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Wound Care Program for Nursing Assistants-
Wound Cleansing ,Types & Presentation
Elizabeth DeFeo, RN, WCC, OMS, CWOCNWound, Ostomy, & Continence Specialist
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Outline/Agenda
At completion of this webinar, the participant will:
Define the role of the Nursing Assistant in wound care;
Demonstrate proper cleansing of wounds and the surrounding
skin;
Identify signs and symptoms of infection;
Identify different types of wounds;
Clearly verbalize wound presentation or changes that are outside
your Scope of Practice, and when to request nurse assessment
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LNA role in wound care
*WITH PROPER TRAINING*,
Appropriate wounds for LNA scope of care
Licensed Nursing Assistants in NH may:
provide ‘routine, stable’ wound care
apply medicated lotions, ointments, and creams related
to skin/wound care.
Wound changes and presentation that are
excluded from LNA scope of care
Deteriorating wounds
Wounds with signs and symptoms of infection
Other changes specific to your agency’s policies
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Wound Cleansing
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Cleaning the wound
How NOT to clean a wound
Making it count…
Assembling the supplies
Use the Force!
A note on pain…
Products videos
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Wound Types
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Wound types
Pressure ulcers: bony prominences/devices
Venous wounds
Arterial wounds
Neuropathic [diabetic] wounds
Surgical wounds/surgical incisions
Traumatic wounds/skin tears
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Pressure Ulcers
Cause Pressure: soft tissue compressed between a bony
prominence [or a device] and an external surface
Contributing factors Shear: gravity + friction; the result of gravity pushing down
and resistance between the patient and a surface
Friction: skin rubbing against another surface
Moisture
Immobility
Inability to feel pressure or pain
Poor nutrition
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Suspected Deep Tissue Injury
Aka, SDTI
Purple or maroon
Intact skin
Blood filled blister
May change rapidly
May appear as thin blister over dark tissue.
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Suspected Deep Tissue Injury
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Pressure Ulcers: Stage I
Stage 1
Skin is intact
Nonblanchable [Pink that does not resolve
when pressure relieved]
No moisture on wound
No drainage
May be painful, firm, soft, warm or cool
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Pressure Ulcers: Stage I
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Pressure Ulcers: Stage II
Stage 2
Shallow, pink/red
Partial thickness/superficial
Moist, dry, shiny
No yellow/slough
May have drainage or be dry
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Pressure Ulcers: Stage II
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Pressure Ulcers: Stage III
Stage 3 Looks like a deep crater
Full thickness
Slough, undermining, tunneling may be
present
No bone/tendon
Depth varies (nose/ear vs. buttocks)
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Pressure Ulcers: Stage III
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Pressure Ulcers: Stage IV
Stage 4
Full thickness
Slough or eschar may be present
Exposed bone, tendon or muscle present
Often include undermining and tunnels
These are may or may not be in your Scope of Practice, but may be if they are chronic/end of life (palliative).
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Pressure Ulcers: Stage IV
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Pressure Ulcers: Unstageable
Unstageable Base of wound is covered so much by slough or
eschar, it can’t be staged.
These are not usually in your Scope of Practice, but may be if they are chronic/without change.
Stable eschar on heels – let it be…
Increased:
Pain
Redness
Drainage
Contact nurse or supervisor!
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Pressure Ulcers: Unstageable
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REMEMBER:
To prevent or to treat pressure ulcers:
Reposition the bed bound patient at
per designated schedule, usually
every 1-2 hours.
Offload pressure anywhere it exists
(heels, elbows, buttock, etc.) with
pillows, foam boots, heel and elbow
pads.
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Key areas to offload:
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Lower extremity wounds…usually..
Venous [‘Stasis’] wounds
Arterial [‘Ischemic’] wounds
Neuropathic [‘Diabetic’] wounds
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Venous Wounds
Usually seen on the inner, lower leg or ankle
Edema
Hemosiderin staining – brown/pink
color to skin
Shallow
Copious drainage
Treatment = Elevate and compress
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Venous Wounds
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Forms of compression:
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Arterial Wounds
Due to poor blood flow
Usually seen between/on the toes, around the outer ankle, on the foot where there may be trauma or rubbing of footwear
Very painful
DO NOT ELEVATE
Avoid cold temperatures, heating devices and topical hot liquids
Avoid tight clothing and crossing legs
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Arterial Wounds
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A note on dry ‘stable’ eschar…
Wound is covered with thick, leathery necrotic
tissue
If this is *dry, non-boggy, and attached on all
edges*, it is considered STABLE.
You may be instructed to ‘paint’
this with povidone-iodine, or to
keep dry, possibly covered with
gauze, always offloaded.
If any changes/bogginess
/drainage, contact your
nurse/supervisor immediately for
instruction.
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Neuropathic [diabetic] wounds
Usually seen on the bottom of the foot, at the
base of the toes and on the heel.
Due to lack of sensation
Treatment = offload!
Footwear at all times
Proper fitting footwear ~ Check those
shoes!
Avoid temperature extremes
Do not soak feet
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Neuropathic [diabetic] wounds
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Surgical incisions/surgical wounds
Incisions - open or closed
Sutured
Stapled
Steri-stripped
Drain sites
When incisions are open, without
sutures, staples, or glue, it becomes a
surgical wound.
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Surgical wounds/surgical incisions
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Traumatic wounds/skin tears
Skin tears
Abrasions
Lacerations
Prevention:
Maintain a safe environment
Ambulate with appropriate device or supervision
Maintain optimal skin status (well
hydrated/moisturized)
If you find: Cleanse, Cover and Contact!
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Traumatic wounds/skin tears
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Applying a dressing
A common order for a skin tear may read:
Remove old dressing, cleanse with saline
spray; apply skin prep to intact skin; hydrogel
to open areas, xeroform to cover, gauze and
gauze wrap to secure every 1-2 days by
skilled clinician.
VIDEO
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Thank you!