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WOUND ASSESSMENT �AND �MANAGEMENT

JOSEPHINE SIMPSON RN, BSN, MS

ARCH NURSE

HYACINTH FOUNDATION

12/ 13/ 2011

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IS THE WOUND INFECTED?

  • Assessment:

-Vital signs/normal or abnormal

- Wound appearance/red, warm, swollen, purulent drainage or foul odor

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SKIN INFECTIONS OF IV DRUG USERS

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SKIN ABSCESS

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CELLULITIS

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NECROTIZING FASCIITIS

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Skin and soft tissue bacterial infections are a common complication of intravenous drug use. This high rate is due to:

  • Injection of drugs into the fatty layer under the skin (skin popping)
  • Leakage of drugs out of veins during the injection (extravasation)
  • Tissue death (necrosis) due to toxic materials in drugs
  • Increased numbers of bacteria on the skin surface.

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WOUND CARE

  • Proper wound cleansing should prevent bacterial colonization from proceeding to the point of clinical infection.
  • A contaminated wound will heal, an infected wound will not.

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WOUND CARE CONTINUED

  • Wound exudate contains bacteria killing enzymes that will help prevent an infection.
  • Proper cleansing and maintaining of a moist wound environment will all create a condition that lessens the chance of infection .
  • Avoid any type cross contamination between patients or multiple wounds on the same patient.
  • Hand washing, clean dressing supplies, new gloves are all required.

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IRRIGATION !!!!!

  • Irrigate, Irrigate, Irrigate, then Irrigate some more to be sure the wound is clean of all debris.
  • Follow standing order that includes applying antibacterial ointment and applying clean sterile dressing.
  • Educate the patient to clean wound and provide dressing change supply’s to take with them.

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DOCUMENTATION

  • Vital signs if taken
  • If a dressing is in place, appearance, if drainage is noticed.
  • Location of wound
  • Size
  • Drainage – color, consistency
  • Odor
  • Necrotic tissue –percentage
  • Treatment

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JUDGEMENT

  • Use your judgment – if you suspect infection refer to PCP or ED.
  • Encourage patient to return to make you aware of the out come.
  • Accompany patient if the need is there.

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OUR GOAL

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Reference’s

  • www.medicaledu.com
  • www.dermnet.org.nz
  • McCance, K.; Huether, S.; Brashers, V.; Rote, N.: Pathophysiology, the Biologic Basis for Disease in Adults and Children. Edition 6; Mosby Elsevier, 2010, Missouri.

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