..WITH YOURSELVES. THAT WAS THE BIG HUGE MODULE
AND THE TRUTH OF THE MATTER IS WE COULD HAVE SPENT ANOTHER EASY TWO WEEKS,
DOING CENTRAL LINES AND DOING OTHER CARE, TPN, BLOOD.
WE COULD SPEND WEEKS AND WEEKS STILL DOING IV'S.
THE TRUTH IS YOU'VE GOT ENOUGH FOUNDATIONAL INFORMATION THAT YOU CAN DO ALL OF THAT.
YOU KNOW HOW TO CLEAN THINGS. YOU KNOW THAT CENTRAL LINES --
YOU BETTER BE THINKING ABOUT A MASK. YOU KNOW ALCOHOL BEFORE BETADINES.
YOU KNOW STERILE TECHNIQUE PRINCIPLES.
SO, YOU REALLY KNOW ENOUGH TO PRACTICE IV SAFELY,
ONCE YOU GET DONE WITH THIS MATH TEST.
SO, YOU'LL BE PASSING THOSE MEDS NEXT WEEK.
JUST KEEP SYSTEMATIC AND THAT'S THE THING.
YOU GUYS DID A GREAT JOB YESTERDAY.
THE AGE OF TECHNOLOGY. YOU LIKE THOSE PUMPS.
YOU JUST DIAL THEM UP, LET'S GET ON WITH IT. THAT'S SWEET.
SO, EVEN THOUGH YOU LOVE PUMPS AND TECHNOLOGY,
DON'T FORGET THE OTHER STUFF
BECAUSE HONESTLY, HONESTLY, THERE ARE ENVIRONMENTS
WHERE YOU REALLY ARE DOING DRIPS AND THERE AREN'T PUMPS.
AND SOMETIMES YOU'RE GRIPPING TILL YOU CAN GET A PUMP,
AND SO YOU STILL HAVE TO HANG ON TO THOSE PRINCIPLES OF SAFE ADMINISTRATION.
SO, ALRIGHT, HERE WE GO WITH NEW MODULES.
AND I THINK EVERY MODULE FROM NOW ON IS A ONE-WEEK MODULE.
SO BLACKBOARD IS BACK ON YOUR AGENDAS AS FAR AS REVIEW
AND GETTING BACK INTO THE TEXT AND SO FORTH.
SO, THIS WEEK WE'RE DOING WOUND CARE AND I THINK YOU'LL ENJOY IT.
IT WILL KIND OF BE A REPRIEVE BECAUSE THERE WILL BE A LOT OF PRINCIPLES
THAT ARE SIMILAR TO WHAT WE'VE DONE.
WE'RE KIND OF PUTTING IT ALL TOGETHER.
LAST SEMESTER WE TALKED ABOUT STAGE I AND STAGE II WOUNDS
AND WE LOOKED AT SOME CARE FOR THEM.
SO THIS SEMESTER, WE'RE GOING TO FOCUS ON STAGE III, STAGE IV AND SURGICAL TYPE WOUNDS.
SO, I WANT TO GIVE YOU SOME INFORMATION PERTINENT TO THOSE PARTICULAR KIND OF WOUNDS,
AND THEN I'LL DO THE TWO WOUNDS THAT YOU'RE GOING TO DO FOR TESTING.
I HOPE THAT YOU INVESTED AND GOT YOURSELF SOME PURPLE BOOKS,
OR YOU GOT ONLINE TO GET YOUR PRESSURE ULCER BOOKS.
YOU'RE ALL LOOKING AT ME, LIKE, "OH, MAN! CAUGHT AGAIN."
SO, YOU REALLY NEED TO DO THAT. I PUT IT IN YOUR SYLLABUS.
I BELIEVE I PUT IT IN YOUR SYLLABUS.
AND THIS IS THE HH CPR BOOK.
AND THE WEBSITE... I'LL REPOST IT. HOW ABOUT THAT?
I WILL JUST PUT IT ON THE ANNOUNCEMENTS SO YOU CAN GET ONLINE TO GET YOUR BOOKS.
ALL YOU HAVE TO DO IS -- YOU CAN GET THE --
YOU CAN DOWNLOAD THE BOOK OFF THE INTERNET
OR YOU CAN CALL THEM AND YOU CAN GET FREE BOOKS.
THERE'S THE TWO BOOKS THAT ARE FOR THE...CLIENTS
AND THEN TWO BOOKS FOR THE CLINICAL PRACTICE.
AND THERE ARE THE GUIDELINES THAT GOVERN WOUND CARE FOR OUR PROFESSION.
I MEAN, THEY ARE THE CLINICAL GUIDELINES FOR US.
SO THEY'RE A REALLY IMPORTANT BOOK TO KNOW. QUICK REFERENCE.
AND A LOT OF WHAT WAS IN YOUR TEXT WAS REFERENCED TO THESE PURPLE BOOKS.
SO I WAS REALLY PLEASED WITH THE UPDATE ON THE WOUND CARE.
THAT IT'S CONSISTENT WITH WHAT THE STANDARD OF CARE IS.
SO, BRIEF REVIEW. WHAT IS A STAGE III WOUND?
WELL, LET'S JUST START FROM THE BEGINNING. STAGE I?
RED. BUT SKIN IS INTACT.
STAGE II?
VERY SUPERFICIAL. JUST SKIN HAS BEEN BROKEN.
WHAT'S STAGE III?
FULL THICKNESS SKIN LOSS.
SO, YOU'RE GETTING DOWN INTO THE SUBCUTANEOUS TISSUE
AND IT CAN GO THROUGH, BUT NOT --
I MEAN, IT CAN GO TO, BUT NOT THROUGH THE UNDERLYING FASCIA.
THAT'S STAGE IV, WHEN IT STARTS GETTING INTO MUSCLE, BONE AND THAT KIND OF TISSUE.
SO, DISTINGUISHING BETWEEN THE TWO.
ON HERE, I JUST WANTED TO POINT OUT A COUPLE OF THINGS...
RELATED TO ASSESSING THESE WOUNDS.
WHEN YOU ASSESS A WOUND, REMEMBER THAT YOU DETERMINE ITS STAGE BY THE BASE OF THE WOUND.
SO IF YOU CAN'T SEE THE BASE OF THE WOUND, YOU CAN'T STAGE THE WOUND.
WHICH MEANS IF THEIR SLOUGH -- WHAT'S SLOUGH?
THIS YELLOWY STUFF, OKAY?
DEBRIS ON THE SKIN.
IF THERE'S NECROSIS.
IF YOU SAW THIS WOUND, WHAT STAGE IS IT?
YOU CAN'T STAGE IT COS YOU CAN'T SEE IT THE BASE.
SO, IT'S UNSTAGEABLE, UNABLE TO SEE BASE.
AND THAT'S ALL YOU WOULD SAY, STAGE UNDETERMINED.
YOU CAN MEASURE IT. HOW DO YOU MEASURE A WOUND?
LENGTH IS...ALWAYS HEAD TO TOE
ON THE PERPENDICULAR, NOT ON THE DIAGONAL.
ALWAYS THE LONGEST PLACE. UP AND DOWN, HEAD TO TOE.
AND THEN WIDTH IS ALWAYS ON THE HORIZONTAL PLANE.
NOT, AGAIN, PERPENDICULAR, BUT THE WIDEST PLACE HORIZONTALLY.
AND DEPTH, YOU PROBE WITH A CUE TIP.
CUE TIP? THAT'S THE WHOLE TRADE NAME APPLICATION
AND YOU WOULD WANT TO USE THE...CLOTH END
AND PROBE IT TO SEE HOW DEEP IT IS.
ALRIGHT, ON MR. SEYMORE. YOU'RE FAMILIAR WITH SEYMORE.
THIS IS HIS STAGE III WOUND, OKAY?
LET'S TALK ABOUT THIS STAGE III WOUND A LITTLE BIT
COS WE'RE GOING TO HAVE TO DESCRIBE THESE.
AND THIS IS WHAT'S GOING TO HAPPEN, THAT'S WHY I'M STARTING WITH DESCRIBING WOUNDS.
YOU'RE ACTUALLY GOING TO BE MEASURING THE SYEMORE BUTT, INSTEAD OF THE CLIENT.
OUR BEDS GET TOO BOGGED DOWN IF WE SIT THERE AND MEASURE, MEASURE.
SO WHEN IT'S TIME TO MEASURE ON THE CLIENT YOU JUST SAY, "I'VE MEASURED."
BUT I'M GOING TO SEND YOU BACK TO THE TABLE AND YOU'RE GOING TO DRAW --
AND WE'RE JUST GOING TO HAND YOU A RANDOM WOUND AND YOU'RE GOING TO GO MEASURE.
IT'LL BE ANYTHING AND ANY COMBINATION ON MR. SEYMORE.
ALRIGHT. SO, IF YOU CAME TO DESCRIBE
AND MEASURE THIS STAGE III WOUND...
YOU'RE GOING TO MEASURE FROM TOP TO BOTTOM.
WHAT ARE YOU GOING TO MEASURE IN?
- CENTIMETERS. - CENTIMETERS.
ALWAYS. NOT INCHES. WHERE'S MY MEASURING TAPE?
CENTIMETERS ALWAYS. AND I'M JUST GOING TO REVIEW THIS.
I DON'T MEAN TO BE INSULTING, BUT I HAVE YET TO GET THROUGH A SEMESTER
WHERE PEOPLE DIDN'T SAY THIS WAS 30CM.
YOU KNOW WHAT 30CM WOULD LOOK LIKE?
WHERE'S MY 30?
30. THAT'S 30CM.
THAT'S A HUGE, BIG DIFFERENCE, RIGHT?
SO WHAT IT MEANS WHEN YOU GET ON THIS TAPE,
WHEN IT SAYS THE TEN, THAT'S MILLIMETERS.
THE LITTLE MARKINGS IN BETWEEN.
SO IT'S 1CM, 10MM.
SO JUST BE CLEAR ON THAT BECAUSE IF YOU MEASURED IT AND YOU SAY, "I HAVE 30CM."
THEN I JUST MARK IT WRONG, BECAUSE THIS IS THE SIZE OF YOUR WOUND
VERSUS THIS LITTLE TEENY GUY, OKAY?
SO UP AND DOWN. YOU FIND THE WIDEST PLACE
AND THEN YOU MARK IT.
SO, LIKE, 3.5 AND THEN BY THE WIDTH, BY 3.
THEN YOU PROBE THE DEPTH AND YOU FIND THE DEEPEST PLACE.
AND I JUST MARK IT WITH MY FINGER NAIL.
YOU CAN TELL BY PROBING AROUND IT, IF IT GOES ANY PLACE ELSE.
TOUCHES IT AND YOU NEED TO GO UP A LITTLE HIGHER.
SO ONCE YOU'VE MARKED IT, THEN YOU COME OVER HERE AND YOU FIND YOUR 0.5.
REMEMBER THAT YOU MEASURE WOUNDS ONCE A WEEK,
NOT EVERY SHIFT AND NOT EVERY DAY.
TOO MANY MEASUREMENTS CAUSE TOO MANY DISCREPANCIES.
SO, ESPECIALLY IN NURSING HOMES AND IN CHRONIC CARE.
LIKE, MONDAY IS WOUND MEASUREMENT DAY.
IN ACUTE CARE, THEY'RE GOING TO MEASURE THE WOUNDS ON ADMISSION
AND THEN MAYBE WITH DRESSING CHANGES.
IF IT'S A DRESSING, LIKE A HYDROCOLLOID THAT YOU'RE DOING EVERY FIVE TO SEVEN DAYS.
BECAUSE IT GETS YOU OFF SYNC, SO YOU CAN'T STAY TRUE TO THE EVERY SEVEN DAYS,
AND YOU DON'T WANT TO RIP THE DRESSING OFF AFTER ONE DAY
JUST COS IT'S WOUND MEASURE DAY.
SO YOU WOULD HIT IT, YOU KNOW, IN AN APPROPRIATE CYCLE.
