infected wounds, protect peri-wound skin, loosely fill cavity wounds and dead space, and avoid trauma.

Front 101

Dressing for deep wet wounds

Back 101

Need an absorptive filler with a cover dressing

Front 102

Dressing for deep dry wounds

Back 102

Need a hydrating filler with a cover dressing

Front 103

Dressing for shallow wet wound

Back 103

Need absorptive dressing such as foam or flat hydrofiber with gauze/foam cover

Front 104

Dressing for Shallow dry wounds

Back 104

Need a hydrogel or hydrocolloid

Front 105

Gauze Sponges

Back 105

The oldest and most common dressing' they are absorbent and useful in wounds to wick-away exudate- but not in largest quantities.

Front 106

Wet-to-dry dressings

Back 106

Used to treat wounds that require debridement. Moisten the contact layer, wring out excess, pack into wound bed, cover with secondary dressing; remove when dry.

Front 107

Nonadherent gauze

Back 107

Dressings like telfa that have a slick surface that does not stick to the incision or wound but allows drainage to pass through to the gauze topper.

Front 108

Transparent file

Back 108

Traps wound's moisture over the wound, moist environment (speeds epithelial cell growth), adheres to undamaged skin, serves a s barrier to external fluids and bacteria (allows wound to breath), can be removed without damaging underlying tissues, permits viewing of wound, does not require secondary dressing.

Front 109

Hydrocolloid dressings

Back 109

Adhesive and occulsive; contact layer forms a gel as fluid is absorbed and maintains moist environment. It absorns drainage through the use of exudate absorbers in the dressing, maintains wound moisture, slowly liquefies necrotic debris, is impermeable to bacteria and other contaminants, is self-adhesive and molds well, can be used as preventive dressing for high-risk friction areas,may be left in place 3-5 days (minimizing skin trauma).

Contraindications: heavy draining wounds, full-thickness wounds, infected wounds.

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Hydrogel

Back 110

Water or glycerin-based gels impregnated gauze or sheet dressings. Hydrates wounds and can absorb some but not large amounts of exudate. Used for partial or full-thickness wounds; necrotic wounds; burns; and radiation damaged skin.

Advantages: Soothing and reduces pain in wound, provides moist environment, can debride the wound (softens necrotic tissue), does not adhere to wound base (easily removed)

Disadvantages: require secondary dressing-take care to prevent peri-wound maceration.

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Foam dressings and alginate dressings

Back 111

Used in wounds with large amounts of exudate and in wounds that need packing

Front 112

Foam dressings

Back 112

Used around drainage tubes to absorb drainage. May or may not have adhesive edges.

Front 113

Calcium alginate

Back 113

Dressings that are manufactured form seaweed and come in sheets and rope form. Alginate forms a soft gel when it comes in contact with wound fluid, absorbs up to 20 times their weight, can be used of infected wounds and do not cause trauma when removed from the wound. They should not be used in dry wounds and they require secondary dressings.

Front 114

Dressings that donate moisture

Back 114

Films, hydrogel, hydrocolloid

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Dressings that remove moisture

Back 115

Alginate, foam, specialty absorbents

Front 116

Packing a wound

Back 116

Assess size, depth, and shape of wound. Dressing should touch all surfaces of wound. The packing helps eliminate dead space (a cavity remaining in a wound). The wound cavity needs to be filled so that areas are not "walled off" to prevent abcesses. Do not over-pack or pack too tightly because it may cut off circulation in the wound bed or macerate the surrounding are.

Front 117

Wound Solutions

Back 117

Dakin solution and Acetic acid. Do not use to clean granulating wounds. Use saline for clean granulation wounds because the others will breakdown new cell growth and create further cell damage. Dakin Solution and Acetic acid are used for debridement and cleansing dirty wound beds.

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Dressings for satge I

Back 118

Film dressing or hydrocolloid

Front 119

Stage II Dressing

Back 119

Hydrocolloid, hydrogel, or foam

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Stage III Dressing

Back 120

Foam, hydorocolloid, hydrogel, alginate

Front 121

Stage IV Dressing

Back 121

Hydrocolloid, hydrogel, gauze roll

Front 122

Wound VAC

Back 122

A device that assists in wound closure by applying negative pressure to draw the edges of a wound together. Negative pressure removes fluid from the area surrounding the wound- reducing local peripheral edema and improving circulation to the area. After 3-4 days, bacterial counts drop.

