Wound Care Binders - PowerPoint PPT Presentation


Title: Wound Care Binders


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Wound CareBinders BandagesUse of Heat and
Cold Module 8, Part A, B and C
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WHY IS WOUND CARE DONE?
  • General purposes of dressings
  • Protecting a wound from microorganism
    contamination
  • Aiding hemostasis
  • Promoting healing by absorbing drainage and
    debriding a wound
  • Supporting or splinting the wound site
  • Protecting the client from seeing the wound
  • Promoting thermal insulation to the wound surface
  • Providing maintenance of high humidity between
    the wound and dressing

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Definitions
  • Abscess a cavity containing pus and surrounded
    by inflamed tissue, formed as a result of
    suppuration in a localized infection. Healing
    usually occurs when an abscess drains or is
    incised.
  • Collagen a protein consisting of bundles of
    tiny reticular fibrils, which combine to form the
    white, glistening, inelastic fibers of tendons,
    ligaments, and fasciae.

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  • Debridement removal of dirt, foreign objects,
    damaged or dead tissue, and cellular debris from
    a wound or a burn to prevent infection and to
    promote healing.
  • Eschar a scab or dry crust resulting from a
    thermal or chemical burn, infection, or
    excoriating skin disease.
  • Exudate fluid, cells, or other substances that
    have been slowly exudated, or discharged, from
    cells or blood vessels through small pores or
    breaks in cell membranes. Perspiration, pus, and
    serum are sometimes identified as exudates.

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  • Fibroblast a flat, elongated undifferentiated
    cell in the connective tissue that gives rise to
    various precursor cells, such as the
    chondroblast, collagenoblast, and osteoblast,
    that form the fibrous, binding, and supporting
    tissue of the body.
  • Fistula an abnormal passage from an internal
    organ to the body surface or between two internal
    organs, caused by a congenital defect, injury,
    infection, the spreading of a malignant lesion,
    radiotherapy of a cancerous growth, or trauma
    during childbirth.
  • Granulation any soft, pink, fleshy projections
    that form during the healing process in a wound
    not healing by first intention.

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  • Inflammation the protective response of the
    tissues of the body to irritation or injury.
  • May be acute or chronic its cardinal signs are
    redness, heat, swelling, and pain, accompanied by
    loss of function.
  • Maceration the softening and breaking down of
    skin from prolonged exposure to moisture.
  • May be caused by prolonged exposure to amniotic
    fluid in a post term infant or dead fetus.
  • Necrosis localized tissue death that occurs
    in-groups of cells in response to disease or
    injury.

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  • Pus a creamy, viscous, pale yellow, or
    yellow-green fluid exudate that is the result of
    fluid remains of liquefactive necrosis of
    tissues. Bacterial infection is its most common
    cause.
  • Purulent producing or containing pus.
  • Regeneration new growth
  • Sanguineous pertaining to blood or containing
    blood.
  • Serous pertaining to, resembling, or producing
    serum.
  • Serosanguineous thin and red composed of serum
    and blood.
  • Ulceration the process of ulcer formation

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Review of AP
  • Skin is the bodys largest organ
  • Functions
  • 1. protective barrier
  • 2. sensory organ for pain temperature and touch
  • 3. synthesize vitamin D
  • Two layers
  • separated by membrane dermal-epidermal junction
  • 1. epidermis
  • 2. dermis

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Stages of wound healing
  1. Inflammatory Phase begins within minutes of
    injury and lasts about 3 days.
  2. Destructive Phase (granulation) begins before
    inflammation ends and lasts for about 2-5 days.
  3. Proliferative Phase (granulation) begins and
    lasts from 3-24 days.
  4. Maturation Phase the final stage of healing and
    may take more than a year

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Stages of wound healing
  • Inflammatory Phase
  • Reparative processes control bleeding
    (hemostasis), deliver blood and cells to the
    injured area, and form epithelial cells at the
    injury site.
  • During hemostasis, injured blood vessels
    constrict and platelets gather to stop bleeding.
  • Clots form a fibrin matrix that later provides a
    framework for cellular repair.

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Inflammatory Phase
  • Damaged tissue and mast cells secrete histamine,
    resulting in vasodilatation of surrounding
    capillaries and exudation of serum and WBCs into
    damaged tissues resulting in localized redness,
    edema, warmth throbbing

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Inflammatory Phase
  • Leukocytes reach the wound within a few hours.
    The primary WBC is the neutrophil, which begins
    to ingest bacteria and small debris.
  • The second WBC is the monocyte, which transforms
    into macrophages, which clean a wound of
    bacteria, dead cells, and debris by phagocytosis.

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Inflammatory Phase
  • After macrophages clean the wound and make it
    ready for tissue repair, epithelial cells gather
    under the wound space for about 48 hours forming
    a barrier against infectious organisms and toxic
    materials.

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Stages of wound healing Destructive Phase
(granulation)
  • Begins before inflammation ends
  • Lasts for about 2-5 days.
  • Macrophages continue the process of cleaning the
    wound, attracting more macrophages, and
    stimulating formation of fibroblasts, the cells
    that synthesize collagen.
  • Collagen can be found as early as the second day
    and is the main component of scar tissue, it
    provides strength and structural integrity to a
    wound.

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Stages of wound healing Proliferative Phase
(granulation)
  • Lasts from 3-24 days.
  • During this period the wound begins to close with
    new tissue.
  • As reconstruction progresses, the tensile
    strength of the wound increases, and the risk of
    wound separation or rupture is less likely.

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Stages of wound healing Maturation Phase
  • Final stage of healing
  • May take more than a year, depending on the depth
    and extent of the wound.
  • Collagen scar continues to gain strength and
    undergoes remodeling or organization before
    assuming their normal appearance.
  • A healed wound usually does not have the strength
    of the tissue it replaces

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Types of wound healing
  • Can be
  • Primary
  • Secondary
  • Tertiary

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Types of wound healing
  • Primary Intention refers to wounds where there
    is not tissue loss and skin edges are well
    approximated.
  • These wounds have a low risk of infection and
    heal quickly, with little scarring i.e). surgical
    incision

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Types of wound healing
  • Secondary Intention refers to wounds where
    there is tissue loss and the skin edges are not
    approximated, such as in a pressure ulcer
  • These wounds tend to heal slowly and have a
    higher rate of infection.

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Types of wound healing
  • Tertiary Intention can be called delayed
    primary intention or third-intention healing,
    refers to surgical incisions that are left open
    because of edema or infection or to allow
    drainage, and are then closed to heal.

