mgccc nursing

the introduction of pathogens or infectious material into or on normally clean surfaces

microbes invade body tissue

• -protect from fecal & urinary contamination
• -cleanse and debride
• -trial of topical antibiotic
• -diagnose soft tissue infection and osteomyelitis
• -systemic antibiotics for systemic infection
• -urgent medical attention for sepsis

will see alot of standing orders in long term facilities (ex:nursing home) not so much in acute care

systemic inflammatory response to infection

• fever
• tachycardia
• 50% of pts diagnosed w/ sepsis die.

• -cleanse wounds initially and at each dressing change
• -saline irrigation is a safe and appropriate method for cleansing most ulcers
• (hydrogen peroxide can be used, but not not in most instances)

• -meds
• -radiation
• -anti-inflammatory drugs
• -chemotherapeutic agents (cytocid medications)
• -immunosupressive agents
• -smoking
• -social circumstances
• -mobility

• -health status
• -age factors
• -circulation & oxygen
• -nutritional status
• -wound condition
• -meds and health status

• -pain
• -anxiety
• -changes in body temp

• -dietary intake
• -height and weight
• -weight change
• -lab values
• -hydration status

• -carbs
• -fats
• -proteins
• -vitamins (a, c, e, zink)
• -fluids

• hemostasis (immediate)
• inflammation (4-6 days)
• proliferation (few weeks)
• remodeling (years)

• -does this pt have the ability to heal?
• -consider overall goals of care
• -etiology of wound
• -factors that contribute to impaired healing

Most wounds heal in a moist environment

• -all layers of tissue below the epidermis are moist
• -without a moist surface, wound healing will take longer
• -providing a moist environment will heal most wounds 3 times faster

• -hydrocolloid wafer dressings
• -dydrogel dressings
• -alginate dressings
• -transparent adhesive dressings
• -foam dressings
• -absorption dressings
• -gauze dressings
• -composite dressings
• -bilogic dressings
• -other (negative pressure)

• -to protect skin at risk from friction or shear
• -to maintain a moist wound environment
• -to facilitate autolytic debridement

• -do not recommend for infected wound
• -maceration of periwound skin not possible
• -not appropriate for heavy exudating wound

• description:
• -non adhesive
• -maintain moist healing environment
• -avalible in 3 sizes
• -requires secondary cover such as gauze or thin film dressing

• -rehydrates dry wounds
• -provides moist wound healing
• -reduces pain associated with the wound
• -ideal for loose packing

• -to facilitate debridement
• -to maintain moist wound healing
• -to fill in "dead space" or pack wound
• -as a primary dressing on a partial thickness wound

• -change every 24-72 hours
• -cleanse or irrigate wound prior to dressing application
• -observe periwound skin for signs of maceration
• -requires use of secondary dressing

• description:-
• -non-adhearent highly absorbent dressing
• -drssing forms a soft, gelatinous mass when they come in contat with wound fluid
• -derived from seaweed (good for use on infected wounds)

• -will decrease the frequency of dressing changes decreasing trauma and manipulation of wound
• -will lower costs of wound care
• -ideal for loose packing in deep wounds

• -must be accurate and done at regular intervals
• -includes evaluation of wound and surrounding skin
• -used to drive treatment decisions
• -provides baseline data to evaluate repair process

• -location
• -stage
• -size (LxWxD in cm)
• -sinus tract
• -undermining
• -exudate
• -necrotic tissue
• -granulation tissue
• -signs/symptoms of infection
• -periwound skin

Length x width x depth

-partial thickness wounds will not have any depth to measure, so they will be measured as L x W only

• when wound is actually larger than the opening
• (you always want to measure the portion that is undermining)

like a cave-narrow and goes downward into the wound-these need to be packed

• -educate! (nutrition, hydration, etc.)
• -prevent! (turn pt every 2 hrs)
• -there will always be a need for more than 1 type of dressing.
• -continually reassess the wound (need to know improvement status, etc.)

• -if its dry, moisten it
• -if its moist, absorb it
• -if its deep, fill it
• -if its shallow, cover it