wound care gops
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WOUND CARE
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Wounds2
A wound (damaged skin or soft tissue) resultsfrom trauma (general term referring to injury).
e.g. tissue trauma include cuts, blows, poor
circulation, strong chemicals, and excessive heator cold. Such trauma produces two basic types of
wounds: open and closed
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Wound Repair5
The process of wound repair proceeds in three
sequential phases:
Inflammation
Proliferation
Remodeling
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Inflammation6
Inflammation, the physiologic defenseimmediately after tissue injury, lasts
approximately 2 to 5 days. Its purposes are to
limit the local damage,
remove injured cells and debris, and
prepare the wound for healing.
Inflammation progresses through several stages
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Figure 28-1 The
inflammatory response. The
words in red are the five
classic signs and symptoms
of inflammation.
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During the first stage, local changes occur.Immediately following an injury, blood vesselsconstrict to control blood loss and confine thedamage. Shortly thereafter, the blood vessels
dilate to deliver platelets that form a loose clot.The membranes of the damaged cells becomemore permeable, causing release of plasma andchemical substances that transmit a sensation of
discomfort. The local response produces thecharacteristic signs and symptoms ofinflammation: swelling, redness, warmth, pain ,and decreased function.
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A second wave of defense follows the local
changes when leukocytes and macrophages(types of white blood cells) migrate to the site
of injury, and the body produces more andmore white blood cells to take their place.
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Proliferation10
Proliferation (period during which new cellsfill and seal a wound) occurs from 2 days to 3
weeks after the inflammatory phase. It ischaracterized by the appearance ofgranulation tissue (combination of new bloodvessels, fibroblasts, and epithelial cells), which
is bright pink to red because of the extensiveprojections of capillaries in the area.
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Granulation tissue grows from the wound
margin toward the center. It is fragile and easily
disrupted by physical or chemical means. As
more and more fibroblasts produce collagen(a tough and inelastic protein substance), theadhesive strength of the wound increases.
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Generally, the integrity of skin and damagedtissue is restored by:
Resolution (process by which damaged cellsrecover and re-establish their normal function),
Regeneration (cell duplication),
Scar formation (replacement of damaged cells
with fibrous scar tissue).
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Remodeling13
Remodeling (period during which the woundundergoes changes and maturation) follows
the proliferative phase and may last 6 months
to 2 years. During this time, the woundcontracts, and the scar shrinks.
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Wound Healing14
Several factors affect wound healing:
Type of wound injury
Expanse or depth of wound
Quality of circulation
Amount of wound debris
Presence of infectionStatus of the client's health
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Wound Healing Complications15
Factors that may interfere include
compromised circulation
infection
purulent
bloody
serous fluid accumulation that prevent skin and
tissue approximation drugs like corticosteroids
obesity.
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The nurse assesses the wound to determinewhether it is intact or shows evidence of unusual swelling
redness
Warmth
Drainage
increasing discomfort
Two potential surgical wound complications
includeDehiscence (separation of wound edges)Evisceration (wound separation with protrusion oforgans)
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Figure (28-4 ( A )Wound dehiscence( B )Wound evisceration).
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Wound Management18
Wound management involves
changing dressings
caring for drains
removing sutures or staples when directed by thesurgeon
applying bandages and binders
administering irrigations.
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Dressings19
A dressing purposes:
Keeping the wound clean
Absorbing drainage
Controlling bleeding
Protecting the wound from further injury
Holding medication in place
Maintaining a moist environment
The most common wound coverings are gauze,
transparent, and hydrocolloid dressings.
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Gauze Dressings20
Gauze dressings are made of woven cloth
fibers. Their highly absorbent nature makes
them ideal for covering fresh wounds that are
likely to bleed or wounds that exude drainage.
Unfortunately, gauze dressings obscure the
wound and interfere with wound assessment.
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Gauze dressings usually are secured with
tape. If gauze dressings need frequent
changing, Montgomery straps (strips of tape
with eyelets) may be used
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A) The adhesive outer edge ofMontgomery straps are applied
to either side of a wound .
B) The inner edges of Montgomery
straps are tied to hold a dressingover a wound. They prevent skin
breakdown and wound
disruption from repeated tape
removal when checking or
changing a dressing.
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Transparent Dressings23
Transparent dressings are clear wound
coverings. One of their chief advantages is
that they allow the nurse to assess a wound
without removing the dressing
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Figure 28-6 Transparent dressing.
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Hydrocolloid Dressings25
Hydrocolloid dressings are self-adhesive,opaque air- and water-occlusive wound
coverings . They keep wounds moist. Moist wounds heal
more quickly because new cells grow morerapidly in a wet environment.
If the hydrocolloid dressing remains intact, itcan be left in place for up to 1 week.
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Figure 28-7
A hydrocolloid dressing absorbs drainage into its matrix.
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Dressing Changes27
Nurses change dressings when a wound
requires assessment or care and when the
dressing becomes loose or saturated with
drainage.
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Drains28
Drains are tubes that provide a means forremoving blood and drainage from a wound.
They promote wound healing by removing fluid
and cellular debris
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Open Drains29
Open drains are flat, flexible tubes that provide a
pathway for drainage toward the dressing.