THE OTHER THING THAT'S REALLY KEY ABOUT MEASURING WOUNDS
IS THAT YOU WANT THE SAME PERSON WHEN POSSIBLE TO DO IT,
AND YOU WANT THE CLIENT TO BE IN THE SAME POSITION WHEN IT'S MEASURED.
IF SOMEONE MEASURES THEM, KIND OF, TWEAKED ON THE SIDE,
COS THAT'S WHERE THEY ARE AT THE MOMENT,
AND THEN SOMEONE ELSE GETS THEM TURNED ALL NICE AND STRAIGHT,
AND SOMEONE ELSE TURNS THEM ANOTHER WAY,
THAT AFFECTS HOW THE WOUND IS MEASURED AS WELL,
AND SO YOU GET INCONSISTENCY.
SO IT LOOKS LIKE THE WOUND'S GETTING BETTER ONE WEEK AND THEN IT'S WORSE ONE WEEK.
AND IT HAS EVERYTHING TO WITH THE PEOPLE, NOT THE CLIENT.
AND SO YOU'RE NOT GETTING GOOD INDICATIONS.
AS WELL AS MEASURING THE WOUND, YOU HAVE TO DESCRIBE THE WOUND.
SO YOU WANT TO LOOK AT THE BASE OF THE WOUND,
YOU WANT TO DESCRIBE EVERYTHING YOU'RE SEEING
AND YOU WANT TO DESCRIBE IT TO THE CLOCK.
SO THE HEAD BEING 12 O'CLOCK, FEET 6 O'CLOCK AND SO FORTH.
SO, IF YOU'RE LOOKING AT THIS WOUND,
IT LOOKS LIKE FROM 9 O'CLOCK TO 3 O'CLOCK.
IT'S RED, BEEFY GRANULATION TISSUE.
RIGHT? DOES THAT, KIND OF, PAINT A PICTURE IN YOUR MIND?
THEN FROM 3 O'CLOCK TO 9'CLOCK, IT'S YELLOW SLOUGH.
YOU ALSO WANT TO SAY A PERCENTAGE OF SLOUGH,
BECAUSE THAT WILL DETERMINE WHAT KIND OF DRESSINGS WE DO.
IF MORE THAT 50% OF THE WOUND BASE IS SLOUGH OR NECROSIS,
THEN WE MAY DO SOME MECHANICAL TYPE DEBRIDEMENT.
LIKE A WET TO DRY DRESSING.
WE PUT IN A MOIST DRESSING AND WE LET IT DRY
AND THEN YOU RIP IT OFF AND THAT RIPS OFF THE DEAD TISSUE.
IT'S CALLED MECHANICAL DEBRIDEMENT.
SO THAT THE WOUND BASE WILL HEAL.
BUT MECHANICAL DEBRIDEMENT IS INDISCRIMINATE.
IT DRIES ON GOOD TISSUE AND BAD TISSUE,
SO WE WANT TO MAKE SURE THAT MORE THAN 50% OF THE WOUND BASE IS SLOUGH,
SO THAT WHEN YOU'RE RIPPING IT UP,
YOU'RE ACTUALLY HELPING MORE OF THE WOUND BED THAN HURTING MORE OF THE WOUND BED.
IF THE WOUND BED IS 60-70% GRANULATION TISSUE AND A LITTLE POCKET OF SLOUGH,
THEN WE'RE NEVER GOING TO DO THAT MECHANICAL DEBRIDEMENT.
IT'S TOO HARD ON THE TISSUE AND IT WRECKS THOSE GOOD FIBROBLASTS
THAT CAUSE GRANULATION HERE. THAT RED, BEEFY TISSUE.
YOU DON'T WANT TO MESS THAT UP.
SO, IN JUST DESCRIBING THE WOUND,
LOOK AT PERCENTAGE SO THAT YOU KIND OF GET AN IDEA
OF WHAT KIND OF TREATMENT IS MOST APPROPRIATE FOR THAT CLIENT.
YOU'RE GOING TO BECOME THE WOUND EXPERT.
AS WELL, YOU'RE GOING TO LOOK AT THE TISSUE AROUND THE WOUND.
THE PERI-WOUND SKIN. AND YOU WANT TO DESCRIBE THAT.
BECAUSE IT'S REAL IMPORTANT THAT WE'RE NOT CAUSING THAT TO BREAKDOWN AS WELL.
ONE OF THE THINGS THAT HAPPENS IN WOUND CARE
IS THAT WE CREATE THIS NICE, MOIST ENVIRONMENT
WHICH IS PERFECT FOR WOUND HEALING,
BUT IF IT ABSORBS TOO MUCH DRAINAGE AND IT GETS ON TO THIS OUTER TISSUE,
IT CAN BEGIN TO BREAK IT DOWN AND MACERATE THAT TISSUE
AND WE BEGIN TO CAUSE MORE PROBLEM THAN WE'RE SOLVING.
AND SO YOU NEED TO WATCH YOUR DRESSINGS.
IF YOUR DRESSING IS A NICE, MOIST DRESSING AND YOU SET IT UP GOOD
AND IT SHOULD LAST THREE TO FIVE DAYS,
BUT IN 24 HOURS YOU'RE STARTING TO GET WHAT WE CALL A STRIKE THROUGH.
DRAINAGE IS COMING THROUGH TO THE TOP.
THEN IT NEEDS TO BE CHANGED.
IT'S NOT GOING TO HOLD ALL OF THAT DRAINAGE FOR THREE TO FOUR DAYS
WITHOUT GETTING ONTO THIS NICE, INTACT TISSUE.
SO TO DESCRIBE THIS, WE GOT OUR MEASUREMENTS, WE'VE GOT ABOUT --
ACTUALLY IT LOOKS LIKE THE SLOUGH GOES FROM ABOUT 3 O'CLOCK TO 7 O'CLOCK.
IF I WAS LOOKING MORE ACCURATELY.
AND I WOULD SAY 35-40% OF THE WOUND BED IS SLOUGH.
JUST -- I MEAN, IT'S SUBJECTIVE
AND YOU'RE JUST MAKING AN ESTIMATE HERE IN DESCRIPTION.
- SO WHAT WOULD YOU DO FROM THE 7 TO 9?
- THEN I WOULD SAY FROM 7 TO 3 IS RED, BEEFY GRANULATION TISSUE.
I JUST WASN'T GETTING A GOOD VIEW OF IT.
OH, SO IF YOU'RE TREATING THIS. I'M GOING TO TALK ABOUT THAT IN A MINUTE.
SOME WOUND CARE OPTIONS. HOW DO WE GET RID OF SLOUGH AND
HOW WE'RE GOING TO DEBRIDE IT AND SO FORTH? BUT...DESCRIBE IT.
ALRIGHT, ONCE IT'S DESCRIBED, YOU'RE GOING TO CHART THAT.
I'LL TALK ABOUT THAT IN A MINUTE.
BUT I WANT TO MOVE ON TO GIVE YOU SOME OTHER IDEAS
OF SOME THINGS YOU NEED TO LOOK AT.
STAGE IV WOUND.
THE STAGE IV WOUND HAS GONE DOWN AND IT'S PASSED THROUGH THE FASCIA
INTO THE MUSCLE AND IT'S GONE DOWN INTO SOME BONE.
SO, WE KNOW WE'VE GOT A PRETTY DEEP WOUND HERE.
SAME MEASUREMENTS. YOU'RE GOING TO GO FROM THE SKIN TO SKIN.
SKIN TO SKIN...HERE.
AND THE REASON I'M SAYING SKIN TO SKIN
IS BECAUSE WE'VE GOT SOME TUNNELING GOING ON HERE.
OKAY? WE GOT A LIP.
SO YOU'RE GOING TO MEASURE AND THEN WHEN YOU MEASURE DEPTH,
YOU'RE GOING TO MEASURE DEPTH,
THEN YOU'RE ALSO GOING TO CHECK FOR TUNNELING.
AND PROBE TO THE DEEPEST PLACE.
AND IT GETS A LITTLE DEEPER HERE.
ALL MEDICARE, ALL CHARTS WANT TO KNOW IS WHERE THE DEEPEST PLACE IS.
SO YOU CAN SAY THAT THERE'S TUNNELING
FROM THE FULL CIRCUMFERENCE OF THE WOUND,
WHICH IS INDEED THE TRUTH HERE.
OR THAT THERE'S MAYBE A TUNNEL OR UNDERMINING --
ACTUALLY, THIS IS UNDERMINING FROM 12 TO 6 O'CLOCK.
OKAY, SO YOU PROBE FOR THIS LIP.
AS WELL, YOU WANT TO PROBE TO MAKE SURE THERE'S NO TUNNELS
OR SINUS TRACKS. AND I KNOW THERE IS ONE HERE.
AND WHOA! ALL OF A SUDDEN, IT GOES IN WAY FAR.
AND YOU LOOK AND THERE'S A TUNNEL IN HERE.
SO YOU HAVE TO MEASURE THE TUNNEL WHICH IS AT 9 O'CLOCK.
OKAY? AND THEN I -- IT WENT TO ABOUT HERE,
AND SO I WOULD GET MY MEASUREMENT AS WELL.
AND I THINK THERE'S ONE UP HERE.
OKAY, SO YOU'RE HUNTING --
THIS ONE HAS EVERYTHING THAT COULD POSSIBLY BE IN A WOUND.
IT CAN BIGGER OR SMALLER, BUT IT'S GOT IT ALL.
ALRIGHT, SO YOU PROBE TO GET ALL YOUR MEASUREMENTS.
YOU'VE GOT A TUNNEL, SINUS TRACK UP HERE AT...
ONE O'CLOCK. YOU'VE GOT ONE OVER HERE AT 9 O'CLOCK.
YOU'VE GOT A BONE IN THE CENTER, YOU'VE GOT SLOUGH,
YOU'VE GOT RED, BEEFY GRANULATION TISSUE
AND YOU'VE GOT UNDERMINING.
WHOA! OKAY. SO LET'S TALK ABOUT THAT.
YOU KNOW HEAD TO TOE. YOU KNOW WIDTH. YOU KNOW PROBE.
YOU'RE GOING TO SAY THAT --
IT LOOKS TO ME LIKE 50% OF THE WOUND BASE IS COVERED WITH SLOUGH.
RIGHT? FROM 12 O'CLOCK TO 6 O'CLOCK.
YOU KIND OF AGREE WITH THAT.
YELLOW, MAYBE EVEN A LITTLE GREENISH SLOUGH.
AND THEN YOU HAVE RED, BEEFY GRANULATION TISSUE
FROM 6 O'CLOCK TO 12 O'CLOCK.
THEN IN THE CENTER OF THE WOUND,
YOU HAVE A TRIANGULAR SHAPED BONE.
AND AGAIN YOU'RE JUST GOING TO TAKE A MEASUREMENT ACROSS.
AND GET THE DESCRIPTION. YOU HAVE TO DESCRIBE EVERYTHING.
WHAT'S INTERESTING ABOUT THIS WOUND
IS AS CRUMMY AS THIS WOUND IS ON THE INSIDE,
THE SKIN AROUND IT IS BEAUTIFUL.
THE SKIN IS INTACT WITHOUT REDNESS OR DRAINAGE, IS WHAT I WOULD SAY.
AS OPPOSED TO THIS ONE,
HAS ABOUT...0.3CM OF REDNESS.
A PERI-WOUND OR FULL CRICUM -- CIRCUMFERENCE OF THE WOUND.
SO, YOU'RE JUST DESCRIBING WHAT YOU'RE SEEING.
ONE OF THE BEST THINGS TO DO IS TAKE A PICTURE.
WHENEVER YOU TAKE A PICTURE AND I THINK I MENTIONED IT IN THE FIRST SEMESTER,
IS ALWAYS PUT A MEASURING DEVICE IN THE PICTURE.
SO THAT IT LAYS LIKE THIS AND PEOPLE HAVE PERSPECTIVE.
