Wound care PDF
Preview Wound care
7020 fm.qxd 1/13/07 13:19 Page i LPN EXPERT GUIDES Wound Care 7020 fm.qxd 1/13/07 13:19 Page ii 7020 fm.qxd 1/13/07 13:19 Page iii LPN EXPERT GUIDES Wound Care 7020 fm.qxd 1/13/07 13:19 Page iv STAFF The clinical treatments described and rec- ommended in this publication are based on EXECUTIVEPUBLISHER research and consultation with nursing, Judith A. Schilling McCann, RN, MSN medical, and legal authorities. To the best of EDITORIALDIRECTOR our knowledge, these procedures reflect currently accepted practice. Nevertheless, H. Nancy Holmes they can’t be considered absolute and uni- CLINICALDIRECTOR versal recommendations. For individual Joan M. Robinson, RN, MSN applications, all recommendations must be considered in light of the patient’s clinical SENIORARTDIRECTOR condition and, before administration of new Elaine Kasmer or infrequently used drugs, in light of the CLINICALMANAGER latest package-insert information. The authors and publisher disclaim any respon- Collette Bishop Hendler, RN, BS, sibility for any adverse effects resulting from CCRN the suggested procedures, from any unde- EDITORIALPROJECTMANAGER tected errors, or from the reader’s misunder- Christiane L. Brownell, ELS standing of the text. CLINICALPROJECTMANAGER © 2008 by Lippincott Williams & Wilkins. Kate Stout, RN, MSN, CCRN All rights reserved. This book is protected EDITOR bdyu cceodp, ysrtiogrhetd. Nino a p raerttr ioefv iatl msyasyte bme, roerp rtroa-ns- Patricia Nale mitted, in any form or by any means—elec- COPYEDITORS tronic, mechanical, photocopy, recording, or Kimberly Bilotta (supervisor), otherwise—without prior written permis- Jen Fielding, Dorothy P. Terry, sion of the publisher, except for brief quota- Pamela Wingrod tions embodied in critical articles and reviews and testing and evaluation materials DIGITALCOMPOSITIONSERVICES provided by publisher to instructors whose Diane Paluba (manager), Joyce Rossi schools have adopted its accompanying Biletz, Donald G. Knauss (project textbook. Printed in the United States of manager) America. For information, write Lippincott Williams & Wilkins, 323 Norristown Road, MANUFACTURING Suite 200, Ambler, PA 19002-2756. Beth J. Welsh EDITORIALASSISTANTS LPNWOUND010307 Megan L. Aldinger, Library of Congress Cataloging-in-Publication Data Karen J. Kirk, Linda K. Ruhf LPN expert guides. Wound care. INDEXER p. ; cm. Dianne Schneider Includes bibliographical references and index. ISBN-13: 978-1-58255-702-1 (alk. paper) ISBN-10: 1-58255-702-0 (alk. paper) 1. Wound healing—Handbooks, manuals, etc. 2. Wounds and injuries—Nursing— Handbooks, manuals, etc. 3. Wounds and injuries—Treatment—Handbooks, manuals, etc. I. Lippincott Williams & Wilkins. II. Title: Wound care. [DNLM: 1. Wounds and Injuries—nurs- ing—Handbooks. 2. Nursing, Practical— methods—Handbooks. WY 49 L9249 2007] RD95.L556 2007 617.1--dc22 2006101491 7020 fm.qxd 1/13/07 13:19 Page v Contents Contributors and consultants vii 1 Wound care fundamentals 1 2 Nutrition in wound care 34 3 Wound assessment and monitoring 48 4 Basic wound care procedures 75 5 Acute wounds 99 6 Vascular ulcers 131 7 Pressure ulcers 166 8 Diabetic foot ulcers 208 9 Wound care products 235 10 Therapeutic modalities 253 11 Legal and reimbursement issues 270 Pressure ulcer prediction and prevention algorithm 284 Pressure ulcer management algorithm 285 Quick guide to wound care dressings 286 Wound and skin documentation tool 294 Selected references 297 Index 298 v 7020 fm.qxd 1/13/07 13:19 Page vi 7020 fm.qxd 1/13/07 13:19 Page vii Contributors and consultants Penny S. Bennett, RN, BSN Charge Nurse Surgical Unit Good Shepherd Health