Pressureulcerandwoundsextrahelp
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A self learning module designed for student nurses to help them understand the nursing care of patients with wounds. I am sharing this with other educators or nursing students to help them in this area. You have my permission to use this to learn about wounds but not to take as your own presentation. I hope you honor this request.
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Pressureulcerandwoundsextrahelp
- 1. NRB 121 Self Learning Module: Wound Assessment Tracey J. Siegel MSN RN CWOCN CNE
- 2. Mrs. Siegel Says: This may help you visualize pressure ulcers and other wounds! Don’t print this up! Save paper! Watch this as a slide show! Then read the information in the notes section to help you better understand the nursing care of wounds!
- 11. Pressure Ulcer vs. Dermatitis Which is which?
- 19. Measurement Undermining L x W x D Pain! Depth
- 20. Sharp Debridement What is wrong with this picture???
- 32. I hope this helped you understand the role of the nurse when caring with patients with wounds! See Mrs. Siegel if you have any questions or comments!
Notes de l'éditeur
- This presentation is just to help you visualize some of the wounds in your self leaning module and reinforce the information. You will not be tested on this content, but examples and explanations of wounds and various dressings are important for you to understand what is happening in clinical and why some dressings are indicated or contraindicated! Depending upon where you have your clinical experiences you may or may not get to see these dressings but you may see other types of wound care treatments- if you do- stop by and share with me what you have seen in clinical!
- In addition to systemic factors there are local factors that can be barriers to wound closure Mechanical stressors - inadequate reduction in pressure, friction and shear. Edema - increased fluid in the interstitial space can interfere with the diffusion of oxygen, which is essential for collagen synthesis, and contributes to the amount of exudate. This can be a major factor in patients with Chronic Venous Insufficiency and is the rationale for using compression therapy. Wound temperature - changes in temperature can cause capillary constriction which in turn may cause decreased perfusion, reduced phagocytic activity and altered cellular mitosis. Cytotoxic agents - can have a detrimental effect on cells necessary to support healing, for example fibroblasts. Excess exudate - wound fluid from chronic wounds has been shown to have a number of deleterious effects on the healing process. Dry wound bed - optimal cellular division and migration only occur in a moist environment. If the wound is allowed to dry out this will contributes to delayed healing. Devitalized tissue - the presence of necrotic tissue in the wound bed significantly impairs healing. This tissue needs to be removed or DEBRIDED- there is many ways to do this- surgically, with medications, or with new types of wound dressings (autolytic). Heavy bioburden - the burden resulting from heavily colonized wounds can impair healing Infection - wounds that are infected cannot heal.
- If anyone could do a full and complete assessment, registered nurses would not be needed! This is an important area of nursing practice that we should never neglect or delegate to ancillary personnel.
- Partial thickness wounds heal by process of migration of epithelial cells from the edges of a wound as well as from around the remaining hair follicles, and contraction of wound edges partial thickness wounds go down to but not completely through the dermis.
- The first picture is a stage II pressure ulcer- over a bony prominence (sacrum) – it looks much like a blister that burst- you are looking at the dermis here. This needs pressure relief and occlusive dressings. The second picture is incontinence related skin damage which resulted in partial thinking skin loss (by the arrow). Look at the surrounding skin- it looks like very bad diaper rash. This is from urine/stool stripping away the epidermis. This is treated much differently from a pressure ulcer. This needs anti-fungal medication and skin protection with barriers such as zinc oxide. Occlusive dressings make this worse!!! Therefore nurses need to know the difference between these 2 problems.
- This process will take many weeks to months to complete. Wounds that heal by secondary intention are filled with scar tissue and covered with a thin layer of epidermis.
- Before topical therapy can be selected, all of these assessments are important!
- Red = beefy granulation tissue Pink- new epithelial cell growth Yellow- slough, necrotic tissue or can also be from dried drainage
- Picture one=eschar that is dry and leather like Picture two= necrotic tissue that is softening with an underlying abscess- this patient is septic and needs immediate surgical debridement.
- “ bruising under intact skin” Remember this is a deep wound, and can develop in seriously ill patients! Frequent skin assessment might prevent or ensure early detection!
- Examples
- We used to believe that full thickness wounds were pain free- nothing could be further from the truth. Patient report burning, aching pains from full thickness wounds therefore pain management is imperative!
- Yikes- no gloves!!!! Sharp debridement is the removal of necrotic tissue by surgical instruments- it is best when immediate debridement is needed for an infected wound. Patients should be given a local anesthetic and pain medication prior to this. Usually performed by surgeons but specially trained nurses can also do this procedure.
- There are so many nursing diagnoses: take some time now and list some that you believe may be relevant Remember: Not all of our patient’s wounds may heal- it depends upon many factors. If the patient is at the end of life, the goal is to keep the wound as clean as possible and to prevent complications- healing may be impossible!
- A local wound environment that mimics healthy tissue by providing hydration and maintaining normal temperature and pH. You can use this in your own life- an abrasion heals best when covered with a band-aid. When we let it “scab over” the new tissue needs to tunnel under the scab before the wound can close. If we protect and cover it, the moisture under the band-aid allows the new cells to “swim” and begin to close the wound.
- When we teach you this semester about a moist saline dressing or a dry sterile dressing (DSD), this is different from a “wet to dry” dressing. Years ago before we had new topical therapy, the only way to debride (or remove necrotic tissue) was by mechanical debridement or actually “ripping off” the necrotic tissue. Not very pleasant for our patients (or us!) and we really shouldn’t be doing it anymore. So, if a physician orders a “wet to dry” dressing, you need to clarify what is meant because often what they mean is a moist saline dressing. Dry gauze is fine for a closed wound or to protect a surgical wound for a few days, however, not indicated for long term use in full thickness wounds.
- A wonderful dressing for many uses- Op-site is just one example but it was the first. It is now used less often for wound care and more for IV sites but it is still a good option for wound care in some situations. It is great to place over other products in area that are prone to moisture (perineum, sacrum) to protect the wound from urine or stool As stated above, it should never be used in fragile geri-skin as it have a strong adhesive and makes skin tears worse.
- Remember the names of the dressing are just examples- there are many hydrocolloids on the market. One of the oldest dressings now, but still an excellent choice in many situations.
- Hydrogels- there are so many – and so many delivery systems- tubes, gel sheets, gel impregnated gauze. One of the most versatile dressing available. When in doubt a hydrogel is often the best selection. Only real concern is if used in heavily draining wounds as it does not absorb any drainage.
- Next time you are at the Jersey Shore, take a look around at the seaweed at your feet and you will see where this dressing came from! A wonderful dressing for wounds with copious amounts of drainage! It is also good for wounds that tend to bleed often as it helps control bleeding.
- There are many of these products available- there are wonderful dressings to help prevent pressure ulcers in high risk areas! This is a SMART dressing, by that I mean it “knows” when the wound needs more or less moisture less acts accordingly!
- This is a medication that comes from the pharmacy; it is used frequently in home care and long term care.
- Look for these dressings on your clinical units-as nursing students we don’t expect you to be experts at applying this modality but it is very interesting to see in action. Make sure you watch the nursing staff or wound care nurses apply these to wounds. These dressings are changed three times each week and the goal is absorption of drainage, stimulation of granulation tissue and wound closure. Patients now go home with portable units and are taught (by nurses!) how to care for and change this type of dressing.