BECAUSE WHEN SHANNON TAKES A PICTURE, SHE LIKES CLOSE-UPS
AND SHE'S GOING TO GET RIGHT DOWN HERE
AND IT'S GOING TO LOOK BIG IN THE PICTURE.
BUT I DON'T LIKE THE SMELL, SO I STAND RIGHT BACK THERE WITH TOM.
YOU KNOW WHAT I'M SAYING? SO PEOPLE GET DIFFERENT VIEW POINTS OF THE CAMERA.
AND SO YOU HAVE TO HAVE A POINT OF REFERENCE HERE
TO SHOW IF THE WOUND IS GETTING BETTER OR WORSE.
SO ALL PICTURES SHOULD HAVE A MEASURING DEVICE IN THEM.
PICTURES VARY, THEY MAY TAKE THEM ONCE A WEEK
OR EVERY TWO TO THREE WEEKS DEPENDING ON THE PROGRESS.
ONE OF OUR RULES OF THUMB RELATED TO WOUND CARE
IS THAT IF THE WOUND ISN'T GETTING BETTER IN TWO TO THREE WEEKS,
THEN WE CHANGE THE TREATMENT THAT WE'RE USING ON THE WOUND.
AND IF IT DOESN'T GET BETTER AFTER THE SECOND OR THIRD CHANGE,
THEN WE USUALLY CLASSIFY IT A NON-HEALING WOUND.
WE'VE DONE ALL WE KNOW TO DO
AND IT'S NOT GETTING BETTER, THERE'S USUALLY A REASON.
WHAT MIGHT BE SOME REASONS WHY A WOUND DOESN'T GET BETTER?
- NUTRITIONAL.
- PROTEIN NUTRITIONAL STATUS IS NOT GOOD.
MAYBE THEY'RE DYING AND WE'RE CONTAINING DRAINAGE,
JUST SO THAT THEY'RE NOT LAYING IN THEIR DRAINAGE,
BUT IT'S NOT GOING TO GET BETTER. WHAT ELSE?
- WHAT ABOUT NECROSIS AND BACTERIA.
- BACTERIA AND INFECTION.
- PARAPLEGICS WHO ARE CONSTANT.
- NOT RELIEVING THE PRESSURE. HMM-MM.
AND THEIR BLOOD COUNT. THEY JUST MAYBE --
THEY MAY BE ANEAMIC. THEY MAY NOT HAVE A GOOD CIRCULATION HAPPENING.
AND SO THERE'S A LOT OF REASONS WHY IT MIGHT NOT BE HEALING.
AND SO WE NEED TO BE AWARE OF THOSE
SO THAT WE CAN GET THE RIGHT THINGS HAPPENING.
YOU MAY NEED TO GET A DIETICIAN IN THERE
TO DO A NUTRITIONAL CONSULT.
YOU NEED TO MAKE SURE THEY'RE ON PRESSURE RELIEF.
LOOK AT THEIR TURNING SCHEDULE.
WHAT'S HAPPENING THAT THIS ISN'T GETTING BETTER?
CULTURING. LET'S TALK BRIEFLY ABOUT CULTURING.
WHAT DO YOU KNOW ABOUT CULTURING WOUNDS?
WE DON'T DO IT. HARDLY AT ALL
BECAUSE THEY'RE ALL GOING TO HAVE THEIR OWN FLORA ON THEM
AND THEY ALL HAVE A LOT OF BACTERIA.
SO, WHAT THEY HAVE TO DO ARE BIOPSIES.
THE DOCTOR HAS TO DO A BIOPSY OF THE WOUND
TO GET A GOOD CULTURE TO SEE WHAT'S GOING ON
AS WELL AS THEY'LL DO A BLOOD CULTURE.
AND THEN THEY'LL TREAT BOTH SYSTEMICALLY AND TOPICALLY TO TREAT --
AND IF THEY DO SOMETHING TOPICALLY,
IF THEY USE DIFFERENT KINDS OF...
RINSES LIKE ACIDIC ACID OR SOMETHING TO GET RID OF THE BACTERIA,
JUST MAKE SURE THAT PEOPLE ARE KEEPING TRACK
AND WE'RE NOT USING THAT SAME THING FOR MORE THAN TWO WEEKS.
IT NEEDS TO GO BACK TO A PLAIN SOLUTION OF JUST SODIUM CHLORIDE.
WHAT'S THE BASIC RULE FOR IRRIGATING A WOUND, FOR CLEANSING A WOUND?
ACTUALLY, THERE'S TWO BASIC RULES.
- CLEANEST TO DIRTIEST.
WHAT YOU WANT TO BE CLEANEST. I ALWAYS THINK THE WOUND IS DIRTIEST.
DOES IT SEEM DIRTY COS IT'S BLEEDY AND UGLY, KIND OF.
AND YOU JUST KIND OF GO "URGH."
BUT THAT'S WHAT YOU WANT TO BE CLEANEST
SO YOU CLEAN FROM WHAT YOU WANT CLEANEST OUT.
MAYBE NOT WHAT YOU THINK IS DIRTIEST.
IT MAY LOOK NICE AND CLEAN OUT HERE,
BUT YOU DON'T WANT TO SCRUB ALL THAT INTO THE WOUND THAT YOU WANT TO BE CLEAN.
BETWEEN EVERY DRESSING CHANGE, A WOUND MUST BE CLEANED.
IT MUST BE RINSED WITH SOMETHING.
WHETHER IT'S WATER, SODIUM CHLORIDE...
OR A WOUND CLEANSER THAT'S BEEN APPROVED FOR WOUND CLEANSING.
THEY HAVE TO -- THE SKIN HAS TO BE CLEANED
SO THAT YOU'RE GETTING RID OF THE MICROBES AND THE BACTERIAS.
OKAY.
- HOW WOULD YOU DESCRIBE THAT LARGE WOUND.
THE STAGE I WOUND.
- THIS? - NO, THE ONE IN THE BACK.
YEAH. - STAGE IV?
- THE RASH?
- OH. I'M GOING, "WHAT? I JUST..."
OKAY. THIS IS ACTUALLY A FUNGAL INFECTION.
AND I WOULD SAY THAT IT'S RED,
AND IT COVERS THE ANUS INTO BOTH GLUTEI FOLD --
OR OUTSIDE THE GLUTEAL FOLDS AND THEN I WOULD JUST MEASURE IT.
HOT, BEEFY RED.
THIS NEEDS AN ANTI-BACTERIAL LIKE MYCOSTATIN OR SOMETHING ON THERE.
FUNGAL TO TREAT THAT.
- WOULD YOU MEASURE IT UP AND DOWN?
- UH-HUH. YEAH.
SAME MEASUREMENTS AS BEFORE. I WOULD JUST GO --
IT EXTENDS FROM -- YOU MIGHT WANT TO SAY...
HALF OF -- HALF A CENTIMETER.
0.5CM ABOVE THE GLUTEAL FOLD
TO THE PERINEUM.
WHAT'S A PERINEUM?
- THE AREA BETWEEN...
- THE LITTLE BIT OF SKIN BETWEEN THE ANUS AND THE VAGINA OR THE SCROTUM.
SO YOU CAN JUST START PICKING LANDMARKS
THAT GIVE THE BEST DESCRIPTION OF WHAT YOU'RE SEEING.
AND THEN...LAY HERE AND JUST MEASURE.
- SO YOU WOULDN'T PUSH DOWN.
- NO, I WOULDN'T PULL IT.
AND YOU CAN SAY THAT WITH BUTTOCKS AT REST
OR, YOU KNOW, JUST TAKE A PICTURE AS WELL,
AND LAY YOUR MEASURING DEVICE HERE SO THAT THEY CAN SEE.
BUT JUST DESCRIBE THAT IT GOES DOWN INTO THE BUTTOCKS, GLUTEAL FOLDS.
WHICH IT DOES.
OKAY.
LET'S TALK ABOUT TREATMENTS A LITTLE BIT.
HOW DO WE DRESS THESE WOUNDS?
DOCTORS TYPICALLY ORDER THE FIRST ROUND OF TREATMENT,
BUT SOMETIMES THEY'LL SAY, "WHAT DO YOU THINK?"
AND YOU'RE LIKE, "NO. I DON'T KNOW."
SO, REMEMBER I GAVE YOU THAT SHEET OF PAPER LAST SEMESTER
THAT HAD FIRST LINE, SECOND LINE, THIRD LINE CHOICES.
A GOOD PIECE OF PAPER TO KEEP.
BUT I THOUGHT YOU MIGHT NOT HAVE KEPT IT.
SO IN YOUR BOOK, IN YOUR SYLLABUS, I GAVE YOU A NEW ARTICLE
THAT I THOUGHT WAS JUST ABSOLUTELY WONDERFUL
AND THEY'RE ALL IN THE BOOK. TO BE PERFECTLY HONEST.
SHARPEN YOUR WOUND ASSESSMENTS SKILLS.
TOPICS ABOUT HOW TO ASSESS.
AND -- OH, I GAVE YOU A T-TUBE. THAT'S NICE.
I TALKED ABOUT THE DISINFECT SPRAY ONE.
WOUND CARE, I BELIEVE HAS A CHART IN IT.
DOES IT? DID SOMEONE FINALLY FIND THE PAGE?
I'M STILL SEARCHING. AH! THERE IT IS.
THAT TALKS ABOUT ALL THE DIFFERENT KINDS OF PRODUCTS,
WHAT THEY'RE BEST UTILIZED FOR
AND HOW LONG YOU CAN EXPECT TO PUT THEM ON A WOUND.
BECAUSE ISN'T THAT A TRICKY THING?
DO I CHANGE THIS ONE EVERY 24 HOURS?
AND IS THIS ONE A FIVE DAY?
AND HOW OFTEN DO I RINSE THIS OUT? AND SO FORTH.
AND SO IT'S A WONDERFUL GUIDE.
AND SO IF YOU CAN FIND THE ONE I GAVE YOU,
THAT KIND OF GIVES YOU A FIRST, SECOND, THIRD CHOICE TO BE THINKING,
BUT THIS ONE GIVES YOU SOME IDEAS OF PRODUCTS
THAT YOU MIGHT WANT TO CHOOSE.
BECAUSE YOU'RE GOING TO BE THE ONE THAT CALLS AND SAYS,
"YOU KNOW, THE CLIENT'S BEEN USING HYDROCOLLOIDS FOR A MONTH IN HIS HOUSE,
AND THIS WOUND LOOKS BAD. WHAT DO YOU THINK ABOUT TRYING A CALCIUM ALGINATE?"
AND THE DOCTOR GOES, "OKAY."
SERIOUS. THEY WANT TO HEAR WHAT YOU HAVE TO SAY.
OR YOU CAN GET AN OSTOMY NURSE,
AN INTRASTROMAL THERAPIST TO COME IN AND GIVE RECOMMENDATION AS WELL
AND THAT'S AN EXCELLENT CHOICE.
I WANT TO INTRODUCE A COUPLE OF CONCEPTS.
LET'S JUST TALK ABOUT THIS STAGE III WOUND.
THE IDEA IS THAT WE'RE MAINTAINING A MOIST ENVIRONMENT.
AND WE WANT A WOUND DRESSING THAT'S GOING TO COVER THIS
AND NOT LEAVE ANY SKIN EXPOSED TO AIR.
BECAUSE WHEN AIR GETS TO IT, THAT'S WHAT DRIES IT UP.
SO COULD YOU PUT A HYDROCOLLOID DRESSING ON THIS ONE?
ONE OF THOSE LITTLE PATCH -- BROWN PATCHES.
[ALL TALKING AT ONCE]
- YEAH, IT MAY NOT TOUCH.
SO REMEMBER WHEN WE TALKED ABOUT THE HYDROCOLLOID PASTE
THAT YOU COULD FILL IT UP WITH?
