Chapter 32Skin Integrity and Wound Care.ppt

Measurement of a Pressure Ulcer Size of wound Depth of wound Presence of undermining, tunneling, or sinus tract A Wound With Various Types of Wound Surface Tissue Question Tell whether the following statement is true or false. A Stage III pressure ulcer requires debridement through wet-to-dry dressings, surgical intervention, or proteolytic enzymes. A. True B. False Answer Answer: A. True A Stage III pressure ulcer requires debridement through wet-to-dry dressings, surgical intervention, or proteolytic enzymes. Cleaning a Pressure Ulcer Clean with each dressing change. Use careful, gentle motions to minimize trauma. Use 0.9% normal saline solution to irrigate and clean the ulcer. Report any drainage or necrotic tissue. Wound Assessment Inspection for sight and smell Palpation for appearance, drainage, and pain Sutures, drains or tube, and manifestation of complications Presence of Infection Wound is swollen. Wound is deep red in color. Wound feels hot on palpation. Drainage is increased and possibly purulent. Foul odor may be noted. Wound edges may be separated with dehiscence present. Assessment of Wound Drainage Serous Sanguineous Serpsamgiomepis Purulent Purposes of Wound Dressings Provide physical, psychological, and aesthetic comfort. Remove necrotic tissue. Prevent, eliminate, or control infection. Absorb drainage. Maintain a moist wound environment. Protect wound from further injury. Protect skin surrounding wound. Types of Wound Dressings Telfa Gauze dressings Transparent dressings Types of Bandages Roller bandages Circular turn Spiral turn Figure-of-eight turn Recurrent-stump bandage Types of Binders Straight—used for chest and abdomen T-binder—used for rectum, perineum, and groin area Sling—used to support an arm Type of Drainage Systems Open systems Penrose drain Closed systems Jackson-Pratt drain Hemovac drain Penrose Drain Jackson-Pratt Drain Color Classification of Open Wounds R = red—protect Y = yellow—cleanse B = black—debride Mixed wound—co