WOUND CARE Wound a damaged skin or soft tissue Signs and symptoms associated with wound inflammation: LOCALIZED:

: swelling redness warmth pain decreased function

SYSTEMIC: fever leukocytosis elevated ESR lymphadenopathy anorexia headache body weakness body malaise OTHER RESPONSES TO TISSUE INJURY: necrosis- is death of tissue hypertrophy- is an increase in cell size hyperplasia- is an increase in cell number metaplasia- replacement of one mature cell type with another mature cell type Two common types of wound that require special attention are pressure ulcers and surgical wound. PRESSURE SORES/DECUBITUS ULCER/ PRESSURE ULCER/ BEDSORES OR DISTORTION SORES- reddened areas, sore or ulcers of the skin occurring

over bony prominences, due to interruption of the blood circulation to the tissue, resulting in a localized ischemia. Causes of Pressure ulcers: Pressure Friction Shearing Force Inactivity Immobility Malnutrition Dehydration Incontinence Ways to prevent/treat pressure ulcers: Change clients position every 1 2 hours Keep the skin clean and dry Prevent friction and shearing force on the skin Encourage ambulation Provide range of motion exercises Stages of Pressure Ulcer Stage 1: reddened area that returns to normal color after 15 to 20 minutes of pressure relief such as turning the client. Skin is intact Area is red and does not blanch with external pressure.

Stage 2: top layer of the skin is missing The ulcer is shallow with a red to pink base, and white or yellow eschar (a hard crust or scab, as from a burn) is present

Stage 3: extends into the dermis and subcutaneous tissue. White, gray, or yellow eschar (a hard crust or scab, as from a burn) is usually present at the bottom of the ulcer, and the ulcer may have a lip or edge Purulent drainage is common

Stage 4: extends into muscles and bones Foul-smelling Brown or black Eschar (a hard crust or scab, as from a burn) is present. Purulent drainage is common

PREVENTION OF PRESSURE SORES 1. provide smooth, firm, wrinkle-free foundation on which the client can lie. 2. use foam, rubber pads, artificial sheepskins, egg crate or flotation mattress under pressure areas. 3. apply thin layer of cornstarch to the bed sheet or wheelchair seat cover 4. reduce shearing force by elevating head of bed of bedfast clients no more than 30 deg 5. on going assessment of early signs and symptoms of pressure sore 6. change position of bedfast clients every 15min. -2 hours 7. meticulous hygiene 8. keep skin clean and dry 9. apply powder to tissue with limited blood flow 10. massage pressure areas gently. 11. apply lotion on dry skin 12. avoid massaging bony prominences with soap when bathing the client Surgical Wound: Open or close drains are place in or near the wound to remove and blood.

Hemovac

Jackson-pratt

penrose drain

Sutures and staples hold the edges of the wound together.

Staples

Stitches

A bandage or a binder helps to hold a dressing in place especially when a tape cannot be used or the dressing is extremely large; reduces pain by supporting the wound, or limits movement to promote healing.

A T-binder is used to secure a dressing to the anus, perineum or groin.

Open Method of Wound care Antimicrobial cream is applied and wound is left open to the air without dressing. Antimicrobial cream is applied every 12 hours. Advantages: Visualization of the wound. Easier mobility and joint range of motion Simplicity in wound care. Disadvantage: 1. Increased chance of hypothermia from exposure.

Closed Method of Wound care: Gauze dressings are wrapped carefully from the distal to the proximal area of the extremity to ensure that circulation is not compromised. No two burn surfaces are allowed to touch; touching can promote webbing of digits, contractures, and poor cosmetic outcomes. Dressings are changed every 8 -12 hours. Advantages: Decreases evaporative fluid and heat loss. Aids in debridement. Disadvantages: Mobility limitations. Prevents effective range of motion exercises. Wound assessment is limited. Debridement removal of eschar to prevent bacteria proliferation and promote wound healing Methods of debridement a. Mechanical Use of scissors and force to lift and trim away loose eschar. Wet-to dry or wet-to-wet dressing changes. A painful procedure. Requires moist environment to be effective. Major problems: pain and bleeding b. Enzymatic application of proteolytic and fibrinolytic enzymes that digest necrotic tissue which facilitates eschar removal c. Surgical excision of eschar and coverage of wound. Heat is applied to promote circulation and speed healing. Cold is used to reduce swelling and stop bleeding. Methods of applying heat and cold include compresses, soaks, and therapeutic baths.