MNAMNAMosby’s Long Term Care AssistantMosby’s Long Term Care Assistant Chapter 35 Wound CareChapter 35 Wound Care

Wound CareWound Care

Skin is body’s first line of defenseWound is a break in the skin or mucous membranePortal of entry for microbes

Types of WoundsTypes of Wounds

Abrasion

Contusion

Incision

Laceration

Penetrating wound

Puncture wound

Scraping or rubbing away of skin

Closed wound caused by blow to body. bruise

Open, clean straight edges

Open, torn, jagged edges

Open, Skin is pierced

Open, made by sharp object

Types of WoundsTypes of Wounds

Abrasion

Types of WoundsTypes of Wounds

Contusion

Types of WoundsTypes of Wounds

Incision

Types of WoundsTypes of Wounds

Laceration

Types of WoundsTypes of Wounds

Penetrating

Wound

Types of WoundsTypes of Wounds

Puncture

Wound

Skin TearsSkin TearsBreak or rip in skin

Thin fragile skinSlight pressure can cause a tearCauses:friction, shearingHolding too tightlyRemoving tape, band aideBumping against something

Portal of entry for microbes

Leg and Foot UlcersLeg and Foot Ulcers

Edema - swellingGangrene - death of

tissue

Circulatory Ulcers – open wounds on legs and feet due to blood flow

Venous Ulcers (Stasis Ulcers) - open wounds on legs and feet due to venous return. Blood pools in feet and legs

Leg and Foot UlcersLeg and Foot Ulcers

Causes:Chronic diseases

Obesity

Inactivity

Risk Factors:

Hx of blood clots Mobility

Obesity

Age

Leg and Foot UlcersLeg and Foot Ulcers

Prevention and TXTED Hose

Avoid constricting clothing

Good foot care

Reposition Q2H Feet

Protective devices

Observation

TED HoseTED Hose

Elastic stockings

Thrombus – blood clot

Embolus – traveling blood clot

Anti Thromboemboletic Hose

Sizes:

Knee high

Thigh high

TED HoseTED Hose

Apply Ted Hose

Remove for 30 minutes every 8 hours (Qshift) for foot care and Circ Checks

Heat and Cold ApplicationsHeat and Cold Applications

Promote healing and comfort

Reduce tissue swelling

Heat and Cold ApplicationsHeat and Cold Applications

Observe skins q5 minutes

Apply no longer then 15 -20 minutes

Hot: never higher then 106 F

Cold: never lower then 50 F

Heat ApplicationsHeat Applications

Relieves pain

Relaxes muscles

Decreases joint stiffness

Promotes healing

Reduces tissue swelling

Blood vessels dilate (widen)

Blood flow increases

More blood = more O2 = faster healing

Can cause burns

Heat ApplicationsHeat Applications

Moist:

Hot compress

Hot soaks

Sitz Baths

Dry:

Aquathermia pad

Soft pad

Body part immersed in water

Perineal and rectal area immersed in water

Like a heating pad

Sitz BathSitz BathPlaced on toilet seat

Observe for signs of dizziness or fainting.

Cold ApplicationsCold Applications

Reduce pain

Prevent swelling

Decrease circulation

Decrease bleeding

Numbs

Blood vessels constrict (get smaller)

Blood flow decreases

Can cause pain, burns blisters and poor circulation

Cold ApplicationsCold Applications

Cold Compresses

Ice bags

Ice collers

Ice Gloves

Remember……

Older persons require special skin care.

Protein is an essential nutrient for skin repair

Follow Standard Precautions

Review

Swelling?

edema

Review

Incision

Review

A closed wound caused by a blow to the body ?

contusion

Review

Embolus ?

Traveling blood clot

Review

gangrene ?

Death of tissue

Review

Thrombus ?

Blood clot

Review

Skin tears usually occur over a

_______________. Bony prominence

Review

Contusion

Review

Elastic stocking are called

___________________.TED hose

Review

Puncture

Wound

Review

Ted Hose (elastic stocking) are used to increase circulation

True or False

Review

Penetrating

Wound

Review

Ted Hose (elastic stocking) are used to hold dressings in place

True or False

Review

Ted Hose (elastic stocking) are used to promote healing

True or False

Review

Abrasion

Review

Ted Hose (elastic stocking) are used to prevent injury

True or False

Review

Protein is the most important nutrient for wound healing.

True or False

Review

Severely underweight?

A. obesity

B. anemia

C. paralysis

D. emaciation

Review

Laceration

Review

Constrict means

Get smaller, narrow

Review

Heat applications

Relieve pain

Relaxe muscles

Decrease joint stiffness

Promote healing

Reduce tissue swelling

Review

During a sitz bath, you need to carefully observe the person for

Weakness, dizziness and faintness

Review

NPO

PC

AC

Qid

Tid

Nothing by mouth

After meals

Before meals

4x day

3x day

Questions??