IT'S LIKE A TOOTHPASTE, BUT IT'S LIKE --
IT'S JUST HYDROCOLLOID GEL. YOU CAN FILL UP THIS WOUND WITH THE GEL,
THEN PUT THE HYDROCOLLOID ON AND YOU'VE SERVED THE SAME PURPOSE.
IT'S A WONDERFUL PRODUCT AND THAT'LL KEEP --
THAT'LL KEEP THE WOUND EDGES INTACT COS IT STICKS,
BUT IT'LL ALSO ABSORB A LITTLE DRAINAGE
AND IT'LL GIVE YOU A GOOD FILL.
A SECOND FAVORITE PRODUCT WITH THESE STAGE III
AND STAGE IV WOUNDS IS CALCIUM ALGINATE.
THIS CALCIUM ALGINATE HAPPENS TO BE IN A ROPE FORM,
BUT IT ALSO COMES IN SQUARES.
AND IT COMES IN SMALL SQUARES OR BIG SQUARES.
AND CALCIUM ALGINATE, IT LOOSELY DESCRIBED IS JUST A SEAWEED PRODUCT.
IT'S KIND OF GRASSY AND SEAWEEDY.
YOU CAN PASS IT AROUND.
AND WHAT YOU DO IS, FIRST OFF YOU HAVE TO KNOW
THAT IT CAN ONLY BE PUT IN A WOUND THAT IS DRAINY.
BECAUSE THAT'S ITS JOB, IS TO ABSORB THE DRAINAGE
AND THAT'S WHAT ACTIVATES THE CALCIUM.
SO YOU WOULD JUST TUCK THIS IN, DRY.
IT STARTS TAKING ON THE WOUND DRAINAGE
AND YOU CAN JUST CLIP IT UP AT ANY POINT.
DON'T WANT IT TOO TIGHT BECAUSE NEED TO ALLOW IT
TO EXPAND ONCE THE MOISTURE HAS HIT IT.
THEN YOU CAN PUT A -- LIKE A LITTLE SQUARE OF TELFA
AND THEN A TRANSPARENT DRESSING ON.
AND THAT WILL HOLD THAT IN PLACE.
AND THIS CAN ACTUALLY STAY...
FOR 12 HOURS, 24 HOURS UP TO 5 DAYS
DEPENDING ON HOW MUCH WOUND DRAINAGE THERE IS.
BECAUSE REMEMBER WHAT I TOLD YOU,
IF IT STARTS TO STRIKE THROUGH AND IT'S STARTING TO BLEED OUT,
THEN YOU NEED TO CHANGE IT BECAUSE YOU'VE GOT TOO MUCH DRAINAGE.
THIS IS GOING TO ABSORB ABOUT, AT LEAST TWICE AS MUCH OF ITS OWN --
THE SPACE THAT'S WHAT'S THERE.
SO IT'LL TAKE ON QUITE A BIT OF DRAINAGE
AND THEN STAY LOCALIZED TO THE WOUND BED AREA.
YOU WANT TO KEEP THIS AREA NICE AND CLEAN.
IF I WAS PACKING THIS WITH CALCIUM ALGINATE,
I WOULD PROBABLY GET A SKIN PREP
AND PUT A SKIN BARRIER ALL ALONG HERE
SO THAT IF DRAINAGE COMES ONTO THE SKIN, IT PROTECTS THE SKIN.
IT ALSO IS GOING TO SEAL THIS OFF.
AND THEN WHAT HAPPENS IS SOMETHING CALLED AUTOLYSIS.
THE CLIENT PRODUCES HIS OWN FLUIDS AND JUICES,
AND THEY ACTUALLY SELF EAT AWAY THE SLOUGH.
INTERESTING, HUH?
HYDROCOLLOIDS AND CLOSED DRESSINGS CAN CAUSE SOME AUTOLYSIS
THAT WILL THE EAT AWAY SOME OF THIS.
AND THAT WILL BEGIN TO SHIFT OVER.
SO YOU WANT TO START WATCHING THAT IN A WEEK OR TWO
AND SEE IS THE SLOUGH COMING AWAY, IS AUTOLYSIS WORKING?
IF IT'S NOT, THIS WOUND BED IS AT THE 50%,
SO IT'S KIND OF BORDERLINE WHETHER WE DO THE MECHANICAL,
WHICH IS THE WET TO DRY,
BUT THERE'S OTHER MECHANICAL METHODS OF REMOVING SLOUGH.
OKAY? SO WE TALKED ABOUT AUTOLYSIS
AND WE TALKED ABOUT THIS WOUND.
LET ME BACK UP BEFORE I GO. I'LL TALK MORE ABOUT IN DEBRIDEMENT.
BUT, HOW DO YOU GET THIS OUT OF HERE?
TWEEZERS MIGHT WORK, BUT IT ACTUALLY SHREDS IT UP, KIND OF.
IT DOES A COUPLE OF THINGS.
THIS IS AN INTERESTING PRODUCT.
LET ME JUST WET SOME DOWN FOR YOU.
THEN I'LL SEND IT AROUND HERE.
IT ACTUALLY TURNS KIND OF SLIMY, KIND OF LIKE SNOT, REALLY.
AND...
PUT IT IN HERE.
AND AFTER IT'S SET WITH --
IT TAKES A FEW MINUTES. IT KIND OF GELS UP.
IT KIND OF WILL SOMETIMES COME OUT AS ONE UNIT.
I'VE HAD IT JUST KIND OF COME OUT ALL AS ONE PLOP, KIND OF.
BUT OTHER TIMES I'VE HAD TO, LIKE, SCOOP IT OUT,
MAYBE GET SOME APPLICATORS AND KIND OF SCOOP IT OUT.
OR OTHER TIMES, I'VE JUST SIMPLY GOTTEN MY IRRIGATION SYRINGE,
FILLED IT UP AND I IRRIGATED IT OUT.
TILL IT WILL JUST COME OUT AND LOOSEN UP.
IF A DRESSING IS DRY AND STUCK, YOU DON'T JUST RIP IT OFF.
YOU'RE GOING TO HAVE TO SOFTEN IT UP AND WET IT DOWN
SO THAT YOU'RE NOT MECHANICALLY DEBRIDING A WOUND
THAT YOU DIDN'T WANT TO DEBRIDE.
- SO THAT CAN STICK TO THE SORE?
- UH-HUH. IF IT GETS DRIED UP.
WHICH WOULD TELL ME, ONE, WE'RE NOT CHANGING IT ENOUGH
AND MAYBE IT'S NOT THE BEST PRODUCT,
THERE'S NOT ENOUGH DRAINAGE TO KEEP THIS MOIST.
COS MOST OF THE TIMES IT STAYS MOIST AND IT TURNS INTO THIS, KIND OF...
THING. IT'S IN THERE.
OKAY, BUT YOU GOT TO GET IT OUT, AND THAT'S THE WHOLE IDEA.
YOU IRRIGATE IT OUT AND THEN PUT FRESH IN.
OKAY.
LET'S GO BACK AND TALK ABOUT DEBRIDEMENTS
THEN I'LL TALK ABOUT IRRIGATING AND WE'LL BE PRETTY GOOD HERE.
OKAY, MECHANICAL DEBRIDEMENT. I TALKED ABOUT WET TO DRY.
WHAT ELSE MIGHT MECHANICALLY DEBRIDE?
- WATER PRESSURE. - ME. WATER PRESSURE. EXACTLY.
YOU NEED TO KNOW HOW MUCH PRESSURE YOU'RE EXERTING BY YOUR SYRINGES.
THIS IS A PISTON SYRINGE AND IT ACTUALLY HAS A PSI.
POUNDS PER SQUARE INCH OF FOUR TO FIVE.
IS THAT GOOD OR BAD?
YOU WOULD WANT TO KNOW THAT AND IT'S IN THE ARTICLES,
AND IT'S IN THE PURPLE BOOK. SO DON'T BELIEVE ME,
VERIFY EVERYTHING I SAY.
BUT YOU WOULD WANT TO RINSE THIS OUT WITH SOMETHING
THAT HAS A PSI OF NOT MORE THAN 15.
BECAUSE 15 DAMAGES THE FIBROBLAST, THAT GOOD GRANULATED TISSUE,
AND IT ACTUALLY DRIVES THE BACTERIA INTO THE GOOD TISSUE.
THE POINT OF IRRIGATING IS TO CLEAN THE WOUND, NOT TO MAKE IT WORSE.
SO, WHAT THEY RECOMMEND IS A PSI OF 4 TO 5,
IF IT'S NICE, BEEFY, RED GRANULATION TISSUE.
BECAUSE IT'S NOT GOING TO DAMAGE, BUT IT'S GOING TO BE ENOUGH PRESSURE
THAT IT REMOVES THE DEBRIS THAT'S IN THE WOUND.
MAYBE EVEN DEBRIS YOU CAN'T SEE.
BUT NEVERTHELESS, YOU NEED TO GET IT OUT OF THERE.
IF THERE'S DEBRIS IN THE WOUND
AND THERE'S A LITTLE MORE SLOUGH AND STUFF GOING ON,
THEN YOU WOULD WANT TO HAVE A PSI OF ABOUT 15.
HOW DO YOU CREATE A PSI OF 15 WHEN THIS IS THE ONLY SYRINGE YOU KNOW?
OKAY.
WHAT THEY FOUND IS...
IN THEIR PSI RESEARCH...
IS IF YOU'LL GET A 35CC SYRINGE,
AND YOU'LL PUT AN 18 GAUGE CATHETER ON THE SYRINGE,
YOU'LL CREATE A PSI OF ABOUT 8, I THINK.
THAT'S WHAT IT WAS, EIGHT OR NINE.
- ...ONE MORE TIME? - I WILL.
WHEN I GET THIS OUT OF HERE, I'LL SHOW YOU WHAT I MEAN.
YOU'RE GOING TO GET YOUR 35CC SYRINGE,
AND YOU WANT TO KEEP YOUR TIP STERILE.
AND WHAT YOU'RE GOING TO DO IS EITHER GET A BLUNT TIP SYRINGE,
IF THEY HAVE THEM, AND BLUNT TIP IS REALLY KEY.
OR YOU'RE GOING TO GET YOUR IV CATHETER, A NUMBER 18.
THE OVER-THE-NEEDLE CATHETER.
TAKE THE NEEDLE OUT. I'VE LOST MY NEEDLE.
AND THEN CONNECT IT ON.
AND NOW YOU'VE GOT THIS REALLY SOFT LITTLE CATHETER IN HERE.
DRAW UP YOUR STERILE FLUID. AND YOU CAN GET DOWN INTO THIS WOUND,
YOU CAN GET DOWN INTO THOSE TUNNELS,
AND YOU CAN GET EVERYTHING ALL CLEANED UP,
NICE AND EASY WITH THIS SYRINGE.
YOU WANT A SYRINGE THAT'S LARGE ENOUGH,
THAT IT DOESN'T FORCE PRESSURE.
THAT'S WHY THE 35 IS THE MINIMUM
THAT YOU WOULD WANT AS FAR AS SYRINGE SIZE.
BECAUSE IF YOU START GETTING A 10,
YOU START INCREASING THE PRESSURE LOAD INTO THAT NEEDLE.
AND THEN THE GAUGE DOESN'T -- IT CAN'T BE ANY SMALLER THAN 18,
OR THAT AGAIN INCREASES THE PRESSURE LOAD.
ALRIGHT. SO, THAT'S A COOL, LITTLE DEVICE.
THEY HAVE HARD NEEDLES THAT ARE CALLED BLUNT TIP,
WHEN YOU'RE LOOKING AT NEEDLES. AND THEY'RE HARD.
AND THEY JUST DON'T HAVE THAT SHARP NEEDLE
THAT YOU WOULD GIVE AN INJECTION WITH.
AND THEY'LL PROBE INTO SOME OF THESE AREAS AS WELL.
YOU JUST HAVE TO BE A LITTLE MORE CAREFUL
THAT YOU'RE NOT PROBING AND DAMAGING SKIN WITH THAT HARD NEEDLE.
