SECTION Arteriosclerosis by nikeborome

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									                          BAKERSFIELD COLLEGE
                 LICENSED VOCATIONAL NURSING PROGRAM

                          1ST SEMESTER FUNDAMENTALS

                           CLIENTS WITH SPECIAL NEEDS


CHAPTER 48 - NURSING CARE OF THE CLIENT WITH WOUNDS


INTRODUCTION

A primary nursing role is to prevent entrance of microorganisms into wounds as well as
to improve and maintain the body’s mechanisms for achieving wound repair. In order to
accomplish these, the nurse must understand normal wound healing, principles of asepsis,
and the effects of heal and cold therapies. In addition, the nurse must be able to properly
assess a wound and its healing and determine what type of dressing is required to reduce
entry of microorganisms.


OBJECTIVES

Upon completion of this unit, the student will be able to:

A.     Theory
       1.     Identify the wound classification.
       2.     Define primary and secondary intention.
       3.     List the nutrients that are needed to promote wound healing.
       4.     Describe the complications of wound healing and their usual time of
              occurrence.
       5.     Explain factors that impair or promote wound healing.
       6.     Describe differences that impair or promote wound healing.
       7.     Describe differences in assessing a wound in a stable versus emergency
              setting.
       8.     Identify the purposes of dressings.
       9.     Describe the purpose of each of the three layers of a surgical dressing.
       10.    Explain nursing care implications in the use of dressings.
       11.    Discuss the purposes of binders.
       12.    Discuss the principles of bandage and binder application.
       13.    Identify the local effects of heat application.
       14.    Identify the local effects of cold application.
       15.    Discuss the types of heat and cold therapies that are used.
B.        Laboratory
          1.     Apply a sterile dry and wet to dry dressing.
          2.     Apply warm and cold applications safely to an injured body part.
          3.     In the laboratory apply a straight abdominal binder and a t-binder.


ASSIGNMENT

     A.      Read Chapter 48 of Potter & Perry, pgs. 1311 – 1341 and Review Questions
     B.      Study guide for Chapter 48




     Chapter 48 - CLIENTS WITH WOUNDS

     A primary nursing role is to prevent entrance of microorganisms into wounds as well
     as to improve and maintain the body’s mechanisms for achieving wound repair
     The nurse must understand normal wound healing, principles of asepsis, and the
     effects of heat and cold therapies
     The nurse must be able to properly assess a wound and its healing and determine
     what type of dressing is required
     A wound is a disruption of normal anatomical structure and function that results from
     pathological processes beginning internally or externally

     Wound Classifications
     Status of skin integrity
            Open wound
            Closed wound
     Cause
            Intentional
            unintentional
     Severity of injury
            Superficial
            penetrating
            Perforating

     Wound Classifications
     Cleanliness
            Clean or infected
     Descriptive Qualities
            Laceration – tearing with irregular edges
            Incision – tissue cut with edges straight
            Abrasion – caused by scraping or rubbing
            Contusion – no tissue break
Wounds Heal by Primary or Secondary Intention
Primary Intention
       Skin edges approximated
       Decreased risk of infection
Secondary Intention
       Wound is left open to granulate in
       Takes longer to heal and greater risk for infection

Nutrition in wound healing
        Need protein, vitamins A and C, zinc and copper
Complications of Wound Healing
Hemorrhage
        May occur internally or externally
Infections
        Occur 4th -5th day, s/s infection
Dehiscence
        Separation of wound layers
Evisceration
        Protrusion of visceral organs through the wound opening

Fistulas
       Abnormal passage between organs or organ and outside of body
Delayed Wound Closure
These are the reasons wounds fail to heal or heal slowly

Factors Influencing Wound Healing
       Age
       Nutritional status
       Obesity
       Extent of the wound
       Tissue oxygenation
       Smoking
       Wound stress

Assessment
In the emergency setting
        Extent of bleeding
        Foreign bodies or contamination
        Size of the wound
        Need for protection of the wound
        Need for tetanus

Assessment
In the stable setting
        Wound appearance
        Character of the drainage
       Status of the drains
       Sutures or staples
       Pain

Assessment
Wound appearance
      Wound edges, inflammation, bruising

Character of drainage
      Serous – clear, watery plasma
      Sanguineous – fresh bleeding
      Serosanguineous – pale, watery
      Purulent – thick, yellow, green or brown

Assessment
Drains – used if a large amount of drainage is expected
       Penrose – tubular drain with a safety pin
       Evacuator units
               Hemovac or Jackson-Pratt
                       Constant, low-pressure vacuum

