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OBJECTIVES: At the completion of the lecture, the students will be able to: identify and stage pressure ulcers. differentiate between incontinence dermatitis and pressure ulcer. select 2 interventions to prevent pressure ulcers. recognize common dressings used for wound care. (JUST READING/ ANSWER THE SAME)

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OBJECTIVES: At the completion of the lecture, the students will be able to: identify and stage pressure ulcers. differentiate between incontinence dermatitis and pressure ulcer. select 2 interventions to prevent pressure ulcers. recognize common dressings used for wound care. (JUST READING/ ANSWER THE SAME)

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What are the Functions of Skin?

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*Protection *Immunological *Electrolyte balance *Metabolism *Thermoregulation *Neurosensory *Personal Identity

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What is wound?

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*Any injury to the skin and it's underlying tissues. *Activate of the immune system to *Promote healing *Remove foreign objects

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What are the Phases of Wound Healing?

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*Inflammatory Phase *Proliferation Phase *Maturation Phase (Remodeling)

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Types of Wounds: What is a Closed Wounds

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Tissue trauma without a break in the skin Can cause internal hemorrhage Example: Contusions

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Phases of Wound Healing: Describe the Inflammatory Phase.

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Vasoconstriction of the blood vessels to stop the bleeding Capillary permeability to allow WBC to the site of injury

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Phases of Wound Healing: Describe the Proliferation Phase.

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Red granulation tissue starts to grow so the wound can shrink. Continues until the wound is healed

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Phases of Wound Healing: Describe the Maturation Phase (Remodeling).

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Scar tissue forms and shrinkage occurs. The wound becomes more pink and less pale.

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Types of Wounds: What are Open Wounds?

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Break in the skin or mucous membrane Intentional (due to surgery) with clean edges or Unintentional with jagged edges Increased chance of infection Decreased movement or function of body part May cause hemorrhage

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Severity of Open Wounds: What is considered a Superficial wound?

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Involves the top skin layer only. Blood supply to the area remains intact. Example: Abrasion

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Severity of Open Wounds: What is considered a Penetrating wound?

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Break in the skin extends to deeper tissue and organs. High risk of infection and damage to organs. Example: Punctures/Stabs

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Severity of Open Wounds: What is considered a Perforating wound?

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Penetrating wound in which foreign object enters and exits an internal organ. Severity depends up the organ that was perforated. Lungs - Compromised airway Intestine - Contamination of abdominal cavity with feces that leaks out Major vessels - hemorrhage Examples: Gun shot wounds

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Cleanliness of the Wound: What is considered a Clean wound?

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Uninfected, usually a surgical wound.

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Cleanliness of the Wound: What is considered a Clean contaminated wound?

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Surgical wound that crosses into an area of the body where microbes live (respiratory, GI, Urinary). While made under aseptic conditions, there is a chance of contamination.

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Cleanliness of the Wound: What is considered a Contaminated wound?

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Open wound that has had a break in the body's sterility such as GI leakage into the abdomen. Evidence of inflammation is present.

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Cleanliness of the Wound: What is considered a Dirty or Infected wound?

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Old wound with evidence of infection and dead tissue. Purulent drainage and inflammation is noted.

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Pressure ulcers: What are the pressure ulcers ?

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Localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction" (NPUAP, 2010)

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Pressure ulcers: What is the pressure ulcers pathology?

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* Ulcers develop from soft tissue compressing on a bony prominence thus interfering with blood supply thus leading to tissue anoxia and cell death. * Pressure ulcer usually occur over bony prominences such as the sacrum, coccyx, occipital, heels where there is little tissue to compress. * Pressure ulcer can also occur under braces, splints, TED hose, C-collars or trachs or anywhere prolong pressure occurs to soft tissue.

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Pressure ulcers: What are the risk factors for developing pressure ulcers?

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*Decreased sensation (Neuropathy) *Decreased mobility *Nutritional challenged *Incontinence of urine and stool *Decreased perception *Don't know or is unable to change position *Shear and Friction

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Pressure ulcers: What conditions are considered STAGE I for pressure ulcers?

