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Wound Care

Wound Care

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02/06/2013

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WOUND CARE

By: NORMAN ANGELO G. CALDERON, MD, RN

WOUND AND HEALING  

A wound is a break in the skin (the outer layer of skin is called the epidermis). Wounds are usually caused by cuts or scrapes. Different kinds of wounds may be treated differently from one another, depending upon how they happened and how serious they are. Healing is a response to the injury that sets into motion a sequence of events. With the exception of bone, all tissues heal with some scarring. The object of proper care is to minimize the possibility of infection and scarring.

Phases of Wound Healing
I. Inflammatory Phase 
 

A) Immediate to 2-5 days 2B) Hemostasis Vasoconstriction Platelet aggregation Thromboplastin forms clot C) Inflammation Vasodilation Phagocytosis

Proliferative Phase     A) 2 days to 3 weeks B) Granulation Fibroblasts lay bed of collagen Fills defect and produces new capillaries C) Contraction Wound edges pull together to reduce defect D) Epithelialization Crosses moist surface Cell travel about 3 cm from point of origin in all directions .II.

Remodeling Phase    A) 3 weeks to 2 years B) New collagen forms which increases tensile strength to wounds C) Scar tissue is only 80 percent as strong as original tissue .III.

insulates and protects nerve endings . ( this allows the tissue to granulate) Moisture enhances cellular activity in all phases of wound repair.New Trends   Major trend is to use moisture retentive dressing rather than drying the wound. facilitates autolytic wound debridement of necrotic tissues. enables epithelial cells to migrate into the wound bed.

Clinical notes    Document how long client has had wound Determine previous treatment if any and treatment results Check for allergies .

WOUND ASSESSMENT .

5. Pliable disposable measuring device CottonCotton-tip applicator stick Plastic disposable bag Clean gloves Sterile gloves . 2. 4.EQUIPMENTS NEEDED 1. 3.

debridement.Wound Assessment Assessment 1. 3. 2. Assess wound for moisture. infection and cleanliness Rationale: To assess wound appropiately Make sure drainage from wound site is contained and adjacent skin is protected Rationale: To prevent microorganisms from entering wounds Make sure skin sealant is used appropriately Rationale: To maintain sterility during dressing changes .

5. Check that dressing is dry on air-exposed airsite Rationale: To prevent bacterial proliferationtion Make sure drainage system is operating Rationale:To Rationale:To maintain drainage if a drainage system is used .Wound Assessment 4.

drainage.WOUND ASSESSMENT PROCEDURE 1. Note appearance of wound bed Check for exudate.  Wear sterile gloves Examine wound. necrotic tissue or sign of infection . 2. exudate.

Assess surrounding area for problems in skin nutrition       Atrophy.black [necrosis].3. brown[venous insufficiency]) Skin temperature (cool. loss of hair.normal) .normal) cold. thickening of nails Edema of skin or scaly skin Skin hydration Skin integrity or maceration Skin color (red [inflammation]. white [arterial insufficiency].warm.warm. cold.

4.Assess extent of wound    Measure length and width of wound using disposable measuring device Measure depth of wound by using cotton-tipped cottonapplicator stick Check for tunneling or sinus tract by placing cottoncotton-tipped applicator stick into suspected area advancing until resistance is met .

C. black (necrotic tissue).debris).debris). Observe color of wound : A.5. pus. B.fibrin. yellow (pus. red (wound ready to heal) .fibrin.

slough]. blueblue-green [pseudomonas]) pseudomonas]) . brown-yellow brown[slough]. Assess for wound drainage: drainage: A. clear[serous]. C. Color of drainage -clear[serous]. -yellow. -brown.yellow-green[pus yellow.yellow-green[pus from strep or staph]. moderate. Amount ( minimum. Type (dry or moist).6. maximum). staph]. B.

7. A moist environment allows wound to heal without forming a scab . Assess for level of moisture in wound.

8. Assess odor of wound: A. foul (infected[necrotic tissue has an odor even if not infected]) B. sweet (pseudomonas infection)

LABORATORY ASSESSMENT
Laboratory values need to be assessed routinely while the wound is healing: 1. Increased WBC count indicates infection 2. Low hemoglobin and hematocrit indicate anemia, which can decrease oxygen transport to the wound 3. Altered serum glucose level

WOUND CLEANING

6. 5.Wound Cleaning Equipment 1. 4. 2. 7. 3. 9. 8. Sterile normal saline or any non-cytotoxic wound noncleanser Sterile dressing Tape Sterile round bowl Sterile emesis basin Sterile gloves Absorbent pads Disposable bags Googles .

cleaning is contraindicated Rationale: Wound healing can be delayed by destroying newly produced tissue. It can also remove exudate that may have bactericidal properties. .Clinical note  If a wound is clean and has granulation tissue present.