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Handout Factors affecting wound healing
  1. Age
  2. Malnutrition
  3. Obesity
  4. Impaired oxygenation
  5. Smoking
  6. Drugs
  7. Diabetes
  8. Radiation
  9. Wound stress

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Complications of Wound Healing
  • Hemorrhage
  • Infection
  • Dehiscence
  • Evisceration
  • Fistula
  • Delayed Wound Healing

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Hemorrhage
  • Bleeding from wound site is normal during
    immediately after the initial trauma.
  • Hemostasis occurs within several minutes unless
    large vessels are involved or the pt has impaired
    clotting function
  • Bleeding after hemostasis could indicate
  • slipped suture
  • dislodged clot
  • infection
  • erosion of a blood vessel by a foreign object (ie
    a drain).

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Hemorrhage
  • Can occur internally or externally.
  • Internal can be detected by observing for
    distention, swelling, change in the type or
    amount of drainage or signs of hypovolemic shock
    Hematoma a localized collection of blood under
    the tissues.
  • External more obvious, all wounds monitored,
    esp surgical wounds for the 1st 24 48hrs
    post-op

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Infection
  • Wound infection is 2nd most common nosocomial
    infection
  • Chances of wound infection are greater
  • when the wound contains dead or necrotic tissue,
  • when there are foreign bodies in or near the
    wound,
  • and when blood supply local tissue defenses are
    reduced
  • A contaminated or traumatic wound may show signs
    of infection early (within 2-3days)
  • A surgical wound infection does not develop until
    the 4th or 5th day

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Dehiscence
  • Partial or total separation of wound layers
  • When a wound fails to heal properly, the layers
    of skin tissue may separate
  • Most commonly occurs during the 3rd to 11th day
    (before collagen formed)
  • Those at risk
  • Obese (stain placed on wounds fatty tissue
    heals poorly)
  • Often occurs with straining (coughing, vomiting,
    sitting up, walking)
  • Pt will report feeling of something's given way
  • Increase in serosanguineous drainage from a
    wound, think Dehiscence (may lead to
    evisceration)

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Evisceration
  • Is the protrusion of visceral organs through a
    wound opening
  • May occur with total separation of wound layers
    (ie. Total dehiscence)
  • A MEDICAL EMERGENCY, will require surgical repair
  • If it occurs, STERILE towels soaked in sterile
    saline are place over the extruding organs to
    reduce chances of bacterial invasion drying
  • If organs protrude thru the wound, blood supply
    to the tissues is compromised

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Fistula
  • An abnormal passage between 2 organs or between
    an organ the outside of the body
  • May be created for therapeutic reasons (as in
    gastrostomy tube for feedings) but MOST form as a
    result of poor wound healing where tissue layers
    are prevented from closing properly
  • Fistulas increase the risk of infection and loss
    of fluid or electrolytes
  • Chronic fluid drainage can also predispose the
    person to skin breakdown

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Delayed Wound Healing
  • Sometimes referred to as third intention wound
    healing
  • Delayed wound closure is a deliberate attempt by
    a surgeon to allow effective drainage of a
    clean-contaminated or contaminated wound
  • Wound not closed until all evidence of edema
    debris removed (may be weeks).
  • Wound covered by occlusive dressing to prevent
    bacterial contamination
  • Wound then closed to heal by first intention

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Factors affecting Wound Healing
  • 1. Age
  • 2. Nutrition
  • 3. Obesity
  • 4. Impaired Oxygenation
  • 5. Smoking
  • 6. Drugs
  • 7. Diabetes
  • 8. Radiation
  • 9. Wound stress

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Types of dressings
  • Generally most drsg have 3 layers
  • a)Contact layer. Fibrin, and debris adhere to
    this layer. If the drsg sticks, moisten it to
    remove carefully
  • If the objective is debridement, then the
    adherence is OK such that removing the dressing
    pulls away the necrotic tissue and debris
  • b)Absorbent layer is a reservoir for secretions.
    The wicking action pulls the extra moisture away
    from the wound.
  • c)Outer layer is a barrier to keep bacteria and
    other contaminants away.

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Types of Dressings
  1. Transparent adhesive films (opsite, Tegaderm) p.
    1545
  2. Impregnated nonadherent dressing (Vaseline gauze)
  3. Hydrocolloids (Duoderm) p. 1545
  4. Hydrogel (intrasite gel) 1546
  5. Polyurethane foams (lyofoam)
  6. Exudate absorbers (debrisan)
  7. Gauze dressings (dry to dry, wet to dry, wet to
    damp or wet) 1541-1545

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How are dressings attached?
  • 1.Tape
  • How do you put it on?
  • How do you remove it?
  • 2.Ties
  • 3.Bandages
  • 4.Anchoring material (netting)
  • 5.Binders

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  • 6.      Measures to minimize discomfort
  • a.       Careful removal of tape, gentle
    cleansing of wound edges, and careful
    manipulation of dressings and drains minimize
    stress on sensitive tissues
  • b.      Careful turning and positioning also
    reduce strain on a wound
  • Administration of analgesic medications 30-60
    minutes before dressing changes

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How do you assess a wound?
  • Who changes dressings?
  • What does the nurse note for charting?
  • Are the wound edges closed?
  • Is there inflammation?
  • Discoloration?
  • What is the nature of the wound drainage?
  • Amount?
  • Color and consistency?
  • Odor?
  • Response to palpation?
  • Pain?

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WOUND CULTURES
  • Do not collect wound culture from old drainage.
  • Cleanse the wound with NS to remove skin flora

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Procedure
  • use a microbiology requisition
  • cleanse the site with saline
  • make certain you note the following information
  • specimen location
  • request CS. gram stain (gm stain)
  • history (usually disease)
  • antibiotics (WHY?)
  • 4. CHART what you have done.

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CHANGING A DRESSING
  • To prepare
  • the nurse must know type of dressing, the
    presence of underlying drains, and the type of
    supplies needed.
  • How do you find that out?
  • 1. physicians order should indicate dressing
    type, frequency of changing, and any solutions or
    ung.
  • 2. chart for operative reports
  • 3. nurses notes
  • 4. other staff
  • 5. the patient

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General Recommendations
  • hand wash before and after
  • an open or fresh wound should be touched only
    with sterile gloves
  • a sealed wound dressings may be handled with
    clean gloves.
  • dressings should be changed when they become wet,
    or if the client has SS of infection.

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  Common cleaning solutions
  • Soap water for minor abrasions, lacerations,
    small puncture wounds
  • Povidone-Iodine solution for staphylococcus
    aureus
  • Dakins solution diluted is a bacteriocidal
    for staphylococcal and streptococcal organisms.
    Very irritating to skin around the wound.
  • Acetic acid solution effective against
    gram-positive and gram-negative bacteria
  • Hydrogen peroxide is a debriding agent. It should
    not be applied to granulation tissue.
  • Saline is most often used to debride wounds. It
    maintains the moist surface needed to promote
    epithelial tissue growth.

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Principles
  • Clean from least contaminated to more
    contaminated (ie clean to dirty)
  • Never use the same piece of gauze to cleanse
    twice
  • Wound is considered LESS contaminated than the
    surrounding skin
  • Drain site is considered MORE contaminated than
    an incisional site. Cleansing moves from the
    incisional site to the drain.
  • Isolated drain site the site is LESS contaminated
    than the skin near it.