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*Skin intact *Red, non-blanching, even after 20 minutes of of relief from pressure

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Pressure ulcers: What conditions are considered STAGE II for pressure ulcers?

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*Breakdown of epidermis layer *Minor skin tears *Shallow crater or fluid filled blister

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Pressure ulcers: What conditions are considered STAGE III for pressure ulcers?

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*Full thickness to the dermis *May have tunneling and or *Undermining *No bony prominence or underlying tissue noted *Sometimes called a "yellow" wound

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Pressure ulcers: What conditions are considered STAGE IV for pressure ulcers?

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*Full thickness tissue loss with exposed bone, tendon or muscle. *Slough or eschar may be present on some parts of the wound bed. *Often include undermining and tunneling.

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Pressure ulcers: What conditions are considered UNSTAGEABLE for pressure ulcers?

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*Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.

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Pressure ulcers: What conditions are considered A (Suspected) Deep Tissue Injury?

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*Purple or maroon discolored intact skin or blood-filled blister *Damage to underlying soft tissue from pressure and/or shear. *Tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

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Pressure ulcers: What is the Difference between Stage I and DTI?

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Stage I: Recovers within 24 hours with pressure relief. Red or eggplant color Skin intact DTI: Doesn't recover within 24 hours with pressure relief Develops rapidly into Stage II Purple/ischemic looking

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Incontinence-Associated Dermatitis (IAD): What is considered to be Incontinence-Associated Dermatitis (IAD)?

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*Major etiology is skin damage caused by exposure to stool & urine. *Liquid fecal incontinence is highly irritating to the skin. is external "top down injury" *Occlusive absorptive product (chux and diapers) have demonstrated an increase in * location in perineal region caused by exposure to external moisture sources, specifically stool and urine

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What is Xenaderm and what is it used for?

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*Consists of Balsam of Peru, Trypsin, and Castor Oil *Wound types *Stage I or II pressure areas *Superficial wounds *Superficial partial thickness burns including donor sites *Provides moisture barrier to protect from excessive moisture and maceration

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Assessment: As a nurse when will I do the initial skin assessment and how often after that? What tool would a nurse use to assess and document their information?

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*Conduct skin assessment within 4 hours admission *Inspect skin each shift *Use a risk assessment scale Braden *Document

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Assessment: What are some measures that a Nurse should take to prevent pressure ulcers?

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*Turn and reposition every two hours *Use pillows to support back and joints *Keep heels raised off the bed *Keep skin clean & dry *Give massages and use skin lotions *Keep bed linens wrinkle free *Ensure good nutrition *Consult wound nurse *Air mattress and turn beds

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Assessment: What is the BRADEN SCALE?

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*Tool used to identify patients at risk for developing pressure ulcers. *The lower the score, less than 18, indicates patients who are at risk. *Need to perform on every patient at least once a shift.

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Wound Healing and Closure: What would a nurse consider to be a Primary Closure (first intention)?

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*Involves cleanly incised skin with approximated edges *Minimal underlying tissue *Minimal drainage

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Wound Healing and Closure: What would a nurse consider to be a Secondary Closure (second intention)?

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*Open wounds such as pressure ulcers, burns, etc. *Involves extensive granulation, wound contraction, and epithelialization. *Generally allowed to heal without surgical intervention, usually debridement. May leave a scar.

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Wound Healing and Closure: What would a nurse consider to be a Delayed Primary Closure (third intention)?

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*Wound left open for several days to monitor for infection and then surgically closed *This is a combination of secondary and primary closure

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Wound Assessment: REDA the wound. What does REDA stand for?

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*Redness *Edema *Drainage *Approximation

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Wound Assessment: COCA the drainage What does COCA stand for?

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*Color *Odor *Consistency *Amount

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Wound Assessment: What is the process for assessing the Drains or Tubes?

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*Inspect that the drain is secure, the amount of drainage, and the drain is functioning *Measure the amount of drainage from dressing and tubes *Describe and chart all types of drains and tubes

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Describing Wound Drainage: How would a nurse describe a SEROUS drainage?