WOUND CLEANING PROCEDURE 1. Rationale:other products such as hydrogen peroxide should be avoided as they are toxic to cells . Check physician s order for wound cleaning solution. Sterile saline or noncytotoxic solution should be used.

Pour cleaning solution over gauze pads.(this can lead to foreign body reaction.2. thus delaying the healing process prolonging the inflammatory phase  If antimicrobial solutions are used. Do not use products that shed cotton fibers. be sure to dilute it  Warm solution to body temperature( this prevents lowering of wound temperature delaying the healing process) .

 Clean wound from cleanest to dirtiest  Clean from top to bottom using new gauze with each stroke . Place emesis basin on side of patient to catch excess cleansing solution. Wear sterile gloves  Pick up several gauze pads.3. pulling edges together to form a ball ( prevents glove from touching the wound)  Sterile cleansing solutions can be poured directly over wound before gauze pads are use for cleaning.

WOUND IRRIGATION .

3. 2. 4.Wound Irrigation Equipment: 1. Same as in wound cleaning Warm irrigation solution Syringe: 30 to 60 ml syringe Clean and sterile gloves (2 pairs) .

discard dressing and gloves in disposable bag Open sterile supplies. 3. pour warmed irrigating solution into sterile basin . Don sterile gloves and remove dressing. 2. Check orders for type and amount of irrigating solution to be used.WOUND IRIGATION PROCEDURE 1.

Place sterile emesis basin next to wound to catch irrigation solution as it drains from wound 7. Draw up solution into syringe 5.4. Instill solution into wound 6. Repeat irrigation process until returns are clear and free from debris . Don sterile gloves.

dry thoroughly with dry gauze pads 9. Remove gloves and place in disposable bag . Remove gloves and place in disposable bag 10.8. Don sterile gloves and apply dressing 11. Cleanse around wound with moist gauze pads.

Dressings .

2. 6.A. 4x4 gauze ABD pads Sterile solutions Sterile gloves Clean gloves Tape Disposable bag . 7. 4. 5. Wet to Damp Dressing Equipment 1. 3.

.Wet to Damp Dressing Procedure: 1. Identify type and number of dressings and type of solution needed.

.  Cut tape strips and place on over-bed overtable. Arrange packages making sure you do not cross sterile field. overopen sterile packages and place on overoverbed table.Clean over-bed table.2.

3.Ensure that two packages of 4 x 4 gauze pads are open for use in outer dressing.  Fanfold top linen to foot of bed. Provide patient s privacy  Place bag for soiled dressing near the table .

4. Pour sterile solution into 4 x 4 gauze dressing container .

Wear clean gloves and remove dressing. Place in disposable bag .5.

 Remove clean gloves and dispose in appropriate container .Obtain wound specimen for culture if ordered.6.

Collecting Wound Specimen        Rinse wound with sterile NSS Use non-cotton tipped swab nonRotate swab while obtaining specimen Swab wound edges starting from top. crisscross wound to bottom Do not take specimen from exudate Remove gloves and place in disposable bag Wash your hands .

Don sterile gloves and have materials needed for dressing change available .7.

Wring out several gauze pads until slightly moist. .  Fluff moistened dressing and lightly packed them in all crevices and depressions in wound.Necrotic tissues are usually in deep crevices(tightly packed wound dressing inhibit wound edges from contracting and may compress capillaries)  Irrigate wound if grossly contaminated.( if dressing is too moist risk of infection and maceration of surrounding skin is increased.8.

9.Apply dry sterile gauze over moist dressing Rationale: This will absorb excess exudates .

Place sterile ABD pads over wound site.10. Rationale: Pads protects wound from trauma and external contamination .

top and bottom of dressing . Tape wound dressing lengthwise .11.Tape wound securely.