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Wound Cleaning
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Wound Cleaning
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Drains
  • Inserted into or close to a surgical wound
  • if large amounts of drainage is expected
  • if keeping wound layers closed is especially
    important
  • If fluid is allowed to accumulate under tissues,
    the inner wound edges wound never close

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Drains
  • Nurses responsibility is to
  • Assess drain placement, patency
  • Assess character of drainage
  • Observe condition of collecting apparatus (must
    be measured as output when emptied)

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TYPES OF DRAINS
  • Penrose
  • No suction
  • Usually secured by a pin
  • Hemovac Jackson-Pratt
  • Low-suction
  • Containers need to be emptied
  • T-Tube
  • T shaped tube gravity drainage
  • SOMETIMES use colostomy bags

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Hemovac
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  • Jackson-Pratt

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Hemovac
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Wound Cleaning with drain in place
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Critical Elements for Wound Care
  • Maintains sterile technique
  • Removes soiled dressings appropriately
  • Cleanses clean to dirty
  • Maintains wound integrity (correct solution, uses
    each sponge only once)
  • Assesses wound drainage and selects appropriate
    cover (for the amount of exudate)
  • Applies dressing, if needed, in appropriate
    fashion
  • Reports and records as per facility policy
    (includes color and amount of drainage, incision
    line, type of dressing, client response)

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Critical Elements
  • Collection of Specimens
  • Gathers appropriate equipment
  • Provides appropriate asepsis medical or surgical
  • Follows procedures
  • Charts date, time type of collection

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Bandages Binders Part B
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definitions
  • AKA above the knee amputation
  • BKA below the knee amputation
  • Blanching to become white or pale, as from
    vasoconstriction Capillary return
  • Cyanosis bluish discoloration of the skin and
    mucous membranes caused by an excess of
    deoxygenated hemoglobin in the blood

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  • CWCM colour, warmth, circulation, and movement
  • Dependent edema a fluid accumulation in the
    tissues influenced by gravity. It is usually
    greater in the lower part of the body than in
    tissues above the level of the heart.
  • Distal away from or being the farthest from the
    midline or central point
  • Proximal nearer to a point of reference,
    usually the truck of the body, than other parts
    of the body.

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Indications for applying binders bandages
  • Binders and bandages applied over or around
    dressings can provide extra protection and
    therapeutic benefits by
  • Creating pressure
  • Immobilizing a body part Supporting a wound
    (abdominal binder applied over a large abdominal
    incision and dressing).
  • Reducing or preventing edema
  • Securing a splint
  • Securing dressings

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Types of bandages and binders
  •  Available in rolls of varying widths and
    materials e.g. gauze, elasticized knit, elastic
    webbing, flannel, muslin
  • Gauze bandages are lightweight, inexpensive and
    mould easily around a limb, and permit air to
    circulate
  • Elastic conforms to body parts, but as well can
    be used to exert pressure over a body part
  • Flannel and muslin are thicker than gauze and
    thus are stronger. A flannel bandage also
    insulates to provide warmth
  • Binders and bandages that are made of large
    pieces of material to fit a specific body part
  • Binders are usually made of elastic, cotton,
    muslin or flannel

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Principles for applying bandages binders
  • Position body part to be bandage in comfortable
    position of normal anatomical alignment
  • Prevent friction between and against skin
    surfaces by applying gauze or cotton padding
  • Apply bandages securely to prevent slippage
    during movement

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Principles for applying bandages binders
  • When bandaging extremities apply bandage first at
    distal end and progress toward trunk
  • Apply bandages firmly with equal tension exerted
    over each turn or layer. Avoid excess overlapping
    of bandage layers
  • Position pins, knots, or ties away from wound or
    sensitive skin

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Before a bandage or binder is applied, the
nurses responsibilities include the following
  • Inspecting the skin for abrasions, edema,
    discoloration, or exposed wound edges
  • Covering exposed wounds or open abrasions with a
    sterile dressing
  • Assessing the condition of underlying dressings
    and changing them if soiled

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The nurses responsibilities include the
following
  • Assessing the skin of underlying body parts and
    parts that will be distal to the bandage for
    signs of circulatory impairment (coolness, pallor
    or cyanosis, diminished or absent pulses,
    swelling, numbness, and tingling) to provide a
    means for comparing changes in circulation after
    bandage application

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  • After a bandage is applied, nurse assesses,
    documents, immediately reports changes in
    circulation, skin integrity, comfort level, and
    body function such as ventilation and movement.

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CHARTING
  • The nurse must chart
  • The type of bandage
  • Area of the body involved
  • Comfort level
  • CWCM
  • Skin integrity
  • Body function
  • Bandage may be loosened or tightened but it must
    be monitored

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Slings
  • Slings support arms with sprains or fractures
  • Usually a large triangular piece of cloth

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Slings
  • Client may sit or lie
  • Bend afflicted arm, bringing arm across chest
  • Open part of sling fits under the afflicted arm
    and across the chest
  • Base of triangle under the wrist and the
    triangle's point at the client's elbow

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Slings
  • One end fits around the back of client's neck
  • Loose end is brought up and over afflicted arm
    and tied in back of neck
  • Knots are tied at side of neck so it does not
    press,
  • Fingers must be supported
  • Hand higher than wrist

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Scultetus (many-tailed) binder
  • a rectangular piece of cotton with 6 to 12 tails
    attached to each side
  • used to provide support to the abdomen or to
    retain dressings.
  • apply while patient is supine
  • line bottom up with pubic bone
  • apply tails upward alternately
  • assess breathing when patient sits up
  • pins last flap

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Heat and cold application
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Bodily responses to heat and cold
  • Exposure to heat and cold can result in both a
    systemic and a local response
  • SYSTEMIC responses occur through heat-loss
    mechanisms (sweating and vasodilatation) or
    through mechanisms that conserve heat
    (vasoconstriction and piloerection)
  • LOCAL responses occur through stimulation of
    temperature sensitive nerve endings within the
    skin

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  • The body can tolerate wide variations
  • Normal skin temperature is 34 C, but the
    receptors will adapt to temperatures between 45
    and 15C
  • Pain develops when temperatures outside this
    range
  • Too much heat burning sensation
  • Too cold numbing sensation

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Therapeutic effects
  • Heat
  • vasodilation
  • reduced blood viscosity
  • reduced muscle tension
  • increased tissue metabolism
  • increased capillary permeability

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Therapeutic effects
  • Cold
  • vasoconstriction
  • local anesthetic
  • reduced cell metabolism
  • increased blood viscosity
  • decreased muscle tension

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Uses for heat
  • Inflamed or edematous body parts
  • New wounds with swelling (e.g. perineal)
  • Infected wounds
  • Arthritis
  • Back and joint pain
  • Muscle strain
  • Menstrual pain
  • Henmorroidal, perianal, vaginal inflammation
  • Inflammation

