Chapter 21
Assisting With Wound Care
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Slide 1
A BREAKDOWN OF SKIN TISSUE THAT OCCURS WHEN
BLOOD FLOW TO AN AREA IS INTERRUPTED.
ALSO CALLED A PRESSURE ULCER, PRESSURE SORE,
OR BEDSORE
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Slide 2
PRESSURE ULCERS

Causes

Pressure, friction, and shearing
 Breaks in the skin
 Poor circulation to an area
 Moisture
 Dry skin
 Irritation by urine and feces
 Age

Friction scrapes the skin.
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Slide 3
 LYING OR SITTING TOO LONG IN ONE POSITION –
CAUSES PRESSURE OVER BONY PROMINENCES
 WRINKLES IN CLOTHING OR BED LINEN
 POOR NUTRITION
 SHEARING – WHEN THE SKIN STICKS TO THE
SURFACE AND THE DEEPER TISSUE MOVE
DOWNWARD (WHEN THE PERSON SLIDES DOWN IN
BED)
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Slide 4

Signs of pressure ulcers


The first sign is pale skin or a reddened area.
Stages of pressure ulcers
• Stage 1

The skin is red. The color does not return to normal when the
skin is relieved of pressure. The skin is intact.
• Stage 2

The skin cracks, blisters, or peels. There may be a shallow
crater.
• Stage 3

The skin is gone. Underlying tissues are exposed. The exposed
tissue is damaged. There may be drainage from the area.
• Stage 4

Muscle and bone are exposed and damaged. Drainage is likely.
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Slide 5
IN STAGE 1 THE SKIN IS RED AND MAY BE WARM TO
THE TOUCH.
THE COLOR DOES NOT RETURN TO NORMAL WHEN
THE SKIN IS RELIEVED OF PRESSURE
ON DARK COLORED SKIN THE AREA MAY APPEAR
Slide 6
Copyright
© 2006 Mosby,
Inc. All PURPLISH
rights reserved.
DARK
BLUE
OR
 GENTLY MASSAGE OUTSIDE OF THE REDDENED
AREA
 KEEP AREA AROUND THE BREAKDOWN CLEAN AND
DRY
 RELIEVE ALL PRESSURE OVER THE AFFECTED
AREA
 ENCOURAGE NUTRITIOUS DIET AND ADEQUATE
FLUIDS
 NURSE MAY APPLY A PROTECTIVE COVERING
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Slide 7
IN STAGE 2 THE SKIN CRACKS, BLISTERS, OR PEELS.
DESTRUCTION OF THE EPIDERMIS AND PARTIAL
DESTRUCTION OF THE DERMIS
MAY LOOK LIKE AN ABRASION, BLISTER, OR SHALLOW
CRATER
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Slide 8
 REMOVE THE PRESSURE
 GENTLY MASSAGE AROUND THE OUTSIDE OF THE
AFFECTED AREA
 MAKE SURE YOU NOTIFY THE NURSE
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Slide 9
IN STAGE 3 THE LAYERS OF SKIN HAVE BEEN
DESTROYED AND A DEEP CRATER HAS FORMED.
YOU MAY SEE MUSCLES AND TENDONS.
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Slide 10
 ASSIST IN KEEPING THE AREA AFFECTED CLEAN
 ASSIST WITH DRESSING CHANGES
 MAY REQUIRE SURGICAL TREATMENT
 ASSIST WITH THE USE OF PRESSURE - RELIEVING
DEVICES ( SPECIALTY MATTRESS, BED, OR
CUSHIONS )
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Slide 11
A STAGE 4 ULCER HAS DEEP TISSUE INVOLVEMENT
EXPOSING MUSCLE AND BONE
THERE MAY BE TUNNELING OF THE WOUND
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Slide 12
 ASSIST WITH DRESSING CHANGES
 MAY REQUIRE SURGICAL TREATMENT
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Slide 13
SKIN TEARS

Skin tears are caused by:




Friction and shearing
Pulling on the skin
Pressure on the skin
Tell the nurse at once if you cause or find a
skin tear.
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Slide 14

To prevent skin tears:
Keep the person’s and your fingernails short and
smoothly filed
 Do not wear rings or bracelets
 Follow the care plan
 Follow safety rules to lift, move, position, transfer,
bathe, and dress the person
 Prevent shearing and friction
 Use an assist device to move the person in bed

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Slide 15
CIRCULATORY ULCERS

Poor circulation can lead to:




Pain
Open wounds
Swelling of tissues (edema)
Infection and gangrene
• Gangrene is a condition in which tissue dies.
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Slide 16

Stasis ulcers (venous ulcers)


The heels and inner aspect of the ankles are common
sites.
Arterial ulcers

Are found:
• Between the toes
• On top of the toes
• On the outer side of the ankles
• On the heels for persons on bedrest
 These ulcers can occur from shoes that fit poorly.
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Slide 17

Prevention and treatment


Follow the person’s care plan.
Elastic stockings and elastic bandages promote
circulation.
• Applying elastic stockings (NNAAP)*
• Applying elastic bandages*
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Slide 18
DRESSINGS

Wound dressings:





Protect wounds from injury and microbes
Absorb drainage
Remove dead tissue
Promote comfort
Provide a moist environment for wound healing
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Slide 19

Securing dressings

Dressings are secured and held in place by:
• Adhesive tape
• Paper and plastic tape
• Elastic tape
• Montgomery ties
• Binders
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Slide 20

Applying dry non-sterile dressings*

Meet fluid and elimination needs before you begin.
 Collect needed equipment and supplies.
 Control your nonverbal communication.
 Remove dressings so the person cannot see the
soiled side.
 Do not force the person to look at the wound.
 Remove tape by pulling it toward the wound.
 Remove dressings gently.
 Report and record your observations.
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Slide 21
BINDERS

Binders promote healing by:

Supporting wounds and holding dressings in place
 Reducing or preventing swelling
 Promoting comfort
 Preventing injury

Types of binders



Straight abdominal binders
Breast binders
T-binders
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Slide 22
HEAT AND COLD APPLICATIONS

Heat and cold applications



Promote healing and comfort
Reduce tissue swelling
Heat applications


Heat applications are often used:
• For musculoskeletal injuries or problems
• To relieve pain, relax muscles, and decrease joint stiffness
• To promote healing and reduce tissue swelling
High temperatures can cause burns.
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Slide 23


Persons at risk for complications are:
• Older and fair-skinned people
• Persons with problems sensing heat or pain
• Persons with dementia
• Persons with metal implants
Moist and dry heat applications.
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Slide 24

Cold applications

Reduce pain
 Prevent swelling
 Decrease circulation and bleeding
 Complications include pain, burns, and blisters.
 Persons at risk for complications include:
• Older and fair-skinned persons
• Persons with mental or sensory impairments
 Moist and Dry cold applications
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Slide 25