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WOUND CARE

WOUND CARE. Presentation for ACC Lab March 22, 2006 By Herlinda M. Burks, RN, BA, CWCN, CCCN. Risk Assessments. Report: focus on Hx of diseases, surgeries, how recent, present wounds, incisions. Read the H&P. 10 minute assessment What do you see?

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WOUND CARE

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  1. WOUND CARE Presentation for ACC Lab March 22, 2006 By Herlinda M. Burks, RN, BA, CWCN, CCCN

  2. Risk Assessments • Report: focus on Hx of diseases, surgeries, how recent, present wounds, incisions. Read the H&P. • 10 minute assessment • What do you see? • Tubes, drains, obesity, weakness, skin damage in patterns?, etc. • Braden Scale Pressure Risk Assessment

  3. Wound Treatments • Never leave a wet open wound open to air (OTA) and unprotected. • Only leave ischemic black dry wounds on the feet and toes OTA or dressed lightly with gauze.

  4. Types of Wound Closures Primary Intention Sutures, staples, skin bonds, etc. Secondary Intention Partial thickness Regenerate specific cells Epithelialize Full thickness Regranulate Epithelialize Remodel Tertiary Intention Processes Involved in Wound healing Acute phase Hemostasis Inflammation Proliferation Remodeling Chronic phase Stalls for 2 weeks Change Tx Reassess full body, meds, labs. Wound Healing Processes

  5. Wound Assessments • Etiology - watch those with ischemia • Size – consistent measure from nurse to nurse • L x W x D in centimeters (head to toe, 9 to 3 o’clock) • Locations of tunnels & undermining by the clock • Drainage – type (color, amount, consistency, odor) • Wound bed % of red, yellow, black tissues • Granulation, Slough, Eschar or tan crust or blister • Wound edges – rolled (epiboly), macerated • Peripheral tissues – discoloration, stains, scars? • Edema, induration, scaling (peeling), plaques?

  6. Wound Culturing • Cleanse the wound with saline • Irrigate till clear if it is a deep wound. • Use culturette that has 2 swabs • Wipe tissue in 1 cm2 area • Infection causing Bacteria is in the tissue • Do not get just a sample of the drainage • Multiple bacteria from peripheral tissues can be in the drainage • Submit to lab

  7. Nutrition for Wound Healing • Assessment of Nutrition - labs • Serum Albumin 18 to 20 days half-life • Affected by hydration (> if dehydrated, < if overhydrated) • Transferrin – 8 to 10 days half-life easily affected by other factors. • Prealbumin – 2 days half-life – best predictor • Nutrients needed for Wound healing • Calories –enough to support healing and other present disease processes • Protein • Vitamins

  8. Nutrients • Protein – fibroplasia, neogenesis, collagen formation, remodeling • Carbohydrates – energy and protein sparing • Fat - cell walls • Vitamins – A, B, C, D, E, K • Copper, Iron, Magnesium, Zinc

  9. Open wounds Incisions, dehisced or delayed closure Pressure ulcers Arterial ulcers Venous stasis ulcers Neuropathic ulcers Diabetic ulcers Abcesses Fistulas Ostomies Trauma, Burns Closed Wounds Incisions Stitched, Stapled, Steri-stripped or Skin bonded Pressure ulcers Hematomas Abcesses, nodules, various dermatologic types. Types of Wounds http://www.medicaledu.com/pictures.htm

  10. Pressure Ulcers • Braden Scale – 16 points or below is considered a risk • Sensory Perception 4pts • Completely, very, slightly, not impaired • Moisture (4pts) • Constantly, very, occasionally, rarely moist • Activity (4pts) – bedfast, chairfast, walks occ, freq. • Mobility (4pts) • Completely, very, slightly immobile, no limitation • Nutrition (4pts) • Very poor, probably Inadequate, adequate, excellent • Friction & Shear (3pts) • Problem, potential problem, no apparent problem

  11. Stages 1 intact, persistent redness 2 partial thickness loss or blister 3 full thickness loss to but not through fascia 4 full thickness loss to muscle, bone, etc. Unstageable –purple, yellow or black Never back stage. Prevention and treatment Turn every 2 hours when in bed Move every 15 minutes or at least every hour in wheel chair or chair Apply appropriate dressing to manage drainage Educate patient and family on reasons for treatment and causes of pressure ulcers. Monitor q shift Pressure Ulcers

  12. Stage 1 • Reddened boggy heel

  13. Stage 2 • Partial thickness loss • Or blister

  14. Stage 3 • Down to but not through the facia

  15. Stage 4 • To muscle, bone, tendons, etc.

  16. Unstageable Pressure Ulcers • Purple, yellow, black

  17. Other Ulcers • Arterial • Venous

  18. Other ulcers • Neuropathic • Diabetic

  19. Stay open-minded • Remain alert to all possibilities.

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