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Uses for cold
  • Direct injury or trauma (strains sprains,
    fractures, muscle spasms)
  • Superficial lacerations or puncture wounds
  • Minor burns
  • Arthritis and joint pain
  • Injections

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Safety issues
  • If heat is used too long
  • reflex vasoconstriction
  • damage to epithelial cells
  • If cold is used too long
  • reflex vasodilation

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Factors affecting heat and cold tolerance
  • duration of application
  • body part.
  • damage to body surface
  • prior skin temperature
  • body surface area
  • age and physical conditions

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Conditions that increase risk of injury
  • 1. age
  • 2. open wounds or broken skin
  • 3. areas of edema or scar formation
  • 4. peripheral vascular disease.
  • 5. confused or unconsciousness
  • 6. spinal cord injury
  • 7.abscessed tooth or appendix

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Assessment
  • assess the client to determine risk factors for
    tolerance to heat and cold.
  • observe the area to be treated
  • establish a baseline.
  • are there any conditions that would directly
    contraindicate the use of heat and cold?
  • check the equipment to be used

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CONTRAINDICATIONS
  • To Heat
  • Bleeding
  • Appendix
  • CV problems
  • To Cold
  • Site of injury is edematous
  • Impaired circulation
  • Both
  • Confusion or unconsciousness
  • Unsafe equipment -

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Applying heat and cold
  • in institution doctor's order required
  • the body site to be treated type, frequency and
    duration of application
  • follow the agency's policies
  • teaching
  • purpose of the therapy,
  • symptoms for temperature exposure
  • precautions to prevent injury

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SAFETY
  • Explain the sensations to be felt
  • Instruct patient to report sensation changes or
    pain
  • Provide patient with a timer or clock
  • Keep the call light with in reach
  • Know the agency's policies
  • Do not allow the patient to adjust temperature
  • Do not allow the patient to move application
  • Do not position patient so they cannot move away
  • Do not leave unattended a client who cannot sense
    temperature changes

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Choice of moist or dry applications
  • Both heat and cold can be applied in a moist or a
    dry form
  • Choice is made according to
  • Type of wound or injury
  • Location of body part
  • Presence of drainage
  • Presence of inflammation

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Advantages
  • MOIST
  • Reduces drying of skin
  • Softens exudate
  • Fit to body area being treated
  • Penetrate deeply into tissue layers
  • Does not promote sweating
  • DRY
  • Less risk of burns to skin
  • Does not cause skin maceration
  • Retains temperature longer

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Disadvantages
  • MOIST
  • Prolonged exposure may cause maceration
  • Cools rapidly because of evaporation
  • Creates greater risk for burns
  • DRY
  • Increases body fluid loss through sweating
  • Does not penetrate deeply into tissues
  • Causes increased drying of the skin

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Hot moist compresses
  • May be used for open wounds
  • They improve circulation
  • Relieve edema
  • Promote consolidation of pus and drainage
  • Heat from hot compresses dissipates quickly
  • Nurse must change the compress often or apply an
    aquathermic pad over top OR a waterproof-heating
    pad.
  • With moist heat there is evaporation and the
    client may feel chilly.

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Applying a hot moist compress
  • inspect condition of exposed skin and wound
  • assess client to sensitivity to temperature
  • check physicians order
  • prepare equipment
  • explain procedure
  • make client comfortable
  • wash hands
  • procedure is sterile
  • after procedure
  • inspect affected area
  • chart

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Methods
  • Hot water bottle
  • Filled to approximately 2/3 full
  • Remaining air is expelled and top secured
  • Bag is dried and held upside down to test for
    leakage
  • Wrapped in a cover
  • Usually stays hot for 45 minutes
  • TEMPERATURES
  • Normal adult 52
  • Debilitated or unconscious 40-46
  • Child 40- 45

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Aquathermia (water flow) pad
  • Device through which warm distilled water
    circulates
  • Distilled water circulates through hollowed
    channels in the pad to the control unit where the
    temperature is set to either heat or cool
  • Water reservoir must be kept 2/3 full
  • Temperature is set with a key
  • Cover is placed between pad and skin
  • Secured with tape NEVER pins
  • Application is 20-30 minutes
  • patient is never allowed to lie on the pad,

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Heating pads
  • C/o an electric coil enclosed in a waterproof pad
    covered with cotton
  • Pad connected to an electric cord with a
    temperature control
  • CAUTION
  • Never use the high setting
  • Never lie on the pad
  • Safety pins and/or water may result in electrical
    shock

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Commercial hot or cold packs
  • Hot packs
  • Apply warm dry heat to an area
  • Instructions tell how to initiate the heating
    (knead, hit or snap the bag)
  • These list the time for which they are effective
  • They are considered disposable
  • COLD PACKS
  • Same as for heat packs

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Ice collar/ bags
  • Ice bag is a rubber or plastic bag with a
    removable cap
  • Ice collar is similar but is long and narrow
  • Ice glove rubber or plastic glove filled with ice
    chips and tied at the end
  • PROCEDURE
  • Crushed ice is placed in container until 2/3 full
  • Air is expelled
  • Top secured and cover tightened
  • Put onto body part so it moulds
  • Apply for 30 minutes. Reapply in 1 hour

96
Sitz Baths
  • Used for rectal surgery, episiotomies,
    hemorrhoids, vaginal inflammation
  • only the perineal area is immersed
  • Patient uses a special tub or a plastic basin
  • Disposable sitz baths have a bag into which hot
    water is placed to run in slowly
  • Treatment usually 20 minutes
  • Client must be kept warm
  • Feet flat on the floor
  • No pressure on the sacrum

97
Warm soaks
  • Promotes circulation
  • Lessens edema
  • Increases muscle relaxation
  • May assist debridement
  • Allows the application of medication
  • PROCEDURE
  • Position the patient comfortably
  • Put waterproofing on the bed
  • Heats solution to 40-43
  • Immerse the body part
  • Cover container and person to prevent heat loss
  • Change solution q 10 min
  • There are also cold soaks

98
Treating Injuries effectively
  • When do you use ice?
  • immediately after injury and up to 72 hours if
    the SS of inflammation are no longer present
  • Use for 20 minutes with an hour off.
  • When do you use heat?
  • AVOID immediately after an injury and for up to
    72 hours
  • Apply for 20 minutes. Repeat several times a day

99
Critical Elements
  • Checks for the physician's order
  • Follows the agency's policies
  • Assesses the patient and the wound before
    the application and after
  • Knows the risks and benefits of heat and cold
    applications
  • Knows how to correctly apply the various types of
    heat and cold applications
  • Knows the time limits for application
  • Provides teaching for the patient
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Wound Care Binders

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Title: Wound Care Binders


1
Wound CareBinders BandagesUse of Heat and
Cold Module 8, Part A, B and C
2
WHY IS WOUND CARE DONE?
  • General purposes of dressings
  • Protecting a wound from microorganism
    contamination
  • Aiding hemostasis
  • Promoting healing by absorbing drainage and
    debriding a wound
  • Supporting or splinting the wound site
  • Protecting the client from seeing the wound
  • Promoting thermal insulation to the wound surface
  • Providing maintenance of high humidity between
    the wound and dressing

3
Definitions
  • Abscess a cavity containing pus and surrounded
    by inflamed tissue, formed as a result of
    suppuration in a localized infection. Healing
    usually occurs when an abscess drains or is
    incised.
  • Collagen a protein consisting of bundles of
    tiny reticular fibrils, which combine to form the
    white, glistening, inelastic fibers of tendons,
    ligaments, and fasciae.