     Assessment
Wound closures
     Sutures
             Threads or wire to sew the tissues together
                     Interrupted suturing
                     Continuous suturing
                     Retention sutures
     Steele staples
             Less trauma and stronger
     Steri-strips
     Wound glue
     Assessment

Palpation of the Wound
        Can detect areas of tenderness of drainage
Pain
        Serious discomfort can indicate underlying problems
Wound cultures
        May be indicated if drainage is present
Nursing Diagnosis
Existence of a wound clearly indicates a diagnosis for actual impaired skin integrity
Directs the nurse to initiate interventions that promote the healing process as these
clients are at risk for wound infection
The client may be at risk for poor wound healing
The wound may cause problems unrelated to wound healing
Planning
The objectives of wound care include:
       Preventing transmission of infection to or from the wound site
       Preventing further injury
       Maintaining skin integrity
       Promoting hemostasis, wound healing, and a return to normal functioning

Implementation
the management of the wound
Dressings
       Purpose of dressings
              Protection
              Aiding hemostasis
              Support or splinting the wound
              Protect client from visualization
              Three Layers of the Surgical Dressing
Contact dressing
       Covers the incision
Absorbent layer
       Collects secretions
Outer protective dressing
       Thicker material prevents contamination

Types of Dressings
Gauze dressings – most common
Wet to dry – debridement
Non-adherent - telfa
Self-adhesive - transparent
Hydrocolloid – hydrogel – occlusive

Changing dressings
      Know the type of dressing
      If there are drains
      Supplies to be used
      Need for pre- medication
      Check the physician order
      Client teaching as needed

Packing a wound
      Assess:
               Size
               Depth
               Shape of wound
      Know material to pack
      Fill in wound
               Don’t over pack
Securing Dressings
       Tape, Montgomery ties, cloth binders
       Some clients are allergic to tape
              Use non-allergic paper, plastic, or silk tape
To remove tape
       Loosen ends and gently pull parallel with the skin surface toward the wound

Cleansing skin and drain sites
      Basic skin cleansing
               Clean from the least contaminated to the surrounding skin
      Irrigations
               Gentle washing action cleans exudate and debris
               Sterile water, normal saline, antiseptic solution

Suture care
       Physician order
       Never pull the visible portion through the tissue

Bandages and Binders
      Exerting pressure
             Reduce bleeding or edema
      Immobilizing a body part
             Protect from movement
      Supporting a wound
             Reduce stress
      Securing a s plint
             Keep in place
      Securing dressings
             hold in place

Principles of Bandage and Binder Application
Position body part
Prevent friction
Apply securely
Wrap from distal end toward trunk
Use firm equal tension
Position closures away from wound or sensitive skin areas

Types of Binders
Breast
       Provides breast support
Abdominal
       Scultetus and straight
T-Binder and Double T-Binder
       Secure rectal or peritoneal dressings
Slings
        Support arm and hand
        Level above the elbow to prevent edema
Elastic Bandage Ace Wrap



Heat and Cold Therapy
LOCAL EFFECTS OF HEAT APPLICATIONS
Vasodilation – lessens venous congestion
reduced blood viscosity
reduced muscle tension
increased tissue metabolism – due to inc. blood flow
increased capillary permeability - inc. movement of waste

LOCAL EFFECTS OF COLD APPLICATIONS
vasoconstriction – dec. blood flow, prevents edema
local anesthesia
reduced cell metabolism – dec. 02 needs
increased viscosity of blood – promotes clotting
decreased muscle tension

BODY’S RESPONSE TO HEAT AND COLD THERAPY is influenced by the:
duration of application,
body part – some areas are more sensitive to heat and cold
damage to the body surface
prior skin temperature
body surface area
client’s age and physical condition

CONDITIONS WHEN HEAT AND COLD APPLICATION IS
CONTRAINDICATED
no heat if there is: 1) bleeding, 2) acute localized inflammation – such as appendicitis
because the heat could cause the appendix to rupture, 3) cardiovascular problems –
massive vasodilation may disrupt blood supply to vital organs
no cold if there is: 1) edema – retards circulation and prevents reabsorption of the
interstitial fluid, 2) impaired circulation – ex. Arteriosclerosis cold further reduces
blood supply to the area, 3) neuropathy – because the client is unable to perceive
temperature change and damage may result from prolonged exposure to extreme
temperatures,
4) shivering – cold application may intensify shivering and increase body
temperature.

ASSESSMENT FOR TEMPERATURE TOLERANCE
     before beginning heat or cold therapies, the nurse assesses the client for
     potential intolerance including:
               assessment of wound character (active bleeding, edema already
               present)
               conditions that contraindicate the therapy
                the client’s LOC.


