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contaminants
the introduction of pathogens or infectious material into or on normally clean surfaces
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infection
microbes invade body tissue
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Managing Infection
- -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
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standing orders
will see alot of standing orders in long term facilities (ex:nursing home) not so much in acute care
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sepsis
systemic inflammatory response to infection
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symptoms of sepsis
- fever
- tachycardia
- 50% of pts diagnosed w/ sepsis die.
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Wound cleansing
- -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)
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Factors that affect wound healing
- -meds
- -radiation
- -anti-inflammatory drugs
- -chemotherapeutic agents (cytocid medications)
- -immunosupressive agents
- -smoking
- -social circumstances
- -mobility
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Intrinsic/stystemic factors
- -health status
- -age factors
- -circulation & oxygen
- -nutritional status
- -wound condition
- -meds and health status
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Psychological effects of wounds
- -pain
- -anxiety
- -changes in body temp
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nutritional assessments
- -dietary intake
- -height and weight
- -weight change
- -lab values
- -hydration status
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essential nutrients
- -carbs
- -fats
- -proteins
- -vitamins (a, c, e, zink)
- -fluids
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normal phases of wound healing
- hemostasis (immediate)
- inflammation (4-6 days)
- proliferation (few weeks)
- remodeling (years)
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-assessment
- -does this pt have the ability to heal?
- -consider overall goals of care
- -etiology of wound
- -factors that contribute to impaired healing
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FACT
Most wounds heal in a moist environment
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wound healing
- -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
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types of topical wound dressings
- -hydrocolloid wafer dressings
- -dydrogel dressings
- -alginate dressings
- -transparent adhesive dressings
- -foam dressings
- -absorption dressings
- -gauze dressings
- -composite dressings
- -bilogic dressings
- -other (negative pressure)
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Advantages of Hydrocolloid dressings
(ex: duoderm & tegasorb)
- -to protect skin at risk from friction or shear
- -to maintain a moist wound environment
- -to facilitate autolytic debridement
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Precautions of Hydrocolloid dressing
- -do not recommend for infected wound
- -maceration of periwound skin not possible
- -not appropriate for heavy exudating wound
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Hydogel dressings
(ex: vigilon, aquasorb)
- description:
- -non adhesive
- -maintain moist healing environment
- -avalible in 3 sizes
- -requires secondary cover such as gauze or thin film dressing
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hydrogel advantages
- -rehydrates dry wounds
- -provides moist wound healing
- -reduces pain associated with the wound
- -ideal for loose packing
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hydrogel indications
- -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
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Hydrogel utilization
- -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
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Alginate dressings
(ex: sorban & algiderm)
- 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)
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alginate dressings
- -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
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wound assessment
- -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
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Documentation
- -location
- -stage
- -size (LxWxD in cm)
- -sinus tract
- -undermining
- -exudate
- -necrotic tissue
- -granulation tissue
- -signs/symptoms of infection
- -periwound skin
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Document Size
Length x width x depth
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Documenting size
-partial thickness wounds will not have any depth to measure, so they will be measured as L x W only
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Undermining
- when wound is actually larger than the opening
- (you always want to measure the portion that is undermining)
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Sinus tract
like a cave-narrow and goes downward into the wound-these need to be packed
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Remember.....
- -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.)
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Assessing Wound
- -if its dry, moisten it
- -if its moist, absorb it
- -if its deep, fill it
- -if its shallow, cover it
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