4
  • Debridement removal of dirt, foreign objects,
    damaged or dead tissue, and cellular debris from
    a wound or a burn to prevent infection and to
    promote healing.
  • Eschar a scab or dry crust resulting from a
    thermal or chemical burn, infection, or
    excoriating skin disease.
  • Exudate fluid, cells, or other substances that
    have been slowly exudated, or discharged, from
    cells or blood vessels through small pores or
    breaks in cell membranes. Perspiration, pus, and
    serum are sometimes identified as exudates.

5
  • Fibroblast a flat, elongated undifferentiated
    cell in the connective tissue that gives rise to
    various precursor cells, such as the
    chondroblast, collagenoblast, and osteoblast,
    that form the fibrous, binding, and supporting
    tissue of the body.
  • Fistula an abnormal passage from an internal
    organ to the body surface or between two internal
    organs, caused by a congenital defect, injury,
    infection, the spreading of a malignant lesion,
    radiotherapy of a cancerous growth, or trauma
    during childbirth.
  • Granulation any soft, pink, fleshy projections
    that form during the healing process in a wound
    not healing by first intention.

6
  • Inflammation the protective response of the
    tissues of the body to irritation or injury.
  • May be acute or chronic its cardinal signs are
    redness, heat, swelling, and pain, accompanied by
    loss of function.
  • Maceration the softening and breaking down of
    skin from prolonged exposure to moisture.
  • May be caused by prolonged exposure to amniotic
    fluid in a post term infant or dead fetus.
  • Necrosis localized tissue death that occurs
    in-groups of cells in response to disease or
    injury.

7
  • Pus a creamy, viscous, pale yellow, or
    yellow-green fluid exudate that is the result of
    fluid remains of liquefactive necrosis of
    tissues. Bacterial infection is its most common
    cause.
  • Purulent producing or containing pus.
  • Regeneration new growth
  • Sanguineous pertaining to blood or containing
    blood.
  • Serous pertaining to, resembling, or producing
    serum.
  • Serosanguineous thin and red composed of serum
    and blood.
  • Ulceration the process of ulcer formation

8
Review of AP
  • Skin is the bodys largest organ
  • Functions
  • 1. protective barrier
  • 2. sensory organ for pain temperature and touch
  • 3. synthesize vitamin D
  • Two layers
  • separated by membrane dermal-epidermal junction
  • 1. epidermis
  • 2. dermis

9
Stages of wound healing
  1. Inflammatory Phase begins within minutes of
    injury and lasts about 3 days.
  2. Destructive Phase (granulation) begins before
    inflammation ends and lasts for about 2-5 days.
  3. Proliferative Phase (granulation) begins and
    lasts from 3-24 days.
  4. Maturation Phase the final stage of healing and
    may take more than a year

10
Stages of wound healing
  • Inflammatory Phase
  • Reparative processes control bleeding
    (hemostasis), deliver blood and cells to the
    injured area, and form epithelial cells at the
    injury site.
  • During hemostasis, injured blood vessels
    constrict and platelets gather to stop bleeding.
  • Clots form a fibrin matrix that later provides a
    framework for cellular repair.

11
Inflammatory Phase
  • Damaged tissue and mast cells secrete histamine,
    resulting in vasodilatation of surrounding
    capillaries and exudation of serum and WBCs into
    damaged tissues resulting in localized redness,
    edema, warmth throbbing

12
Inflammatory Phase
  • Leukocytes reach the wound within a few hours.
    The primary WBC is the neutrophil, which begins
    to ingest bacteria and small debris.
  • The second WBC is the monocyte, which transforms
    into macrophages, which clean a wound of
    bacteria, dead cells, and debris by phagocytosis.

13
Inflammatory Phase
  • After macrophages clean the wound and make it
    ready for tissue repair, epithelial cells gather
    under the wound space for about 48 hours forming
    a barrier against infectious organisms and toxic
    materials.

14
Stages of wound healing Destructive Phase
(granulation)
  • Begins before inflammation ends
  • Lasts for about 2-5 days.
  • Macrophages continue the process of cleaning the
    wound, attracting more macrophages, and
    stimulating formation of fibroblasts, the cells
    that synthesize collagen.
  • Collagen can be found as early as the second day
    and is the main component of scar tissue, it
    provides strength and structural integrity to a
    wound.

15
Stages of wound healing Proliferative Phase
(granulation)
  • Lasts from 3-24 days.
  • During this period the wound begins to close with
    new tissue.
  • As reconstruction progresses, the tensile
    strength of the wound increases, and the risk of
    wound separation or rupture is less likely.

16
Stages of wound healing Maturation Phase
  • Final stage of healing
  • May take more than a year, depending on the depth
    and extent of the wound.
  • Collagen scar continues to gain strength and
    undergoes remodeling or organization before
    assuming their normal appearance.
  • A healed wound usually does not have the strength
    of the tissue it replaces

17
Types of wound healing
  • Can be
  • Primary
  • Secondary
  • Tertiary

18
Types of wound healing
  • Primary Intention refers to wounds where there
    is not tissue loss and skin edges are well
    approximated.
  • These wounds have a low risk of infection and
    heal quickly, with little scarring i.e). surgical
    incision

19
Types of wound healing
  • Secondary Intention refers to wounds where
    there is tissue loss and the skin edges are not
    approximated, such as in a pressure ulcer
  • These wounds tend to heal slowly and have a
    higher rate of infection.

20
Types of wound healing
  • Tertiary Intention can be called delayed
    primary intention or third-intention healing,
    refers to surgical incisions that are left open
    because of edema or infection or to allow
    drainage, and are then closed to heal.

21
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22
Handout Factors affecting wound healing
  1. Age
  2. Malnutrition
  3. Obesity
  4. Impaired oxygenation
  5. Smoking
  6. Drugs
  7. Diabetes
  8. Radiation
  9. Wound stress

23
Complications of Wound Healing
  • Hemorrhage
  • Infection
  • Dehiscence
  • Evisceration
  • Fistula
  • Delayed Wound Healing

24
Hemorrhage
  • Bleeding from wound site is normal during
    immediately after the initial trauma.
  • Hemostasis occurs within several minutes unless
    large vessels are involved or the pt has impaired
    clotting function
  • Bleeding after hemostasis could indicate
  • slipped suture
  • dislodged clot
  • infection
  • erosion of a blood vessel by a foreign object (ie
    a drain).