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Tape

Back 123

Comes in many sizes, may be make of paper or silk. Never apply tape over broken skin. Make sure patient is not allergic to tape product. Adhesive remover may be used to remove sticky tape without traumatizing underlying tissue. Assess skin under tape during dressing change.

Front 124

Ties (Montgomery Straps)

Back 124

To avoid repeated removal of tape from sensitive areas or with frequent dressing changes. Half the dressing has adhesive back, other half is not and holds the ties to connect other side

Front 125

Secondary Dressing

Back 125

An outer, protective dressing used to secure the underlying dressing.

Front 126

Bandages

Back 126

Available in rolls, various widths and materials. Gauze bandages are lightweight and inexpensive, they mold easily around contours and permit circulation. Elastic bandages conform well to body parts but can be used to exert pressure.

Front 127

Binders

Back 127

Bandages that are made of large pieces of material to fit a specific body part. Most are elastic or cotton

Front 128

Principles for applying bandages and binders

Back 128

Inspect the skin, cover exposed wounds with sterile dressing, assess condition of underlying dressings and change when soiled, Assess skin underlying areas that will be distal to the bandage for signs of impaired circulation.

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Slings

Back 129

Support arms with muscular sprains or fractures. The lower arm and hand should be supported at a level above the elbow to prevent formation of dependent edema.

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Applying Heat

Back 130

Vasodilation, reduced blood viscosity, reduced muscle tension, increased tissue metabolism, increased capillary permeability. Improves blood flow to an injured part but do not use over 1 hour at a time because it will cause result in rebound vasoconstriction.

Contraindications: active bleeding, infection/inflammation, CV problems (results in mass vasodilation)

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Applying cold

Back 131

Vasoconstriction, local anesthesia, reduced cell metabolism, increased blood viscosity, decreased muscle tension. Initially diminishes swelling and pain (prolonged exposure results in reflex vasodilation).

Contraindications: edema (cold will further impede circulation) CV problems (results in mass vasoconstriction), neuropathy, shivering (cold may intensify and dangerously increase body temp)

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Contraindications that increase risk of injury from heat or cold

Back 132

Very young or older clients, open wounds, broken skin, stomas, areas of edema or scar formation, PVD, confusion/unconsciousness, SCI, Abscessed appendix. Some areas are more sensitive (neck, wrist, perineal region). Tolerance changes with age and the young and old are most sensitive. Impaired sensory reception/perception means that there is a greater risk for injury.

Front 133

Warm or Cold compresses

Back 133

A piece of gauze dressing moistened in a prescribed solution

Front 134

Pack

Back 134

A larger cloth or dressing applied to a larger body area

Front 135

Soaks

Back 135

Immersion of a body part into a solution or wrapping the body part in dressings and saturating them with solution

Front 136

Sitz baths

Back 136

Bath in which only the pelvic are is immersed in warm fluid.

Front 137

Aquathermia pad

Back 137

The unit consists of a waterproof plastic or rubber pad connected by two hoses to an electrical control unit that has a heating element; distilled water circulates through the hollowed channels and it may be warm or cold.

Front 138

Application of cold or heat requires. .

Back 138

MD order

Front 139

Nursing Process: Implementation

Back 139

Select nursing interventions to promote improved skin integrity/wound healing. Consult with nutritionist & wound care specialist. Involve Patient/Family in using intervention.

Front 140

Clinical Documentation

Back 140

Exact size in centimeters (length, width, depth), location, approximation of edges, appearance of surrounding area, describe exudate/stain on dressing, Time of last dressing change, procedure used (solution, dressings, closure, etc)

Front 141

Evidence that wound has improved

Back 141

Higher percentage of granulation tissue in wound base, current wound measurements, no further skin breakdown, caloric intake increased by 10% (200 kcal/day)