MNA Mosbys Long Term Care Assistant Chapter 30
MNA Mosby’s Long Term Care Assistant Chapter 30 Wound Care
Wound Care Skin is body’s first line of defense Wound is a break in the skin or mucous membrane Portal of entry for microbes
Common Causes of Skin Breakdown Age Loss of fatty layer under the skin Decrease sensation to touch, heat, cold Decrease mobility Chronic diseases Poor nutrition and hydration Incontinence Pressure on bony prominences Friction and shearing
Types of Wounds Abrasion Scraping or rubbing away of skin Contusion Closed wound caused by blow to body. bruise Incision Open, clean straight edges Laceration Open, torn, jagged edges Penetrating wound Open, Skin is pierced Puncture wound Open, made by sharp object
Types of Wounds Abrasion
Types of Wounds Contusion
Types of Wounds Incision
Types of Wounds Laceration
Types of Wounds Penetrating Wound
Types of Wounds Puncture Wound
Skin Tears Break or rip in skin Thin fragile skin Slight pressure can cause a tear Causes: friction, shearing Holding too tightly Removing tape, band aide Bumping against something Portal of entry for microbes
Leg and Foot Ulcers Edema - swelling Gangrene - death of tissue Circulatory Ulcers – open wounds on legs and feet due to blood flow Venous Ulcers (Stasis Ulcers) open wounds on legs and feet due to venous return. Blood pools in feet and legs
Leg and Foot Ulcers Causes: Chronic diseases Obesity Inactivity Risk Factors: Hx of blood clots ¯ Mobility Obesity Age
Leg and Foot Ulcers Prevention and TX TED Hose Avoid constricting clothing Good foot care Reposition Q 2 H Feet Protective devices Observation
TED Hose Elastic stockings Sizes: Thrombus – blood clot Embolus – traveling blood clot Anti Thromboemboletic Hose Knee high Thigh
TED Hose Apply Ted Hose Remove for 30 minutes every 8 hours (Qshift) for foot care and Circ Checks
Heat and Cold Applications Promote healing and comfort Reduce tissue swelling
Heat and Cold Applications Observe skins q 5 minutes Apply no longer then 15 -20 minutes Hot: never higher then 106 F Cold: never lower then 50 F
Heat Applications Relieves pain Relaxes muscles Decreases joint stiffness Promotes healing Reduces tissue swelling Blood vessels dilate (widen) Blood flow increases More blood = more O 2 = faster healing Can cause burns
Heat Applications Moist: Hot compress Soft pad Hot soaks Body part immersed in water Sitz Baths Perineal and rectal area immersed in water Dry: Aquathermia pad Like a heating pad
Sitz Bath Placed on toilet seat Observe for signs of dizziness or fainting.
Cold Applications Reduce pain Prevent swelling Decrease circulation Decrease bleeding Numbs Blood vessels constrict (get smaller) Blood flow decreases Can cause pain, burns blisters and poor circulation
Cold Applications Cold Compresses Ice bags Ice collers Ice Gloves
Remember…… Older persons require special skin care. Protein is an essential nutrient for skin repair Follow Standard Precautions
Review Swelling? edema
Review Incision
Review A closed wound caused by a blow to the body ? contusion
Review Embolus ? Traveling blood clot
Review gangrene ? Death of tissue
Review Thrombus ? Blood clot
Review Skin tears usually occur over a Bony prominence ________.
Review Contusion
Review Elastic stocking are called TED hose __________.
Review Puncture Wound
Review Ted Hose (elastic stocking) are used to increase circulation True or False
Review Penetrating Wound
Review Ted Hose (elastic stocking) are used to hold dressings in place True or False
Review Ted Hose (elastic stocking) are used to promote healing True or False
Review Abrasion
Review Ted Hose (elastic stocking) are used to prevent injury True or False
Review Protein is the most important nutrient for wound healing. True or False
Review Severely underweight? A. obesity B. anemia C. paralysis D. emaciation
Review Laceration
Review Constrict means Get smaller, narrow
Review Heat applications Relieve pain Relaxe muscles Decrease joint stiffness Promote healing Reduce tissue swelling
Review During a sitz bath, you need to carefully observe the person for Weakness, dizziness and faintness
Review NPO PC Nothing by mouth After meals AC Before meals Qid 4 x day Tid 3 x day
Questions? ?
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