OKAY, SO THAT'S A MECHANICAL METHOD.
YOU CAN ALSO USE WATER PIKS.
INTERESTING, HUH? GET THE OLD WATER PIK OUT.
LET ME JUST TELL YOU ON MY LITTLE GRAPH HERE, ALL THESE PRESSURES.
WATER PIKS. GETTING THERE.
OKAY.
A SPRAY BOTTLE LIKE THIS HAS A PRESSURE OF 1.2.
IT DOES HARDLY ANY CLEANING. IT'S A PURE RINSE.
SO IT'S NOT GOING TO GET DEBRIS OF THAT'S KIND OF STUCK.
THAT'S WHY YOU WANT TO GO UP TO YOUR PISTON SYRINGE.
A BULB SYRINGE LIKE THIS...
ONLY HAS A PRESSURE OF 2.
SO IT'S NOT RECOMMENDED FOR CLEANING WOUNDS EITHER
BECAUSE IT JUST DRIBBLES ON THEM,
IT DOESN'T KNOCK OFF ANY DEBRIS.
SO YOUR PISTON SYRINGE THEN,
PISTON PLUNGER SYRINGE,
IS GOING TO GET YOU UP TO A 4.
SO THE PISTON CATHETER TIP SYRINGE, 4.
A SALINE SQUEEZE BOTTLE.
SORRY, TOM. I'M WALKING AL OVER AND I'M NOT SUPPOSED TO DO THAT.
THAT KEEPS YOU AWAKE AT NIGHT.
THESE LITTLE GUYS DO ABOUT A 4.
THESE LITTLE SALINE PUSH BOTTLES.
AND SO THEY WILL GIVE YOU A LITTLE BIT OF PRESSURE.
A WATER PIK AT ITS LOWEST SETTING IS A 6.
A 35 MM SYRINGE I TOLD YOU --
THIS ONE ACTUALLY IS A 9. I'M SORRY 8.
OKAY, A WATER PIK NOW AT ITS MEDIUM SETTING,
ALL OF A SUDDEN WE GO TO 42.
WHOA! THAT'S BIG, HUH?
AND THEN A WATER PIK AT ITS HIGHEST SETTING IS OVER 50.
SO WATER PIKS ARE ONLY SAFE IN THEIR LOWEST SETTING.
AND THAT'S AT THE LOW SETTING.
WHAT WAS IT? 6.
ALRIGHT. SO, THIS NICE LITTLE GRAPH WILL BE ON THE INTERNET
WHEN YOU LOOK UP YOUR PURPLE BOOKS
AND IT GIVES YOU ALL THOSE PRESSURE SETTINGS.
ALRIGHT, SO THAT'S MECHANICAL DEBRIDEMENT.
THERE'S SHARP DEBRIDEMENT,
WHICH IS SIMPLY THAT, A KNIFE OR A SCISSORS.
AND SOMEONE CUTS AWAY THE SLOUGH OR THE NECROSIS.
AND THEN THERE'S...
MEDICINE, AND I FORGET THE WORD FOR IT.
WELL, THEY'RE CALLING IT ENZYMATIC. OKAY, FINE.
IT'S MEDICINE AND IT WOULD BE SOMETHING LIKE ELASIS,
THE PRODUCT I HAVE MOST USED.
BUT IT'S A PRODUCT THAT YOU WOULD PUT ON TO THE SLOUGH AREAS AND NOT THE BAD AREAS
BECAUSE AGAIN, IT'S INDISCRIMINATE,
IT JUST WORKS ON TISSUE AND IT EATS AWAY THE BAD TISSUE.
SO ENZYMATIC OR MEDICINAL DEBRIDEMENT IS WHAT YOU WOULD DO.
SO WHAT ARE THE FOUR TYPES?
MECHANICAL. - WATER, IRRIGATE WITH WATER.
- THAT'S MECHANICAL. - SHARP.
ENZYMATIC.
- AND AUTOLYTIC. - AUTOLYTIC.
ANOTHER WAY TO DO AUTOLYTIC,
AND THIS IS A VERY INTERESTING METHOD
IS WHEN A WOUND IS DRAINING QUITE A BIT
AND THERE'S A LOT OF SLOUGH IN THE WOUND,
IF YOU WILL TAKE A PLAIN, OLD TRANSPARENT DRESSING
AND JUST LET IT GATHER UP ALL OF THOSE JUICES LIKE A BLISTER.
THAT WILL ALSO BE --
IT WILL CAUSE AUTOLYSIS AND THAT WILL EAT AWAY.
IT'S VERY INTERESTING.
BUT ANY OF THOSE CLOSED DRESSINGS
LIKE THE HYDROCOLLOIDS OR THE CALCIUM ALGINATES,
BECAUSE IT'S LEAVING THAT DRAINAGE IN THERE WILL ALSO PERFORM, LIKE, AN AUTOLYSIS.
ALRIGHT. I TALKED ABOUT KEEPING THIS WOUND BED BASE,
BUT WHAT ARE YOU GOING TO DO ABOUT THIS UNDERMINING,
THIS LIP THAT GOES AROUND OR THESE TUNNELS?
IF WE DON'T PUT SOMETHING IN THESE TUNNELS OR SINUS TRACKS,
THEY CAN SEAL UP ON TOP AND THEN THEY CAN ABSCESS UNDERNEATH.
THEY CAN HEAL AND CLOSE UP.
SO WHAT WE WANT TO DO IS CREATE A MOIST ENVIRONMENT INSIDE THE TRACK
SO THAT IT HEALS FROM THE BOTTOM UP TO THE TOP AND CLOSES IN.
SO WHAT YOU CAN DO IS GET A PRODUCT LIKE NU GAUZE.
THIS ONE'S GOT AN IODOFORM, IT'S AN ANTIBACTERIAL COATING ON IT.
AND THEN THIS A PLAIN NU GAUZE.
YOU CAN GET THESE NU GAUZE STRIPS.
AND IF IT'S A WOUND THAT'S A LITTLE DRY, YOU CAN PUT...
LIKE A WATER SOLUBLE,
LIKE A KY TYPE OF A LIQUID ON HERE.
AND THEN YOU CAN PACK IT INTO THE WOUND.
GET YOURSELF LIKE A SUTURE REMOVAL KIT,
SO YOUR LITTLE SCISSORS ARE STERILE.
I WOULDN'T USE MINE OUT OF MY POCKET.
I DON'T MIND EVEN HOOKING IT INTO THE THING.
POKE IT IN THERE THERE AND THEN CUT THE END OUT HERE SO THAT YOU CAN FIND IT,
AND THEN THAT WILL KEEP THAT LITTLE TUNNEL MOIST.
DON'T PACK IT IN REAL TIGHT, JUST PACK IT IN ENOUGH
SO THAT IT'S NOT GOING TO DRY UP ON ITSELF AND CLOSE OUT.
OKAY. SO NU GAUZES ARE A FUN LITTLE PRODUCT.
IT COMES IN A LOT OF DIFFERENT WIDTHS.
IT COMES IN QUARTER INCH, HALF INCH, ONE INCH,
DEPENDING ON HOW LARGE YOUR WOUND IS.
OKAY. I THINK I'VE COVERED JUST ABOUT EVERYTHING THEORY-WISE I WANTED TO.
YOU CAN READ YOUR MATERIAL AND SEE
THAT THERE IS A LOT OF PRODUCTS THAT I DON'T HAVE.
THERE'S POLYURETHANES THAT YOU CAN USE AS DIFFERENT CHOICES.
ONE OF MY FAVORITES, AND I DON'T HAVE IT HERE. IT'S JUST A SAMPLE.
IT'S CALLED BARD ABSORPTIVE GEL.
AND WHAT IT IS ARE THESE GRANULE BEADS
THAT YOU MIX UP WITH SOME STERILE WATER.
AND IT TELLS YOU ON THE PACKAGE HOW MUCH TO HOW MUCH.
BUT YOU JUST MIX UP ENOUGH TILL IT TURNS LIKE AN APPLE SAUCE CONSISTENCY.
THEN YOU PUT IT INTO A STAGE IV WOUND.
A WOUND THAT DRAINS A LOT.
AND IT ACTUALLY ABSORBS FOUR TIMES ITS WEIGHT IN DRAINAGE.
COVER IT WITH A TELFA AND MAYBE AN ABD
OR SOMETHING TO CONTAIN IT.
AND THAT GETS RINSED OUT ABOUT EVERY SHIFT.
BUT IT TAKES ON A LOT OF DRAINAGE
AND IT STAYS RIGHT IN THAT WOUND BED.
AND IT'S A NEAT PRODUCT TO USE AS WELL.
SO THERE'S A LOT OF PRODUCTS TO USE.
YOU JUST WANT TO KEEP IN MIND PRINCIPLE.
IS THE WOUND GETTING BETTER OR IS IT NOT,
WITH ALL OF THE WORK THAT YOU ARE PUTTING INTO THIS WOUND?
ALRIGHT. ANY QUESTIONS ABOUT --
THERE'S A LOT OF THIS STUFF HERE.
ALRIGHT.
WHAT YOU ARE GOING TO DO -- OH, DEAR, MORE PROPS.
JUST SO I DON'T FORGET.
I AM GOING TO PUT ON THE INTERNET.
I FOUND THIS NEW ARTICLE.
AND IT'S ABOUT HOW NUTRITION AND AGEING AFFECT WOUND CARE.
BUT WHAT WAS MOST INTERESTING TO ME. THE ARTICLE WAS WONDERFUL.
AND IT TALKS ABOUT THE PROTEIN GRAMS
THAT ELDERLY NEED SO THAT THEIR WOUNDS WILL HEAL.
BUT IT HAS A MINI NUTRITIONAL ASSESSMENT GUIDE
THAT YOU CAN GET OFF THE INTERNET,
SO YOU COULD MAKE SOME ASSESSMENTS YOURSELF
AND HAVE THAT GUIDE AVAILABLE TO YOU.
SO I'LL GIVE YOU A COUPLE OF INTERNET SITES TO GO ON
SO THAT YOU CAN HAVE A HANDLE ON WOUND HEALING.
ALRIGHT. DID CAROL SHOW YOU --
YOU GUYS HAD CAROL LAST SEMESTER.
DID SHE SHOW YOU THE VAC VIDEO?
OKAY.
GOOD. I KNEW SHE DID IT AND WE WERE BOTH
KIND OF DUPLICATING THERE FOR A WHILE.
I KNOW THEY HAVE A NEW TEACHER, SO I JUST WANT TO MAKE SURE IT'S GETTING DONE.
OKAY.
ALRIGHT. YOU ARE GOING TO DO TWO WOUNDS.
AND I EXPLAINED TO YOU THAT IN THE MIDDLE OF THIS SECOND WOUND...
THAT I AM GOING TO DO THAT YOU NEED TO MEASURE.
SO YOU WOULD SAY THIS IS THE POINT THAT I WOULD MEASURE,
BUT IT'S NOT WOUND-MEASURING DAY, OKAY?
BUT THEN I'M GOING TO SEND YOU BACK
AND I'M GOING TO GIVE YOU --
YOU ARE GOING TO DRAW FROM A STACK.
THERE WILL BE A WOUND DESCRIPTION.
AND IT SAYS MEASURE THE STAGE IV WOUND, BUT OMIT THE TUNNELS
OR MEASURE THE STAGE IV WOUND AND OMIT THE UNDERMINING.
MEASURE THE STAGE III WOUND.
MEASURE THE NECROTIC WOUND. MEASURE --
WHATEVER IT TELLS YOU IS WHAT YOU'RE GOING TO MEASURE.
AND WE WANT YOU TO FILL OUT THIS FORM CORRECTLY FOR YOUR DOCUMENTATION.
AND SO YOU WILL JUST HAND IT IN AND I WILL GRADE IT LATER
WHEN I CAN SIT DOWN AND READ THEM ALL.
AND THIS IS HOW IT WORKS.
LET'S SAY YOU HAD TO MEASURE THIS WOUND.