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* clear portion of blood

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Describing Wound Drainage: How would a nurse describe a Purulent drainage?

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*serum and pus; may be yellow or green, depending on organism

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Describing Wound Drainage: How would a nurse describe a Sanguineous drainage?

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* red blood cells (old is dark red; new is bright red)

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Describing Wound Drainage: How would a nurse describe a Purosanguineous drainage?

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* red-tinged pus

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Describing Wound Drainage: How would a nurse describe a Serosanguineous drainage?

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* a combination of bloody and serous drainage.

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Wound Assessment: When assessing for drainage, as a nurse what would you look for?

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*Note location of wound *Note the degree of saturation of the dressing * if it is Reinforced * if it is Outlined

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Wound Assessment: When assessing for Swelling, as a nurse what would you look for?

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*With sterile gloves, palpate the edges for tension and tauntness *Minimal to moderate swelling is normal in the early stages of healing

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WHAT IS PAIN?

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* is what, where and when the patient say it is! * The Fifth Vital Sign

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Goals in Wound Care: As a nurse, What are some of the goals for wound care?

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*Prevent infection *Prevent further tissue damage and wound stress *Promote healing *Clean wound *Provide means to absorb drainage *Prevent hemorrhage *Prevent skin damage

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Factors that delay healing: How will Nutritional deficiencies be a factor in the delay of healing?

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*Lack of protein, lack of vitamin A, C, D *Anemia *Malnourished clients should receive enteral or parenteral nutrition pre-operatively if the surgery is not urgent

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Factors that delay healing: How will Obesity be a factor in the delay of healing?

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*Adipose tissue heals poorly *Has a poor vascular supply *Higher cause of dehiscence

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Factors that delay healing: How will Infection be a factor in the delay of healing?

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*Bacterial infections should be treated before surgery *Pre-op hospital stay should be as short as possible

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Factors that delay healing: What other factor in the delay of healing?

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*Smoking *Advanced age--nDecreased immune systems *Immunocompromised *Corticosteriods

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Dehiscence often involves abdominal wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed The first sign of dehiscence is an increased amount of serosanguinous drainage What does the term "Dehiscence" mean for a wound?

answer

*partial or total separation of wound layers

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Dehiscence and Evisceration: What does the term "Evisceration" mean for a wound?

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*Protrusion of visceral organs (bowels) through the wound opening

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Dehiscence and Evisceration: What are some causes for a wound to Dehiscence? What The first sign of dehiscence (S&S)?

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*This often involves abdominal wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. * increased amount of serosanguinous drainage

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Dehiscence and Evisceration: AS a nurse, What are the steps Treatment of Evisceration?

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*Have patient lay down -- Not flat, but don't raise HOB higher than 30 degrees * Cover area with sterile towels or gauze soaked in sterile saline to keep tissues moist *Notify surgeon immediately *Prepare patient for surgery *Remain with patient, supporting abdominal area with sterile gloved hands to prevent further injury

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Infection: What are the signs and symptoms of a Systemic infection?

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* fever, malaise, anorexia, leukocytosis (increase in WBCs & purulent drainage), nausea, vomiting, enlarged lymph nodes

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Infection: What are the signs and symptoms of a local infection?

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*redness, swelling, pain, & warmth

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Pre-Op Infection Prevention: As a nurse, What are some measures to prevent a Pre-Op Infection?

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*Clients having elective surgery should bathe with an antimicrobial soap the night before surgery. *Hair near pre-operative site should not be removed unless absolutely necessary. *Prep the surgical site prior to the surgery, removing hair by snipping with scissors' (can't shave - cuts cause infection), antimicrobial scrub. *If there is a high risk for infection, pre-op with antibiotics is recommended.

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Hemorrhage: As a nurse, what are some measures that you would take on assessing for a hemorrhage?

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Monitor vital signs, urinary output, drainage from wound

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Planning Wound Care: As a nurse what are some Variables influencing type of wound care you will provide?