System Longview, Tex. KATHYCOCHRAN, RN, MSN Director of Practical Nursing Department Chair for Health Technologies Coosa Valley Technical College Rome, Ga. Dolores Cotton, RN, BSN, MS Practical Nursing Coordinator Meridian Technology Center Stillwater, Okla. Nancy Glassgow, RN, BSN Nursing Instructor Western Dakota Technical Institute Rapid City, S.Dak. Dustin Hicks, RN, BSN Practical Nursing Instructor Meridian Technology Center Stillwater, Okla. vii 7020 fm.qxd 1/13/07 13:19 Page viii viii ■ Contributors and consultants Roxanne Leisky, MSN, FNP, CWS Owner Advanced Wound Care, LLC Springfield, Ill. Patricia B. Lisk, RN, BSN Instructor, Department Chair for CNA Augusta (Ga.) Technical College Kendra S. Seiler, RN, MSN Nursing Instructor Rio Hondo Community College Whittier, Calif. Gina Sirach, RN, MSN Nursing Faculty Southeastern Illinois College Harrisburg Laura Travis, RN, BSN Health Careers Coordinator Tennessee Technology Center at Dickson 702001.qxd 1/13/07 14:01 Page 1 1 W OUND CARE FUNDAMENTALS Skin basics The skin, or integumentary system,is the largest organ of the body. It accounts for 6 to 8 lb (2.5 to 3.5 kg) of a pa- tient’s body weight and has a surface area of more than 20square feet. The thickest skin is located on the palms and on the soles; the thinnest skin, around the eyes and over the tympanic membranes in the ears. Skin is made up of distinct layers that function as a single unit. The outermost layer, which is actually a layer of dead cells, is completely replaced every 4 to 6 weeks by cells that migrate to the surface from the layers beneath. The living cells in the skin receive oxygen and nutrients through an extensive network of small blood vessels. In fact, every square inch of skin contains more than 15(cid:1) blood vessels. Skin protects the body by acting as a barrier between internal structures and the external world. Skin also stands between each of us and the social world around us, so it’s no wonder that the condition and characteristics of a pa- tient’s skin influence how he feels about himself. When a patient has healthy skin—unblemished skin with good tone (firmness) and color—he feels better about himself. 1 702001.qxd 1/13/07 14:01 Page 2 2 ■ Wound care fundamentals Skin also reflects the general physical health of the body. For example, if blood oxygen levels are low, skin may look bluish; skin appears flushed or red when a patient has a fever. Skin anatomy and physiology Skin has two main layers: the epidermis and dermis. A layer of subcutaneous fatty connective tissue, sometimes called the hypodermis,lies beneath these layers. (See A close look at skin.) Within the epidermis and dermis, which function as one interrelated unit, are five structural networks: ■ collagen fibers ■ elastic fibers ■ small blood vessels ■ nerve fibrils ■ lymphatics. These networks are stabilized by hair and sweat gland ducts. EPIDERMIS The epidermis is the outermost of the skin’s two main lay- ers. It varies in thickness from about 0.004 inch (0.1 mm) thick on the eyelids to as much as 0.04 inch (1 mm) thick on the palms and soles. The epidermis is slightly acidic, with an average pH of 5.5. Covering the epidermis is the keratinized epithelium, a layer of cells that migrate up from the underlying dermis and die when they reach the surface. These cells are continuously generated and re- placed. The keratinized epithelium is supported by the dermis and underlying connective tissue. The epidermis also contains melanocytes(cells that produce the brown pigment melanin), which give skin and hair their color. The more melanin produced by
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