I DO IT ON TIME. OH! I GOT TO GET GOING SO YOU CAN DO THE TEST.
IF YOU WERE MEASURING THIS WOUND,
YOU ARE GOING TO TO DRAW A CIRCLE OF IT AND DATE IT,
SO THAT WE KNOW WHERE THE WOUND IS THAT YOU ARE TALKING ABOUT.
AND THEN THIS IS YOUR NUMBER ONE WOUND.
AND YOU ARE GOING TO SAY, NUMBER ONE, NUMBER ONE,
AND THEN USE THESE DESCRIPTORS
OF TIME AND INITIALS OF WHAT THE DRESSING IS.
YOU CAN SKIP THAT BECAUSE YOU DON'T HAVE ONE FOR HERE.
BUT I WANT TO SEE YOUR MEASUREMENTS IN CENTIMETERS.
DRAINAGE, YOU WON'T HAVE ANY.
ODOR, YOU WON'T HAVE ANY. SOLUTION USED.
NONE OF THIS REALLY MATTERS HERE.
WHAT YOU ARE GOING THEN DO IS COME UP HERE AND DESCRIBE THIS WOUND
AND TALK TO ME ABOUT THE SLOUGH, THE GRANULATION AND SO FORTH,
AS ACCORDING TO WHATEVER YOUR WOUND IS THAT WE TALKED ABOUT.
OKAY? SO YOU WRITE A LITTLE NARRATIVE NOTE IN INK,
SIGN YOUR NAME, DON'T LEAVE ANY BLANK SPACES
AND THEN PUT A LINE THROUGH.
ALRIGHT.
DON'T DO ONE LINE, SKIP A LINE, ONE LINE, SKIP A LINE.
YOU NEVER LEAVE SPACES IN CHARTING. EVER.
OKAY? AND DON'T LEAVE ANY BLANK AFTER YOUR CHART,
PUT A LINE AND SIGN YOUR WHOLE NAME.
- OH, SO YOU DRAW A LINE IN THE REST OF THE PARAGRAPH.
- JUST FOR YOUR PURPOSES, OTHER PEOPLE WOULD WRITE.
BUT FOR NOW THIS IS JUST A ONE TIME SHEET.
OKAY. WE HAVE TWO WOUNDS THAT YOU ARE GOING TO CHANGE.
ONE IS A WOUND WITH A DRAIN
AND THE OTHER IS AN OPEN GRANULATING WOUND
IN THE ABDOMEN, A SURGICAL WOUND.
SO WHAT I WANT YOU DO IS I WILL GO THROUGH MY SUPPLIES
AND YOU HAVE THESE EXACT SAME SUPPLIES IN YOUR KITS.
I WANT YOU TO PRACTICE WITH THEM.
YOU CAN GET THEM WET. YOU CAN DO WHATEVER.
THEN JUST PACK THEM UP AND THEN WE JUST PRETEND THEY ARE DRY,
EVEN IF THEY ARE SLOPPY WET. IT DOESN'T MATTER. OKAY?
IF YOU CHANGE A DRESSING LIKE WE ARE GOING TO CHANGE THIS ONE
AND THEN YOU PUT YOUR STUFF ON,
THEN JUST TAKE THAT STUFF AND MAKE IT YOUR STUFF THEN.
YOU DON'T HAVE TO KEEP CHANGING IT OVER AND OVER.
IT'S ALL THE SAME STUFF. SO THERE YOU GO.
ALRIGHT. WE CHECKED OUR DOCTOR'S ORDERS.
THE DOCTOR SAYS CHANGE THE DRESSING WITH THE DRAIN,
Q DAY, PRN. HOWEVER, IT NEEDS TO BE CHANGED.
SO WE'RE COMING TO CHANGE IT.
IT'S REALLY NICE IF THE NURSE BEFORE,
PUTS ON THE CARDEX, WHAT SHE USED TO CHANGE THE DRESSING,
SO YOU DON'T HAVE TO SPEND SO MUCH TIME
TRYING TO FIGURE IT ALL OUT.
BUT IF YOU DON'T, THEN I JUST COME IN AND KIND OF TAKE A LOOK AND SEE
WHAT THEY'VE GOT ON TOP AT LEAST,
AND I KNOW I'M GOING TO BE NEEDING A FEW THINGS MINIMALLY.
THAT IS, I PUT A CHUX UNDER THEIR ARMS, IN CASE THERE'S ANY DRAINAGE.
I'M GOING TO NEED A SPLIT -- OR A DRAIN SPLIT GAUZE OR A DRAIN GAUZE.
A DRAIN'S GOING TO BE COMING OUT OF THE SKIN OR THE WOUND
AND I'M GOING TO NEED TO GO AROUND IT
SO THAT I CAN PROTECT THE SKIN.
SO I HAVE MY SPLIT DRAIN.
I'M GOING TO PILE UP A PIECE OF GAUZE ON TOP OF THE SPLIT DRAIN
TO ABSORB THE DRAINAGE. SO I'VE GOT THAT.
I'M ALSO GOING TO NEED TO DRY THE SKIN OFF A LITTLE BIT AFTER I CLEAN IT,
BECAUSE WE ALWAYS CLEAN SKIN. SO I HAVE AN EXTRA 4 BY 4.
AND THEN I'M GOING TO USE MY SUPER SPONGE PACK.
YOU GUYS HAVE A PACK OF TEN.
SO YOU CAN PRETEND IT'S ONE OR TWO OR WHATEVER.
SO YOU'RE JUST GOING TO WET IT UP AND USE THEM ON AND THEN LATER SHUT IT.
OKAY? BUT I'M GOING TO CLEAN WITH THIS.
I'M GOING TO COVER MY DRESSING WITH A ABD PAD.
I'VE GOT STERILE GLOVES FOR DOING THE DRESSING.
I HAVE SOME NON-STERILE FOR TAKING IT OFF.
THIS IS TO REMIND ME, INCASE I NEED TO MEASURE IT.
I HAVE TWO-INCH TAPE.
I HAVE A BAG TO PUT THE OLD DRESSING IN.
SO BRING YOUR BAGGIES THAT YOU HAVE.
I THINK THERE WAS ONE BAGGY IN THERE THAT HAD YOUR DRESSINGS.
OR GRAB A BAGGY. WE HAVE A FEW.
BUT THEY'RE PRETTY PRECIOUS AROUND HERE.
AND THEN YOU NEED SOME SODIUM CHLORIDE.
CHECK THE EXPIRATION DATE. YES, WE'RE EXPIRED.
AND MAKE SURE IT'S A GOOD PRODUCT.
ONCE THIS HAS BEEN OPENED, HOW LONG IS IT GOOD?
- 24 HOURS. - 24 HOURS, OKAY?
SO ONCE YOU OPEN IT, THEN IT NEEDS TO BE DATE, TIME AND INITIALED.
WASH MY HANDS, IDENTIFY MY CLIENT, SAM SPADE.
AND PROVIDE PRIVACY.
SAM, I AM GOING TO CHANGE THAT DRESSING ON YOUR UPPER SHOULDER HERE.
AND...
OOPS.
THAT'S NOT WHAT I WANT TO DO. JUST CAN'T GO UP IN HERE.
WE TRIED A NEW BED METHOD HERE FOR YOU
SO THAT MAYBE YOU CAN SEE A LITTLE BETTER.
WE PUT HIM IN REVERSE TRENDELENBURG'S, DID YOU NOTICE?
ALRIGHT.
ARE YOU HAVING ANY PAIN, MR. SPADE?
NO? GOOD. ALRIGHT.
HAVE YOU HAD THIS DRESSING CHANGED BEFORE? WAS THERE ANY PROBLEM?
SOMETIMES DRESSING CHANGES ARE PAINFUL,
SO YOU MIGHT WANT TO CONSIDER MEDICATING AN HOUR BEFORE
IF YOU HAVE THE TIME TO DO THAT,
AND THEN CHANGE THE DRESSING LATER.
THERE'S TWO WAYS THAT YOU CAN GET READY FOR A DRESSING.
ONE IS YOU CAN SET ALL YOUR SUPPLIES UP FIRST,
AND THEN TAKE IT OFF AND CHANGE IT.
OR IF YOU DON'T KNOW WHAT YOU'VE GOT GOING HERE,
THEN YOU CAN UNDO IT AND THEN SET UP YOUR SUPPLIES.
IT KIND OF DEPENDS ON THE CLIENT.
IF YOU THINK THE CLIENT'S NOT GOING TO BE ABLE TO TOLERATE THAT MUCH TIME,
THEN DO EVERYTHING AHEAD.
THERE'S REALLY NO ABSOLUTE ANSWER.
I THINK ON ONE OF YOUR PAPERS, I HAD YOU SETTING UP FIRST
AND ON THE OTHER ONE, I HAVE YOU SETTING UP
AFTER YOU TAKE THE DRESSING OFF.
IT'S JUST TO GIVE YOU TWO DIFFERENT WAYS
TO DO YOUR THING.
DRAINS ARE PUT INTO SURGICAL INCISIONS
TO LEAVE A PATHWAY SO THAT THE DRAINAGE CAN GET OUT.
AND SO THAT IT DOESN'T CAUSE PRESSURE UNDERNEATH THE SUTURES.
SO IT'S KIND OF -- IT LOOKS A LOT LIKE A TOURNIQUET THAT WE USED.
OTHER THAN -- IT'S KIND OF A TUBING...
THAT'S WITHIN THE SKIN.
ONCE I START TAKING THIS OFF,
I'M PEELING THE TAPE TOWARDS THE CLIENT INSTEAD OF RIPPING IT.
AND I LIKE TO SUPPORT MY DRESSINGS HERE
SO THAT I DON'T INADVERTENTLY PULL IT OUT THE DRAIN.
COS THAT WOULD NOT BE A HAPPY DAY.
ALRIGHT. LIFT THIS EVER SO CAREFULLY TO MAKE SURE
THINGS AREN'T STUCK AND THAT YOU AREN'T PULLING THE DRAIN OUT
AND YOU DON'T HAVE TAPE, LIKE, STUCK TO THINGS.
THEN I'M PULLING AND I'M LOOKING TO SEE
WHAT KIND OF DRAINAGE IS ON THERE.
THE AMOUNT, THE COLOR, THE QUANTITY...
THE QUALITY, THE ODOR AND SO FORTH.
PLUCK THAT OFF.
ALRIGHT. THIS IS WHAT A PENROSE DRAIN LOOKS LIKE.
AND IT JUST COMES OUT OF THE WOUND.
IT MENTIONS THAT YOU COULD MEASURE THE WOUND.
WE'VE JUST STUCK INTO THIS PLATE SO THAT YOU HAVE SOMETHING TO DO.
SO THERE'S REALLY NOTHING TO MEASURE.
SO YOU CAN JUST SUFFICE IT TO SAY THAT YOU WOULD.
ALRIGHT. THEY CAN BE --
THE DRAINAGE DOESN'T COME OUT OF THE TUBING.
THAT'S NOT THE POINT. THE DRAIN IS A PASSAGEWAY
TO ALLOW THE FLUID TO ESCAPE THE WOUND EDGES.
IT'S NOT SUTURED CLOSE. THEY PUT A DRAIN IN,
SO THAT THE BLEEDING AND THE SEROSANGUINOUS FLUID
CAN GET OUT OF THERE.
SO IT JUST COMES, IT FOLLOWS THIS PATHWAY
AND THESE ARE SOPPY AND THEN THERE'S JUST DRAINAGE ON THEIR SKIN.
SO WHAT WE WANT TO DO IS CLEAN THAT SKIN OFF,
AND THEN REDRESS IT.
SO KEEPING A STERILE FIELD HERE IN MIND,
I WANT TO SET UP MY SUPPLIES SO THAT I DON'T CROSS OVER.
AND SO THAT MY SUPPLIES ARE, KIND OF, IN THE ORDER
THAT I'M GOING TO BE USING THEM.
