NRB 121 Self Learning Module: Wound Assessment Tracey J. Siegel MSN RN CWOCN CNE
Mrs. Siegel Says: This may help you visualize pressure ulcers and other wounds! Don’t print this up! Save paper! Watch th...
Objectives: <ul><li>Following this self directed Power Point, nursing students will be able to: </li></ul><ul><li>Describe...
Why is this topic important to student nurses? <ul><li>New RN graduates are responsible for the prediction, prevention an...
Everything Old is New Again! <ul><li>“ Nature alone cures…nature heals the wound. What nursing has to do…is put the patie...
Assessment! <ul><li>Often as nurses we get so wrapped up in the wound itself, we forget an important thing- we need to loo...
Patient Assessment and Wound Care <ul><li>Subjective/Objective Data </li></ul><ul><li>Remember, the client is more than...
Assessment : Objective Data <ul><li>Mechanical stressors </li></ul><ul><li>Edema </li></ul><ul><li>Wound temperature </li>...
Assessment! <ul><li>“… it must never be lost sight of what observation is for. It is not for the sake of piling up miscel...
Partial-Thickness Wounds <ul><ul><li>Tissue destruction through the epidermis extending into but not through the dermis </...
Pressure Ulcer vs. Dermatitis Which is which?
Stage III and Stage IV Pressure Ulcers vs. Full Thickness Wounds <ul><li>All Stage III and IV PU are full thickness wounds...
Full-Thickness Wounds <ul><li>Tissue destruction extending through the dermis to involve subcutaneous tissue and possibly ...
“ ASSESSMENTS” <ul><li>A natomic Location- A ge of wound </li></ul><ul><li>S ize, S hape and S tage </li></ul><ul><li>S ...
Assessment and Classification by Color <ul><li>RED WOUND </li></ul><ul><li>YELLOW WOUND </li></ul>If charting this wound-...
Assessment and Classification by Color <ul><li>BLACK WOUND </li></ul><ul><li>BLACK WOUND </li></ul>
Deep Tissue Injury- new classification of pressure ulcer <ul><li>Purple or maroon localized area of discolored intact skin...
Deep Tissue Injury
Measurement Undermining L x W x D Pain! Depth
Sharp Debridement What is wrong with this picture???
Nursing Diagnosis and Goals <ul><li>Impaired Skin Integrity </li></ul><ul><li>Altered Tissue Perfusion </li></ul><ul><li>...
Moist Wound Healing is the current Standard of Care <ul><li>Enhances angiogenesis </li></ul><ul><li>Enhances epithelial c...
Assessment- Management <ul><li>Wound care products are now classified by action and structure similar to medications-there...
Disadvantages to Gauze in Topical Therapy <ul><li>Non research based therapy </li></ul><ul><li>More painful </li></ul><ul...
Transparent Dressings ( Op Site ®) First dressings developed to promote moist wound healing <ul><li>Actions </li></ul><ul>...
Hydrocolloids (Duoderm ® ) An occlusive moldable wafer <ul><li>Actions </li></ul><ul><li>Supports autolytic debridement <...
Hydrogel ( Intrasite ®) Water or glycerin based gels, sheets or impregnated gauzes <ul><li>Actions </li></ul><ul><li>Sup...
Calcium Alginate (Sorbsan®) Highly absorbent sheets or ropes of “seaweed” <ul><li>Actions </li></ul><ul><li>Exudate absorp...
Foams ( Allevyn ®)- “Sponges” <ul><li>Actions </li></ul><ul><li>Creates a moist wound environment </li></ul><ul><li>Absorb...
Enzyme Debriders ( Santyl®) <ul><li>Actions </li></ul><ul><li>Selective debridement of fibrin slough </li></ul><ul><li>Dig...
Vacuum Assisted Closure ® <ul><li>The application of negative pressure to remove wound exudate and stimulate the growth of...
I hope this helped you understand the role of the nurse when caring with patients with wounds! See Mrs. Siegel if you have...
Reference <ul><li>Baranoski, S., & Ayello, E. A. (2007). Wound care essentials (2 nd ed.). New York: Lippincott, William...
of 33

Pressureulcerandwoundsextrahelp

A self learning module designed for student nurses to help them understand the nursing care of patients with wounds. I am sharing this with other educators or nursing students to help them in this area. You have my permission to use this to learn about wounds but not to take as your own presentation. I hope you honor this request.
Published on: Mar 4, 2016
Source: www.slideshare.net


