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CHAPTER 42

WOUND CARE
Wound Care
The skin is the bodys first line of defense.
It protects the body from microbes that cause infection.

You must prevent skin injury and give good skin care to help prevent
skin breakdown.
Older and disabled persons are at great risk.
WOUND CARE (contd)
A wound is break in the skin or mucous membrane.
Common causes are
Surgery
Trauma
Pressure ulcers from unrelieved pressure
Decreased blood flow through the arteries or veins
Nerve damage

When injury does occur,infection is a major threat.


WOUND CARE (contd)
Wound care involves:
Prevention of infection
Preventing further injury to the wound and nearby tissues
Preventing blood loss
Preventing pain

Your role in wound care depends on:


Your Job description
The clients condition
Provincial or territorial law
TYPES OF WOUND
Wounds are described in the following ways:
Intentional and unintentional wounds
Open and closed wounds
Clean wounds: not infected
Clean-contaminated wounds: occurs from the surgical entry of urinary,
reproductive or digestive
Contaminated wounds (dirty wounds): high risk of infection
Chronic wounds: does not heal easily
Partial (dermis and epidermis) and full-thickness wounds (dermis,
epidermis and subcutaneous tissue)
Intentional: created treatment
Unintentional: cause by trauma
DESCRIPTION OF WOUNDS
Wounds also are described by their cause.
Abrasion
Scraping away or rubbing of the skin.
Contusion
Blow to the body (bruise)
Incision
Clean, intentionally cut into the skin
Laceration
Torn, jagged wound
Penetrating wound
Skin and underlying tissue pierced
Puncture Wound
Open wound caused by sharp object
SKIN TEARS
A skin tear is a break or rip in the skin.
The epidermis separates from the underlying tissues.
The hands, arms, and lower leg are common sites for skin tears.

Causes includes:
Friction and shearing : tearing of skin tissues; rub against another surface
Pulling or pressure on the skin
Bumping a hand, arm or leg on any hard surface
Holding the clients arm or leg too tight
Repositioning, moving or transferring client
SKIN CARE (contd)
Skin tears are painful.
Skin tears are portals of entry for microbes.
Tell the supervisor at once if you cause or find a skin tear , bruise,
bump or scrape.
Persons at risk for skin tears:
Need moderate to complete help in moving
Have poor nutrition or are very thin
Have poor hydration
Have altered mental awareness
Are older
Careful and safe care helps prevent skin tears and further injury
GUIDELINES FOR PREVENTING SKIN TEARS
Follow care plan and safety measures for moving, lifting,
repositioning.
Keep clients nails and your nails short/filed.
Do not wear rings.
Gently transfer or position the client.
Use a turning sheet.
Prevent friction during moving/positioning.
PRESSURE ULCERS
Decubitus ulcers, bed sores and pressure sores
A pressure ulcer is an injury caused by unrelieved pressure to the skin
and/or underlying tissue
The back of the head, shoulder blades, elbows, hips, spine, sacrum,
knees, ankles, heels and bony prominences are considered pressure
points.
Pressure points that are moist are especially prone to developing a
pressure ulcer.
CAUSES OF PRESSURE ULCERS
Pressure, shearing and friction are common causes

Risk factors include:


Breaks in the skin
Poor circulation to an area
Moisture
Dry skin
Irritation by urine and feces
CLIENTS AT RISK FOR PRESSURE ULCERS
Clients at risk for pressure ulcers are those who:
Confined to a bed or chair
Require moderate to complete help in moving
Have loss of bowel or bladder control
Have poor nutrition
Have altered mental awareness
Have problems sensing pain or pressure
Have circulatory problems
Are older
Are obese or very thin
SIGNS OF PRESSURE ULCERS
Pale skin, warm reddened area
Complaints of pain, burning, itching or tingling in the area
Some clients may not feel anything unusual.
Immediately notify supervisor of any signs of a pressure ulcer.
SIGNS OF PRESSURE ULCER (contd)
Pressure usually occurs over bony areas called pressure points.
Pressure on the ears can be caused by:
The mattress when in the side-lying position
Eyeglasses and oxygen tubing
In obese people, pressure ulcers can occur in areas where skin has
contact with skin.
Between abdominal folds
The legs
The buttocks
The thighs
Under the breast
STAGES OF PRESSURE ULCERS
Pressure ulcer stages
Stage 1 (Skin intact)
There is usually redness over a bony prominence. The colour does not
return to normal when skin is relieved of pressure.
Stage 2 (Partial-thickness skin loss)
Skin cracks blisters or peels.
Stage 3 (Full-thickness skin loss)
Skin is gone
There may be drainage from the area.
Stage 4 (Full-thickness tissue loss)
Muscle, tendon and bone exposure.
PREVENTION AND TREATMENT
Preventing pressure ulcers is much easier than healing them.

Good nursing care, cleanliness and skin care are essential.


Thee health team must develop a plan of care for each person at risk.
The client at risk for pressure ulcers is placed on a surface that reduces or
relieves pressure.
The doctor orders wound care products, drugs, treatments and special
equipment to promote healing.
PROTECTIVE DEVICES
These protective devices are used to prevent and treat pressure ulcer
and skin breakdown:
Special beds
Bed cradles
Heel and elbow protectors
Flotation pads, gel or fluid-filled pads and cushions
Egg crate-like mattress
Trochanter rolls
Food boards
Other positioning devices
LEG AND FOOT ULCERS
Some diseases affect blood flow to and from the legs and feet.
Edema
Swelling caused by fluid collecting in tissues