B. 7. Dry Dressing for Open Wound Drainage Equipments: 1. 8. 2. 3. 4. 9. 5. ABD pads) Precut sterile 4 x 4 gauze pads (2) Forceps and cotton balls Sterile cleansing solution and sterile container Sterile safety pin Sterile scissors Sterile gloves Clean gloves Disposable bag . 6. Dressings (4 x 4 gauze.

place on overoverbed table  Pour sterile cleansing solution into container  Observe wound closely for sign of infection or healing. Wear clean gloves 2. .Dry Dressing Procedure: 1. Remove soiled dressing and place in disposable bag  Remove clean gloves  Open sterile packages.

Be careful not to dislodge pin .Don sterile gloves and closely observe pin in Penrose drain. If pin is crusted replace with new sterile pin.3.

Cut off excess tubing with sterile scissors. 3. complete the following steps: Using sterile forceps. This prevents drain from being drawn back into wound opening. pull drain out of wound number of centimeters ordered Reposition safety pin so it is at level of skin. Pin prevents drain from slipping back into wound.Penrose Cleaning  1. To advance Penrose drain. 2. .Leave at least 2 inches of tubing on outside.

Start cleansing at drain site.  Discard cottons balls in disposable bag  Advance drain if ordered .4. Clean drain site with sterile solution.Rationale: this prevents infection of the drain site. Use forceps with cotton balls soaked in cleansing solution. moving in circular motion towards periphery.

Place precut 4 x 4 gauze under Penrose drain  Place several 4 x 4 gauze pads under drain site  Apply 4 x 4 gauze pads over drain (Pads absorbs drainage and prevents drainage from accumulating into skin.5.) .

. Remove gloves and place in disposable bag. Place ABD pads over sterile gauze pads.6.

. Montgomery tie tape should be use if frequent dressing changes are recquired or client have sensitive skin. Tape ABD pads securely to skin.7.

Wound Drainage .

Drainage Bag for Wounds Purpose:       Collecting drainage specially if it is excessive Measuring drainage Protecting skin from drainage Containing drainage Containing microorganisms to decrease their spread to other areas Decreasing frequency of dressing changes .

as ordered .Care for the Client with Drainage Bags: PROCEDURE: 1. 2. 3. Don clean gloves Remove dressing and place in disposable bag Measure drainage from pouches.

Remove clean gloves and wear sterile gloves 5. drainage pouches may be left open for assessment . New cotton balls for each site Apply sterile dressing as ordered. Clean drain site with sterile cleansing solution and forceps and cotton balls.4. 6.

3. Specimen cup for measuring drainage Input & Output bedside record Absorbent pad Clean gloves . 2.Closed Wound Drainage System Equipments: 1. 4.

If occluded notify physician .   Wear clean gloves.Closed Wound Drainage Procedure: 1. seal and stability. Expose catheter insertion site while keeping client draped Place drainage system on absorbent pad or towel(to protect bed from being soiled) Examine Jackson Pratt or hemovac catheter for patency.

Empty hemovac drainage system by removing Hemovac plus from pouring spout.2. . Pour drainage into specimen bottle.

Safety alert: To maintain patency. compress Jackson Pratt or Hemovac container every 4 hrs .

Compress hemovac by pressing top and bottom together with your hands.3. Keep pump tightly compressed while you reinsert plug .

Pour drainage into specimen container .Disconnect tubing from Jackson Pratt system.4.

Compress bulb on JacksonJackson-Pratt system.5.  Hold bulb tightly compressed and connect to tubing .

6. consistency and odor . (this facilitates observation and drainage of wound)  Measure and record amount of drainage  Observe color. Place drainage system on bed.

Decubitus Ulcer .

Pressure Ulcer Staging  Stage I.Nonintact skin. The ulcer is superficial and presents clinically as an abrasion.Partial thickness skin loss IIinvolving epidermis and dermis.Non-blanching erythema of I. blister or shallow crater  . the heralding lesion of skin ulceration Stage II.

damage to bone.Fullwith extensive destruction. Stage III.Full-thickness skin loss III. but not through the underlying fascia. muscle and surrounding structures  . Presents as deep crater with or without the undermining of he adjacent tissue Stage IV. necrosis. destruction.Fullinvolving damage or necrosis of subcutaneous tissue that may extend down to.Full-thickness skin loss IV.

.

Treatment protocol .

The End .

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