Transcripts - Pressureulcerandwoundsextrahelp

  • 1. NRB 121 Self Learning Module: Wound Assessment Tracey J. Siegel MSN RN CWOCN CNE
  • 2. Mrs. Siegel Says: This may help you visualize pressure ulcers and other wounds! Don’t print this up! Save paper! Watch this as a slide show! Then read the information in the notes section to help you better understand the nursing care of wounds!
  • 3. Objectives: <ul><li>Following this self directed Power Point, nursing students will be able to: </li></ul><ul><li>Describe the best practices to manage acute and chronic wounds. </li></ul><ul><li>Explain the role of the nurse when caring for acute and chronic wounds. </li></ul>
  • 4. Why is this topic important to student nurses? <ul><li>New RN graduates are responsible for the prediction, prevention and management of pressure ulcers in all settings. As our population gets older, understanding pressure ulcers and the care of all wounds is a priority! </li></ul>
  • 5. Everything Old is New Again! <ul><li>“ Nature alone cures…nature heals the wound. What nursing has to do…is put the patient in the best condition for nature to act upon him.” Florence Nightingale </li></ul>
  • 6. Assessment! <ul><li>Often as nurses we get so wrapped up in the wound itself, we forget an important thing- we need to look at the whole patient….not just the hole in the patient! </li></ul>
  • 7. Patient Assessment and Wound Care <ul><li>Subjective/Objective Data </li></ul><ul><li>Remember, the client is more than the wound- need to do a complete nursing history </li></ul><ul><li>Focus on: Nutrition, hydration, oxygen and vascular status, immune state, other illnesses </li></ul><ul><li>Contributing Factors: pressure, shear, friction, impaired mobility </li></ul><ul><li>Overall prognosis and/or client goals </li></ul>
  • 8. Assessment : Objective Data <ul><li>Mechanical stressors </li></ul><ul><li>Edema </li></ul><ul><li>Wound temperature </li></ul><ul><li>Cytotoxic agents </li></ul><ul><li>Excess exudate </li></ul>Local Dry wound bed Presence of devitalized tissue Contaminated Infection
  • 9. Assessment! <ul><li>“… it must never be lost sight of what observation is for. It is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort.” </li></ul>
  • 10. Partial-Thickness Wounds <ul><ul><li>Tissue destruction through the epidermis extending into but not through the dermis </li></ul></ul><ul><ul><li>Heals by: </li></ul></ul><ul><ul><li>Epithelialization </li></ul></ul><ul><ul><li>Contraction of wound margins </li></ul></ul><ul><li>For example: Skin Tears, blisters, and Stage II pressure ulcers </li></ul>Skin Tear
  • 11. Pressure Ulcer vs. Dermatitis Which is which?
  • 12. Stage III and Stage IV Pressure Ulcers vs. Full Thickness Wounds <ul><li>All Stage III and IV PU are full thickness wounds but not all full thickness wounds are pressure ulcers! </li></ul><ul><li>Surgical, arterial, venous, and other wounds do not get staged…only pressure ulcers. </li></ul><ul><li>These wounds are classified as either partial or full thickness </li></ul>
  • 13. Full-Thickness Wounds <ul><li>Tissue destruction extending through the dermis to involve subcutaneous tissue and possibly muscle or bone </li></ul><ul><li>Heals by: </li></ul><ul><li>Granulation </li></ul><ul><li>Wound Contraction </li></ul><ul><li>Epithelialization </li></ul>Clean dehised surgical wound Clean granular Stage III or IV Pressure Ulcer
  • 14. “ ASSESSMENTS” <ul><li>A natomic Location- A ge of wound </li></ul><ul><li>S ize, S hape and S tage </li></ul><ul><li>S inus Tracts </li></ul><ul><li>E xudate </li></ul><ul><li>S epsis </li></ul><ul><li>S urrounding Skin </li></ul><ul><li>M aceration </li></ul><ul><li>E dges, E pithelialization </li></ul><ul><li>N ecrotic Tissue </li></ul><ul><li>T issue Bed </li></ul><ul><li>S tatus </li></ul><ul><li>Baranoski and Ayello (2007) </li></ul>
  • 15. Assessment and Classification by Color <ul><li>RED WOUND </li></ul><ul><li>YELLOW WOUND </li></ul>If charting this wound- 60% slough 40% red granulation tissue
  • 16. Assessment and Classification by Color <ul><li>BLACK WOUND </li></ul><ul><li>BLACK WOUND </li></ul>
  • 17. Deep Tissue Injury- new classification of pressure ulcer <ul><li>Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Further description : Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. </li></ul>
  • 18. Deep Tissue Injury
  • 19. Measurement Undermining L x W x D Pain! Depth
  • 20. Sharp Debridement What is wrong with this picture???
