N210 Week 2 Lab Wound Care Bandages and Binders Thermal Therapy

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N210 Week 2 Lab Wound Care Bandages and Binders Thermal Therapy
2015-10-12 21:57:38
N210 Week Lab Wound Care Bandages Binders Thermal Therapy
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  1. a. Identify the three (four) stages of wound healing.
    • • These four stages systematically lead to repair of the injury.
    • 1. Hemostasis: occurs immediately after the initial injury
    • a. Blood vessels constrict and blood clotting begins through platelet activation and clustering
    • b. After quick constriction, these blood vessels dilate and capillary permeability increases which allows plasma and blood components to leak out into the area that is injured forming a liquid called exudate
    • c. The forming of exudate causes swelling and pain
    • d. Increased perfusion results in redness and heat
    • e. f wound is small, the clot loses fluid and a hard scab is formed to protect the injury
    • f. Platelets are also responsible for releasing substances that stimulate other cells to migrate to the injury for healing.
    • 2. Inflammatory stage: lasts about 4-6 days
    • a. Leukocytes arrives first to ingest bacteria and cellular debris
    • b. After 24 hours, macrophages (a larger phagocytic cell) enter the wound area and remain for a long time
    • c. Macrophages are essential to the healing process because they also release growth factors that are necessary for the growth of epithelial cells and new blood vessels
    • d. The macrophages also help attract fibroblasts for the wound
    • e. Characterized by pain, heat, redness, swelling, mildly elevated temperature, leukocytosis (increasing number of white blood cells) and malaise
    • 3. Proliferation stage: is known as the fibroblastic, regenerative, or connective tissue stage.
    • a. Several weeks
    • b. Filling the wound space
    • c. Fibroblasts are connective tissue cells that synthesize and secrete collagen and produce specialized growth factors responsible for inducing blood vessel formation as well as increasing the number/movement of endothelial cells
    • d. Fibroblasts form fibrin and stretches all over the clot where a thing layer of epithelial cells forms across the wound and blood flow is reinstituted
    • e. This new tissue is called granulation tissue (forms foundation for scar tissue development)
    • a. Very vascular, red and bleeds easily
    • f. Collagen synthesis and accumulation peak at 5 to 7 days
    • g. End of second week, majority of white blood cells have left the wound area and is brighter in color
    • h. Granulation tissue fills the wound and is then covered by skin cells that grow over the granulation tissue
    • 4. Maturation stage: (remodeling) begins about 3 weeks after injury
    • a. Collagen is remodeled which makes the healing wound stronger
    • b. New collagen continues to be deposited which compresses blood vessels
    • c. Scar: avascular collagen tissue
    • d. Wounds that heal by secondary intention take longer to remodel and form a scar
  2. b. Discuss the difference between primary, secondary and tertiary intention wound healing
    • 1. Primary intention
    • a. Well approximated
    • b. Intentional wounds with minimal tissue loss such as surgical incision usually heal by primary intention
    • 2. Secondary intention
    • a. have edges that are not well approximated
    • b. Large open wounds require more tissue replacement and are often contaminated are often healed by secondary intention
    • c. If wound that is healing by primary intention becomes infected, it will heal by secondary intention
    • d. wounds that heal by secondary intention take longer to heal and form more scar tissues
    • 3. Tertiary intention (delayed primary closure): wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed
  3. c. List the factors that can affect wound healing to include nutrition, medications, and health status.
    • • Local Factors: local to the wound and can cause prolong wound healing
    • 1. Local Factors: factors occurring local to the wound itself can prolong wound healing
    • 2. Pressure: disrupts blood supply and blood flow to the tissue and delays healing
    • 3. Desiccation: Cells dehydrate and die in a dry environment. This causes the crust to form over the wound site which delays healing. Wounds that are kept moist and hydrated experience enhanced epidermal cell migration, which supports epithelialization
    • 4. Maceration: prolonged exposure to moisture, which can lead to, impaired skin integrity. The damage is related to change in pH, overgrowth of bacteria and infection/erosion of skin
    • 5. Trauma: repeated trauma delays healing
    • 6. Edema: interferes with blood supply to area which results an inadequate supply of oxygen and nutrients to the tissue
    • 7. Infection: bacteria increase stress on body. Requires a lot of energy to fight the invaders. Toxins also interfere with wound healing
    • 8. Excessive bleeding: large clots, which increases amount of space that must be filled during healing and interferes with oxygen diffusion to tissue. It also makes it easier for bacteria to come in and promote infection
    • 9. Necrosis: dead tissue delays healing such as slough and eschar. Removal of the dead tissue must occur for healing to begin.
