Wound Care Program for Nursing Assistants-

Transcription

1 Wound Care Program for Nursing Assistants- Wound Cleansing,Types & Presentation Elizabeth DeFeo, RN, WCC, OMS, CWOCN Wound, Ostomy, & Continence Specialist

2 Outline/Agenda At completion of this webinar, the participant will: Define the role of the Nursing Assistant in wound care; Demonstrate proper cleansing of wounds and the surrounding skin; Identify signs and symptoms of infection; Identify different types of wounds; Clearly verbalize wound presentation or changes that are outside your Scope of Practice, and when to request nurse assessment

3 LNA role in wound care *WITH PROPER TRAINING*, Appropriate wounds for LNA scope of care Licensed Nursing Assistants in NH may: provide routine, stable wound care apply medicated lotions, ointments, and creams related to skin/wound care. Wound changes and presentation that are excluded from LNA scope of care Deteriorating wounds Wounds with signs and symptoms of infection Other changes specific to your agency s policies

4 Wound Cleansing

5 Cleaning the wound How NOT to clean a wound Making it count Assembling the supplies Use the Force! A note on pain Products videos

6 Wound Types

7 Wound types Pressure ulcers: bony prominences/devices Venous wounds Arterial wounds Neuropathic [diabetic] wounds Surgical wounds/surgical incisions Traumatic wounds/skin tears

8 Pressure Ulcers Cause Pressure: soft tissue compressed between a bony prominence [or a device] and an external surface Contributing factors Shear: gravity + friction; the result of gravity pushing down and resistance between the patient and a surface Friction: skin rubbing against another surface Moisture Immobility Inability to feel pressure or pain Poor nutrition

9 Suspected Deep Tissue Injury Aka, SDTI Purple or maroon Intact skin Blood filled blister May change rapidly May appear as thin blister over dark tissue.

10 Suspected Deep Tissue Injury

11 Pressure Ulcers: Stage I Stage 1 Skin is intact Nonblanchable [Pink that does not resolve when pressure relieved] No moisture on wound No drainage May be painful, firm, soft, warm or cool

12 Pressure Ulcers: Stage I

13 Pressure Ulcers: Stage II Stage 2 Shallow, pink/red Partial thickness/superficial Moist, dry, shiny No yellow/slough May have drainage or be dry

14 Pressure Ulcers: Stage II

15 Pressure Ulcers: Stage III Stage 3 Looks like a deep crater Full thickness Slough, undermining, tunneling may be present No bone/tendon Depth varies (nose/ear vs. buttocks)

16 Pressure Ulcers: Stage III

17 Pressure Ulcers: Stage IV Stage 4 Full thickness Slough or eschar may be present Exposed bone, tendon or muscle present Often include undermining and tunnels These are may or may not be in your Scope of Practice, but may be if they are chronic/end of life (palliative).

18 Pressure Ulcers: Stage IV

19 Pressure Ulcers: Unstageable Unstageable Base of wound is covered so much by slough or eschar, it can t be staged. These are not usually in your Scope of Practice, but may be if they are chronic/without change. Stable eschar on heels let it be Increased: Pain Redness Drainage Contact nurse or supervisor!

20 Pressure Ulcers: Unstageable

21 REMEMBER: To prevent or to treat pressure ulcers: Reposition the bed bound patient at per designated schedule, usually every 1-2 hours. Offload pressure anywhere it exists (heels, elbows, buttock, etc.) with pillows, foam boots, heel and elbow pads.

22 Key areas to offload:

23 Lower extremity wounds usually.. Venous [ Stasis ] wounds Arterial [ Ischemic ] wounds Neuropathic [ Diabetic ] wounds

24 Venous Wounds Usually seen on the inner, lower leg or ankle Edema Hemosiderin staining brown/pink color to skin Shallow Copious drainage Treatment = Elevate and compress

25 Venous Wounds

26 Forms of compression:

27 Arterial Wounds Due to poor blood flow Usually seen between/on the toes, around the outer ankle, on the foot where there may be trauma or rubbing of footwear Very painful DO NOT ELEVATE Avoid cold temperatures, heating devices and topical hot liquids Avoid tight clothing and crossing legs

28 Arterial Wounds

29 A note on dry stable eschar Wound is covered with thick, leathery necrotic tissue If this is *dry, non-boggy, and attached on all edges*, it is considered STABLE. You may be instructed to paint this with povidone-iodine, or to keep dry, possibly covered with gauze, always offloaded. If any changes/bogginess /drainage, contact your nurse/supervisor immediately for instruction.

30 Neuropathic [diabetic] wounds Usually seen on the bottom of the foot, at the base of the toes and on the heel. Due to lack of sensation Treatment = offload! Footwear at all times Proper fitting footwear ~ Check those shoes! Avoid temperature extremes Do not soak feet

31 Neuropathic [diabetic] wounds

32 Surgical incisions/surgical wounds Incisions - open or closed Sutured Stapled Steri-stripped Drain sites When incisions are open, without sutures, staples, or glue, it becomes a surgical wound.

33 Surgical wounds/surgical incisions

34 Traumatic wounds/skin tears Skin tears Abrasions Lacerations Prevention: Maintain a safe environment Ambulate with appropriate device or supervision Maintain optimal skin status (well hydrated/moisturized) If you find: Cleanse, Cover and Contact!

35 Traumatic wounds/skin tears

36 Applying a dressing A common order for a skin tear may read: Remove old dressing, cleanse with saline spray; apply skin prep to intact skin; hydrogel to open areas, xeroform to cover, gauze and gauze wrap to secure every 1-2 days by skilled clinician. VIDEO

37 Thank you!