SO THE FIRST THING I'M GOING TO DO IS CLEAN.
POUR A LITTLE OF THAT ON.
THEN I'M GOING TO --
I'M JUST GOING TO USE MY PACKAGES AS A STERILE FIELD.
YOU COULD PUT A STERILE FIELD DOWN
AND THROW EVERYTHING ON IT, EXCEPT FOR THE WET STUFF.
BUT OPEN YOUR PACKAGES.
THAT ONE I'M GOING TO DRY THE SKIN WITH.
THEN I'M GOING TO PUT ON MY DRAIN SPONGE.
THEN I'M GOING TO DRY THE SKIN.
MY ABD PAD, I DON'T NEED TO OPEN UP
BECAUSE IT'S GOING TO BE THE OUTSIDE DRESSING, RIGHT?
AND I KNOW THAT IT'S FOLDED INSIDE THIS PACKAGE
SO THAT THE OUTSIDE PART IS ON THE OUTSIDE.
SO I COULD ACTUALLY TOUCH THIS WITH CONTAMINATED HANDS
AND THEN UNFOLD IT WITH THE NO-TOUCH TECHNIQUE
AND PUT THE STERILE SURFACE TOWARDS THE CLIENT.
SO I DON'T WORRY SO MUCH ABOUT THIS PACKAGE
BEING OPEN OR EXPOSED RIGHT NOW.
I WANT TO GO AHEAD AND HAVE MY TAPE READY.
IT JUST SAVES A LOT OF TIME ONCE YOU GET THOSE GLOVES ON.
I KNOW I NEED TWO LONG AND TWO MEDIUM.
AND THEN I'M GOING TO GO AHEAD AND DATE, TIME AND INITIAL THIS GUY.
OKAY. AND NOW I'M GOING TO PUT MY STERILE GLOVES ON.
SO HOPEFULLY YOU'VE STILL GOT A PAIR OR TWO OF STERILE GLOVES.
WE HAVE A FEW SPARES, BUT NOT TOO MANY.
I NEED YOU TO PROBE THE STERILE GLOVING.
OH, MAN.
THAT'S NOT TOO GOOD. I RIPPED THEM.
IF I WAS IN SURGERY, I WOULD WORRY ABOUT IT,
BUT IT'S AT MY WRIST AND I AM NOT GOING TO WORK WITH MY WRISTS RIGHT NOW.
SO I'M NOT GOING TO WORRY ABOUT THAT TOO MUCH.
OKAY.
MOVE YOUR TABLE WITH YOUR FOOT. DON'T TOUCH ANYTHING.
KEEP YOUR HANDS UP AND OUT.
AND YOU WILL BE GOOD TO GO.
REMEMBER THAT WHEN YOU ARE CONTAMINATED WITH THE CLIENT,
YOU ARE CONTAMINATED WITH HIM.
BUT GLOVES ARE SO YOU DON'T INTRODUCE ANYTHING NEW.
SO DON'T THINK OR WORRY ABOUT THAT YOU'VE TOUCHED HIM
AND NOW EVERYTHING IS CONTAMINATED.
I AM CLEANING FROM WHAT I WANT TO BE CLEANEST, OUT.
ONE MORE, IF I NEED IT. I ALWAYS SQUEEZE SO IT'S NOT TOO SOPPY.
DON'T PULL THESE OUT.
THE DOCTOR HAS THEM PLACED, BUT THEY ARE NOT SUTURED IN,
THEY ARE JUST LOOSE.
ALRIGHT. AND THEN MAKE SURE YOU DRY THE SKIN
BECAUSE IF YOU DON'T WANT THAT MACERATION SKIN BREAKDOWN
BECAUSE IT'S TOO MOIST.
THEN YOU ARE JUST GOING TO GET YOUR DRAIN SPONGE
AND PUT IT IN HERE ONE WAY.
AND THEN TAKE YOUR SECOND ONE AND PUT IT ANOTHER WAY.
OTHERWISE IF YOU LEAVE THAT OPEN SPLIT, THE DRAINAGE GETS ON TO THE SKIN.
DID I SAY THAT CLEARLY ENOUGH?
SO GET IT GOING IN TWO DIRECTIONS.
THEN I JUST WAD IT UP.
BECAUSE AGAIN, IT'S NOT ABOUT A STRAIGHT LINE.
IT'S NOT COMING OUT OF THE TUBING.
IT'S THE TUBING PATH IS ALREADY KEPT.
THEN PUT THOSE THERE.
AND NOW IT DOESN'T MATTER THAT I'M STERILE OR NOT.
I AM GOING TO HANDLE THIS FROM THE TOP, NO-TOUCH TECHNIQUE.
AND THEN I AM GOING TO PLACE IT DOWN LIKE THAT
SO EVERYTHING UNDER THERE IS STERILE.
GO AHEAD AND PUT MY DRESSINGS ON.
YOU WANT IT TO BE IN OCCLUSIVE DRESSING,
SO ALL FOUR EDGES ARE TAPED.
HOW DOES THAT FEEL?
KIND OF, IN YOUR NECK THERE.
YOUR ARMPITS ARE NOT DOING TOO GOOD EITHER.
I'M NOT REAL PLEASED WITH THAT.
WELL, LET'S SEE HOW THAT HOLDS UP.
CLEAN UP YOUR AREA.
I AM GOING TO CHECK THAT IN AN HOUR OR SO
AND SEE IF THAT'S GOING TO HOLD ON WITH YOUR ARM THERE.
NEVER JUST GET IT ON THERE AND GO,
"I DON'T LIKE THAT WOUND SO GOOD."
DEPENDING UPON THE MOVEMENTS OF THEIR BODY,
YOU MAY JUST NEED TO FIX IT UP.
ALRIGHT, TIE THEIR GOWNS ON AND MAKE SURE THEY'RE COMFORTABLE.
MAKE SURE THAT ALL YOUR DRESSING STUFF IS CLEANED UP WITH GLOVES ON
BECAUSE THAT'S PART OF SEQUENCE. IT'S REALLY IMPORTANT.
YOU DON'T WANT TO BE CONTAMINATED.
PUT YOUR BED DOWN ALL THE WAY.
THEN ALL OF THIS WILL GO INTO THE TRASH CAN.
I'M SAVING MY PRECIOUS BAG.
TAKE OFF YOUR GLOVES, WASH YOUR HANDS AND THEN DOCUMENT YOUR DRESSING CHANGE.
OKAY? YOU'RE JUST GOING TO SAY YOU'RE GOING TO DOCUMENT.
OUR DOCUMENTATION'S GOING TO BE ON THAT GUY.
ALRIGHT? ANY QUESTIONS?
NOT TOO BAD.
ALRIGHT, THE NEXT ONE IS AN IRRIGATION...
OF AN ABDOMINAL WOUND.
YOU NEED LOTS OF SUPPLIES.
YOU NEED TOWELS. CHUX. LOTS OF THEM.
THIS IS A MOIST TO DAMP DRESSING.
THE IDEA IS THAT WE'RE GOING TO PUT IN MOIST GAUZE. MOIST.
AND IT'S GOING TO ABSORB DRAINAGE
AND IT'S NOT GOING TO DRY ON TO THE SKIN
BECAUSE WE DON'T WANT TO DEBRIDE IT.
SO WE'RE GOING TO GET SOME KERLIX SPONGES.
YOU'RE GOING TO USE YOUR 4 BY 4'S IN THAT TUB.
YOU NEED -- WHENEVER YOU USE WATER,
YOU NEED TO MAKE SURE THAT IT'S IN A NON-PERMEABLE CONTAINER.
THAT IT'S NOT GOING TO LEECH ON TO A CONTAMINATED SURFACE
AND CONTAMINATE YOUR DRESSING.
SO THAT'S WHAT I'M GOING TO --
ACTUALLY, THIS WILL BE OKAY.
YOU WILL LIKE YOUR PACK BETTER.
YOU HAVE GOT PLENTY TO CLEAN WITH AND I ONLY HAVE A COUPLE.
I NEED SOMETHING TO DRY THE SKIN WITH.
I NEED SOMETHING TO PUT ON TOP.
MY COMBINE.
I DO NOT NEED TAPE ON THIS ONE
BECAUSE I'VE RIGGED UP ANOTHER SCENARIO HERE.
I DO NEED AN IRRIGATION SET.
SYRINGES AND A BATH BLANKET AND PILLOWS.
AND I THINK I'M SET.
OKAY, I'M GOING TO IRRIGATE THIS WOUND, THAT'S OUR ASSIGNMENT.
THEN WE'RE GOING TO PUT IN A MOIST TO DRY DRESSING
ON THIS ABDOMINAL WOUND.
I'VE GATHERED MY EQUIPMENT. I'VE WASHED MY HANDS.
I'VE IDENTIFIED MY CLIENT SAM SPADE.
PROVIDE PRIVACY.
MR. SPADE, I NEED TO CHANGE THAT DRESSING ON YOUR STOMACH.
AND I MEDICATED YOU AN HOUR AGO,
SO I THINK YOU OUGHT TO BE DOING PRETTY GOOD.
HOW'S THE PAIN? GREAT.
ALRIGHT. WHAT I NEED FOR YOU TO DO IS GET ON YOUR SIDE
BECAUSE I NEED TO IRRIGATE IT WITH SOME SOLUTION.
AND...
IT'S GOING TO RUN DOWN AND SO I DON'T WANT IT TO RUN DOWN YOUR GROIN.
IF WE CAN GET IT TO RUN DOWN YOUR STOMACH,
THAT WILL BE MUCH MORE PLEASANT.
AND YOU GUYS MAY HAVE TO MOVE A LITTLE BIT.
I'M TRYING TO FIND A GOOD PLACE FOR YOU, BUT --
HOW'S THAT?
ALRIGHT. AND HE IS JUST EVER SO COOPERATIVE TO ROLL OVER.
I CAN'T GET BACK THERE TO FIX MY PILLOW.
BUT I WANT HIM PRETTY HIGH.
SO HE'S PRIVATE, NOT EXPOSED.
AND HERE'S THE SITUATION.
I KNOW THAT WHAT WE'VE CREATED IS THAT HE'S GOT AN ABDOMINAL WOUND.
AND INSTEAD OF REMOVING THE TAPE EVERY SINGLE TIME THAT WE DO THE DRESSING,
BECAUSE THE TAPE CAN CAUSE AS MUCH IRRITATION AS THE WOUND ITSELF,
IS WE PUT ON WHAT'S CALLED A MONTGOMERY STRAP.
AND THE TAPE ON THIS STRAP STAYS ON ALL THE TIME,
AND THEN IT HAS, LIKE, SHOELACE TIES IN HERE
WHERE WE ARE GOING TO HOLD IT TOGETHER.
SO I'LL UNDO IT, FOLD THAT BACK AND THEN CHANGE MY DRESSING.
AND THEN IT WILL BE SECURED WITH THESE STRAPS
THAT I'M GOING TO KEEP LAYING BACK AND FORTH.
YOU'LL SEE IT.
OKAY, YOU'RE NOT GOING TO FALL THERE, MR. SPADE, ARE YOU?
OKAY. NOW WHERE'S MY LITTLE TRASH BAG?
FORGOT GOGGLES. MY TRASH BAG.
MANY THINGS. THIS IS A BIG SETUP.
OKAY.
ON THIS ONE, I'M GOING TO GO AHEAD AND GET HIM ALL POSITIONED,
AND THEN I'M GOING TO SET MY SUPPLIES UP
SO THAT I CAN GET THIS ALL DONE.
I NEED BAND-AIDS. SO THERE'S MY DRESSING.
YOU KNOW WHAT, MR. SPADE? THAT MIGHT HELP ME OUT.
GET YOUR HAND OUT OF THE WAY THERE.
OKAY, I'M WORKING FLUIDS, SO PAD UP THAT BED AND PAD UP OUR LINENS
SO THINGS AREN'T GETTING SOAKED.
