Chapter 36 & 37. Types of wounds. Skin Tear

Transcription

1 Chapter 36 & 37 Wound Care and Pressure Ulcers Types of wounds A wound is a break in the skin d/t trauma, surgical incision, pressure sore, circulatory ulcers Abrasion, Contusion, Incision, Laceration, Penetrating, Puncture Generally nursing assistants do not do wound care. See delegation guidelines on P. 588 The more common one that you may observe, or cause is a skin tear. Skin Tear Thin, fragile skin is common in older persons Skin tears are painful. They are portals for microbes. Infection is a risk. Tell the nurse at once if you cause or find a skin tear. P.607, box 36-2 preventing skin tears 1

2 Circulatory Ulcers (AKA Vascular Ulcers) Are open sores on the lower legs or feet. They are caused by decreased blood flow through the arteries and veins. You must help prevent skin breakdown on the legs and feet. Venous Ulcers Also known as stasis ulcers, are open sores on the lower legs or feet caused by poor venous blood They develop when the valves in the veins do not close well. Blood and fluid collects in the legs and feet. Small veins rupture. This allows blood to enter the tissues causing the skin to turn brown. The skin is dry, leathery and hard. Itching is common Risk factors for venous ulcers History of blood clots History of varicose veins Decreased mobility Obesity Surgery: leg, foot, bones, joints Advanced age Phlebitis inflammation of a vein 2

3 Prevention and Treatment Box 36-3, page 608 Prevent injury. Do not bump the legs and feet. Move and transfer the person carefully and gently Person needs professional foot care Hard to heal Diabetic Foot Ulcers Is an open wound on the foot caused by complications from diabetes. Nerves. The person can lose sensation in a foot or leg. Blood vessels. Blood flow decreases. Tissues and cells do not get needed oxygen and nutrients. Sores heal poorly. Tissue death (gangrene) can occur. Foot problems common with diabetes, P. 581 Corns & callusus Blisters Ingrown toenails Bunions Plantar warts Hammer toes Dry and cracked skin Athlete s foot 3

4 Diabetic Foot Care Box 36-4, page 609 Pressure Ulcers Chapter 37 Pressure Points Know Supine Lateral Prone Fowlers Sitting P. 622, figure

5 Pressure Ulcers Decubitus ulcer, bedsore, pressure sore Is any injury caused by unrelieved pressure Occurs over a boney prominence Causes Pressure: occurs when the skin over a bony area is squeezed between hard surfaces. Mattress or chair. Ex. Ankle bone/skin/mattress. Squeezing or pressure prevents blood flow to the skin and underlying tissues. Causes Friction: scrapes the skin. (rug burn) An open area, the scrape is a portal of entry for microbes. The open area needs to heal. Infection is prevented. A poor blood supply or an infection can lead to an pressure ulcer. 5

6 Causes Shearing: is when the skin sticks to a surface (usually the bed or chair), while deeper tissues move downward. Occurs when the person slides down in the bed or chair. Blood vessels and tissues are damaged. Blood flow to the area is reduced. Person at Risk Are confined to bed or chair Need some or total help in moving Have loss of bowel or bladder control Have poor nutrition Have poor fluid balance Have altered mental awareness Have problems sensing pain or pressure Have circulatory problems Are older Are obese or very thin Signs of pressure ulcers The first sign of pressure ulcer or a reddened area. Color changes may be hard to notice in persons with dark skin The person may complain of pain, burning, or tingling in the area Some don t feel anything unusual 6

7 Sites Pressure ulcers usually occur over bony areas The bony area are called pressure points Because they bear the weight of the body in a certain position Pressure from body weight can reduce the blood supply to the area Sites (cont) In obese people, pressure ulcers can occur where skin is in contact with skin Common sites are abdominal folds, the legs, buttocks and under the breasts. Friction occurs in these areas Persons who spend a lot of time in bed are at risk for pressure on the ears when in the side-lying position. Stages of pressure ulcers 7

8 Prevention & treatment Preventing ulcers is much easier than trying to heal them. Good nursing care, cleanliness and skin care are essential At risk persons are placed on surfaces that reduce or relieve pressure Protective Devices & Surfaces Foam Air mattress Alternating air mattress Gel mattress Water mattress The health team decides on the best surface for the person Cont. Page Bed cradle Elbow protectors Heel elevators Flotation pads Eggcrate-like mattress Air flotation beds Other equipment, trochanter rolls, footboards 8