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2010-09-23 20:57:17

Lecture four cards
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  1. Learning objectives for lecture 4:
    • 1. State the different types of wound categories and identify the differences in each type.
    • 2. Identify ways to prevent wounds and / or skin breakdown.
    • 3. Define the different stages of wound healing.
    • 4. State the goals of proper wound care.
    • 5. Define aseptic conscience.
    • 6. State the process of setting up and maintaining a sterile field.
    • 7. Demonstrate donning sterile gloves.
    • 8. State differences between aseptic and sterile technique.
    • 9. Apply knowledge of wounds and wound care in documentation of procedure.
    • 10. Identify different types of wound drains.
    • 11. Compare different ways pressures ulcers can occur.
    • 12. Compare different stages of pressure ulcers.
    • 13. State factors that can affect pressure ulcer formation.
    • 14. Identify ways to prevent pressure ulcer formation.
    • 15. Define heat therapy and identify different treatment options.
    • 16. Define cold therapy and identify different treatment options.
    • 17. Calculate a patients Intake and Output.
  2. Why such the emphasis on wound care / sterile technique?
    • õ Healthcare Associated Infections
    • õ 1.7 million infections
    • õ 99,000 deaths
    • õ $45 billion spent
    • õ Could save $31.5 billion
  3. What are some functions of skin?
    • õ 1st line of defense
    • õ Function:
    • ô Protection
    • ô Temperature regulation
    • ô Sensation
    • ô Psychosocial
    • ô Immunological
    • ô Absorption
    • ô Elimination
  4. Factors affecting skin integrity:
    • ô Resistance
    • ô Nourished
    • ô Hydrated
    • ô Circulation
    • ô Children (<2)
    • ô Thinner skin
    • ô Risk for infection
    • ô Very thin or Very obese
    • ô Fluid loss
    • ô Elderly
    • ô Fragile
    • ô Circulation / oxygenation
    • ô Nutrient absorption-elderly taste sweet last
    • ô Collagen
    • ô Risk for infection
  5. What is a wound and what are four things to consider?
    • ô Any break or disruption in the normal integrity of skin / tissues.
    • ô 4 things to take into consideration:
    • ô How was it acquired? Intentional or unintentional?
    • ô Is it open or closed?
    • ô How long have they had it?
    • ô How deep is it?
  6. Description of intentional wound:
    • ô Planned / purposeful
    • ô Created for a specific purpose
    • ô Edges are clean
    • ô Bleeding is controlled
    • ô Decreased risk for infection risk for infection
  7. Description of unintentional wounds:
    • ô Accidental/ unexpected
    • ô Occurs in unsterile environment
    • ô Contamination likely
    • ô Edges are jagged
    • ô Bleeding uncontrolled
    • ô High Risk infection risk
    • ô Longer healing time
    • ô Multiple injuries
  8. Differences between closed and open wounds:
    • OPEN
    • ô Skin broken
    • ô Portal for entry
    • ô Bleeding / tissue damage
    • ô Delayed healing
    • ô Abrasion / incision
    • CLOSED
    • · Blow / force / strain due to trauma
    • o Internal injury-cardiac contusion
    • o May have internal hemorrhage
    • o May see ecchymosis or hematoma
  9. Differences between acute and chronic wounds:
    • õ ACUTE
    • ô Heals within days to weeks
    • ô Edges meet
    • ô Decreased risk for infection
    • ô Chronic
    • ô Edges not well approximated
    • ô Healing process impeded
    • ô Increased risk for infection
    • ô Remains in inflammatory process
  10. Deepness of wounds:
    • ô PARTIAL
    • ô All or at least a portion of the dermis is intact
    • ô Full thickness
    • ô Entire dermis is affected including sweat glands, and hair follicles
    • ô Complex full thickness is when dermis and underlying subcutaneous fat tissue is damaged or destroyed
  11. PRIMARY Healing:
    • ô Little tissue loss
    • ô Edges are approximated (close together)
    • ô Heals rapidly
    • ô Little scarring
    • ô Small risk for infection
    • ô Surgical incisions
  12. Secondary Healing:
    • ô Loss of tissue
    • ô Wound edges are widely separated
    • ô Wound is pink to dark red
    • ô Granulation à large scar
    • ô Healing time is longer
    • ô Burns; pressure ulcers
  13. Tertiary healing:
    • ô Widely separated tissue
    • ô Deep wound
    • ô Extensive drainage / debris
    • ô High risk for infection
    • õ Dehiscence - a splitting open.