25
Hemorrhage
  • Can occur internally or externally.
  • Internal can be detected by observing for
    distention, swelling, change in the type or
    amount of drainage or signs of hypovolemic shock
    Hematoma a localized collection of blood under
    the tissues.
  • External more obvious, all wounds monitored,
    esp surgical wounds for the 1st 24 48hrs
    post-op

26
Infection
  • Wound infection is 2nd most common nosocomial
    infection
  • Chances of wound infection are greater
  • when the wound contains dead or necrotic tissue,
  • when there are foreign bodies in or near the
    wound,
  • and when blood supply local tissue defenses are
    reduced
  • A contaminated or traumatic wound may show signs
    of infection early (within 2-3days)
  • A surgical wound infection does not develop until
    the 4th or 5th day

27
Dehiscence
  • Partial or total separation of wound layers
  • When a wound fails to heal properly, the layers
    of skin tissue may separate
  • Most commonly occurs during the 3rd to 11th day
    (before collagen formed)
  • Those at risk
  • Obese (stain placed on wounds fatty tissue
    heals poorly)
  • Often occurs with straining (coughing, vomiting,
    sitting up, walking)
  • Pt will report feeling of something's given way
  • Increase in serosanguineous drainage from a
    wound, think Dehiscence (may lead to
    evisceration)

28
Evisceration
  • Is the protrusion of visceral organs through a
    wound opening
  • May occur with total separation of wound layers
    (ie. Total dehiscence)
  • A MEDICAL EMERGENCY, will require surgical repair
  • If it occurs, STERILE towels soaked in sterile
    saline are place over the extruding organs to
    reduce chances of bacterial invasion drying
  • If organs protrude thru the wound, blood supply
    to the tissues is compromised

29
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30
Fistula
  • An abnormal passage between 2 organs or between
    an organ the outside of the body
  • May be created for therapeutic reasons (as in
    gastrostomy tube for feedings) but MOST form as a
    result of poor wound healing where tissue layers
    are prevented from closing properly
  • Fistulas increase the risk of infection and loss
    of fluid or electrolytes
  • Chronic fluid drainage can also predispose the
    person to skin breakdown

31
Delayed Wound Healing
  • Sometimes referred to as third intention wound
    healing
  • Delayed wound closure is a deliberate attempt by
    a surgeon to allow effective drainage of a
    clean-contaminated or contaminated wound
  • Wound not closed until all evidence of edema
    debris removed (may be weeks).
  • Wound covered by occlusive dressing to prevent
    bacterial contamination
  • Wound then closed to heal by first intention

32
Factors affecting Wound Healing
  • 1. Age
  • 2. Nutrition
  • 3. Obesity
  • 4. Impaired Oxygenation
  • 5. Smoking
  • 6. Drugs
  • 7. Diabetes
  • 8. Radiation
  • 9. Wound stress

33
Types of dressings
  • Generally most drsg have 3 layers
  • a)Contact layer. Fibrin, and debris adhere to
    this layer. If the drsg sticks, moisten it to
    remove carefully
  • If the objective is debridement, then the
    adherence is OK such that removing the dressing
    pulls away the necrotic tissue and debris
  • b)Absorbent layer is a reservoir for secretions.
    The wicking action pulls the extra moisture away
    from the wound.
  • c)Outer layer is a barrier to keep bacteria and
    other contaminants away.

34
Types of Dressings
  1. Transparent adhesive films (opsite, Tegaderm) p.
    1545
  2. Impregnated nonadherent dressing (Vaseline gauze)
  3. Hydrocolloids (Duoderm) p. 1545
  4. Hydrogel (intrasite gel) 1546
  5. Polyurethane foams (lyofoam)
  6. Exudate absorbers (debrisan)
  7. Gauze dressings (dry to dry, wet to dry, wet to
    damp or wet) 1541-1545

35
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36
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37
How are dressings attached?
  • 1.Tape
  • How do you put it on?
  • How do you remove it?
  • 2.Ties
  • 3.Bandages
  • 4.Anchoring material (netting)
  • 5.Binders

38
  • 6.      Measures to minimize discomfort
  • a.       Careful removal of tape, gentle
    cleansing of wound edges, and careful
    manipulation of dressings and drains minimize
    stress on sensitive tissues
  • b.      Careful turning and positioning also
    reduce strain on a wound
  • Administration of analgesic medications 30-60
    minutes before dressing changes

39
How do you assess a wound?
  • Who changes dressings?
  • What does the nurse note for charting?
  • Are the wound edges closed?
  • Is there inflammation?
  • Discoloration?
  • What is the nature of the wound drainage?
  • Amount?
  • Color and consistency?
  • Odor?
  • Response to palpation?
  • Pain?

40
WOUND CULTURES
  • Do not collect wound culture from old drainage.
  • Cleanse the wound with NS to remove skin flora

41
Procedure
  • use a microbiology requisition
  • cleanse the site with saline
  • make certain you note the following information
  • specimen location
  • request CS. gram stain (gm stain)
  • history (usually disease)
  • antibiotics (WHY?)
  • 4. CHART what you have done.

42
CHANGING A DRESSING
  • To prepare
  • the nurse must know type of dressing, the
    presence of underlying drains, and the type of
    supplies needed.
  • How do you find that out?
  • 1. physicians order should indicate dressing
    type, frequency of changing, and any solutions or
    ung.
  • 2. chart for operative reports
  • 3. nurses notes
  • 4. other staff
  • 5. the patient

43
General Recommendations
  • hand wash before and after
  • an open or fresh wound should be touched only
    with sterile gloves
  • a sealed wound dressings may be handled with
    clean gloves.
  • dressings should be changed when they become wet,
    or if the client has SS of infection.

44
  Common cleaning solutions
  • Soap water for minor abrasions, lacerations,
    small puncture wounds
  • Povidone-Iodine solution for staphylococcus
    aureus
  • Dakins solution diluted is a bacteriocidal
    for staphylococcal and streptococcal organisms.
    Very irritating to skin around the wound.
  • Acetic acid solution effective against
    gram-positive and gram-negative bacteria
  • Hydrogen peroxide is a debriding agent. It should
    not be applied to granulation tissue.
  • Saline is most often used to debride wounds. It
    maintains the moist surface needed to promote
    epithelial tissue growth.

45
Principles
  • Clean from least contaminated to more
    contaminated (ie clean to dirty)
  • Never use the same piece of gauze to cleanse
    twice
  • Wound is considered LESS contaminated than the
    surrounding skin
  • Drain site is considered MORE contaminated than
    an incisional site. Cleansing moves from the
    incisional site to the drain.
  • Isolated drain site the site is LESS contaminated
    than the skin near it.