Draining occurs passively by gravity and capillary
action. Sometimes a safety pin or long clip isattached to the drain as it extends from the
wound.
As the drainage decreases, the physician may
instruct the nurse to shorten the drain
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Figure 28-8 An open drain is pulled from the wound, and the excess portion is cut.
A drain sponge is placed around the drain, and the wound is covered with a gauze
dressing.
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Closed Drains31
Closed drains are tubes that terminate in a
receptacle. Some examples of closed
drainage systems are a Hemovac.
Closed drains are more efficient than opendrains because they pull fluid by creating a
vacuum or negative pressure.
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Sutures and Staples32
Sutures, knotted ties that hold an incisiontogether, generally are constructed from silk or
synthetic materials such as nylon.
Staples (wide metal clips) perform a similarfunction. Staples do not encircle a wound like
sutures; instead, they form a bridge that holds
the two wound margins together.
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Sutures and staples are left in place until the
wound has healed sufficiently to prevent
reopening. Depending on the location of the
incision, this may be a few days to as long as2 weeks.
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Figure 28-10 ( A )Technique for suture removal( .B )Technique for staple removal.
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Bandages and Binders35
A bandage is a strip or roll of cloth wrappedaround a body part. One example is Crib
bandage.
A binder is a type of bandage generallyapplied to a particular body part such as the
abdomen or breast.
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Dbridement36
Some wounds require dbridement (removalof dead tissue) to promote healing. The four
methods for dbriding a wound are sharp,
enzymatic, autolytic, and mechanical.
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Sharp Dbridement37
Sharp dbridement is the removal ofnecrotictissue (nonliving tissue) from the healthyareas of a wound with sterile scissors, forceps,
or other instruments.
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Enzymatic Dbridement38
Enzymatic dbridement involves the use of
topically applied chemical substances that
break down and liquefy wound debris.
This form of dbridement is appropriate foruninfected wounds or for clients who cannot
tolerate sharp dbridement.
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Wound Irrigation39
Wound irrigation generally is carried out just
before applying a new dressing. This
technique is best used when granulation tissue
has formed. Surface debris should be removedgently without disturbing the healthy
proliferating cells.
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Heat and Cold Applications40
Heat and cold have various therapeutic uses
The terms hot and cold are subject to wide
interpretation
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Therapeutic Baths43
Therapeutic baths (those performed for otherthan hygiene purposes) help to reduce a high
fever or apply medicated substances to the
skin to treat skin disorders or discomfort.
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The most common type of therapeutic bath is
a sitz bath (soak of the perianal area). Sitzbaths reduce swelling and inflammation and
promote healing of wounds after ahemorrhoidectomy(surgical removal of
engorged veins inside and outside the anal
sphincter) or an episiotomy (incision that
facilitates vaginal birth).
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Pressure Ulcers45
A pressure ulcer is a wound caused byprolonged capillary compression that is
sufficient to impair circulation to the skin and
underlying tissue. The primary goal inmanaging pressure ulcers is prevention. Once
a pressure ulcer forms, however, the nurse
implements measures to reduce its size and to
restore skin and tissue integrity
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Pressure ulcers or sores, also referred to asdecubitus ulcers, most often appear over bony
prominences of the sacrum, hips, and heels.
They also can develop in other locations such
as the elbows, shoulder blades, back of the
head, and places where pressure is unrelieved
because of infrequent movement
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Figure 28-17 Locations where pressure ulcers commonly form( .A )Supine
position( .B )Side-lying position( .C )Sitting position.
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The tissue in these areas is particularly
vulnerable because body fat, which acts as a
pressure-absorbing cushion, is minimal.
Consequently, the tissue is compressedbetween the bony mass and a rigid surface
such as a chair seat or bed mattress. If the
compression on local capillaries continues
without intermittent relief, the cells die from
lack of oxygen and nutrition.
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Stages of Pressure Ulcers49
Pressure ulcers are grouped into four stages
according to the extent of tissue injury
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Figure 28-18
Pressure sore stages( .A
)Stage I( .B
)Stage II( .C
)Stage III( .D
)Stage IV.
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Stage I is characterized by intact but reddenedskin. The hallmark of cellular damage is skinthat remains red and fails to resume its normalcolor when pressure is relieved.
A stage II pressure ulcer is red andaccompanied by blistering or a skin tear(shallow break in the skin). Impairment of theskin may lead to colonization and infection ofthe wound.
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A stage III pressure ulcer has a shallow skin craterthat extends to the subcutaneous tissue. It may beaccompanied by serous drainage (leaking plasma)orpurulent drainage (white or greenish fluid)caused by a wound infection. The area is relativelypainless despite the severity of the ulcer.
Stage IV pressure ulcers are life threatening. Thetissue is deeply ulcerated, exposing muscle and
bone. The dead or infected tissue may produce afoul odor. The infection easily spreads throughoutthe body, causing sepsis (potentially fatal systemicinfection).
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Prevention of Pressure Ulcers54
The first step in prevention is to identify clients
with risk factors for pressure ulcers.The
second step is to implement measures that
reduce conditions under which pressure ulcersare likely to form.
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Nursing Implications57
Acute Pain
Impaired Skin Integrity
Ineffective Tissue Perfusion
Impaired Tissue Integrity
Risk for Infection