  14. Phases in healing process:
    • ô Hemostasis
    • ô Inflammatory
    • ô Proliferation
    • ô Maturation
  15. What is hemostasis?
    • Hemostasis:
    • Immediately after injury
    • Vessels constrict, platelets arrive and begin clot formation
    • Vessels then dilate allowing blood and plasma to leak into area – exudates
    • Scab may form to protect site
  16. What is the Inflammatory stage of in healing process?
    • 4-6 days
    • WBC’s arrive to ingest bacteria
    • Macrophages ingest debris and release growth factorsThis attracts fibroblasts
  17. What is proliferation in the healing process?
    • Fibroblasts build new tissue
    • New blood vessels form
    • O2 and nutrients brought in
    • New tissue is granulation tissue
    • Very vascular – bleeds easilyWound begins to close during this phase
  18. What is Maturation in the healing process?
    • 3 weeks after injury
    • Continues months to years after injury
    • Collagen that was deposited is now remodeled to look like adjacent tissue
  19. Factors affecting local wound healing:
    • ô Pressure
    • ô Desiccation-extreme dryness
    • ô Maceration-softening by soaking in a liquid, wet pants, pruny looking, skin can tear
    • ô Trauma-if sticks use light saline solution to loosen
    • ô Edema- mutrients blocked from swollen capillaries
    • ô Infection
    • ô Necrosis-premature death of skin cells, dead tissue, wounds need to be debreided. Slough-moist yellow stringy material, not quite dead, eschar- black dry leathery, debridement-surgical removal of crap, premedicate patient
  20. Factors affecting systemic wound healing:
    • ô Age, elderly, infants, children
    • ô Circulation / Oxygenation-elderly
    • ô Nutritional status-sweet tastebuds are the last to go; diet consult can help
    • ô Wound condition
    • ô Medications / health status –steroid inhibit healing
  21. Wound complications:
    • ô Infection
    • ô Hemorrhage
    • ô Dehiscence-splitting open wound
    • ô Evisceration
  22. Facts about infection:
    • ô 2-7 days after surgery
    • ô Purulent drainage
    • ô Pain
    • ô Swelling
    • ô Redness
    • ô Temp
  23. Hemorrhage:
    • ô Watch dressing closely
    • ô Pressure dressing
    • ô Fluid replacement
    • ô Hematoma: collection of blood under the skin
  24. Dehiscence and evisceration:
    • õ Dehiscence
    • o Partial/total separation of wound
    • õ Evisceration
    • ô Total separation of wound with Total separation of sound with viscera protruding STAY CALM Low Fowler’s position. Keep a POKER FACE!
  25. Pressure ulcers:
    • õ Can be acute or chronic
    • õ Cause: pressure, insurance will not cover until stage 1 or 2
    • õ Elderly are the typical patient:
    • ô Chronic illness
    • ô Immobility
    • ô Malnutrition
    • ô Fecal / urine incontinence-will break skin down if left to sit
    • ô Altered LOC- altered level of consciousness
  26. Friction and Shearing with blood vessels:
    • o Friction
    • o 2 forces rub together.
    • o Looks like an abrasion.
    • o Seen on elbows / heels when patient tries to push themselves up in bed.
    • ô Shearing
    • o Layer of skin slides over another layer separating the underlying tissue.
    • o Occurs when you pull instead of lift or when patient slides in bed / chair.
    • o Properly move is to lift not drag a person
  27. Risk factors for pressure ulcers:
    • ô Immobility
    • ô Nutrition / Hydration
    • ô Moisture
    • ô Mental Status
    • ô Age
  28. Stage 1 pressure ulcer:
    • õ Signs:
    • ô Non-blanchable erythema – red even with pressure
    • ô Darker skin tones: blue / purple tones
    • ô Epidermis layer only
    • ô Reversible if pressure relieved
    • õ Treatment:
    • ô Frequent turning
    • ô Pressure reduction surface
    • ô Keep area clean and dry
    • ô Keep well nourished
  29. Stage two pressure ulcers:
    • õ Signs:
    • ô Partial thickness (epidermis / dermis)
    • ô Presents as abrasion, blister, shallow crater
    • ô Swollen, painful
    • ô Several weeks to heal as long as pressure relieved
    • õ Treatment:
    • ô Moist healing environment
    • ô Saline or occlusive dressing to promote healing but prevent scar
    • ô Will not be tested on dressing in notes on last 3 pages
  30. Stage three pressure ulcers:
    • õ Signs:
    • ô Full thickness – subcutaneous tissue down to fascia
    • ô Deep crater with / without undermining or tunneling
    • ô Infection = foul smelling drainage
    • ô Months to heal
    • ô Seen on coccyx
    • õ Treatment:
    • ô Debride
    • ó Surgery
    • ó Proteolytic enzymes-Dakin solution
    • ó Wet to dry-put saline soaked gauze in, collects bacteria and is pulled out with the dressing
  31. Stage four pressure ulcers:
    • õ Signs:
    • ô Extensive damage – tendons, muscle, bone
    • ô May look small but tunneled underneath
    • ô Foul smelling discharge
    • ô Infection à Sepsis
    • ô Months à Years to heal
    • õ Treatment:
    • ô Non-adherent dressing changes every 8-12 hours.
