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Nursing Aspect - Wound Management
Nursing Aspect - Wound Management
A wound is a disruption of continuity of skin or underlying tissues with or with out an opening onto the body surface.
Classification of wounds
1.
Acute wound - caused by trauma, animal bites, burns and surgical incisions
- generally managed by the surgical team
Classification of wounds
2. Chronic wound 3 basic types:
BURN
BURN
BURN
2.
3. 4.
5.
Relieving pain Correcting nutritional deficits Wound debridement Wound dressing Management of infection
Burns
4. Nursing Process
1 Burn (Superficial)
- involves epidermis
dermis, subcutaneous tissue - appear pale and white - no pain - require grafting
Burns
Rule of 9
- To estimate severity of burns
Prevention of shock
1.
Prevention of shock
3. Administration of oral fluids
Burned patients are thirsty and if given too much to drink too quickly, they will vomit because of gastric dilatation and paralytic ileus.
Prevention of shock
4. Urinary output
accurately recorded
Inform Doctor for any decrease in urinary output
or presence of blood
Prevention of shock
5. Observations Hourly TPR, BP & SPO2
Temperature can be subnormal because the skin surfaces are destroyed and elevated subsequently when infection sets in. Pulse Rate, volume and regularity of pulse should be noted. Increase in pulse rate indicates over transfusion and acute gastric dilatation. Respiration observe for its depth and frequency and state of airway. Tracheostomy / intubation may be indicated for laryngeal edema, respiratory distress, restrict chest movement SPO2 Any decrease in SPO2 must be referred. Blood Pressure Any change must be referred. Can be over / under transfusion.
Prevention of shock
Restlessness - often an indication of under transfusion or can result from anoxia. Color and temperature of extremities - any coldness accompanied with any changes indicates circulation
impairment . Inform doctor immediately
Prevention of Infection
Infection control measures
1.
Staff
Barrier nursing Hand washing technique: prior & after.
2.
-
Visitors
Restriction- close family members only Hand washing prior to patient contact
3. -
Environmental measures Air conditioned room Temp 25-28C Bed linen Sterile linen for exposed method dressings Soiled linen removed immediately
4. 5.
Wound Care
6.
Nutrition
- High calorie &Protein - Supplementary feed eg. Enercal - Vitamin C, B complex, Iron
Major burns
- sips of water -NG tube - Enteral feeding
Prevention of contracture
Physio & Occupational Therapy
All joints into active & passive movements
Encourage exercises
Involve family in activities Need for JOBST Garment
Provision of Psychotherapy
Psychotherapy
On admission reassurance (allay fear and anxiety) Adequate pain relief Social worker role Counselor role Family support Constructive diversional therapy
WOUND ASSESSMENT
management Relieve the psychological burden of the person (and family members) with the wound To give appropriate health information and thus advice Cost saving
Wound Assessment
Location
Clinical appearance
Dimension Exudates
Wound edges
Surrounding skin Infection Pain Psychosocial implications
Location
Clinical appearance
- Degree of tissue loss - ? Black hardened, necrotic,
Clinical appearance
Pus exudate Infected with heavy exudate
Clinical appearance
Granulation
Clinical appearance
Epithilialising
Dimensions
Length Width
Depth
Pain -Assessment
Hydrocolloids
Today's market offers a vast selection of products, from simple gauzes to silvercontaining dressings to negative pressure therapies.
Selecting a Dressing
Consider the following general recommendations:
Avoid standard wet-to-dry dressings If it's wet, dry it; if it's dry, wet it.
- This means that a wound with heavy exudate will need a more absorptive dressing, such as a foam or alginate, while a dry wound will require rehydration with a hydrogel or an occlusive dressing, such as a hydrocolloid.
Types of dressing
1.
Alginates. - Derived from seaweed, these highly absorptive dressings are soft, nonwoven, and non-adhesive, and conform to the shape of the wound. - When in contact with drainage, they form a gel. Alginates are most useful for wounds with heavy exudate. - Don't use them for dry or eschar-covered wounds, because they won't form a gel and may stick to the wound, causing tissue trauma when you remove them - Some contain silver, which has an antimicrobial action - If a patient has a silver dressing, you may need to remove it before magnetic resonance imaging (MRI).
Cont Alginates Alginates come in sheets that you can cut to size. They also come in rope form, which is especially good for areas of undermining or tunneling. When using an alginate, you'll need to cover the wound with a secondary dressing to hold the product in place and to protect the wound from outside contaminants. Leave the alginate in place for one to three days, until it begins to gel and shows evidence of breakthrough drainage. Throughly irrigate the wound with sterile normal saline solution before reapplying the alginate.
Types of dressing
2.
Foams. - Typically polyurethane-based, this type of dressing is non-adhesive and comes in various sizes, shapes, and degrees of thickness. - foam dressings provide thermal insulation and help keep the wound moist. - They may be used as a primary or secondary dressing, to promote autolytic debridement, and to inhibit hypergranulation. - When using a foam dressing, make sure it's one to two inches larger than the wound; you can leave it in place for up to seven days.
Types of dressing
3. Hydrocolloids.
Hydrocolloid dressings contain hydrophilic colloidal particles in an
adhesive compound laminated to a flexible wafer. Like foams, they come in numerous sizes, shapes, and levels of thickness.
- They help keep the wound moist and promote autolysis of necrotic areas. - Don't use them on wounds that are infected or have heavy exudate. - To avoid damaging fragile skin by removing the dressings too frequently, keep them in place for as long as possible, but no longer than seven days.
Types of dressing
4. Hydrogels.
- Available as gels, sheets, or gauze impregnated with various percentages of water, - Hydrogels are hydrophilic polymers with few absorptive properties. - They add moisture to the wound bed and are non-adherent, and they're used mainly for dry and minimally exudative
Type of Dressing
5. Hydrofiber
Why choose Hydrofiber Wound Dressing? - Absorbs and retains exudate and harmful components - Locks exudate in the dressing - Conforms to the wound surface, thereby reducing dead space - Does not damage tender, granulating wound tissue or healthy tissue surrounding exudating wounds during dressing changes - Absorbs wound fluid and creates a soft gel - Aids in autolytic debridement (removal of nonviable tissue from the wound) - Removes without leaving residue or causing trauma to wound - Manages painful wounds
- This is an option for treating wounds that are draining heavily, failing to heal, or healing slowly. - NPWT applies sub-atmospheric pressure to the wound through the use of special foam dressings occlusively sealed and connected to a pump and collection chamber. - NPWT is useful in removing exudates and debris, promoting blood flow, hastening tissue granulation, and encouraging the contracture of wound edges. - It's especially helpful in treating deep, cavernous wounds. - The foam fills in dead space, and this can enhance closure of tunneling and undermined areas.
Debride the wound first Before you apply the dressing of choice, make sure that nonviable tissue, such as slough, eschar, and fibrin, have been debrided. Eschar that's dry, hard, and stable need not be removed, however, unless signs of infection are presentredness, pus, fluctuance (bogginess or mushiness), wound edge separation with drainage Whenever you suspect infection, refer to doctor in charge; wound cultures and/or antimicrobial therapy may be indicated.
Taking wound swab for C&S properly please!!!
Nursing Process
Dimension
Exudates Wound edges
Surrounding skin
Infection Pain
Psychosocial implications
Take photos
Any Question?
Thank You.