Wound Care

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234 Nurse to Nurse — Provided is a practitioner’s action, not an outcome. — Promoted is a process, not an outcome. • Behavioral terms to use in outcomes: — Answer, apply, compare, choose, decrease, demonstrated, describe, explain, increase, participate, prepare, select, etc. AVOID learn, feel, understand, know, and accept. CONSIDERATIONS IN ACUTE WOUNDS • Primary intention: — Stringent safeguards against infection — Support client’s immune system — Some research indicates that wounds closed with the newer closure tapes develop increased resistance to infection more quickly and effectively than those sutured or stapled. Sutures and staples may allow bacteria under the skin. Tincture of benzoin placed on the skin and allowed to dry before application of the cloth strips creates longer wearing time for the strips. Remember that this tincture is destructive to fibroblasts and temporarily alters the pH of the skin to which it is applied. Using a skin barrier wipe such as 3M No Sting or Kendall Preppies may accomplish the same outcome without fibroblast destruction. — If the wound is sutured or stapled keep it clean and dry until sutures or staples are removed. — Dressing purpose is to support healing in a dry, low bacterial count (all skin has bacteria on it) environment. Remember: bacteria thrive in warm, dark, and moist environments so if dressings become moist and wet they should be changed (not reinforced) immediately. • At the first encounter educate the client and caregiver that the purpose of the outpatient or home evaluations is to provide them support until one of them is able to perform the wound care.
<strong>Wound</strong> Management, Products, and Support Surface Selection 235 *Indicates acute care or skilled nursing facility initial encounter or admission — The practitioner develops a plan of care with the independence of the patient and caregiver as both a goal and an outcome. Consider referrals to OT, MSW*, PT*, WOC nurse, and RN to assist in this. Include in the first encounter: º Education on infection control*: • Dressings • Storage • Handwashing* • Keeping wound covered* (if part of POC) • Nutrition* (may have the client and caregiver keep a 72-hour diet and fluid log) • Disposal of used supplies* Homework*: activities the client and caregiver are to perform before the next encounter even if that encounter is later in the day. For example, on admission the client and caregiver are educated about handwashing for all care providers before wound evaluation or treatment. The client and caregiver are expected to observe and request when necessary for care providers to perform handwashing before wound evaluation or treatment is performed. • Superficial: • Stringent safeguards against infection — Keep wound covered to prevent shear, friction, and other trauma. • Dressing purpose is to support healing in a dry, low bacterial count (all skin has bacteria on it) environment. — Remember: bacteria thrive in warm, dark, and moist environments so if dressings become wet they should be changed (not reinforced) immediately.
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Nurse to Nurse WOUND CARE
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Nurse to Nurse WOUND CARE Donna Sce
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Professional Want to learn more? We
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xii List of Acronyms RBC Red blood
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2 Nurse to Nurse THE ROLE OF ETHICS
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4 Nurse to Nurse — Who does not h
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6 Nurse to Nurse • Specific amoun
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8 Nurse to Nurse disclosure of info
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10 Nurse to Nurse Remember Doing go
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12 Nurse to Nurse or guarantee anyt
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14 Nurse to Nurse Remember Provide
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16 Nurse to Nurse evaluation and ca
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18 Nurse to Nurse • The Hastings
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20 Nurse to Nurse Jacobs BB, Taylor
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22 Nurse to Nurse KEY POINTS • Su
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24 Nurse to Nurse Hair follicle Seb
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26 Nurse to Nurse Table 2-1 Common
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28 Nurse to Nurse — Brands of lig
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30 Nurse to Nurse • Acute wound:
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32 Nurse to Nurse Explicit chemoatt
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34 Nurse to Nurse • Diabetic foot
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36 Nurse to Nurse healing. This pha
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38 Nurse to Nurse or staples may be
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40 Nurse to Nurse increase in tempe
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42 Nurse to Nurse º If the wound i
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44 Nurse to Nurse º Linear wounds
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46 Nurse to Nurse Trauma Patient/ca
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48 Nurse to Nurse º Poor protein i
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50 Nurse to Nurse — Vitamin A: me
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52 Nurse to Nurse MULTIDISCIPLINARY
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54 Nurse to Nurse • Refer the pat
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58 Nurse to Nurse KEY POINTS • De
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Head Bony prominence Shoulder Sacru
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62 Nurse to Nurse • The proposed
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64 Nurse to Nurse Epidermis Muscle
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66 Nurse to Nurse Non blanchable er
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68 Nurse to Nurse — High intensit
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70 Nurse to Nurse • Elevated temp
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72 Nurse to Nurse • Corn starch s
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74 Nurse to Nurse • Diet and flui
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76 Nurse to Nurse — Occupational
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78 Nurse to Nurse — Use antifunga
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80 Nurse to Nurse — Keep the woun
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82 Nurse to Nurse • Stage III —
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84 Nurse to Nurse Apply hydrogel di
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86 Nurse to Nurse • The word “p
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88 Nurse to Nurse Table 3-3 Compone
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90 Nurse to Nurse Table 3-5 Categor
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92 Nurse to Nurse • Risk for pres
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94 Nurse to Nurse — If patient ha
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96 Nurse to Nurse • The Hartford
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98 Nurse to Nurse Hall JC. Sauer’
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100 Nurse to Nurse KEY POINTS • V
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102 Nurse to Nurse Deep leg veins E
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104 Nurse to Nurse Muscle contracti
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106 Nurse to Nurse • Trap hypothe
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108 Nurse to Nurse • Varicose vei
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110 Nurse to Nurse Nursing Alert A
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112 Nurse to Nurse formation due to