    • ô Skin grafts
  32. Prevention of pressure ulcers:
    • ô Proper
    • ô Avoid hard surfaces
    • ô Keep area clean & dry
    • ô Avoid massaging over boney prominences
    • ô Smooth, wrinkle free linen
    • ô Reposition every 2 hours
    • ô Shift weight every 15 minutes
  33. Supporting the healing process of pressure wounds:
    • ô Adequate fluid intake
    • ô Adequate nutrition
    • ô Prevent infection
    • ô Position to relieve pressure
  34. Assessment of wound care:
    • ô Inspect:
    • ó What does it look like?
    • ó What does it smell like?
    • ó Any drainage?
    • ó Any odor?
    • ô Palpate area around site for pain / tenderness

    • ô Timeline:
    • ó Acute care – upon admission and each shift and transferred to unit
    • ó Long term care – upon admission and weekly
    • ó Home Health – upon admission then each visit
  35. Appearance of wound:
    • ô Location:
    • ó Relate to the nearest anatomic landmark
    • ô Size
    • ó Mm or cm
    • ó Length x width x depth;
    • ó sterile -Qtip and measuring tape
    • ô Approximation of wound edges
    • ô Color of wound and surrounding edges- when you are documenting you are painting a verbal picture
    • ô Presence of drains, tubes, staples, sutures
    • ô Odor
  36. Color of open wounds:
    • ô Red = protect / cover
    • ó Cleanse gently
    • ó Topical antimicrobials
    • ó Transparent film
    • ó Change as little as possible
    • ô Yellow= cleanse
    • ó Wet – to – dry dressing
    • ó Wound irrigation
    • ó Absorbent dressing
    • ô Black (BAD)= debride
    • ó Debride for healing to occur
    • ó Sharp debridement:
    • õ Scalpel or scissors
    • ó Mechanical debridement:
    • õ Scrubbing or wet-to-dry dressing
    • ó Chemical debridement:
    • õ Enzymes to remove dead tissue
  37. Drainage of a wound:
    • ó Exudate
    • õ Forms during inflammatory process
    • õ Fluid / cells that leak from blood vessels
    • ó Serous
    • õ Clear and watery
    • ô Sanguineous
    • ó Looks like blood
    • ó Bright red – fresh
    • ó Dark red – old
    • Serosanguineous:
    • ó Serum and blood cells
    • ó Light pink to blood tinged
    • ô Purulent
    • ó WBC’s, liquefied dead tissue debris, bacteria
    • ó Thick
    • ó Foul odor
    • ó Different colors-yellow green most common colors
  38. Documentation of wound (COCA)
    • ô C: color of wound, bed, drainage
    • ô O: odor if any
    • ô C: consistency of drainage
    • ô A: amount (scant, moderate, large)
  39. Goals of proper wound care:
    • ô Promote healing
    • ô Provide comfort
    • ô Prevent / eliminate / control infection
    • ô Absorb drainage
    • ô Maintain a moist environment
    • ô Protect surround skin
    • ô Protect wound from further injury
  40. Asepsis:
    • ô Freedom from disease producing organisms
    • ô #1 way to prevent spread of organisms: HANDWASHING
    • ô Medical: areas contaminated if they bear or are suspected of bearing pathogens
    • ô Surgical: areas contaminated if they are touched by anything non-sterile
    • ô Sterile: ALL pathogens have been destroyed
    • ô Aseptic Conscience: You broke sterile technique
  41. Sterile Technique:
    • ô Open packages awayfrom body.
    • ô Surface below must be sterile if handling fluid.
    • ô Keep all items above waist level
    • ô Don’ t cough, sneeze, talk, or reach over field.
    • ô Don’t walk away or turn your back.
    • ô 1 inch around edge is not sterile.
