12 - Wound Care Flashcards
What are acute wounds?
Heal quickly (typically w/in 4 weeks)
What are examples of acute wounds?
- Bites
- Scrapes
- Minor lacerations
- Punctures
- Burns
What are chronic wounds?
- Fail to progress through normal healing w/in 4 weeks
- Healing is delayed or impaired
What are examples of chronic wounds?
- Pressure ulcers
- Diabetic ulcers
In which locations do chronic wounds tend to occur?
Hospital and home-care settings
What are the 4 phases of the healing process?
1) Hemostasis
2) Inflammatory phase
3) Proliferative phase
4) Maturation phase
What occurs in the first stage of healing?
- Hemostasis
- Begins w/in minutes of injury
- Vasoconstriction occurs and platelets aggregate to form a clot
- Appearance – temporary blanching of skin and blood clot forms
What occurs in the second stage of healing?
- Inflammatory phase
- Begins shortly after injury and can last up to 4 days
- Vasodilation allows increased blood flow
- Neutrophils cleanse wound and macrophages remove bacteria and debris
- Appearance – redness, heat, swelling, pain and may have some drainage
What occurs in the third stage of healing?
- Proliferative phase
- Can last from 4-24 days
- Granulation tissue formed, wound contraction, and new epithelium formed
- Wound is considered closed, but not healed (scar formation)
- Appearance – bright red tissue and raised; scar tissue beginning to form
What occurs in the fourth stage of healing?
- Maturation phase
- Also called remodeling phase as the dermal tissue strengthens
- Collagen forms early scar tissue and continues to be deposited to increase strength of tissue
- Starts about 3 weeks after injury and complete healing can take up to 2 years
- Appearance – changes from pink to red to white
How can you determine if a wound is in the third phase of healing or if it is infected?
- Third phase produces a raised, red wound
- Infection will also produce pus and expansion of red areas
Can the wound become infected in the fourth phase of healing?
No
What are some factors that affect wound healing?
- DIDNT HEAL
- Diabetes
- Infection
- Drugs (steroids, ASA, anticoagulants, cancer drugs)
- Nutritional problems
- Tissue necrosis
- Hypoxia
- Excessive tension on wound edges
- Another wound
- Low temp
Which locations will wounds have slower healing?
Bony areas and lower extremities because of decreased blood flow
What patient factors should be assessed when they present with a wound?
- Tetanus immunization?
- Medical conditions that affect healing (diabetes, immunocompromised)
- Factors that delay healing?
- Bleeding longer than 10 minutes?
- Age?
What are red flags for a wound?
- Wound larger than 2 cm
- Lacerations on face or hand where edges don’t fall together
- Deep wound
- Px unable to move injured part
- Dirt and debris cannot be removed w/o scrubbing
- Infected wound
What are some non-pharms are basic wound care management?
- Cleanse wound (wash w/ water and remove dirt/debris)
- Stop bleeding (use clean dressing or gauze to apply pressure to wound for 10 minutes)
- Protect wound (apply dressing to protect and improve healing)
What is debridement and who performs it?
- Removal of dead or contaminated tissue
- Only done by a health care professional
What products are recommended for cleaning wounds?
- Lukewarm drinkable water to remove dirt and debris
- Normal saline to remove dirt and debris
What products are not recommended for cleaning wounds?
- Hydrogen peroxide 3% (may impair healing and cause tissue toxicity)
- Isopropyl alcohol 70% (may dry and irritate skin)
- Iodine (may irritate tissue and impair healing)
- Povidone-iodine (may impair healing)
What are signs of a skin infection?
- Area around wound is red
- Localized pain
- Warm to touch around affected area
- Edema/swelling
- Drainage/pus/yellow discharge
- Fever
- Redness extending from wound after 2 days
- Abnormal smell
Can antibiotic ointments be used to prevent a skin infection?
- No, only work after infection has occurred
- Can use soap and water for prevention
When are topical antibiotics used?
For superficial, mildly infected wounds only
When are topical antibiotics used prophylactically?
- Wounds at high risk for infection
- Chronic wounds
- Wounds that haven’t been cleaned properly
What is the concern w/ prolonged use of topical antibiotics?
Resistance or secondary fungal infection
What is the spectrum of bacitracin?
GM+ and minimal GM-
What is the dosage of bacitracin?
1-3 times daily
What are adverse effects of bacitracin?
- Common sensitizer/allergic contact dermatitis
- Itching, burning, redness
There is a cross-sensitivity potential w/ bacitracin and _____
Neomycin and polymyxin
What is the spectrum of gramicidin?
GM+
What is the dosage of gramicidin?
1-3 times daily
What are adverse effects of gramicidin?
- Low risk of sensitivity
- Itching, burning
Where should gramicidin not be applied and why?
- Nasal membranes
- Damages sensory epithelium of nose
What is the spectrum of polymyxin B?
GM-
What is the dosage of polymyxin B?
1-3 times daily
What are adverse effects of polymyxin B?