    • 10. Biofilm: decreased effectiveness of antibodies against a bacteria and decreases normal immune response. It also impairs wound healing and contributes to chronic wound inflammation
    • • Systemic factors: not related to wound location but can cause prolong wound healing
    • 1. Age: decreased fibroblastic activity and circulation. Skin becomes more fragile
    • 2. Circulation and Oxygenation: Adequate blood flow to deliver nutrients and oxygen and to remove local toxins, bacteria and other debris is essential for wound healing. They are more prone in obese people
    • 3. Nutrition Status: Calories and protein are necessary to rebuild cells and tissues. All phases of wound healing are slowed or inadequate in the patient with poor nutritional status and fluid balance
    • 4. Medication and Health Status: Corticosteroids and postoperative radiation therapy are at high risk of delayed healing and wound complication
    • 5. Immunosuppressant: suppression of immune system
  4. d. Identify the signs and symptoms of a wound infection
    • 1. Symptoms are apparent within 2 to 7 days
    • 2. Purulent drainage
    • 3. Increased drainage
    • 4. Pain
    • 5. Redness
    • 6. Swelling in and around the wound
    • 7. Increased body temperature
    • 8. Increased white blood cell count
    • 9. Delayed healing
    • 10. Discoloration of granulation tissue in the wound
  5. e. Identify the solutions used for wound irrigation and rationale for use.
  6. f. Describe various types of wound drainage.
    • • Inflammatory response results in the formation of exudate, which then drains from the wound.
    • a. The exudate is composed of fluid and cells that escape from blood vessels and are deposited in or on tissue surfaces
    • a. Serous Drainage: is composed primarily of the clear serous portion of the blood and from serious membranes
    • a. Serous drainage is clear and watery
    • b. Sanguineous drainage: consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding
    • c. Serosanguineous drainage: is a mixture of serum and red blood cells. It is light pink to blood tinged
    • d. Purulent drainage: is made up of white blood cells, liquefied dead tissue debris and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor and varies in color (such a dark yellow or green), depending on the causative organism
  7. A. Types
    • 1. Alldress
    • 2. Covaderm
    • 3. Stratsorb
    • B. Purposes
    • 1. Combine two or more physically distinct products in a single dressing with several functions
    • 2. Allow exchange of oxygen between wound and environment
    • 3. May facilitate autolytic debridement
    • 4. Provide physical bacterial barrier and absorptive layer
    • 5. Semiadherent or nonadherent
    • 6. Primary or secondary dressing
    • C. Use
    • 1. Partial- and full-thickness wounds
    • 2. Wounds with minimal to heavy exudate
    • 3. Necrotic tissue
    • 4. Mixed (granulation and necrotic tissue) wounds
    • 5. Infected wounds
    • b. May be connected to a mechanical suction device or have a portable built-in reservoir to maintain constant low suction
    • c. Usually sutured to the skin
    • d. Prevents microorganisms from entering the wound from saturated dressings
    • e. Allow accurate measurement of drainage
    • 3. Example of use: After breast removal, abdominal surgery
    • C. Hemovac ***(CHECK pp. 1019-1022, Caring for a Hemovac drain)
    • 1. Purpose: Decreases dead space by collecting drainage
    • 2. Characteristics (Same characteristics as a Jackson-Pratt drainage tube)
    • b. May be connected to a mechanical suction device or have a portable built-in reservoir to maintain constant low suction
    • c. Usually sutured to the skin
    • d. Prevents microorganisms from entering the wound
    • 3. Example of use: After abdominal surgery, orthopedic surgery
  9. k. State the guidelines for maintaining a sterile field.
    • 1. Allow only a sterile object to touch another sterile object. Unsterile touching sterile means contamination has occurred.
    • 2. Open sterile packages so the first edge of the wrapper is directed away from the worker to avoid possibility of a sterile surface touching unsterile clothing.
    • 3. Avoid spilling any solution on a cloth or paper used as a field for a sterile setup. Moisture penetrates through the sterile cloth or paper and carries organisms by capillary action to contaminate the field. Wet field is considered contaminated if surface below is not.
    • 4. Hold sterile objects above the level of the waist. This will ensure keeping object within sight and preventing accidental contamination.
    • 5. Avoid talking, coughing, sneezing, or reaching over a sterile field or object.
    • 6. Never walk away from or turn your back on a sterile field.
    • 7. Keep all items sterile that are brought into contact with broken skin, or used to penetrate the skin to inject substances into the body, or to enter normally sterile body cavities.
    • 8. Use dry, sterile forceps when necessary. Forceps soaked in disinfectant are NOT considered sterile.
