Nursing 104

N104: Essentials of Nursing Care – Health Safety Study Guide Wound Dressings Dressings are applied to wounds to protect the wound from further injury, to protect from contamination, to provide humidity to the wound, to absorb drainage from the wound, to apply pressure to stop bleeding, to immobilize the site, to facilitate healing, and to cover up an esthetically unpleasant wound. When choosing the type of dressing to be used on a wound, the prudent nurse will be guided by the physician’s order, institution policies and procedures, and input from a wound care specialist when available. Types of dressings: • Gauze dressings can be wet or dry and are capable of trapping exudates from thewound. When the nurse removes the gauze dressing, the debris is also removed. • Transparent films are used to provide a see-through barrier against friction and contamination, which allows the nurse to assess the wound without removing the dressing. • Non-adherent dressings may be impregnated with medication and are used to protect wounds without exudates. • Hydrocolloids absorb exudates and provide a moist environment that facilitates the healing process and protects against contamination. • Hydrogel dressings liquefy any necrotic (dead) tissue and fill in space in the wound to aid the granulation process. • Polyurethane foam dressings can be used to absorb small amounts of exudates to aid in wound debridement. Wound Healing Complications Because a wound is an unnatural opening in the skin, there are complications that can occur in the process. • Infection is one of the most common complications during the healing process and is a result of contamination that activates the body’s immune system. When a pathogen activates the immune response, the resulting infection will move through the specific stages stated previously. • A hematoma is a collection of blood under the skin. Commonly called a bruise, small hematomas absorb over time, while larger hematomas may take longer and sometimes require surgical intervention to promote continued healing. • Hemorrhage is a loss of the blood in volumes greater than expected. This bleeding may occur externally or internally. If the bleeding is external, it will be visible to the nurse who does a full exam of the patient. If the bleeding is internal, it may be indicated by swelling, pain, abnormal vital signs, or bloody drainage from a drain or catheter. • Dehiscence is defined as a wound edge separation. Common causes of wound dehiscence are poor nutritional status, swelling and infection of the wound, and mechanical stress on the wound from vomiting, coughing or obesity. • Evisceration is defined as the protrusion of internal organs through an abdominal wound. When dehiscence is deep enough, evisceration may occur.

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