Understanding Wound Healing: Types, Phases, and Procedures, Schemes and Mind Maps of Health sciences

Download Understanding Wound Healing: Types, Phases, and Procedures and more Schemes and Mind Maps Health sciences in PDF only on Docsity! WOUND CARE RLE 112/113 BY: JOAN F. AKUT, RN, MN (C) OPEN WOUND ◼ An open wound is an injury involving an external or internal break in body tissue, usually involving the skin. ◼ Nearly everyone will experience an open wound at some point in their life. ◼ Most open wounds are minor and can be treated at home. ◼ Falls, accidents with sharp objects, and car accidents are the most common causes of open wounds. ◼ In the case of a serious accident, you should seek immediate medical care. ◼ This is especially true if there’s a lot of bleeding or if bleeding lasts for more than 20 minutes. THERE ARE TYPES OF OPEN WOUNDS, WHICH ARE CLASSIFIED DEPENDING ON THEIR CAUSE. 1. Incision cleaned to avoid infection. LACERATION ◼ A laceration is a deep cut or tearing of your skin. Accidents with knives, tools, and machinery are frequent causes of lacerations. In the case of deep lacerations, bleeding can be rapid and extensive. PUNCTURE ◼ A puncture is a small hole caused by a long, pointy object, such as a nail or needle. Sometimes, a bullet can cause a puncture wound. ◼ Punctures may not bleed much, but these wounds can be deep enough to damage internal organs. If you have even a small puncture wound, visit your doctor to get a tetanus shot and AVULSION ◼ An avulsion is a partial or complete tearing away of skin and the tissue beneath. Avulsions usually occur during violent accidents, such as body-crushing accidents, explosions, and gunshots. They bleed heavily and rapidly. MATURATION PHASE ◼ The maturation phase begins on about day 21 and can extend 1 or 2 years after the injury. ◼ The wound is remodeled and contracted. The scar becomes stronger but the repaired area is never as strong as the original tissue. In some individuals, particularly dark-skinned individuals, an abnormal amount of collagen is laid down. This can result in a hypertrophic scar, or keloid. WOUND EXUDATE Exudate is material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces. The nature and amount of exudate vary according to the tissue involved, the intensity and duration of the inflammation, and the presence of microorganisms. FOUR TYPES OF WOUND EXUDATE: 1. Serous 2. Sanguineous 3. Serosanguineous 4. Purulent SEROUS ◼ A serous exudate consists chiefly of serum (the clear portion of the blood) derived from blood and the serous membranes of the body, such as the peritoneum. It looks watery and has few cells. ◼ An example is the fluid in a blister from a burn. SANGUINEOUS 1. PLASTER 2. STERILE GAUZE (6 PCS) 3. BETADINE (SMALL) 4. CLEAN GLOVES (1 PAIR) 5. STERILE GLOVES (1 PAIR) 6. BANDAGE SCISSORS 7. BALLPEN PROCEDURE RATIONALE Review the medical orders for wound care or the nursing plan of care related to wound 1 care. Reviewing the order and plan of care validates the correct patient and correct procedure. Preparation promotes efficient time management and organized approach to the task. Bringing everything to 2Gather the necessary supplies and bring to the bedside stand or overbed table. the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. 3 Perform hand hygiene Hand hygiene and PPE prevent the spread of microorganisms PROCEDURE RATIONALE 4 Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 5Close curtains around bed and close door to room if possible. This ensures the patient’s privacy. 6Explain what you are going to do and why you are going to do it to the patient. Explanation relieves anxiety and facilitates cooperation. Assess the patient for possible need for nonpharmacologic pain-reducing interventions or analgesic medication before wound care dressing change. Administer 7 appropriate prescribed analgesic. Allow enough time for analgesic to achieve its effectiveness. Pain is a subjective experience influenced by past experience. Wound care and dressing changes may cause pain for some patients. PROCEDURE RATIONALE Place a waste receptacle or bag at a convenient location for use during the 8 procedure. Having a waste container handy means the soiled dressing may be discarded easily, without the spread of microorganisms 9Adjust bed to comfortable working height, usually elbow height of the caregiver Assist the patient to a comfortable position that provides easy access to the wound area. Having the bed at the proper height prevents back and muscle strain. Patient positioning and use of a bath blanket provide 10 Use the bath blanket to cover any exposed area other than the wound. Place a waterproof pad under the wound site. for comfort and warmth. Waterproof pad protects underlying surfaces 11Check the position of drains, tubes, or other adjuncts before removing the dressing Checking ensures that a drain is not removed accidentally if one is Present PROCEDURE RATIONALE of soiled dressings Used gloves prevents spread of microorganisms. 18 Check the status of sutures, adhesive closure strips, staples, and drains or tubes, if present. Note any problems to include in your documentation. Wound healing or the presence of irritation or infection should be documented. Assessing dressing that has been removed. Removing clean gloves. PROCEDURE RATIONALE 19Using sterile technique, prepare a sterile work area and open the needed supplies Open the sterile cleaning solution. Depending on the amount of cleaning Supplies are within easy reach and sterility is maintained 20 needed, the solution might be poured directly over gauze sponges over a container for small cleaning jobs, or into a basin for more complex or larger cleaning. Sterility of dressings and solution is maintained. Use of sterile gloves maintains surgical asepsis and 21 Put on sterile gloves sterile technique and reduces the risk for spreading microorganisms. PROCEDURE RATIONALE 22 Clean the wound with gauze dampened with Normal saline. a. Clean the wound from top to bottom and from the center to the outside. Following this pattern, use new gauze for each wipe, placing the used gauze in the waste receptacle. b. If a drain is in use at the wound location, clean around the drain from center to outside Cleaning from top to bottom and center to outside ensures that cleaning occurs from the least to most contaminated area and a previously cleaned area is not contaminated again. Using a single gauze for each wipe ensures that the previously cleaned area is not contaminated again. Cleaning the insertion site helps PROCEDURE RATIONALE Apply a layers of dry, sterile dressing over the wound. Forceps may be used to apply the 25 dressing. a. 1st layer serves as a wick for drainage b. 2nd layer is for increased absorption of drainage c. 3rd layer act as additional protection for the wound against microorganism Use of forceps helps ensure that sterile technique is maintained. Dressing must be at least 1 inch larger than the wound. Applying dry dressing to site. PROCEDURE RATIONALE 26 Remove and discard gloves. Proper disposal of gloves prevents the spread of microorganisms 27 Apply tape Tape or other securing products are easier to apply after gloves have been removed Recording date and time provides communication and 28After securing the dressing, label dressing with date and time. Remove all remaining equipment; place the demonstrates adherence to plan of care. Proper patient and bed positioning