    • 9. Consider the edge (1 inch) of a sterile field to be contaminated.
    • 10. Consider an object contaminated if you have any doubt to its sterility.
  10. l. Describe steps and rationale for each step for performing a sterile wet to moist dressing.
    • 1. Review medical orders – validates the correct patient and procedure.
    • 2. Hand hygiene and if applicable, PPE – prevent spread of microorganisms
    • 3. ID patient – ensure right patient
    • 4. Assemble equipment on overbed table within reach – organization facilitates performance of the task
    • 5. Give privacy.
    • 6. Assess patient for possible need for pain-reducing interventions – wound care and dressing changes may cause pain for some patients
    • 7. Place a waste bag at a convenient location – discard soiled dressing easily without spread of microorganisms
    • 8. Adjust bed to working height – prevents back and muscle strain
    • 9. Assist patient to a comfortable position, and position so would cleanser solution will flow from clean end of the wound to the dirtier end – provide comfort and gravity directs flow of liquid from least contaminated to most contaminated area
    • 10. Put on gloves.
    • 11. After removing dressing, note presence, amount, type, color, and odor – documentation
    • 12. Assess wound for appearance, stage, presence of eschar, granulation tissue, epitheliazation, undermining, tunneling, necrosis, drainage – provides evidence about wound healing process and/or presence of infection
    • 13. Remove gloves
    • 14. Using sterile technique, open supplies and dressings. Place fine-mesh gauze into basin and pour ordered solution over mesh to saturate it – gauze touching the wound surface must be moistened to increase the absorptive ability and promote healing.
    • 15. Place sterile gloves on.
    • 16. Clean wound – removes previous drainage and wound debris
    • 17. Dry surround skin with sterile gauze dressings – moisture provides a medium for growth of microorganisms
    • 18. Apply skin protectant to surrounding skin if needed – prevents skin irritation and breakdown
    • 19. Squeeze excess fluid from gauze dressing. Unfold and fluff the dressing – gauze provides a thin, moist layer to contact all the wound surfaces
    • 20. Gently press to loosely pack the moistened gauze into the would – dressing provides moist environment for all would surfaces. Avoid overpacking the gauze; loosely pack to prevent too much pressure in the wound bed which could impede would healing
    • 21. Apply several dry, sterile gauze pads over the wet gauze – dry gauze absorbs excess moisture and drainage.
    • 22. Place ABD pad – prevents contamination
    • 23. Discard gloves. Apply tape, Montgomery straps or roller gauze to secure dressings
    • 24. Label dressing with date and time – provides communication and demonstrates adherence to the plan of care
    • 25. Hand hygiene.
    • 26. Check wound dressing q shift – ensures assessment of changes in patient condition and timely intervention to prevent complications
  11. a. State The Purposes of Bandages and Binders (Taylor, pp. 988)
    • 1. Bandages & Binders: are used to secure dressings, apply pressure, and support the wound
    • 1. Bandages (strips of cloth/gauze): used to wrap a body part
    • Ex: Roller gauze, Kerlix, Kling, ACE bandages
    • 1. Binders: used for a specific body part
    • Ex: slings, abdominal binders, chest binders, T-Binders
  12. b. Discuss the General Guidelines for Application/Removal of Bandages and Binders
    • General Guidelines For Applying Bandages and Binders
    • 1. Clean the area to be covered and dry it thoroughly before applying a bandage or binder
    • a. Reason: Prolonged heat and moisture may cause skin breakdown
    • 2. Bandage the body part in the normal functioning position to prevent deformities and discomfort
    • 3. Apply the bandage or binder with sufficient pressure to provide the amount of immobilization of support desired, to remain in place, and to secure a dressing when present. DO NOT apply pressure to such a degree that circulation to involved body part is impeded
    • 4. Maintain equal tension with all bandage turns: avoid unnecessary and uneven overlapping of turns
    • 5. After application, assess circulation and comfort at regular intervals
    • General Guidelines for Removal of Bandages and Binders
    • 1. Cut the bandage with bandage scissors to prevent excessive manipulation of the part
    • 2. Cut on the side opposite the injury or the wound, from one end to the other, so that the bandage can be folded its entire length
  13. c. Demonstrate Application of the Following (Taylor , pp. 990)
    • Abdominal Binder: designed to circle the torso, usually 6-8 in. width
    • ACE Bandage Using Spiral Turn: useful for—wrist, fingers, trunk
    • 1. Complete one circular turn to anchor the bandage
    • 2. Continue circulation in ascending spiral order
    • 3. Each turn overlaps the preceding one by 1/2 - 2/3 the width
    • Figure of Eight Turn (990): joint areas—knee, elbow, ankle, wrist
    • 1. Making oblique overlapping turns that ascend and descend alternately
    • Recurrent Bandage: used for —fingers,head and residual limb
    • 1. Make a few circular turns to anchor bandage
    • 2. Place the initial end of the bandage at the center of the body part being bandaged well back from the tip to be covered
    • 3. Pass the bandage back and forth over the tip, first on the one side and then on the other side of the centerpiece of the bandage
  14. a. List the common uses for both heat and cold as therapeutic modalities.
