Pressure Ulcers
tissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period; tissue ischemia that leads to necrosis.
What factors can affect wound healing?
Systemic: Affects the entire body
Local: Affects one system or part
When Removing a dressing...
-Wash hands thoroughly and apply gloves before applying and removing old dressing
-Apply new clean dressing
-If the dressing sticks; pour a small amount of saline solution to loosen it
-Observe the wound noting the color, odor, drainage and for any other
Cytotoxic:
These products can harm healing cells and should be avoided
Handle the skin gently especially with an _________ patient
elderly
Start with clean innermost area to less clean outermost areas from the wound. Use _____ stroke method
one
Apply cleansing solution to __________, squeeze excessive solution from gauze
gauze
Cleanse from top to bottom on a _________ wound.
linear
Open wound care
-Work in half or full circles; using new gauze pad for each circle
-From center of wound, to outward
-Clean at least 1 inch beyond the dressing edge; for areas without dressings clean at least 2 inches
-Rinse, if necessary
Dressings
Cover the wounds _____________
Gauze, film, or other synthetic substances
Prevent infection, promote comfort, and prevent injury
directly
What are the eight "rights" for dressing changes?
Patient
Dressing
Time
Treatment product
Amount/quantity
Environment
Technique
Documentation
Transparent film dressings
1. Permit gaseous exchange
2. Minimally absorbent
3. Impermeable to fluid and bacteria
4. Permit visualization
5. Partial thickness wounds, Stage I and II, secondary dressing
6. Promote autolytic debridement
7. Potential for maceration of peri-wound skin
hydrocolloid dressings (gelatin)
-Maintains a moist environment
-Used for uninfected pressure ulcers and other wounds
-No cover dressing required
-Should extend 1-1/4 inches beyond the edges of the wound
Sutures
-Close surgical wounds and large lacerations
-Usually removed within 7 to 10 days
-May be interrupted sutures or continuous sutures
Staples
Used especially to close wounds of the abdomen and chest
Removal of sutures and staples may cause discomfort but should not be painful. Remove __________ __________ suture or staple first
every other
A simple gauze dressing is often not enough to ______________ or provide support to a wound. Binders and bandages applied over or around dressings can provide extra protection and therapeutic benefits.
immobilize
Flannel and muslin bandages are _______________ and therefore stronger for supporting or applying _______________. A flannel bandage also insulates to provide warmth.
thicker; pressure
Binders are bandages that are made of large pieces of material to fit a specific _________ __________. Most binders are made of elastic, cotton, muslin, or flannel. Examples of these are breast or abdominal binders.
body part
Before a bandage or binder is applied, the medical assistant should:
-Inspect the skin for abrasions, edema, discoloration, or exposed wound edges.
-Cover exposed wounds or open abrasions with a sterile dressing.
-Assess the condition of the underlying dressings and change them if soiled.
Circular Bandage Turn
Bandage turn overlapping previous turn completely. Anchors bandage at the first and final turn. Typically used to cover small body parts like a finger or toe.
Spiral Bandage Turn
Bandage ascending body part with each turn overlapping previous one by one-half or two-thirds width of the bandage. Used to cover cylindrical body parts such as wrist or upper arm.
Spiral-reverse bandage turn
Turn requiring twist of bandage halfway through each turn. Typically used to cover cone-shaped body parts such as the forearm, thigh, and calf. Normally used with non-stretching bandages such as gauze or flannel.
Figure Eight Bandage turn
Oblique overlapping turns alternating ascending and descending. Each turn crosses the previous turn to form a figure eight. Used for joints and provides a secure fit for immobilization.
Recurrent bandage turn
Bandage first secured with two circular turns around proximal end of body part; half turn made perpendicular up from bandage edge; body of bandage brought over distal end of body part to be covered with each turn folding back over itself. Used for body pa
Abdominal binders
support large abdominal incisions that are vulnerable to tension or stress as the patient moves or coughs. The binder is typically secured with Velcro, safety pins, or metal stays.
T - binders
look like the letter T and are used to secure rectal or perineal dressings. The single T is used for females and the double T is used for males.
Slings
have a series of straps that extend around the neck and/or thoracic region