Chapter 28 - Wound Care

what is a skin tear

- a break or rip in the skin

what is a diabetic foot ulcer?

- an open wound on the foot caused by complications from diabetes

how often do you remove elastic stockings?

- check the care plan - usually every 8 hours for 30 minutes - before person goes to bed

describe diabetic footcare

- check the person's legs & feet every day - wash the feet daily in warm water with mild soap & mild water - don't soak feet in water - dry feet well, especially b/w toes - apply thin layer of lotion to tops & bottoms of feet - have person wear closed-toed shoes & clean socks - make sure lining of shoes are smooth - do not allow person to walk barefoot - wear elastic stockings & elastic bandages

after applying heat or cold, how often should you check the person?

- every 5 minutes

what do elastic stockings and elastic dressings do?

- exert pressure on the veins to promote venous blood to return to the heart -> thus prevents blood clots/thrombi

persons at risk for thrombi are:/... have heart disorders are on bedrest have had surgery are younger

- have heart disorders - are on bedrest - have had surgery

what is a venous ulcer

- open sores on the lower legs or feet - caused by poor blood flow through veins - commonly found on heels and inner aspects of the ankles

what is a circulatory ulcer

- open sores on the lower legs or feet caused by decreased blood flow through the arteries or veins (much harder for blood to go to lower parts of the legs)

what is an arterial ulcer?

- open wounds on the lower legs or feet caused by poor arterial blood flow - found b/w the toes, on top of the toes, & on the outer side of the ankle

what are complications of cold applications?

- pain, burns, blisters, poor circulation - dilation of blood vessels following prolonged application

how do you apply stockings?

- position person supine - turn stocking inside out down at least to the heal - slip foot of stocking over toes, foot, heal, & leg - remove twists, creases, or wrinkles - apply stocking so that toe opening is over top of toes or under toes

what can heat and cold applications do?

- promote healing and comfort - reduce tissue swelling - have opposite effects on body function (heat = dilate; cold = constrict)

what are the functions of wound dressings?

- protect wounds from injury and microbes - absorb drainage - remove dead tissue - promote comfort - cover unsightly wounds - provide a MOIST environment for wound healing (actually allows healing action to occur) - apply pressure to help control bleeding

what are the benefits of cold applications?

- reduce pain, prevent swelling, decrease circulation + bleeding due to constriction of blood vessels

what are complications associated w/ heat applications?

- risk of burns - long applications causes constriction of blood vessels -> skin may then appear pale

what is the purpose of elastic bandages?

- same person as elastic stockings to prevent blood clots - hold dressings in place

how to secure dressings?

- use either tape and montgomery ties (the tape used should either be paper, plastic, cloth, or elastic) - apply tape to top middle, & bottom parts of dressing - tape extends several inches beyond each side of the dressing - tape is not applied to circle the entire body part

what are the two types of circulatory ulcers?

- venous ulcer - arterial ulcer

what is an ulcer?

a shallow or deep crater-like sore of the skin or a mucous membrane

The type of heat application that may be used to stimulate voiding is

a sitz bath

when are stockings applied?

before the person gets out of bed

what are thrombi?

blood clots

When applying an elastic bandage, you should replace a wrinkled bandage. re-apply a moist bandage. expose the abdomen. check the extremity every hour

check the extremity every hour

An example of a moist cold application is

cold compress

When providing foot care to a diabetic patient, you should (Select all that apply.) dry well between the toes. apply tape around the dressing. apply a compression device. apply lotion between the toes

dry well between the toes

how often should you check the skin after applying hot and cold applications?

every 5 minutes DON'T LEAVE THE PATIENT ALONE

when are heat applications most commonly used?

for musculo-skeletal injuries or problems

When doing a dressing change, extra dressings should be

left in the room

which is more effective: moist or dry cold applications?

moist

which is more effective: moist or dry heat?

moist heat

how long at most should you leave hot and cold applications on the skin for?

no longer than 15 to 20 minutes

when a heat application is applied to the skin, tissues ahve increased nutrients fluid constriction oxygen

nutrients oxygen

when are you allowed as a CNA to apply a wound dressing?

only when the skin is still in tact IF SKIN IS NOT IN TACT DO NOOOOOT APPLY A STERILE WOUND DRESSING

When applying an aquathermia pad, which instruction should you question? - place the pad under the person - Use a cloth cover to insulate the pad. - Secure the pad with ties, tape, or rolled gauze. Incorrect - Make sure the water flows freely through the hoses.

place the pad under the person (this prevents the escape of heat... resulting in burns

what are the benefits of heat applications

promote healing and reduce tissue swelling by increasing circulation

what should you do to remove tape?

pull it towards the wound!!

what are some guidelines for how hot hot applications should be?

should not be above 106 degrees F

The type of heat application commonly used for hemorrhoids is

sitz bath (cleans the perineum)

Which is a type of wound that can be caused by holding an arm or leg too tight?

skin tear

A sign that the person is experiencing a complication from heat application is the skin is red. Incorrect the skin is pale the skin is warm the skin is moist

the skin is pale

how tight should elastic bandages be?

tight enough such that 2 fingers are still able to fit in it - check for 7Ps to ensure that it isn't too tight!!

what are binders?

wide bands of elastic fibers that promote healing by: - supporting wounds - holding dressings in place - prevent or reduce swelling - promote comfort - prevent injury - reduce swelling - prevent further injury