Na Ii Ppt Module 4


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Na Ii Ppt Module 4

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