  • 21. Nursing Diagnosis and Goals <ul><li>Impaired Skin Integrity </li></ul><ul><li>Altered Tissue Perfusion </li></ul><ul><li>???????????? </li></ul><ul><li>Cure vs. Palliative Care </li></ul><ul><li>Pain Management </li></ul><ul><li>Multidisciplinary Approach </li></ul>
  • 22. Moist Wound Healing is the current Standard of Care <ul><li>Enhances angiogenesis </li></ul><ul><li>Enhances epithelial cell migration </li></ul><ul><li>↑ activity of fibroblasts, essential for collagen formation </li></ul><ul><li>Prevents dehydration and tissue cooling </li></ul>
  • 23. Assessment- Management <ul><li>Wound care products are now classified by action and structure similar to medications-therefore just as all Beta Blockers or Penicillins act in a similar fashion- so do all hydrocolloids and calcium alginates! </li></ul><ul><li>It doesn’t matter what the brand name is- get to know wound care products by how they work in the wound environment! </li></ul>
  • 24. Disadvantages to Gauze in Topical Therapy <ul><li>Non research based therapy </li></ul><ul><li>More painful </li></ul><ul><li>May impede wound healing </li></ul><ul><li>Increased risk for infection </li></ul><ul><li>Costly and labor intensive </li></ul>
  • 25. Transparent Dressings ( Op Site ®) First dressings developed to promote moist wound healing <ul><li>Actions </li></ul><ul><li>semi permeable membrane that permits gaseous exchange but prevents bacterial invasion </li></ul><ul><li>Maintains moist wound environment </li></ul><ul><li>Supports autolytic debridement of dry eschar </li></ul><ul><li>Insulates and protects </li></ul><ul><li>Indicated for partial thickness wounds, prevention, and protection, secondary dressing </li></ul><ul><li>Contraindicated in fragile geriatric skin over skin tears </li></ul>
  • 26. Hydrocolloids (Duoderm ® ) An occlusive moldable wafer <ul><li>Actions </li></ul><ul><li>Supports autolytic debridement </li></ul><ul><li>Absorbs moderate exudate </li></ul><ul><li>Protects and insulates wound </li></ul><ul><li>Normal for exudate to look yellow with a slight odor- doesn’t mean that wound is infected </li></ul><ul><li>Change q. 3-5 days </li></ul><ul><li>Indicated for partial and full thickness wounds with minimal exudate </li></ul><ul><li>Contraindications include infected diabetic ulcers </li></ul>
  • 27. Hydrogel ( Intrasite ®) Water or glycerin based gels, sheets or impregnated gauzes <ul><li>Actions </li></ul><ul><li>Supports autolytic debridement </li></ul><ul><li>Rehydrates dry, desiccated wounds </li></ul><ul><li>Fills dead space as packing </li></ul><ul><li>Limited absorptive action </li></ul><ul><li>There are no contraindications for gels </li></ul><ul><li>Frequency of dressing changes depends upon type </li></ul><ul><li>Excellent for pain management as they soothe and cool especially radiation burns and herpes zoster </li></ul>
  • 28. Calcium Alginate (Sorbsan®) Highly absorbent sheets or ropes of “seaweed” <ul><li>Actions </li></ul><ul><li>Exudate absorption </li></ul><ul><li>Wound packing </li></ul><ul><li>Supports autolytic debridement of yellow slough </li></ul><ul><li>Contraindicated in dry eschar and non draining wounds </li></ul><ul><li>Change q. 2-4 days </li></ul>
  • 29. Foams ( Allevyn ®)- “Sponges” <ul><li>Actions </li></ul><ul><li>Creates a moist wound environment </li></ul><ul><li>Absorbs exudate </li></ul><ul><li>Insulates wound </li></ul><ul><li>Support autolytic debridement </li></ul><ul><li>Contraindicated in dry eschar and non draining wounds </li></ul><ul><li>Can be used on all partial and full thickness wounds </li></ul><ul><li>Change q. 3-7 days </li></ul>
  • 30. Enzyme Debriders ( Santyl®) <ul><li>Actions </li></ul><ul><li>Selective debridement of fibrin slough </li></ul><ul><li>Digests nonviable protein but is harmless to granulation tissue </li></ul><ul><li>Only works in moist environment and thick eschar must be scored </li></ul><ul><li>Daily or BID dressing </li></ul>
  • 31. Vacuum Assisted Closure ® <ul><li>The application of negative pressure to remove wound exudate and stimulate the growth of granulation tissue </li></ul><ul><li>Indicated for full thickness wounds, grafts and flaps </li></ul>
  • 32. I hope this helped you understand the role of the nurse when caring with patients with wounds! See Mrs. Siegel if you have any questions or comments!
  • 33. Reference <ul><li>Baranoski, S., & Ayello, E. A. (2007). Wound care essentials (2 nd ed.). New York: Lippincott, Williams & Wilkins. </li></ul>

Related Documents