Define the Key Terms Listed in This Chapter s1

Chapter 32 Wound Care

LEARNING OUTCOMES:

 Define the key terms listed in this chapter  Describe skin tears, pressure ulcers, circulatory ulcers, and diabetic foot ulcers and their causes  Identify the pressure points in each body position  Identify the signs and symptoms of pressure ulcers  Identify the persons at risk for skin tears, pressure ulcers, circulatory ulcers, and diabetic foot ulcers  Describe how to prevent skin tears, pressure ulcers, circulatory ulcers, and diabetic foot ulcers  Describe the process, types, and complications of wound healing  Describe what to observe about wounds and wound drainage  Explain how to secure dressings  Explain the rules for applying dressings  Explain the purpose of binders and how to apply them  Describe how to meet the basic needs of persons with wounds  Perform the procedures described in this chapter

 The skin is the body’s 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.

 A wound is a 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 involves: • Preventing infection • Preventing further injury to the wound and nearby tissues • Preventing blood loss • Preventing pain  Your role in wound care depends on: • State law • Your job description • The person’s condition

 TYPES OF WOUNDS  Wounds are described in the following ways: • Intentional wounds and unintentional wounds • Open and closed wounds • Clean wounds • Clean-contaminated wounds • Contaminated wounds (dirty wounds) • Infected wounds • Chronic wounds • Partial- and full-thickness wounds

 Wounds also are described by their cause. • Abrasion • Contusion • Incision • Laceration • Penetrating wound • Puncture wound

 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 legs are common sites for skin tears.  Causes include: • Friction and shearing • Pulling or pressure on the skin • Bumping a hand, arm, or leg on any hard surface • Holding the person’s arm or leg too tight

 Skin tears are painful.  Skin tears are portals of entry for microbes.  Tell the nurse at once if you cause or find a skin tear.  Persons at risk for skin tears: • Need moderate to total help in moving • Have poor nutrition • Have poor hydration • Have altered mental awareness • Are very thin  Careful and safe care helps prevent skin tears and further injury.

 PRESSURE ULCERS (DECUBITUS ULCERS, BED SORES, PRESSURE SORES)  A pressure ulcer is a localized injury to the skin and/or underlying tissue over a bony prominence. • It is the result of pressure or pressure in combination with shear and/or friction. • The back of the head, shoulder blades, elbows, hips, spine, sacrum, knees, ankles, heels, and toes are bony prominences.

 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

 Persons at risk for pressure ulcers are those who: • Are bedfast or chairfast • Need some or total help in moving • Are agitated or have involuntary muscle movements • Have loss of bowel or bladder control • Are exposed to moisture • Have poor nutrition • Have poor fluid balance • Have lowered mental awareness • Have problems sensing pain or pressure • Have circulatory problems • Are older • Are obese or very thin

 Pressure ulcer stages • Stage 1 (The skin is intact. There is usually redness over a bony prominence. The color does not return to normal when skin is relieved of pressure.) • Stage 2 (Partial-thickness skin loss) • Stage 3 (Full-thickness skin loss) • Stage 4 (Full-thickness tissue loss with muscle, tendon, and bone exposure) • Unstageable (Full thickness tissue loss with the ulcer covered by slough and/or eschar)

 Sites • 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 breasts

 Prevention and treatment • Good nursing care, cleanliness, and skin care are essential. • The health team must develop a plan of care for each person at risk. • The person 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.

 These protective devices are used to prevent and treat pressure ulcers and skin breakdown: • Bed cradles • Heel and elbow protectors • Heel and foot elevators • Gel or fluid-filled pads and cushions • Eggcrate-type pads • Special beds • Pillows • Trochanter rolls • Foot boards • Other positioning devices

 Report and record any signs of skin breakdown or pressure ulcers at once.

 CIRCULATORY 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 diseases affecting the blood vessels are at risk. • These wounds are painful and hard to heal.

 Venous ulcers (stasis ulcers) are open sores on the lower legs or feet caused by poor blood flow through the veins. • These ulcers can develop when valves in the legs do not close well. • The veins cannot pump blood back to the heart in a normal way. • Blood and fluid collect in the legs and feet. • The heels and inner aspect of the ankles are common sites for venous ulcers. • They can occur from skin injury. • They can occur without trauma. • Venous ulcers are painful and make walking difficult. • Infection is a risk.

• Risk factors for venous ulcers include:  History of blood clots  History of varicose veins  Decreased mobility  Obesity  Leg or foot surgery  Advanced age  Surgery on the bones and joints  Phlebitis (inflammation of a vein)

• Prevention and treatment  Follow the person’s care plan to prevent skin breakdown.  Prevent injury.  Handle, move, and transfer the person carefully and gently.  Persons 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 ulcers are often ordered.  The doctor may order elastic stockings or elastic bandages.