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*Type of wound *Size of wound *Amount of exudate present *Status of the wound (open or closed) *Location of the wound *Personal preference of the surgeon *Presence of complicating factors

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Dependent Nursing Fuctions: Wound care instructions, orders from surgeon Application of protective ointments and paste to surrounding skin to prevent irritation and excoriation (JUST READING/ ANSWER THE SAME)

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Dependent Nursing Fuctions: Wound care instructions, orders from surgeon Application of protective ointments and paste to surrounding skin to prevent irritation and excoriation (JUST READING/ ANSWER THE SAME)

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Wound Cleaning: As a nurse, What are the steps for cleaning a wound?

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*Check order and agency policy *Wash hands *Start with incision *Clean from top to bottom, or center to outward *Use one swab per stroke *Clean drain site last (if present) *Cleanse in a direction from the LEAST contaminated area, such as a wound, to the surrounding skin or an isolated drain *Use gentle friction when applying antiseptic locally to the skin *When irrigating, allow solution to flow from the LEAST to the MOST contaminated area *A wound is thought to be less contaminated than the surrounding skin. *Clean AWAY from the wound *NEVER use the same piece of gauze to cleanse across an incision or wound twice *A drain site is HIGHLY contaminated since the moist drainage harbors microbes

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Wound Culture: When would a nurse obtain a wound culture?

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*Obtain wound culture if purulent or suspicious looking drainage. *Never collect culture from old drainage. *Clean the wound to remove skin flora. *Follow procedure for aerobic or anaerobic culture. *Send the culture to the lab ASAP. If over 30 minutes, discard and repeat.

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Wound Culture - Aerobic: What are aerobic cultures? As a nurse, What is the procedure for obtaining a aerobic wound culture?

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*Aerobic cultures are ones exposed to air *Insert sterile swab from culturette tube into drainage. *Return the swab to the culturette tube. *Cap the tube. *Crush the inner ampule of the medium.

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Wound Culture -Anaerobic: What are anaerobic cultures? As a nurse, What is the procedure for obtaining a anaerobic wound culture?

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*Anaerobic cultures are not exposed to air. Looking for bacteria growing in the body. *Grows in body cavities - usually collected by physicians. *Apply a sterile needle to the syringe to aspirate drainage. *Expel air from the syringe and needle. *Once specimen is placed in culture tube, take to lab ASAP.

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Tissue Biopsy: Gold standard for culturing wounds. Invasive procedure, usually performed by physicians. Can be quite painful. (JUST READING/ ANSWER THE SAME)

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Tissue Biopsy: Gold standard for culturing wounds. Invasive procedure, usually performed by physicians. Can be quite painful. (JUST READING/ ANSWER THE SAME)

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Types of debridement: What types of debridement can be used?

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*Surgical-Sharp *Mechanical- Wet to dry dressings & Hydrotherapy *Chemical- -Enzymatic Uses exogenous enzymes to liquefy necrotic tissue - Autolytic

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Advantages to Dressings: What are the advantages to dressings?

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*Absorbs drainage and debrides the wound when removed *Protects wound from external microbes *Aides in hemostasis when applied with elastic bandage (pressure dressing) *Approximating wound edges *Covering unpleasant disfigurement *Comfort

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Disadvantages to Dressings: What are some Disadvantages to Dressings?

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*Provides a dark, warm, moist environment for microorganisms *Dressing can be irritating to the wound *Hides to the wound so harder to assess

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Comfort Measures for Dressing Changes: As a nurse, What are some Comfort Measures for Dressing Changes ?

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*Remove tape carefully (may use alcohol pad over tape to loosen the adhesive) *Use Montgomery Straps to prevent skin breakdown *Gentle cleansing of wound edges *Careful manipulation of dressings and drains minimize stress on sensitive tissue *Administer pain medication 30-60 minutes prior to dressing change.

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Dressing-Dry Dressing: What effects do Dry Dressing have on a wound?

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Protect wound from injury, bacteria Promote wound healing Reduce discomfort from the wound

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Dressing-Wet to Dry: What is the process for a wet to dry dressing?

