Na Ii Ppt Module 4
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Na Ii Ppt Module 4 Na Ii Ppt Module 4 Presentation Transcript

    • Module Title: Wound Care: Part A
    • Sterile Dressing Change for Wounds over 48 Hours Old
  • Sterile Dressing Change
    • Two Main Types of Wounds:
    • Open
    • Closed
  • Sterile Dressing Change
    • Open Wounds:
    • One in which the surface of the skin or mucus membrane is no longer intact, usually from an accident or surgical incision
    • Types :
    • Incision- clean separation of skin and tissue with smooth edges
    • Laceration- separation of skin and tissue with irregular edges
    • Abrasion- surface layers of the skin are scraped away
    • Avulsion- stripping away of a large area of skin and underlying tissue, leaving bone and cartilage exposed
    • Ulceration- shallow crater in which skin or mucous membrane are missing
    • Puncture- opening of skin, underlying tissue, or mucous membrane caused by a sharp pointed narrow object
  • Sterile Dressing Change
    • Closed Wounds:
    • Ones in which there is no opening in the skin or mucous membrane usually caused by blunt trauma or pressure
    • Types of Closed Wounds:
    • Contusion- injury to soft tissue underlying the skin from the force of contact with a hard object
  • Sterile Dressing Change
    • Factors Affecting Wound Healing:
    • Extent of injury
    • Blood supply
    • Type of injury
    • Presence debris
    • Presence of infection
    • Health of Patient
  • Sterile Dressing Change
    • Types of Dressings:
    • Cean Dressing
    • Sterile Dressing
    • Dressing a Drain
    • Wet-to-Dry Dressings
    • Transparent Film and Hydrocolloid Dressings
  • Sterile Dressing Change
    • Wound Care: Removing Old Dressing
    • Slowly remove tape or old bandages
    • Remove old dressing
    • Apply small amounts of Normal Saline to gauze if sticking to wound and debridement is not the goal of the ordering MD.
    • Note color, odor and amount of drainage on dressing
    • Observe wound for s/s of infection, granulation, necrotic tissue, slough
    • Notify nurse to assess the patient before redressing
    • Cleanse the wound
  • Sterile Dressing Change
    • Wound Care: Cleaning the wound
    • Clean wound using sterile gauze pads and ordered cleaning solution
    • Know the directions for use of the cleaning product
    • Cleanse linear/surgical wounds from top to bottom from clean to less clean areas
    • Use new gauze for each stroke
    • Work outward in parallel lines/ Do not rub back and forth
    • Cleanse open wounds in half circles or full circles.
    • Begin at center and work outward to one inch beyond the edge of the dressing.
    • Use a new gauze for each circle
  • Sterile Dressing Change
    • Dressings and Bandages
    • Dressings protect the wound, preventing contamination. Increase comfort and prevent further injury
    • Some dressings are used to apply pressure to control bleeding
    • Dressings are usually gauze, film or other synthetic substances that cover a wound
    • Bandages are used to hold dressings in place and can be gauze, net or elastic wrappings
    • Some dressings have an adhesive backing
    • Some are held on with tape
    • Be aware that some patients may be allergic to tape
  • Sterile Dressing Change
    • Wound Care: Redressing the Wound
    • Before applying the dressing, check the wound care orders
    • Gather your supplies,
    • Select a dressing that will extend at least one inch beyond the borders of the wound
    • Place the patient in a position that he or she can maintain for the entire procedure without discomfort
    • Gloves may be removed once the wound is covered if there is no drainage noted
    • Secure the dressing with tape, bandage, binder or Montgomery Straps
  • Sterile Dressing Change
    • Wound Care: Dressing a Drain
    • Use Sterile Technique when working with drains
    • Handle the drain as little as possible
    • Cleanse using a circular motion from center outward
    • Apply at least two layers of precut drain gauze
    • Cover with two layers of uncut gauze
    • Handle Sterile Cover Dressing by the corners only
    • Tape securely in place
    • During procedure note: drain is not intact or not patent, condition of peri skin, color and odor of drainage, change in amount of drainage, patient has fever.
  • Sterile Wound Dressing
    • W ound Care: Wet-to-Dry Dressing
    • Used for wound healing or for debridement
    • Use Sterile Technique
    • Normal Saline is used to moisten gauze
    • After cleaning the wound area, pick up moist gauze sponge one at a time and squeeze so it is damp not dripping.
    • Open and unfold the dressing
    • Place over wound
    • Pick up the Sterile Cover Dressing by the corner
    • Cover the damp dressing and wound completely
    • Tape securely in place
  • Sterile Wound Dressing
    • Wound Care: Transparent Film and Hydrocolloid Dressing
    • Transparent film dressings : adhesive membranes of various sizes and thicknesses
    • Select one that will allow 1 ¼ inch of dressing
    • Promote healing; protect from bacteria; never used if infection is present
    • Change every 3 to 7 days
    • Can be used as a cover dressing instead of tape
  • Sterile Dressing Change
    • Hydrocolloid Dressings
    • Made of materials such as gelatin and pectin
    • Self adhesive and come in various sizes and thicknesses
    • Should extend 1 ¼ inch beyond the edge of the wound
    • Used for pressure ulcers and some other wounds
    • Change ever 7 days
    • Provide a moist environment for wound healing
    • Never use when infection is present, deep wounds or when tendons and bones are exposed
  • Sterile Dressing Changes
    • Wound Care: Applying Bandages
    • Most are conforming and some are self adhering gauze
    • Hold bandage in dominant hand
    • Hold bandage against the skin approximately one inch below the dressing
    • Wrap around extremity two or three times then wrap from distal to proximal in overlapping spiral turns
    • Should be snug but not so tight it restricts blood flow
    • Wrap at least one inch above top of dressing
    • Wrap it twice then cut end
    • Tape the end to the bandage NOT to the skin
    • Module Title:
    • Wound Care: Part B – Wound Irrigation
  • Wound Care: Irrigation
    • Purpose :
    • to remove bacteria and debris, drainage and exudate from the wound
    • Materials:
    • Strict sterile technique must be used
    • MD orders the solution to be used for irrigating
    • Irrigation is usually performed using a piston syringe
    • Nurse will need to assess wound
  • Wound Care: Irrigation
    • Being too aggressive or not aggressive enough with irrigation could lead to damage of the wound bed
    • Before irrigating the wound observe:
    • Amount of drainage, condition of the wound, stage of healing
    • If inflammation is present, a more aggressive approach is necessary
    • If the wound bed is mostly pink tissue with small amounts of tissue debris use a more gentle approach