 Arterial ulcers are open wounds on the lower legs or feet caused by poor arterial blood flow. • They are found between the toes, on top of the toes, and on the outer side of the ankle. • These ulcers are very painful. • 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

 Diabetic foot ulcers are open wounds on the feet caused by complications from diabetes. • Diabetes can affect the nerves and blood vessels.  Both problems can lead to diabetic foot ulcers.  Infection and gangrene are risks.  Sometimes amputation of the affected part is needed to prevent the spread of gangrene. • You need to:  Check the person’s feet every day.  Report any sign of a foot problem to the nurse at once.  Follow the care plan.

 WOUND HEALING  The healing process has three phases: • Inflammatory phase (3 days)  Bleeding stops.  A scab forms over the wound. • 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.

 Healing occurs in three ways: • First intention (primary intention, primary closure)  Wound edges are brought together to close the wound. • Second intention (secondary intention)  Wounds are cleaned and dead tissue removed.  Wound edges are not brought together. • Third intention (delayed intention, tertiary intention)  The wound is left open and closed later.

 Many factors affect healing and increase the risk of complications. • The type of wound • The person’s age, general health, nutrition, and life-style • Circulation • Nutrition • Immune system changes • Persons taking antibiotics  An environment may be created that allows other pathogens to grow and multiply.

 Complications include: • Hemorrhage and shock  You cannot see internal hemorrhage. Common signs are shock, vomiting blood, coughing up blood, and loss of consciousness.  Common signs of external hemorrhage are bloody drainage and dressings soaked with blood.  Hemorrhage and shock are emergencies. • Infection • 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.

 Wound appearance • Doctors and nurses observe the wound and its drainage. • You need to make certain observations when assisting with wound care. • Report and record your observations according to agency policy.  The amount and kind of wound drainage depend on: • Wound size and location • Bleeding and infection  Wound drainage is observed and measured. • Serous drainage is clear, watery fluid. • Sanguineous drainage is bloody drainage. • Serosanguineous drainage is thin, watery drainage that is blood-tinged. • Purulent drainage is thick, green, yellow, or brown drainage.

 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 drains onto a dressing.  It is an open drain.  Microbes can enter the drain and wound. • Closed drainage systems prevent microbes from entering the wound.  A drain is placed in the wound and attached to suction.

 Drainage is measured in three ways: • Weighing dressings before applying them to the wound • Noting the number and size of dressings 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

 DRESSINGS  Wound dressings 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

 Dressing type and size depend on many factors: • The type of wound • Wound size and location • Amount of drainage • Infection • The dressing’s function • The frequency of dressing changes  The doctor and nurse choose the best type of dressing for each wound.

 Dressings are described by the material used and application method. • The following are common:  Gauze comes in squares, rectangles, pads, and rolls.  Non-adherent gauze is a gauze dressing with a non-stick surface.  Transparent adhesive film allows wound observation. • Some dressings contain special agents to promote wound healing. • Dressings are wet or dry:  Dry dressing  Wet-to-dry dressing  Wet-to-wet dressing

 Microbes can enter the wound, and drainage can escape if the dressing is dislodged. • Tape and Montgomery ties are used to secure dressings. • Binders hold dressings in place. • Adhesive tape sticks well to the skin. • Paper, plastic, and cloth tapes usually do not cause allergic reactions. • Elastic tape allows movement of the body part.

• Tape comes in different sizes. • Tape is applied to the top, middle, and bottom parts of the dressing. • The tape extends several inches beyond each side of the dressing. • Tape is not applied to circle the entire body part. • Montgomery ties are used for large dressings and frequent dressing changes.  You may assist the nurse with dressing changes. • Some agencies let you apply simple, dry, non-sterile dressings to simple wounds.

 BINDERS  Binders are applied to the abdomen, chest, or perineal areas.  Binders promote healing by: • Supporting wounds • Holding dressings in place • Preventing or reducing swelling • Promoting comfort • Preventing injury

 An abdominal binder provides abdominal support and holds dressings in place.  A breast binder: • Supports the breasts after surgery • Applies pressure to the breasts after childbirth in the non-breastfeeding mother • Promotes comfort and supports swollen breasts after childbirth  T-binders secure dressings in place after rectal and perineal surgeries.

 MEETING BASIC NEEDS  The wound causes pain and discomfort. • Allow pain-relief drugs to take effect before giving care.  Good nutrition is needed for healing.  Pain and odors can affect appetite.  Infection is always a threat.  Delayed healing and infection are risks for persons who: • Are older or obese • Have poor nutrition • Have poor circulation and diabetes

 Many factors affect safety and security needs.  Victims of violence have many other concerns.  Whatever the wound site or size, it affects function and body image.