46
Wound Cleaning
47
Wound Cleaning
48
Drains
  • Inserted into or close to a surgical wound
  • if large amounts of drainage is expected
  • if keeping wound layers closed is especially
    important
  • If fluid is allowed to accumulate under tissues,
    the inner wound edges wound never close

49
Drains
  • Nurses responsibility is to
  • Assess drain placement, patency
  • Assess character of drainage
  • Observe condition of collecting apparatus (must
    be measured as output when emptied)

50
TYPES OF DRAINS
  • Penrose
  • No suction
  • Usually secured by a pin
  • Hemovac Jackson-Pratt
  • Low-suction
  • Containers need to be emptied
  • T-Tube
  • T shaped tube gravity drainage
  • SOMETIMES use colostomy bags

51
Hemovac
52
  • Jackson-Pratt

53
Hemovac
54
Wound Cleaning with drain in place
55
Critical Elements for Wound Care
  • Maintains sterile technique
  • Removes soiled dressings appropriately
  • Cleanses clean to dirty
  • Maintains wound integrity (correct solution, uses
    each sponge only once)
  • Assesses wound drainage and selects appropriate
    cover (for the amount of exudate)
  • Applies dressing, if needed, in appropriate
    fashion
  • Reports and records as per facility policy
    (includes color and amount of drainage, incision
    line, type of dressing, client response)

56
Critical Elements
  • Collection of Specimens
  • Gathers appropriate equipment
  • Provides appropriate asepsis medical or surgical
  • Follows procedures
  • Charts date, time type of collection

57
Bandages Binders Part B
58
definitions
  • AKA above the knee amputation
  • BKA below the knee amputation
  • Blanching to become white or pale, as from
    vasoconstriction Capillary return
  • Cyanosis bluish discoloration of the skin and
    mucous membranes caused by an excess of
    deoxygenated hemoglobin in the blood

59
  • CWCM colour, warmth, circulation, and movement
  • Dependent edema a fluid accumulation in the
    tissues influenced by gravity. It is usually
    greater in the lower part of the body than in
    tissues above the level of the heart.
  • Distal away from or being the farthest from the
    midline or central point
  • Proximal nearer to a point of reference,
    usually the truck of the body, than other parts
    of the body.

60
Indications for applying binders bandages
  • Binders and bandages applied over or around
    dressings can provide extra protection and
    therapeutic benefits by
  • Creating pressure
  • Immobilizing a body part Supporting a wound
    (abdominal binder applied over a large abdominal
    incision and dressing).
  • Reducing or preventing edema
  • Securing a splint
  • Securing dressings

61
Types of bandages and binders
  •  Available in rolls of varying widths and
    materials e.g. gauze, elasticized knit, elastic
    webbing, flannel, muslin
  • Gauze bandages are lightweight, inexpensive and
    mould easily around a limb, and permit air to
    circulate
  • Elastic conforms to body parts, but as well can
    be used to exert pressure over a body part
  • Flannel and muslin are thicker than gauze and
    thus are stronger. A flannel bandage also
    insulates to provide warmth
  • Binders and bandages that are made of large
    pieces of material to fit a specific body part
  • Binders are usually made of elastic, cotton,
    muslin or flannel

62
Principles for applying bandages binders
  • Position body part to be bandage in comfortable
    position of normal anatomical alignment
  • Prevent friction between and against skin
    surfaces by applying gauze or cotton padding
  • Apply bandages securely to prevent slippage
    during movement

63
Principles for applying bandages binders
  • When bandaging extremities apply bandage first at
    distal end and progress toward trunk
  • Apply bandages firmly with equal tension exerted
    over each turn or layer. Avoid excess overlapping
    of bandage layers
  • Position pins, knots, or ties away from wound or
    sensitive skin

64
Before a bandage or binder is applied, the
nurses responsibilities include the following
  • Inspecting the skin for abrasions, edema,
    discoloration, or exposed wound edges
  • Covering exposed wounds or open abrasions with a
    sterile dressing
  • Assessing the condition of underlying dressings
    and changing them if soiled

65
The nurses responsibilities include the
following
  • Assessing the skin of underlying body parts and
    parts that will be distal to the bandage for
    signs of circulatory impairment (coolness, pallor
    or cyanosis, diminished or absent pulses,
    swelling, numbness, and tingling) to provide a
    means for comparing changes in circulation after
    bandage application

66
  • After a bandage is applied, nurse assesses,
    documents, immediately reports changes in
    circulation, skin integrity, comfort level, and
    body function such as ventilation and movement.

67
CHARTING
  • The nurse must chart
  • The type of bandage
  • Area of the body involved
  • Comfort level
  • CWCM
  • Skin integrity
  • Body function
  • Bandage may be loosened or tightened but it must
    be monitored

68
Slings
  • Slings support arms with sprains or fractures
  • Usually a large triangular piece of cloth

69
Slings
  • Client may sit or lie
  • Bend afflicted arm, bringing arm across chest
  • Open part of sling fits under the afflicted arm
    and across the chest
  • Base of triangle under the wrist and the
    triangle's point at the client's elbow

70
Slings
  • One end fits around the back of client's neck
  • Loose end is brought up and over afflicted arm
    and tied in back of neck
  • Knots are tied at side of neck so it does not
    press,
  • Fingers must be supported
  • Hand higher than wrist

71
Scultetus (many-tailed) binder
  • a rectangular piece of cotton with 6 to 12 tails
    attached to each side
  • used to provide support to the abdomen or to
    retain dressings.
  • apply while patient is supine
  • line bottom up with pubic bone
  • apply tails upward alternately
  • assess breathing when patient sits up
  • pins last flap

72
Heat and cold application
73
Bodily responses to heat and cold
  • Exposure to heat and cold can result in both a
    systemic and a local response
  • SYSTEMIC responses occur through heat-loss
    mechanisms (sweating and vasodilatation) or
    through mechanisms that conserve heat
    (vasoconstriction and piloerection)
  • LOCAL responses occur through stimulation of
    temperature sensitive nerve endings within the
    skin

74
  • The body can tolerate wide variations
  • Normal skin temperature is 34 C, but the
    receptors will adapt to temperatures between 45
    and 15C
  • Pain develops when temperatures outside this
    range
  • Too much heat burning sensation
  • Too cold numbing sensation

75
Therapeutic effects
  • Heat
  • vasodilation
  • reduced blood viscosity
  • reduced muscle tension
  • increased tissue metabolism
  • increased capillary permeability

76
Therapeutic effects
  • Cold
  • vasoconstriction
  • local anesthetic
  • reduced cell metabolism
  • increased blood viscosity
  • decreased muscle tension

