Chapter 21 Assisting With Wound Care Copyright 2006

A BREAKDOWN OF SKIN TISSUE THAT OCCURS WHEN BLOOD FLOW TO AN AREA IS

PRESSURE ULCERS Causes Pressure, friction, and shearing Ø Breaks in the skin Ø Poor

v LYING OR SITTING TOO LONG IN ONE POSITION – CAUSES PRESSURE OVER BONY

Signs of pressure ulcers The first sign is pale skin or a reddened

IN STAGE 1 THE SKIN IS RED AND MAY BE WARM TO THE TOUCH.

v GENTLY MASSAGE OUTSIDE OF THE REDDENED AREA v KEEP AREA AROUND THE BREAKDOWN

IN STAGE 2 THE SKIN CRACKS, BLISTERS, OR PEELS. DESTRUCTION OF THE EPIDERMIS AND

v REMOVE THE PRESSURE v GENTLY MASSAGE AROUND THE OUTSIDE OF THE AFFECTED AREA

IN STAGE 3 THE LAYERS OF SKIN HAVE BEEN DESTROYED AND A DEEP CRATER

v ASSIST IN KEEPING THE AREA AFFECTED CLEAN v ASSIST WITH DRESSING CHANGES v

A STAGE 4 ULCER HAS DEEP TISSUE INVOLVEMENT EXPOSING MUSCLE AND BONE THERE MAY

v ASSIST WITH DRESSING CHANGES v MAY REQUIRE SURGICAL TREATMENT Copyright © 2006 Mosby,

SKIN TEARS Skin tears are caused by: Friction and shearing Ø Pulling on the

To prevent skin tears: Keep the person’s and your fingernails short and smoothly

CIRCULATORY ULCERS Poor circulation can lead to: Pain Ø Open wounds Ø Swelling of

Stasis ulcers (venous ulcers) Ø The heels and inner aspect of the ankles

Prevention and treatment Follow the person’s care plan. Ø Elastic stockings and elastic

DRESSINGS Wound dressings: Protect wounds from injury and microbes Ø Absorb drainage Ø Remove

Securing dressings Ø Dressings are secured and held in place by: • Adhesive

Applying dry non-sterile dressings* Meet fluid and elimination needs before you begin. Ø

BINDERS Binders promote healing by: Supporting wounds and holding dressings in place Ø Reducing

HEAT AND COLD APPLICATIONS Heat and cold applications Promote healing and comfort Ø Reduce

Persons at risk for complications are: • Older and fair-skinned people • Persons with

Cold applications Reduce pain Ø Prevent swelling Ø Decrease circulation and bleeding Ø

Slides: 25

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PRESSURE ULCERS Causes Pressure, friction, and shearing Ø Breaks in the skin Ø Poor circulation to an area Ø Moisture Ø Dry skin Ø Irritation by urine and feces Ø Age Ø Friction scrapes the skin. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 3

v LYING OR SITTING TOO LONG IN ONE POSITION – CAUSES PRESSURE OVER BONY PROMINENCES v WRINKLES IN CLOTHING OR BED LINEN v POOR NUTRITION v SHEARING – WHEN THE SKIN STICKS TO THE SURFACE AND THE DEEPER TISSUE MOVE DOWNWARD (WHEN THE PERSON SLIDES DOWN IN BED) Copyright © 2006 Mosby, Inc. All rights reserved. Slide 4

Signs of pressure ulcers The first sign is pale skin or a reddened area. Ø Stages of pressure ulcers • Stage 1 Ø The skin is red. The color does not return to normal when the skin is relieved of pressure. The skin is intact. • Stage 2 The skin cracks, blisters, or peels. There may be a shallow crater. • Stage 3 The skin is gone. Underlying tissues are exposed. The exposed tissue is damaged. There may be drainage from the area. • Stage 4 Muscle and bone are exposed and damaged. Drainage is likely. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 5

IN STAGE 1 THE SKIN IS RED AND MAY BE WARM TO THE TOUCH. THE COLOR DOES NOT RETURN TO NORMAL WHEN THE SKIN IS RELIEVED OF PRESSURE ON DARK COLORED SKIN THE AREA MAY APPEAR Slide 6 Copyright © 2006 Mosby, Inc. All. PURPLISH rights reserved. DARK BLUE OR

v GENTLY MASSAGE OUTSIDE OF THE REDDENED AREA v KEEP AREA AROUND THE BREAKDOWN CLEAN AND DRY v RELIEVE ALL PRESSURE OVER THE AFFECTED AREA v ENCOURAGE NUTRITIOUS DIET AND ADEQUATE FLUIDS v NURSE MAY APPLY A PROTECTIVE COVERING Copyright © 2006 Mosby, Inc. All rights reserved. Slide 7