WATER FINDS THE PATH OF LEAST RESISTANCE
AND SO YOU WANT TO PAD UP THE GROIN SO IT DOESN'T GO BETWEEN THE LEGS
AS MUCH AS POSSIBLE.
- AGAINST THE CHUX THERE. - YEAH.
BUT YOU DON'T WANT YOUR STUFF SO CLOSE THAT IT CONTAMINATES YOUR SITE.
AND YOU WANT TO MAKE SURE THAT YOU HAVE ENOUGH TOWELS,
THAT YOU'RE GOING TO BE COVERING UP
THOSE MONTGOMERY STRAPS WHEN YOU'RE READY.
OKAY. BECAUSE I'M GOING TO IRRIGATE...
I MAY WANT TO WEAR GOGGLES, I MAY NOT.
JUST DEPENDS IF I THINK I'M GOING TO SPLASH MYSELF OR NOT, OKAY?
WHEN YOU GET AN IRRIGATION SET, IT COMES LIKE THIS.
IT COMES WITH A STERILE TOP.
BUT YOU'RE GOING TO TAKE THE STERILE TOP OFF,
AND WHAT DO YOU GET IN THIS KIT?
A BULB. REMEMBER WHAT WAS THE PSI OF THIS BULB SYRINGE?
2, AND I DON'T WANT A 2. WHAT DO I WANT?
- 4. - 4.
SO YOU'RE GOING TO NEED TO GET A 2-OUNCE CATHETER TIP SYRINGE
OUT OF HERE, MAINTAINING STERILITY OF THE CATH TIP END.
I MEAN, RIGHT NOW I DO NOT HAVE ANYTHING STERILE ON, RIGHT?
BUT I HAVEN'T CONTAMINATED ANYTHING YET.
OKAY? IT'S THE TIP AND IT'S THE INSIDE OF THIS CONTAINER
I NEED TO STAY STERILE.
SO I'M SET UP OKAY AND I CAN GET RID OF THIS
BECAUSE I DON'T WANT THIS SYRINGE.
ACTUALLY, I DON'T EVEN REALLY WANT THIS BUCKET OVER HERE.
I'M GOING TO GO AHEAD AND FILL UP MY CONTAINER SO I CAN IRRIGATE...
AND THEN GET MY SUPPLIES SET UP.
I'M GOING TO IRRIGATE FIRST.
THEN I'M GOING TO DRY THE SKIN.
SO I NEED MY 4 BY 4.
THEN I'M GOING TO PACK THE SKIN SO I NEED MY KERLIX.
AGAIN, NOTICE HOW I SET UP ORDERLY,
SO I'M NOT GOING BACK AND FORTH OVER MY SUPPLIES.
I DON'T WANT TO CONTAMINATE INTO STUFF.
THAT I'M GOING TO LAY ON TOP.
AND AGAIN, I'M NOT SO WORRIED ABOUT THIS DRESSING, SETTING IT OUT.
I JUST WANT TO GET THE PACKAGE OPEN SO I CAN GET TO IT.
BECAUSE I'M GOING TO USE THE NO-TOUCH TECHNIQUE
AND NEVER TOUCH THE INSIDE OF THIS ABD.
HOW YOU DOING THERE, MR. SPADE? RIGHT.
OKAY, I DO NEED A LITTLE FLUID ON HERE.
YOU CAN DO IT WITH YOUR SYRINGE OR YOU CAN JUST POUR IT ON.
I'VE GOT MEASURING TAPE AND I'M GOOD.
- AND THERE WE GO. WE'VE GOT THIS OPEN WOUND
THAT NEEDS TO BE IRRIGATED.
AT THIS POINT, IT WOULD BE A GOOD TIME TO MEASURE THE WOUND
BEFORE YOU'RE ALL STERILE.
SO YOU CAN SAY I WOULD MEASURE HERE.
AND I WOULD DESCRIBE LENGTH BY WIDTH BY DEPTH,
AND DESCRIBE THE BASE OF THE WOUND'S RED, BEEFY GRANULATION AND THE SKIN OUTSIDE.
ALRIGHT. I'M STILL NOT STERILE
BECAUSE I DON'T NEED TO BE QUITE YET.
I WANT TO IRRIGATE THIS...
WOUND WITHOUT STERILE GLOVES.
SO WITHOUT TOUCHING THE CATHETER TIP TO THE WOUND,
I'M GOING TO SQUIRT --
SORRY, MR. SPADE. RIGHT DOWN YOUR GROIN. OH, NO.
YOU'RE GOING TO SQUIRT IN HERE.
SQUIRTING THE WOUND,
WHAT YOU WANT TO BE CLEANEST TO WHAT IS DIRTIEST.
DON'T RINSE ALL OF THIS DIRTY SKIN
DOWN INTO WHAT YOU WANT TO BE A CLEANER WOUND.
OKAY, SO SQUIRT IT TILL IT COMES OUT CLEAR.
AND BECAUSE THIS IS NICE, BEEFY RED,
OUR 4 PHI IS PERFECTLY ADEQUATE FOR THIS KIND OF CLEANING.
ALRIGHT. NOW I AM GOING TO BE PLUNGING INTO THIS WOUND
SO IT'S HERE THAT I WANT TO SWITCH TO STERILE GLOVES.
I'M JUST TOTALLY RUNNING OUT OF SPACE.
SO I'M GOING TO COME UP HERE AND PUT THEM UP ON HIS PILLOW.
UP AND OUT SO THAT NOTHING IS CONTAMINATED IN.
YOU GET KIND OF A ROLL HAPPENING THERE.
OKAY. WHAT I WANT TO DO NOW IS TAKE ONE OF MY 4 BY 4'S,
AND I WANT TO PUT IT RIGHT INSIDE THE WOUND
AND, KIND OF, WHIP OUT ALL OF THE PUDDLES OF WATER.
YOU DON'T WANT A BUNCH OF FLUID IN THERE
THAT'S GOING TO CAUSE MACERATION,
THAT'S GOING TO CAUSE MORE BREAKDOWN.
SO EVER SO GENTLY GET RID OF THAT.
THEN I'M GOING TO TAKE ONE OF MY WET...4 BY 4'S,
SQUEEZE IT OUT AND I'M GOING TO WIPE
WITHOUT GETTING CONTAMINATED ON THIS TOWEL.
THE SKIN AROUND IT.
AND THEN I'M GOING TO DRY THE SKIN AROUND THE WOUND.
NOTICE I DON'T SCRUB, I JUST GO AROUND ONCE AND I'M DONE.
I'M NOT GOING TO WORRY ABOUT THOSE RIGHT NOW.
I NEED IT TO GET A BARRIER DOWN. MY TOWEL IS TOO HIGH.
OKAY. I NEED TO PACK THE WOUND.
SO WHEN YOU PACK THE WOUND,
TAKE YOUR FLUFF AND SQUEEZE IT OUT GOOD.
GET AS MUCH MOISTURE OUT OF IT AS POSSIBLE.
BECAUSE YOU WANT THIS TO TAKE ON THE DRAINAGE.
TAKE IT AND FLUFF IT UP.
IT'S THE FLUFFING THAT ALLOWS THIS TO TAKE ON THE DRAINAGE.
IF IT'S PACKED TOO TIGHT, IT WON'T ABSORB.
THEN WHAT YOU WANT TO DO IS PACK IT LOOSELY IN THIS WOUND.
AND I MEAN LOOSE, SO THAT AGAIN IT CAN TAKE ON DRAINAGE.
BUT YOU WANT IT TO BE SNUG ENOUGH SO THAT ALL THE SKIN IS TOUCHED...
AND THERE'S NO AIR GAPS IN THERE.
SO IT SHOULD LOOK LIKE THAT.
NOW I HAD A STUDENT ONE TIME THAT DIDN'T BELIEVE THAT LOOSE THING,
AND I CAN TELL YOU THAT YOU CAN ACTUALLY GET TWO OF THESE FLUFFS IN THERE.
EVER SO TIGHTLY.
HE HAD IT PACKED REALLY, REALLY TIGHT.
WELL, WHAT HAPPENS WHEN YOU DO THAT?
- YOU CAN'T GET IT OUT?
- YOU CAN GET IT OUT, BUT IT CAUSES PRESSURE.
RIGHT? SO NOW YOU'RE CAUSING A PRESSURE SORE
AND YOU'RE DESTROYING THOSE FIBROBLAST.
HOW MUCH DRAINAGE IS THAT GOING TO BE ABLE TO TAKE ON?
NONE. BECAUSE THERE'S NO ROOM FOR IT TO TAKE ON DRAINAGE.
SO IT CAUSES PRESSURE AND IT WON'T ABSORB.
ALRIGHT. NOW I KNOW THAT I'M GOING TO HAVE A LOT OF DRAINAGE
AND I WANT TO ABSORB THAT.
SO I'M GOING TO TAKE THE 4 BY 4 AND FOLD IT AND LAY IT HERE,
SO THAT THE SKIN -- THE DRAINAGE DOESN'T GET ON THE SKIN.
AND WHAT I MEAN IS, YOU DON'T WANT TO LAY IT LIKE THIS
BECAUSE AS DRAINAGE COMES UP AND THIS GETS WET,
WHERE IS THAT WET 4 BY 4 GOING TO BE LAYING
ON THAT NICE, GOOD SKIN?
OKAY, SO HOLD IT SO THAT YOU KEEP ALL OF THE MOISTURE...
WITHIN THOSE WOUND EDGES.
AND THEN NOW AGAIN, I'M NOT SO WORRIED ABOUT TOUCHING THIS
BECAUSE I'M GOING TO USE THE NO-TOUCH TECHNIQUE FOR THE CENTER HERE.
NOW I CAN MOVE ALL THIS STUFF OUT OF THE WAY.
TAKE THIS...
PUT YOUR LITTLE RUBBER BANDS AROUND THOSE SAFETY PINS.
IT IS A DONE DEAL.
I HAD A CLIENT THAT I DID A BEAUTIFUL DRESSING LIKE THIS ONE TIME.
IT IS BEAUTIFUL. DON'T YOU THINK THAT'S BEAUTIFUL?
JUST FOR TIME'S SAKE, I WOULD ALSO GET A PIECE OF TAPE OUT OF MY POCKET HERE
AND PUT A DATE, TIME AND INITIALS ON HERE
AND JUST STICK IT RIGHT HERE ON THIS ABD.
AFTER DOING MY BEAUTIFUL DRESSING,
HE DECIDED HE NEEDED TO WALK IN THE HALLWAY.
IT WAS FINE. HE HAD WALKING PRIVILEGES.
GETS UP TO WALK AND AS I'M FOLLOWING BEHIND HIM,
LITTLE PIECES OF THE DRESSING ARE FALLING OUT THE BOTTOM.
I FELT LIKE HANSEL AND GRETEL FOLLOWING THE CRUMBS
DOWN THE HALLWAY GOING, "OH, BUMMER."
ALL OF THE BASE OF THIS. IT'S NICE LAYING DOWN, DON'T YOU THINK?
BUT WHEN HE STOOD UP, IT ALL CAME OUT THE BOTTOM.
SO YOU MIGHT WANT TO CONSIDER HOW MUCH DRESSING YOU HAVE ON THERE
AND YOU MAY NEED TO PUT A PIECE OF TAPE FOR GRAVITY PURPOSES
TO KEEP EVERYTHING CONTAINED.
SO I PICKED UP THE CRUMBS AND WE DID ANOTHER DRESSING.
IT'S NOT LIFE OR DEATH.
JUST A MESS.
ALRIGHT, CLEAN UP YOUR AREA WITH YOUR GLOVES ON.
ARE YOU COMFORTABLE ON YOUR SIDE?
YOU ARE GREAT. OKAY.
PUT THE BED DOWN IN THE LOW POSITION.
CLEAN UP YOUR MESS, WASH YOUR HANDS AND DOCUMENT.
THANK YOU. ISN'T IT LOVELY?
IT WILL GET MORE OOZY BY THE END.
ALRIGHT, ANY QUESTIONS?