THERAPIES
      both heat and cold applications can be administered in dry and moist forms
     They usually require a physician’s order and should include the body site to
     be treated, and the type, frequency, and duration of application
      may involve the nurse’s judgment


DRY HEAT
ADVANTAGES –1) dry heat has less risk of burns to skin than moist applications, 2)
dry application does not cause skin maceration – maceration is to soften the skin by
soaking in water - , 3) dry heat retains temperature longer because it is not influenced
by evaporation
DISADVANTAGES – 1) dry heat increases body fluid loss through sweating, 2) dry
heat applications do not penetrate deep into tissues, 3) dry heat causes increased
drying of the skin

TYPES:
Aquathermia (water flow) pads -- (aqua – K pads) -- provides heat by circulating
warm water through the pad. It is filled with distilled water and should be checked
daily to be replenished. The client should not lie on this pad, as pressure against a
mattress prevents normal heat dissipation. The temperature is set with a key. Cover
pad with a pillowcase or towel, use tape or gauze to hold, never use a pin, as it could
cause leaks; application should last only 30 minutes. This method is safer than
conventional heating pads, but care must still be taken with its use.
Heat lamp -- which is used mainly to increase circulation to a wound.
Commercial hot packs -- used by striking, kneading, or squeezing the pack,
chemicals are mixed and release heat
Hot water bottles -- these are rarely used in the hospital setting because of the risk or
burns
Electric heating pads – again these are rarely used in the hospital setting

SAFETY CONCERNS
Always monitor the equipment for malfunction
Do not place heating pads directly on the patient’s skin
Do not allow the client to lay on the pad
An application should never last for longer than 30 minutes

MOIST HEAT
ADVANTAGES
moist application reduces drying of skin and softens wound exudate
moist compresses conform well to body areas being treated
moist heat penetrates deeply into tissue layers
warm moist heat does not promote sweating and insensible fluid loss ( water loss
through excess perspiration)


MOIST HEAT
DISADVANTAGES
prolonged exposure can cause maceration of skin – softening the skin by soaking in
water
moist heat will cool rapidly because of moisture evaporation
moist heat creates greater risk for burns to skin because moisture conducts heat

TYPES:
moist compresses -- a moistened gauze dressing moistened in t prescribed warmed
solution. A layer of plastic wrap or a dry towel can be used to insulate the compress
and retain heat.
warm soaks – immersion of body part in a warmed solution. Can provide a means to
debride wounds and apply medicated solution. A soak can also be accomplished by
wrapping the body part in dressings and saturating them with the warmed solution;
105 to 110 degrees F
sitz baths -- a bath only in which the pelvic area immersed in warm solution. Used
for a client who has had rectal surgery, hemorrhoids, or vaginal inflammation, or after
childbirth for a patient with an episotomy
paraffin baths – mixture of heated paraffin wax and mineral oil. Physical therapists
administer the applications by having the client with painful arthritis or the hands or
feet dip them in the bath -- usually 128-130 degrees F.

SAFETY CONCERNS
keeping the solution at a constant temperature, never add a hotter solution while the
patient is immersed
moist heat promotes vasodilation and evaporation of heat from the skin’s surface so
the client may feel chilled, control room temperature and cover client with a blanket
or robe
because exposure of a large portion of the body may cause extensive vasodilation the
nurse should assess the pulse and facial color, ask the client if he feels light- headed or
nauseated

DRY AND MOIST COLD
     cold moist and dry compresses should be applied for 20 minutes at 59 degrees
     F.
     They are applied the same as warn compresses.
     There are also commercially prepared cold packs that are chemically
     activated.
     They are used to relieve inflammation and swelling.
     May be either clean or sterile.
ADVANTAGES
used for a client who has muscle sprain, localized hemorrhage, or hematoma or has
undergone dental surgery. Is ideal to prevent edema, control bleeding, and numb the
body part
DISADVANTAGES
assess for burning or numbness, mottling of the skin, redness, extreme paleness, and a
bluish discoloration of skin -- remember the recovery period of 1 hour before
reapplying

TYPES:
Dry cold:
       ice bags
       ice collars
       commercially prepared cold packs that are chemically activated – similar to
       the heat packs
moist cold:
       cold soaks -- immersion of body part in cold solution
       moist compresses -- cold dressings

SAFETY CONCERNS:
explain to the client sensations to be felt during the procedure
instruct the client to report changes in sensation of discomfort immediately
have the client watch the clock to help keep track of the time of the application
keep the call light within reach
do not allow the client, or family, to adjust temp. settings
do not allow the client to move the application or place hands on the wound site
do not place the client in a position that prevents movement away from the temp.
source
do not leave unattended a client who is unable to sense temp. changes or move away
from the temp. source
know the agencies policy and procedure for administering hot or cold applications

								
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