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114 Nurse to Nurse Measure 5 centim
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116 Nurse to Nurse • Some studies
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118 Nurse to Nurse — Stockings ar
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120 Nurse to Nurse Figure 4-4 Extre
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122 Nurse to Nurse • Provide thor
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124 Nurse to Nurse Table 4-5 Advant
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126 Nurse to Nurse Table 4-8 Indica
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128 Nurse to Nurse Table 4-10 Indic
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130 Nurse to Nurse • Treatment fo
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132 Nurse to Nurse Seaman S. Evalua
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134 Nurse to Nurse KEY POINTS • F
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136 Nurse to Nurse Chronic pain and
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138 Nurse to Nurse Aorta Superficia
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140 Nurse to Nurse Tunica initima E
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142 Nurse to Nurse Morphologically,
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144 Nurse to Nurse Carotid bifurcat
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146 Nurse to Nurse — These patien
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148 Nurse to Nurse ischemia from th
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150 Nurse to Nurse Table 5-1 Relati
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152 Nurse to Nurse DIAGNOSTIC PROCE
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154 Nurse to Nurse — Paint with a
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156 Nurse to Nurse º Enhanced work
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158 Nurse to Nurse • Cleanse gent
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160 Nurse to Nurse Hilleman D. Mana
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162 Nurse to Nurse KEY POINTS • P
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164 Nurse to Nurse • 5% to 10% of
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166 Nurse to Nurse — Hypertrophy
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168 Nurse to Nurse Symptoms include
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170 Nurse to Nurse Table 6-1 Wagner
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172 Nurse to Nurse Table 6-2 Evalua
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174 Nurse to Nurse — Antimicrobia
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176 Nurse to Nurse — Erythrocyte
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178 Nurse to Nurse Table 6-4 Wagner
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180 Nurse to Nurse 3. Armstrong DG,
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182 Nurse to Nurse Mayfield JA, Rei
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Page 216 and 217: 200 Nurse to Nurse KEY POINTS • C
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Page 220 and 221: 204 Nurse to Nurse — Place a shal
Page 222 and 223: 206 Nurse to Nurse All these agents
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Page 226 and 227: 210 Nurse to Nurse Abnormal lung fu
Page 228 and 229: 212 Nurse to Nurse — No sun expos
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Page 232 and 233: 216 Nurse to Nurse • Treatment
Page 234 and 235: 218 Nurse to Nurse (systemic lupus
Page 236 and 237: 220 Nurse to Nurse • In individua
Page 238 and 239: 222 Nurse to Nurse • Usually star
Page 240 and 241: 224 Nurse to Nurse 3. Pruitt BA, Le
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Page 244 and 245: 228 Nurse to Nurse KEY POINTS • E
Page 246 and 247: 230 Nurse to Nurse functional outco
Page 248 and 249: 232 Nurse to Nurse — Phase change
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Page 254 and 255: 238 Nurse to Nurse º Dressings* º
Page 256 and 257: 240 Nurse to Nurse include the CNA
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Page 260 and 261: 244 Nurse to Nurse the health-care
Page 262 and 263: 246 Nurse to Nurse — Consistency:
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Page 266 and 267: 250 Nurse to Nurse • Certain woun
Page 268 and 269: 252 Nurse to Nurse — Safe to use
Page 270 and 271: 254 Nurse to Nurse — Wound contam
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Page 274 and 275: 258 Nurse to Nurse Infected wounds:
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284 Nurse to Nurse Table 9-24 Advan
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286 Nurse to Nurse Table 9-26 Advan
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288 Nurse to Nurse • Stage IV: fu
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290 Nurse to Nurse Shows 30° sidel
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292 Nurse to Nurse Slide hand (palm
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294 Nurse to Nurse — Appropriate
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296 Nurse to Nurse — Diet and flu
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298 Nurse to Nurse — Home rehabil
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300 Nurse to Nurse Pressure Ulcer T
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302 Nurse to Nurse • Home rehabil
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304 Nurse to Nurse • Diabetes nur
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306 Nurse to Nurse — Two (2) inch
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308 Nurse to Nurse weight distribut
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310 Nurse to Nurse — Gravitationa
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312 Nurse to Nurse Hill-Rom Huntlei
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314 Nurse to Nurse • Cleanse gent
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316 Nurse to Nurse — Avoid use of
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318 Nurse to Nurse Cunningham D. Tr
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322 Nurse to Nurse KEY POINTS • S
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324 Nurse to Nurse with the ability
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326 Nurse to Nurse º Tensile stren
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328 Nurse to Nurse Melanocytes tran
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330 Nurse to Nurse PATIENT HISTORY
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332 Nurse to Nurse — Often darker
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334 Nurse to Nurse — Any changes
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336 Nurse to Nurse — Any thyroid
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338 Nurse to Nurse — The sclera m
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340 Nurse to Nurse • Symmetry, ul
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342 Nurse to Nurse • Senile lenti
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344 Nurse to Nurse • Document the
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346 Nurse to Nurse 9 O’ Clock Rig
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348 Nurse to Nurse Nursing Alert Al
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350 Nurse to Nurse • Provide supp
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352 Nurse to Nurse Whenever the pat
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356 Index Arterial ulcer, 33 Arteri
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358 Index Debridement (Cont.): cuta
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360 Index Hematopoietic system, in
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362 Index Multizoned support surfac
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364 Index Pressure ulcers (Cont.):
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366 Index Skin temperature, in lowe
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368 Index Wheelchair positioning, 9
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Wound Care

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