77
Uses for heat
  • Inflamed or edematous body parts
  • New wounds with swelling (e.g. perineal)
  • Infected wounds
  • Arthritis
  • Back and joint pain
  • Muscle strain
  • Menstrual pain
  • Henmorroidal, perianal, vaginal inflammation
  • Inflammation

78
Uses for cold
  • Direct injury or trauma (strains sprains,
    fractures, muscle spasms)
  • Superficial lacerations or puncture wounds
  • Minor burns
  • Arthritis and joint pain
  • Injections

79
Safety issues
  • If heat is used too long
  • reflex vasoconstriction
  • damage to epithelial cells
  • If cold is used too long
  • reflex vasodilation

80
Factors affecting heat and cold tolerance
  • duration of application
  • body part.
  • damage to body surface
  • prior skin temperature
  • body surface area
  • age and physical conditions

81
Conditions that increase risk of injury
  • 1. age
  • 2. open wounds or broken skin
  • 3. areas of edema or scar formation
  • 4. peripheral vascular disease.
  • 5. confused or unconsciousness
  • 6. spinal cord injury
  • 7.abscessed tooth or appendix

82
Assessment
  • assess the client to determine risk factors for
    tolerance to heat and cold.
  • observe the area to be treated
  • establish a baseline.
  • are there any conditions that would directly
    contraindicate the use of heat and cold?
  • check the equipment to be used

83
CONTRAINDICATIONS
  • To Heat
  • Bleeding
  • Appendix
  • CV problems
  • To Cold
  • Site of injury is edematous
  • Impaired circulation
  • Both
  • Confusion or unconsciousness
  • Unsafe equipment -

84
Applying heat and cold
  • in institution doctor's order required
  • the body site to be treated type, frequency and
    duration of application
  • follow the agency's policies
  • teaching
  • purpose of the therapy,
  • symptoms for temperature exposure
  • precautions to prevent injury

85
SAFETY
  • Explain the sensations to be felt
  • Instruct patient to report sensation changes or
    pain
  • Provide patient with a timer or clock
  • Keep the call light with in reach
  • Know the agency's policies
  • Do not allow the patient to adjust temperature
  • Do not allow the patient to move application
  • Do not position patient so they cannot move away
  • Do not leave unattended a client who cannot sense
    temperature changes

86
Choice of moist or dry applications
  • Both heat and cold can be applied in a moist or a
    dry form
  • Choice is made according to
  • Type of wound or injury
  • Location of body part
  • Presence of drainage
  • Presence of inflammation

87
Advantages
  • MOIST
  • Reduces drying of skin
  • Softens exudate
  • Fit to body area being treated
  • Penetrate deeply into tissue layers
  • Does not promote sweating
  • DRY
  • Less risk of burns to skin
  • Does not cause skin maceration
  • Retains temperature longer

88
Disadvantages
  • MOIST
  • Prolonged exposure may cause maceration
  • Cools rapidly because of evaporation
  • Creates greater risk for burns
  • DRY
  • Increases body fluid loss through sweating
  • Does not penetrate deeply into tissues
  • Causes increased drying of the skin

89
Hot moist compresses
  • May be used for open wounds
  • They improve circulation
  • Relieve edema
  • Promote consolidation of pus and drainage
  • Heat from hot compresses dissipates quickly
  • Nurse must change the compress often or apply an
    aquathermic pad over top OR a waterproof-heating
    pad.
  • With moist heat there is evaporation and the
    client may feel chilly.

90
Applying a hot moist compress
  • inspect condition of exposed skin and wound
  • assess client to sensitivity to temperature
  • check physicians order
  • prepare equipment
  • explain procedure
  • make client comfortable
  • wash hands
  • procedure is sterile
  • after procedure
  • inspect affected area
  • chart

91
Methods
  • Hot water bottle
  • Filled to approximately 2/3 full
  • Remaining air is expelled and top secured
  • Bag is dried and held upside down to test for
    leakage
  • Wrapped in a cover
  • Usually stays hot for 45 minutes
  • TEMPERATURES
  • Normal adult 52
  • Debilitated or unconscious 40-46
  • Child 40- 45

92
Aquathermia (water flow) pad
  • Device through which warm distilled water
    circulates
  • Distilled water circulates through hollowed
    channels in the pad to the control unit where the
    temperature is set to either heat or cool
  • Water reservoir must be kept 2/3 full
  • Temperature is set with a key
  • Cover is placed between pad and skin
  • Secured with tape NEVER pins
  • Application is 20-30 minutes
  • patient is never allowed to lie on the pad,

93
Heating pads
  • C/o an electric coil enclosed in a waterproof pad
    covered with cotton
  • Pad connected to an electric cord with a
    temperature control
  • CAUTION
  • Never use the high setting
  • Never lie on the pad
  • Safety pins and/or water may result in electrical
    shock

94
Commercial hot or cold packs
  • Hot packs
  • Apply warm dry heat to an area
  • Instructions tell how to initiate the heating
    (knead, hit or snap the bag)
  • These list the time for which they are effective
  • They are considered disposable
  • COLD PACKS
  • Same as for heat packs

95
Ice collar/ bags
  • Ice bag is a rubber or plastic bag with a
    removable cap
  • Ice collar is similar but is long and narrow
  • Ice glove rubber or plastic glove filled with ice
    chips and tied at the end
  • PROCEDURE
  • Crushed ice is placed in container until 2/3 full
  • Air is expelled
  • Top secured and cover tightened
  • Put onto body part so it moulds
  • Apply for 30 minutes. Reapply in 1 hour

96
Sitz Baths
  • Used for rectal surgery, episiotomies,
    hemorrhoids, vaginal inflammation
  • only the perineal area is immersed
  • Patient uses a special tub or a plastic basin
  • Disposable sitz baths have a bag into which hot
    water is placed to run in slowly
  • Treatment usually 20 minutes
  • Client must be kept warm
  • Feet flat on the floor
  • No pressure on the sacrum

97
Warm soaks
  • Promotes circulation
  • Lessens edema
  • Increases muscle relaxation
  • May assist debridement
  • Allows the application of medication
  • PROCEDURE
  • Position the patient comfortably
  • Put waterproofing on the bed
  • Heats solution to 40-43
  • Immerse the body part
  • Cover container and person to prevent heat loss
  • Change solution q 10 min
  • There are also cold soaks

98
Treating Injuries effectively
  • When do you use ice?
  • immediately after injury and up to 72 hours if
    the SS of inflammation are no longer present
  • Use for 20 minutes with an hour off.
  • When do you use heat?
  • AVOID immediately after an injury and for up to
    72 hours
  • Apply for 20 minutes. Repeat several times a day

99
Critical Elements
  • Checks for the physician's order
  • Follows the agency's policies
  • Assesses the patient and the wound before
    the application and after
  • Knows the risks and benefits of heat and cold
    applications
  • Knows how to correctly apply the various types of
    heat and cold applications
  • Knows the time limits for application
  • Provides teaching for the patient
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