    • ô Items must be sterile if entering skin / cavity.
  42. Sterile solution:
    • ô All contents inside are sterile, all contents outside are contaminated.
    • ô Date and initial label when opened.
    • ô If date 24 >hours toss it!
    • ô Hold label into hand when pouring.
    • ô LIP when previously opened. – pour a bit out
  43. Sterile gloves:
    • ô Skin to inside only.
    • ô Dominate hand 1st.
    • ô Outer part handled by gloves only.
  44. Cleansing the wound:
    • ô Linear
    • õ Clean from top to bottom
    • õ Move from incision outward
    • õ Replace gauze / sponge with each swipe
    • ô Circular
    • õ New gauze / swab with each circle
    • õ Begin in center and move outward
    • õ Clean 1 inch beyond dressing
  45. Types of Drains:
    • õ Open
    • ô Penrose – drainage empties into gauze.
    • o Drainage moves from area of greater pressure to lesser pressure.
    • o Safety pin on end to keep from losing tube.
    • õ Closed
    • ô Jackson-Pratt (JP) – applies low suction to area being drained.
    • o Must be emptied, measured, and suction reapplied.
  46. Other wound therapies:
    • õ Fibrin Sealants
    • õ Inject into tissue to seal off.
    • õ Angioseal – see after heart catheterizations.
    • õ Vacuum-assisted Closure (VAC)
    • õ Applies constant negative pressure to pull drainage out of the wound.
    • õ Promotes blood flow, growth of new vessels, and pulls edges together.
  47. Other wound therapies:
    • õ Ultrasound
    • õ Transport sound waves through gel to bone. When it hits the bone it breaks apart and creates thermal energy.
    • õ Increases blood supply.
    • õ Stimulates inflammatory process.
    • õ Acute wounds, hematomas, bruises.
    • õ Pulsed Diathermy
    • õ Electromagnetic energy.
    • õ Increases vasodilation, hematoma absorption, fibroblast action. Decreases edema.
    • õ Wounds covered by casts, surgical incisions, skin grafts, diabetic wounds.
    • õ One more therapy…
    • õ Hyperbaric Oxygen
    • õ Chamber where patient breathes 100% oxygen in increased atmospheric pressure.
    • õ Increases O2 perfusion to tissue.
    • õ Acute burns, gas gangrene, skin grafts / flaps, carbon monoxide poisoning, radiation tissue damage.
  48. Heat therapy:
    • õ Joint Stiffness / Low back pain.
    • õ increases blood flow to area – promotes tissue healing.
    • õ Muscle relaxation.
    • õ Reduced joint stiffness.
    • õ Excessive vasodilation à drop in BP à fainting.
    • õ Do not use for >30 minutes at a time.
    • Heat Therapy
    • õ Hot water bag / bottle
    • õ Aquathermia / K-pad
    • õ Commercial hot packs
    • õ Moist compress
    • õ Heating pad
    • õ Soak
    • õ Sitz bath
    • õ Bair Hugger
  49. Cold therapy:
    • õ Vasoconstriction.
    • õ Skin color decreases and becomes cool. Pale
    • õ Can damage skin due to decreased O2 and nutrients.
    • õ Blood being shunted to other areas à increased BP.
    • õ If temp drops to <60, vasodilation will kick in to prevent tissue from freezing.
    • Cold therapy
    • õ Commercial ice packs / cold packs
    • õ Cold compress
    • õ Ice bag / glove / collar
    • õ Soak
    • õ Cooling sponge bath
  50. Precautions for heat and cold therapy:
    • õ Neurosensory impairment
    • õ Impaired mental status
    • õ Impaired circulation
    • õ immediately after surgery
    • õ Open wounds
  51. Blood Glucose Monitoring:
    • õ Wash hands (yours and patient) or clean the site with alcohol. Do not fan to dry!
    • õ Warm = vasodilation = blood sample.
    • õ Discard 1st drop.
    • õ Hold pressure to site with gauze not alcohol pad.
    • õ Check your result against patient’s signs / symptoms.
  52. Intake and output:
    • õ Intake
    • õ Any fluid or food that is fluid at room temperature.
    • õ Ice cream / jello
    • õ 1 oz = ___________ mL
    • õ Output
    • õ Anything that comes out of the body in liquid form.
    • õ Vomitus
    • õ Diarrhea
    • õ Drainage from suction / devices.
    • Intake should equal output. May take 2-3 days to balance out, but eventually should.Make family aware if patient on I/O so they can help you keep track and also inform you of anything extra brought in