mgccc nursing

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mgccc nursing
2010-10-29 10:54:30
Fain\'s lecture on skin integrity wound care day

day 2 of skin integrity and wound care
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  1. contaminants
    the introduction of pathogens or infectious material into or on normally clean surfaces
  2. infection
    microbes invade body tissue
  3. Managing Infection
    • -protect from fecal & urinary contamination
    • -cleanse and debride
    • -trial of topical antibiotic
    • -diagnose soft tissue infection and osteomyelitis
    • -systemic antibiotics for systemic infection
    • -urgent medical attention for sepsis
  4. standing orders
    will see alot of standing orders in long term facilities (ex:nursing home) not so much in acute care
  5. sepsis
    systemic inflammatory response to infection
  6. symptoms of sepsis
    • fever
    • tachycardia
    • 50% of pts diagnosed w/ sepsis die.
  7. Wound cleansing
    • -cleanse wounds initially and at each dressing change
    • -saline irrigation is a safe and appropriate method for cleansing most ulcers
    • (hydrogen peroxide can be used, but not not in most instances)
  8. Factors that affect wound healing
    • -meds
    • -radiation
    • -anti-inflammatory drugs
    • -chemotherapeutic agents (cytocid medications)
    • -immunosupressive agents
    • -smoking
    • -social circumstances
    • -mobility
  9. Intrinsic/stystemic factors
    • -health status
    • -age factors
    • -circulation & oxygen
    • -nutritional status
    • -wound condition
    • -meds and health status
  10. Psychological effects of wounds
    • -pain
    • -anxiety
    • -changes in body temp
  11. nutritional assessments
    • -dietary intake
    • -height and weight
    • -weight change
    • -lab values
    • -hydration status
  12. essential nutrients
    • -carbs
    • -fats
    • -proteins
    • -vitamins (a, c, e, zink)
    • -fluids
  13. normal phases of wound healing
    • hemostasis (immediate)
    • inflammation (4-6 days)
    • proliferation (few weeks)
    • remodeling (years)
  14. -assessment
    • -does this pt have the ability to heal?
    • -consider overall goals of care
    • -etiology of wound
    • -factors that contribute to impaired healing
  15. FACT
    Most wounds heal in a moist environment
  16. wound healing
    • -all layers of tissue below the epidermis are moist
    • -without a moist surface, wound healing will take longer
    • -providing a moist environment will heal most wounds 3 times faster
  17. types of topical wound dressings
    • -hydrocolloid wafer dressings
    • -dydrogel dressings
    • -alginate dressings
    • -transparent adhesive dressings
    • -foam dressings
    • -absorption dressings
    • -gauze dressings
    • -composite dressings
    • -bilogic dressings
    • -other (negative pressure)
  18. Advantages of Hydrocolloid dressings
    (ex: duoderm & tegasorb)
    • -to protect skin at risk from friction or shear
    • -to maintain a moist wound environment
    • -to facilitate autolytic debridement
  19. Precautions of Hydrocolloid dressing
    • -do not recommend for infected wound
    • -maceration of periwound skin not possible
    • -not appropriate for heavy exudating wound
  20. Hydogel dressings
    (ex: vigilon, aquasorb)
    • description:
    • -non adhesive
    • -maintain moist healing environment
    • -avalible in 3 sizes
    • -requires secondary cover such as gauze or thin film dressing
  21. hydrogel advantages
    • -rehydrates dry wounds
    • -provides moist wound healing
    • -reduces pain associated with the wound
    • -ideal for loose packing
  22. hydrogel indications
    • -to facilitate debridement
    • -to maintain moist wound healing
    • -to fill in "dead space" or pack wound
    • -as a primary dressing on a partial thickness wound
  23. Hydrogel utilization
    • -change every 24-72 hours
    • -cleanse or irrigate wound prior to dressing application
    • -observe periwound skin for signs of maceration
    • -requires use of secondary dressing
  24. Alginate dressings
    (ex: sorban & algiderm)
    • description:-
    • -non-adhearent highly absorbent dressing
    • -drssing forms a soft, gelatinous mass when they come in contat with wound fluid
    • -derived from seaweed (good for use on infected wounds)
  25. alginate dressings
    • -will decrease the frequency of dressing changes decreasing trauma and manipulation of wound
    • -will lower costs of wound care
    • -ideal for loose packing in deep wounds
  26. wound assessment
    • -must be accurate and done at regular intervals
    • -includes evaluation of wound and surrounding skin
    • -used to drive treatment decisions
    • -provides baseline data to evaluate repair process
  27. Documentation
    • -location
    • -stage
    • -size (LxWxD in cm)
    • -sinus tract
    • -undermining
    • -exudate
    • -necrotic tissue
    • -granulation tissue
    • -signs/symptoms of infection
    • -periwound skin
  28. Document Size
    Length x width x depth
  29. Documenting size
    -partial thickness wounds will not have any depth to measure, so they will be measured as L x W only
  30. Undermining
    • when wound is actually larger than the opening
    • (you always want to measure the portion that is undermining)
  31. Sinus tract
    like a cave-narrow and goes downward into the wound-these need to be packed
  32. Remember.....
    • -educate! (nutrition, hydration, etc.)
    • -prevent! (turn pt every 2 hrs)
    • -there will always be a need for more than 1 type of dressing.
    • -continually reassess the wound (need to know improvement status, etc.)
  33. Assessing Wound
    • -if its dry, moisten it
    • -if its moist, absorb it
    • -if its deep, fill it
    • -if its shallow, cover it