Chapter 32 - Wound Care Flashcards
Bandages and Binders
Purpose- Apply pressure Cover and protect Immobilize Prevent or reduce edema Secure splints and dressings Support wounds/injuries
Types of Bandages
Elasticized or made of gauze, flannel, or muslin
Examples- 4X4s, Kerlix, Kling, Ace, roller gauze, slings
Maintain sterility (clean technique when applicable)
Rollers bandages available in 1” to 6” (Generally use narrow width for UE’s, feet and lower legs, wide for thigh and abdomen)
Secure with tape, pins, self-closure
Applying Roller Bandages
Circular turns-Overlaps and anchors the dressing
Spiral turns- Overlaps ½ to 2/3 ascending (extremity use)
Figure of eight turns- Alternates above and below wound (joint use)
Recurrent stump- After circular anchor, dressing is passed over tip of stump till covered, then figure of eight is used to secure it (easier with 2 persons) & completed with circular turn (fingers, head wounds, amputated stumps)
Binders
Straight – 15 to 20cm wide and long enough to encircle torso/chest/abdomen (gastric bypass, hernias, surgical incisions, etc.)
Montgomery straps
“T” – rectum, perineum, and groin areas (surgery, dehiscence, etc. single for female/double “T” for male)
Slings – used for upper extremities. Can use a triangular piece of cloth if needed.
Nurse’s Checklist
Wound must be clean and dry Assess for pain and edema Note appearance of surrounding skin Perform neurovascular check distally Bandage in normal functioning position Maintain support when applying Provide sufficient pressure to immobilize/support. Do not impede circulation! Assess circulation & comfort initially and regularly Replace soiled/damp bandages promptly
Patient Education
Increased use of “Same Day Surgery”
Clients discharged earlier
Teach at client’s pace
Circulation, infection, protection, elevation, etc
Supplies and back up plan
Have them reciprocate teaching (If possible have them accomplish an application before discharge)
Heat and Cold Therapy
Hypothalamus regulates body temperature by responding to signals from thermal receptors close to skin surface
Increased body temperature/Heat application causes vasodilation & sweating which dissipates heat
Decreased body temperature/Cold application causes vasoconstriction, shivering and piloerection to preserve warmth
Pain receptors also affected by heat (“burning”) and excessive cold (numbness leading to pain)
Reactions varies with age, degree, amount used, and physiological differences
Effects of applying heat
Dilates peripheral vessels, thus dissipating heat and ↑ circulation, nutrients & O2, tissue metabolism, and capillary permeability, waste products removed
Accelerates inflammatory response/healing
↓ blood viscosity, muscle tension, muscle spasm and pain
Relaxes joints and stimulates specific nerve fibers which ↓ pain
Treat infections, surgical wounds, inflamed tissues, arthritis, joint & muscle pain, dysmenorrhea, chronic pain
Heat: Timing and Temperature
MD order includes: type, body area, frequency and length of time
Avoid skin damage
105- 110° F – All ages (including infants, young children, elderly, diabetic patients, unconscious)
Maximum therapeutic effect from heat occurs in 20-30 minutes, leave off for an hour
Prolonged exposure:
Rebound phenomenon after 45 minutes (vasoconstriction, tissue congestion)
Increased risk for burns
Extensive, prolonged heat- ↑CO, sweating, ↑pulse rate, ↓BP (Hypovolemic shock)
Warn pt not to ↑temperature or lengthen time of application
Heat sources
Dry heat Hot water bags/bottles-watch for leaks Electric pads-hospital provided Aquathermia pads-uses distilled water (20-30 min) Heat lamps-pressure ulcer/circulation Heat cradles-half circle with light bulb Hot packs-”crack” the chemical
Heat sources
Moist heat
Sterile warm compresses-promotes circulation/reduces edema if elevated (max 30 min)
Sitz baths-good for hemorrhoids (15-20 min)
Warm soaks-may need to sterile tubs, pans, tools, etc. 15-20 minutes. Try to maintain temperature
Effects of applying cold
Constricts peripheral blood vessels
↓ blood flow, muscle spasms, alters tissue sensitivity, ↓ pain producers such as histamine, ↓ edema,
↓ inflammation, ↓ cell metabolism and capillary permeability = Comfort
↑ coagulation at wound site, ↓ bleeding
Treats direct trauma, muscle spasms, muscle sprains, dental pain, chronic pain syndromes
Cold: Timing and Temperature
MD order includes: type, body area, frequency and length of time
Maximum therapeutic effect from cold occurs at 15° C (60 ° F)
Limit exposure to 20-30 minutes
Wait 1 hour before reapplication
Prolonged exposure:
Rebound phenomenon-compensatory vasodilation begins at 60° F
↑BP, shivering, piloerection
Tissue injury
Warn pt not to lengthen time of application
Cold sources
Moist cold
Cold compresses (gauze, washcloth)
On for 20 minutes, repeat every 2-3 hours
Dry cold
Ice bags- 30 minutes on, 1 hour off
Cold packs-commercial that need to be frozen or have chemical “cracks”
Hypothermia blankets- a pad or blanket with a machine that circulates cool fluid
Nursing Action: Heat and Cold Therapies
Review MD order Gather equipment Explain procedure to patient Consider pre-analgesia Use correct temperature Monitor time Frequently assess condition of skin and patient’s response Cold for K+ infusion Heat for infiltration
