wound care program for nursing assistants-appropriate wounds for lna scope of care licensed nursing...

Wound Care Program for Nursing Assistants-

Wound Cleansing ,Types & Presentation

Elizabeth DeFeo, RN, WCC, OMS, CWOCNWound, Ostomy, & Continence Specialist

ldefeo@cornerstonevna.org

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

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

Wound Cleansing

Cleaning the wound

How NOT to clean a wound

Making it count…

Assembling the supplies

Use the Force!

A note on pain…

Products videos

Wound Types

Wound types

Pressure ulcers: bony prominences/devices

Venous wounds

Arterial wounds

Neuropathic [diabetic] wounds

Surgical wounds/surgical incisions

Traumatic wounds/skin tears

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

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.

Suspected Deep Tissue Injury

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

Pressure Ulcers: Stage I

Pressure Ulcers: Stage II

Stage 2

Shallow, pink/red

Partial thickness/superficial

Moist, dry, shiny

No yellow/slough

May have drainage or be dry

Pressure Ulcers: Stage II

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)

Pressure Ulcers: Stage III

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).

Pressure Ulcers: Stage IV

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!

Pressure Ulcers: Unstageable

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.

Key areas to offload:

Lower extremity wounds…usually..

Venous [‘Stasis’] wounds

Arterial [‘Ischemic’] wounds

Neuropathic [‘Diabetic’] wounds

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

Venous Wounds

Forms of compression:

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

Arterial Wounds

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.

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

Neuropathic [diabetic] wounds

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.

Surgical wounds/surgical incisions

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!

Traumatic wounds/skin tears

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

Thank you!