dressings
types of dressings
1. dry or moist = gauze
2. film dressing
3. hydrocolloid
4. hydrogel
5. vacuum-assisted closure
inflammatory phase/hemostasis
stopping of blood flow, clot formation, wound exudates and becomes warm, swells, and reddish in color
stage 1
-erythema not resolving in 30 min
-non-blanchable redness
penrose drain
-hollow, fat rubber tube placed directly into the incision or into a stab wound
-allows fluid to drain through capillary action into absorbent dressings
an obese patient slid down to the bottom of the hospital bed and was assisted back up by several unit staff members. the most likely type of mechanical force that might cause injury to the skin in this case is:
A. pressure
B. friction
C. shear
D. gravity
C. Shear
shear happens when skin remains relatively immobile because friction anchors it to sheets or other surfaces, but deeper body structures move with the patient and stretch blood vessels. this most often happens when a patient is moved in bed
main things to remember when doing a dressing change
1. assess the skin beneath the tape
2. perform hand hygiene before and after wound care
3. wear sterile gloves before directly touching an open wound
4. remove/change dressing when closed wound becomes wet or if there are s/s of infection
proliferative phase
wound is completely covered by epithelium by formation of granulation
stage 2
-partial thickness loss-epidermis but not through dermis
-shallow open ulcer with red/pink wound bed
-intact or open blister
vacuum-assisted closure (V.A.C)
-hydrophobic sponge dressings to fill wound cavity, is covered in a transparent dressing, and then connected to a tubing machine that provides negative pressure to the wound
is the following statement true or false?
Clean surgical incisions heal by primary intention
true
packing a wound
assess size, depth, and shape
malnutrition phase
fibroblasts cover the wound bed as a new layer, the wound is completely closed, scar is formed
stage 3
- may include tunneling and undermining
-bone, tendon, muscle is not exposed
jackson-pratt drainage device
permits drainage to collect in a bulb-like device that can be compressed to create gentle suction
is the following statement true or false?
An application of a cold pack to the leg of a patient with peripheral vascular disease is much less likely to cause a complication than the application of a hot pack
false
cold causes vasoconstriction, thus decreasing circulation to the already compromised area.
securing
tape, ties, or binders
primary intention
wounds with minimal tissue loss (surgical incisions, sutured wounds)
stage 4
-full-thickness loss with destruction to fascia, muscle, bone
- exposed tendon, bone, muscle
-includes undermining and tunneling
comfort measures
1. carefully remove tape
2. gently clean the wound
3. administer analgesics before dressing change
secondary intention
wounds with full thickness tissue loss (deep lacerations, burns, pressure ulcers)
partial thickness wound vs. full thickness wound
partial: loss of epidermis and possibly partial loss of the dermis
full: extends through the dermis to involve subcutaneous tissue and possibly muscle and bone