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UNIT 4 Supporting Physiological Function
return and helps the ulcer to heal. You will need to keep the following in mind: ■ Before applying elastic compression, be sure the limb is not increasing in size because of edema. ■ Lower extremity arterial disease must be ruled out before applying compression because it can com- promise arterial circulation. To see the complete procedure, See Chapter 36, Procedure 36-2: Applying Antiembolism Stockings, in Volume 2. The rest of the chapter will assist you in obtaining If you need to review content to answer these questions, see the Interventions in the Example Client Condition: Pressure Injury. ■ Identify the major interventions for preventing pressure injury. ■ What nursing diagnosis is most appropriate for a patient at risk for pressure injury development? Cleansing Wounds Cleansing removes exudate, slough, foreign materi- als, and microorganisms from the wound. This helps various wound care competencies. Knowledge Check 32-8
promote healthy tissue healing. Always clean a wound initially and with each dressing change. To cleanse a wound, gently pat the surface with gauze soaked with saline or other prescribed wound cleanser. If there is granulation tissue, be careful not to disrupt it. The ideal solution should be isotonic, easy to sterilize, inexpen- sive, and available. It should not irritate or damage tis- sue or cause bleeding. ■ Antiseptic solutions include Dakin’s solution, acetic acid, hydrogen peroxide, povidone-iodine, chlorhexi- dine, and alcohol. Historically, these solutions have been used to cleanse all types of wounds. However, some of these antiseptic solutions can damage granulating tis- sue and should not be used on healing tissue. Although controversial, betadine may be nontoxic and effective in cleansing chronically infected wounds (National Institute for Health and Care Excellence [NICE], 2016). Antiseptic solutions should be reserved for: ■ New wounds ■ Wounds that won’t heal ■ Wounds in which the bacterial burden is more harmful than the solution itself ■ Normal saline is isotonic (same concentration as the blood and other cells in the body); it is safe, and it will
EXAMPLE CLIENT CONDITION: Pressure Injury
Definition Pressure Injury: Localized injury to the skin and underlying tissue, usually over a bony prominence (see Fig. 32-11). Formerly called decubitus ulcers, pressure ulcers, bedsores. Stages Staged by degree of tissue involvement (see Table 32-3) • Become progressively shallow by filling with granulation tissue • Reduced muscle, subcutaneous fat • Dermis not replaced • Healing pressure injuries are not “reverse” staged. A stage 4 pressure injury does not become a stage 3; it is described as “stage 4 pressure injury: healing.” Risk Factors • Impaired circulation, such as patients with diabetes, atherosclerosis, or low blood pressure • Reduced oxygen supply in the blood, such as patients who use tobacco or have anemia • Limited mobility or reduced sensation to feel pressure points: • nerve damage • head injury, stroke, spinal cord injury • contractures • diabetes
Contributing Factors • Pressure —Compresses small blood vessels, hindering blood flow and nutrient supply. Tissues become ischemic or injured. • Friction —When skin is moist, fragile, or rubbed against another surface (wrinkled sheets). • Shear —When one layer of tissue slides horizontally over another, compressing adipose and muscle tissue and reducing normal blood flow. Shear is friction plus the force of gravity (e.g., when patient slides down in the bed). • Moisture— Urine, stool, and sweat macerate the skin. Patient Health History Patient’s health condition combined with unrelieved pressure increases the risk (see Fig. 32-10): • Immobility • Poor nutrition • Fever • Infection • Dehydration • Edema • Impaired sensation (spinal cord injury, stroke)
CLIENT CONDITION
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