Gangrene
A condition in which there is death of tissue

Infection and gangrene can result from an open wwoud and poor
circulation.
CIRCULTORY ULCERS
Circulatory ulcers (vascular ulcers) are open sores on the lower legs or
feet.
They are caused by decreased blood flow through the arteries or veins.
Persons with disease affecting the blood vessels are at risk.
These wounds are painful and hard to heal.
VENOUS ULCERS
Venous ulcer (stasis ulcer) are open sores on the lower legs or feet
caused by poor blood flow through the veins.
Can develop when valves in the legs do not close well
Veins cannot pump blood back to the heart in a normal way.
Blood and fluid collect in the legs and feet.
Pitting edema can occur.
The heels and inner aspect of the ankles are common sites for venous
ulcer.
They can occur without trauma.
Venous ulcer are painful and make walking difficult.
Infection is a risk.
APPEARANCE OF VENOUS ULCER
Edema in tissue give swollen appearance.
Skin may appear shiny and stretched.
Walking may be painful and difficult.
Venous ulcer may weep fluid.
Healing is slow, infection great
Edema last for a long period.
Skin will change in appearance and texture brown leathery, hard.
Itching is common.
PREVENTION AND TREATMENT
Follow the clients care plan to prevent skin breakdown.
Prevent injury.
Handle, move and transfer the client carefully and gently.
Clients at risk need professional foot care.
The doctor may order drugs for infection and to decrease swelling.
Medicated bandages and other wound care products are often
ordered.
Devices used for pressure ulcer are often ordered.
The doctor may order elastic stockings or elastic bandages.
ARTERIAL ULCERS
Arterial ulcer are open wounds on the lower legs or feet caused by
poor arterial blood flow.
They are caused by diseases or injuries that decrease arterial blood flow
to the legs and feet.
Smoking is a risk factor.
The doctor treats the disease causing the ulcer.
The doctor orders:
Drugs and wound care
A walking and exercise program
Professional foot care
APPEARANCE OF ARTERIAL ULCERS
Affected leg/foot may feel cool.
Appears blue or shiny.
May be painful during rest-usually worse at night.
Sites:
They are found between the toes, on top of the toes, and o the other side
of the ankle.
Heels are common sites.
WOUND HEALING
The healing process has three phases:
Inflammatory phase (3 days)
Bleeding stops.
A scab forms over the wound.
Blood supply increases bringing nutrients and healing substances to
area.
Redness, swelling, heat or warmth may be present.
May have some loss of function and pain.
Proliferative Phase (day 3 to day 21)
Tissue cells multiply to repair the wound.
Maturation Phase (day 21 to 2 years)
The scar gains strength.
TYPES OF WOUND HEALING

Healing occurs in three ways:


First intention (primary intention, primary closure)
Wound edges are brought together to close the wound.
Sutures, staples, clips, adhesive strips
Second intentions (secondary intentions)
Wounds are cleared and dead tissue removed.
Wound edges are not brought together.
Scar forms slowly, threat of infection is great.
Third intention (delayed intention, tertiary intention)
The wound is left open and closed later.
COMPLICATION OF WOUNDS
Many factors affect healing and increase the risk of complication.
The type of wound
The clients age, general health and lifestyle
Circulation
Nutrition
Immune system changes
Clients taking antibiotic
An environment may be created that allows other pathogens to grow
and multiply.
HEMORRHAGE
Excessive loss of blood in a short period of time
May be internal or external
Internal cannot be seen- bleeding occurs into tissues and body cavities.
Hematoma- collection of blood under the skin
Tissues appears swollen, reddish-blue colour.
Signs and symptoms of internal bleeding
Shock, vomiting blood, coughing up blood and loss of consciousness.
External bleeding
Is visible bloody drainage and dressing soaked with blood.
SHOCK
Results when there is not enough blood supply to organs and tissues
Signs and symptoms
Low or falling blood pressure, rapid and weak pulse
Rapid respiration, cold, moist and pale skin
Client is restless and may complain of thirst.
Confusion and loss of consciousness eventually occur.
Hemorrhage and shock are emergencies.
Follow Standard Practices when in contact with blood.
COMPLICATIONS OF WOUNDS
Infection can occur at any time.
Signs and symptoms:
Wound is tender to the touch, may have drainage.
Client may have fever.
Dehiscence and evisceration are surgical emergencies.
Dehiscence is the separation of wound layers.
Evisceration is the separation of the wound along with the protrusion of
abdominal organs.
Coughing, vomiting and abdominal distension place stress on the wound.
Sterile dressing saturated with sterile saline will be placed over wound.
WOUND APPEARANCE
Doctors and nurses observe the wound and its drainage.
You need to make certain observation when assisting with wound care.
Report and record your observation according to agency policy.
The amount and kind of wound drainage depends on:
Wound size and location
Bleeding and infection
WOUND DRAINAGE
Wound drainage is observed and measured.
Serous drainage is clear, watery fluid.
Serous drainage is bloody drainage.
Sanguineous drainage is thin, watery drainage that is blood-tinged.
Purulent drainage is thick, green, yellow or brown drainage.
WOUND DRAINAGE (contd)
Drainage must leave the wound for healing.
When large amounts of drainage are expected, the doctor inserts a drain.
A Penrose drain is a rubber tube that drain onto a dressing.
It is an open drain
Microbes can enter the drain and wound
Closed drainage system prevent microbes from entering the wound.
A drain is placed in the wound and attached to suction.
DRAINAGE MEASUREMENT

Drainage is measured in two ways:


Noting the number and size of dressing with drainage.
The amount and kind of drainage on each dressing is noted.
Measuring the amount of drainage in the collection container if closed
drainage is used.
STERILE DRESSING
Wound dressing have the following 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.
STERILE DRESSINGS (contd)
Dressing type and size depend on many factors.
The type of wound
Wound size and location
Amount of drainage
Presence or absence of infection
The dressings function
The frequency of dressing changes
The physician and nurse choose the best type of dressing for each
wound.