IN STAGE 2 THE SKIN CRACKS, BLISTERS, OR PEELS. DESTRUCTION OF THE EPIDERMIS AND PARTIAL DESTRUCTION OF THE DERMIS MAY LOOK LIKE AN ABRASION, BLISTER, OR SHALLOW CRATER Copyright © 2006 Mosby, Inc. All rights reserved. Slide 8

v ASSIST IN KEEPING THE AREA AFFECTED CLEAN v ASSIST WITH DRESSING CHANGES v MAY REQUIRE SURGICAL TREATMENT v ASSIST WITH THE USE OF PRESSURE - RELIEVING DEVICES ( SPECIALTY MATTRESS, BED, OR CUSHIONS ) Copyright © 2006 Mosby, Inc. All rights reserved. Slide 11

SKIN TEARS Skin tears are caused by: Friction and shearing Ø Pulling on the skin Ø Pressure on the skin Ø Tell the nurse at once if you cause or find a skin tear. Copyright © 2006 Mosby, Inc. All rights reserved. Slide 14

To prevent skin tears: Keep the person’s and your fingernails short and smoothly filed Ø Do not wear rings or bracelets Ø Follow the care plan Ø Follow safety rules to lift, move, position, transfer, bathe, and dress the person Ø Prevent shearing and friction Ø Use an assist device to move the person in bed Ø Copyright © 2006 Mosby, Inc. All rights reserved. Slide 15

CIRCULATORY ULCERS Poor circulation can lead to: Pain Ø Open wounds Ø Swelling of tissues (edema) Ø Infection and gangrene • Gangrene is a condition in which tissue dies. Ø Copyright © 2006 Mosby, Inc. All rights reserved. Slide 16

Stasis ulcers (venous ulcers) Ø The heels and inner aspect of the ankles are common sites. Arterial ulcers Are found: • Between the toes • On top of the toes • On the outer side of the ankles • On the heels for persons on bedrest Ø These ulcers can occur from shoes that fit poorly. Ø Copyright © 2006 Mosby, Inc. All rights reserved. Slide 17

Prevention and treatment Follow the person’s care plan. Ø Elastic stockings and elastic bandages promote circulation. • Applying elastic stockings (NNAAP)* • Applying elastic bandages* Ø Copyright © 2006 Mosby, Inc. All rights reserved. Slide 18

DRESSINGS Wound dressings: Protect wounds from injury and microbes Ø Absorb drainage Ø Remove dead tissue Ø Promote comfort Ø Provide a moist environment for wound healing Ø Copyright © 2006 Mosby, Inc. All rights reserved. Slide 19

Securing dressings Ø Dressings are secured and held in place by: • Adhesive tape • Paper and plastic tape • Elastic tape • Montgomery ties • Binders Copyright © 2006 Mosby, Inc. All rights reserved. Slide 20

Applying dry non-sterile dressings* Meet fluid and elimination needs before you begin. Ø Collect needed equipment and supplies. Ø Control your nonverbal communication. Ø Remove dressings so the person cannot see the soiled side. Ø Do not force the person to look at the wound. Ø Remove tape by pulling it toward the wound. Ø Remove dressings gently. Ø Report and record your observations. Ø Copyright © 2006 Mosby, Inc. All rights reserved. Slide 21

BINDERS Binders promote healing by: Supporting wounds and holding dressings in place Ø Reducing or preventing swelling Ø Promoting comfort Ø Preventing injury Ø Types of binders Straight abdominal binders Ø Breast binders Ø T-binders Ø Copyright © 2006 Mosby, Inc. All rights reserved. Slide 22

HEAT AND COLD APPLICATIONS Heat and cold applications Promote healing and comfort Ø Reduce tissue swelling Ø Heat applications are often used: • For musculoskeletal injuries or problems • To relieve pain, relax muscles, and decrease joint stiffness • To promote healing and reduce tissue swelling Ø High temperatures can cause burns. Ø Copyright © 2006 Mosby, Inc. All rights reserved. Slide 23

Persons at risk for complications are: • Older and fair-skinned people • Persons with problems sensing heat or pain • Persons with dementia • Persons with metal implants Ø Moist and dry heat applications. Ø Copyright © 2006 Mosby, Inc. All rights reserved. Slide 24

Cold applications Reduce pain Ø Prevent swelling Ø Decrease circulation and bleeding Ø Complications include pain, burns, and blisters. Ø Persons at risk for complications include: • Older and fair-skinned persons • Persons with mental or sensory impairments Ø Moist and Dry cold applications Ø Copyright © 2006 Mosby, Inc. All rights reserved. Slide 25