- Low risk of sensitivity
- Itching, burning
Is contact allergy from polymyxin B common?
No
What is the spectrum of neomycin?
GM- and partially active against GM+
What is the dosage of neomycin?
1-3 times daily
What are adverse effects of neomycin?
- Low risk of sensitivity
- Itching, burning
What is the spectrum of fusidic acid?
GM+
What is the dosage of fusidic acid?
2-3 times daily for 7-10 days
What are adverse effects of fusidic acid?
- Dryness
- Itching, burning
- Some local irritation
What is the 1st line therapy for impetigo?
Fusidic acid
What is the spectrum of mupirocin?
GM+ including some strains of MRSA
What is the dosage of mupirocin?
2-3 times daily for 7-10 days **should not be used more than 10 days
What are adverse effects of mupirocin?
- Dryness
- Itching, burning
- Some local irritation possible
What should be monitored for w/ wounds?
- Bleeding should stop w/in 10 minutes (15 mins for px on anticoagulants)
- Infection - monitor daily for 48 hours
- Wound healing - monitor daily for 4-14 days; if not closing w/in 2-4 weeks, refer
What is the purpose of dressings?
- Protect wounds from further damage
- Help stop bleeding
- Help prevent infection
- Some help promote healing
What are primary dressings?
Placed directly on wound, absorbs fluids, prevents infection and adhesion of secondary dressing
What are secondary dressings?
Placed over primary dressing for protection, absorption, compression, and occlusion
What are the types of dressings?
- Gauze
- Transparent films
- Hydrogels
- Hydrocolloids
- Alginates
- Foams
- Liquid tissue adhesives
Purpose of gauze dressings
- Absorbent and protectant
- May be used for wet or dry wounds
What are the types of gauze dressings?
- Non-adherent (doesn’t stick to wound)
- Self-adherent (clings to itself)
What is the application for gauze?
- Place directly on wound, used as a primary dressing
- Moisten w/ saline, wring out excess fluid, and apply secondary dressing
Purpose of transparent films
- Provide moist environment
- Protective and waterproof
- May be used for superficial clean wounds where it is required to frequently view the wound
What is the application of transparent films?
- Gently lay dressing over wound, avoid wrinkling and don’t stretch
- Overlap wound by 2.5 cm and apply tape
When should use of transparent films be avoided?
Moist wounds
What is an example of a transparent film?
Tegaderm transparent
Purpose of hydrogels
- High moisture content, some absorption properties
- May be used for dry wounds, painful wounds, pressure ulcers, and burns
What is the application of hydrogels?
- Apply moderate amount to wound and cover w/ gauze
- May require secondary dressing
- If self-adherent, may be used as primary dressing
When should use of hydrogels be avoided?
Gangrenous wounds and weeping wounds
What are examples of hydrogels?
- Dudoerm gel
- Intrasite
Purpose of hydrocolloid dressings
- Retains moisture
- May be used for burns or small abrasions
What is the application for hydrocolloid dressings?
- Apply adherent side to skin and hold in place
- Painless to remove
When should hydrocolloid dressing use be avoided?
- Dry wounds that are infected
- Weeping wounds
What is an example of a hydrocolloid dressing?
Duoderm
Purpose of alginates
- Create moist environment, highly absorbent
- May be used for packing cavities and wounds, wound drainage, and pressure ulcers
- Can reduce pain
What is the application for alginates?
Apply dressing to area, cover w/ secondary dressing and tape in place
When should alginate use be avoided?
Dry wounds
What are examples of alginates?
- Algisite
- Tegaderm
- Kaltostat
Purpose of foam dressings
- Retains moisture, highly absorbent, protective
- May be used for wounds w/ mild to moderate exudate, partial to full thickness wounds
What is the application for foam dressings?
- Gently lay dressing over wound, cover w/ gauze, tape in place if necessary
- May need a secondary dressing
When should foam dressing use be avoided?
- Dry wounds
- Wounds that need to be frequently checked
What is an example of a foam dressing?
Allevyn
When are liquid adhesives used?
- Paper cuts
- Minor cuts
- Skin cracks
How long do liquid adhesives last?
5-10 days
What is the application for liquid adhesives?
Wash cut first, apply pressure to stop bleeding then apply adhesive
What are the 3 types of adhesive tape?
- Cloth tape
- Silicone tape
- Paper
Cloth tape?
- Breathable but not water resistant
- Can adhere to dry or damp skin
- Generally used if dressing needs to stay intact or area is damp/moist
When is silicone tape used?
For sensitive or “at risk” skin or if dressings are to be replaced often
Paper tape?
- Breathable but does not adhere as well as others
- Generally used for sensitive areas or if dressings are to be replaced often
What determines the choice of tape?
- Size and type of wound
- Potential skin sensitivities
- Personal preference
What are adhesive skin closures used for and what are the 2 types?
- Generally used to hold wounds closed after suture removal
- Steri-strips
- Butterfly closures