    • HEAT
    • 1. Local heat…
    • a. Dilates peripheral blood vessels
    • b. Increases tissue metabolism
    • c. Reduces blood viscosity and increases capillary permeability
    • d. Reduces muscle tension
    • e. Helps relieve pain
    • 2. Vasodilation
    • a. Increases local flood flow
    • b. The supply of oxygen and nutrients to the area is increased
    • c. Venous congestion is decreased.
    • 3. Heat
    • a. Reduces muscle tension to promote relaxation and helps to relieve muscle spasms and joint stiffness
    • b. Helps relieve pain by stimulating specific nerve fiber, closing the gate that allow the transmission of main stimuli to centers in the brain
    • COLD
    • 1. Local application of cold...
    • a. Constricts peripheral blood vessels
    • b. Reduces muscle spasm, and promotes comfort
    • c. Reduces blood flow to tissues
    • d. Decreases the local release of pain producing substances such as histamine, serotonin, and bradykinin.
    • a. This action in turn reduces the formation of edema and inflammation.
    • b. Decreased metabolic needs and capillary permeability, combined with increased coagulation of blood at the wound site.
    • e. Reduces muscle spasm
    • f. Alters tissue sensitivity (producing numbness)
    • g. Promotes comfort by slowing the transmission of pain stimuli.
    • h. It is used after direct trauma.
  15. b. Describe techniques and related nursing responsibilities for heat and cold applications.
    • Dry Heat
    • A. Hot water bags, electric heating pads, aquathermia pads and hot packs.
    • B. Moist heat: warm moist compresses, sitz baths, warm soaks.
    • 1. Hot water bags
    • a. They may leak
    • b. Weight of the bag or bottle on the patient’s body part can be uncomfortable.
    • 2. Electric heating pads
    • a. Avoid using pins to secure hating pad
    • b. Place a covering over the pad
    • c. Place a heating pad anteriorly or laterally to not under the body part.
    • d. Use a heating pad with a selector switch that cannot be turned up beyond safe temperature
    • e. Asses the skin at regular intervals for the effects of excessive exposure to heat
    • f. Check agency protocol for the use of heating pads.
    • 3. Aquathermia pads
    • a. Must be checked carefully
    • 4. Hot packs need specific instructions
    • a. Instructions on the package describe how to activate the pack
    • Moist Heat
    • 1. Warm moist compresses
    • a. Evaporate and cool rapidly
    • b. Change these compresses frequently and cover them with a heating agent
    • 2. Sitz baths cannot be used in a regular bathtub because the heat causes generalized vasodilation, altering the effect desired.
    • 3. Warm soaks.
    • a. f a soak is prescribed for a large wound expect to adapt sterile technique
    • b. Unless the temperature of the soak is prescribed otherwise, set the temperature of the water within a range of 105-109 F°
    • c. Position the container holding the fluid so that the part to be immersed is comfortable and the patient is in good body alignment
    • Dry Cold
    • 1. Ice bags
    • a. Fill the bag with small pieces of ice to about two-thirds full
    • b. Remove air from the ice bag in the same manner as removing air from hot water bag
    • c. After securing the cap test the ice bag for leaks and wipe off excess moisture
    • d. Place a cover on the ice bag to provide comfort and to absorb moisture that may accumulate on the outside of the bag
    • e. Apply an ice bag for 30 minutes
    • f. Remove it for an hour before reapplying.
    • 1. Cold packs
    • a. These packs are advantageous because the frozen solution remains pliable and can be easily molded to fit a body part
    • b. They are covered with a ribbed cotton sleeve so that the bag can be slipped onto an extremity or the bag can be place on the body part such as the head
    • c. Assess the skin beneath the pack periodically for symptoms of numbness and pain.
    • Moist cold
    • a. Uses cold compression
    • b. Might be used for an injured eye, a headache, or a tooth extraction
    • c. Change the compress frequently, continuing the application for 20 minutes
    • d. Repeat the application every 2 to 3 hours as ordered
    • e. Immerse the material used for the application in a clean basin that contains pieces of ice and a small amount of water
    • f. Wring the compress thoroughly before applying it to avoid dripping.