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Wide mesh cotton gauze saturated with saline or an antimicrobial solution Second layer covered by moist absorbent material maintained with the same solution Used for debridement of necrotic debris and to dilute thick or viscous exudate

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Common Solutions: What are some Common Solutions that are used when caring and dressing a wound?

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*Normal Saline - used for irrigating a wound that is non-infected; used to moisten necrotic tissue for removal *Betadine - not used as much as it used to be; used for treating infection *Hydrogen peroxide - usually diluted with normal saline; used in cleaning necrotic tissue *Dakins solution - Clorox and water used to dissolve necrotic tissue and retard Pseudomonas growth

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Gauze: As a nurse, What is the purpose of using gauze in wound care?

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*Absorptive *Acts as secondary dressing to secure primary dressing *Moistened with solution for wet to dry dressing

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Dressing-Transparent Dressings: Why are Transparent Dressings used?

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*Semipermeable polyurethane membrane dressings *Oxygen permeable but impermeable to bacteria *Non-absorptive *Frequently used as dressing on donor sites of burn patients *Will epithelialize and then remove *Promotes autolytic debridement *Provide for easy visualization of a wound

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Dressing-Hydrocolloid dressing: Why are Hydrocolloid dressing used?

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*May be used on light to moderately exudating wounds *Upon removal may have tan residue in wound bed *May leave in place 3 to 7 days depending on strikethrough *Effective for debridement and maintaining a moist wound environment (insulates the wound)

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Dressing-Hydro Gel (Foam): Why are Hydro Gel (Foam) used?

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*Composed of polyurethane foam *Effective under compression dressings *Absorbs moderate to heavy amount of exudate *May leave in place up to 7 days or until exudate has saturated the edge of the dressing (usually 2 to 3 days) *Not indicated for dry eschar

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Wound Vacs: What are wound vacs?

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*Contains a foam pad that is cut to the size of the wound *Covered with a transparent dressing that has a built in tube *Tube connects to a low suction canister that removes exudate.

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Pressure Dressing : What would a nurse use a pressure dressing for?

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*Control bleeding from hemorrhage *Support skin grafts *Control bleeding from arterial puncture sites *Dry dressing with bandage applied tightly

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Bandage (Binder): What would a nurse use a Bandage (Binder)?

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*Elastic bandage *Apply pressure to a specific area *Support a strained or sprained extremity

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Bandaging Turns: What are the different types of Bandaging Turns used ?

answer

*Circular: used to anchor bandages and to terminate them. Usually are not applied over wounds because of the discomfort the bandage would cause. *Spiral: use on extremities uniform in circumference. Distal to proximal. *Spiral reverse: use on extremities not uniform in circumference (rarely used) *Recurrent: used to cover distal parts of the body (end of fingers, stumps, head) *Figure eight: used to bandage an elbow, knee or ankle. Permits movement with proper application

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Principles of Binding: What Principles of Binding use?

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Before applying binder or bandage: *Inspect skin for abrasion, edema, discoloration or exposed wound edges. *Cover exposed wounds or open abrasions with sterile dressing. *Assess condition of underlying body parts and parts that will be distal to bandage for signs of impaired circulation: coolness, pallor, cyanosis, diminished or absent pulses, swelling, numbing or tingling. *Assess the condition of underlying dressing and change them if soiled.

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Abdominal Binder: What is the purpose of a Abdominal Binder?

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*Support underlying muscles and viscera *Support an operative incision *Support a strained visceral muscle

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Sling: What is the purpose of using a sling?

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*Support the arms injured from muscular sprain or skeletal fracture *Reduce excessive pressure on neck and shoulder structures

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Removing Sutures and Staples:

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Removing staples and sutures is considered a "clean" technique. The skin is well healed by this time. However, DO NOT take all of them out if the edges start to separate. You may only take out every other one. You NEED TO USE GOOD JUDGEMENT on this, and let the surgeon know.

NSG 106 Wounds and Dressings #12 – Flashcards

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