5] Surgical Wounds Flashcards
Sutures are for
Small incisions
Steristrips for?
Reinforcing subcutaneous skin closures
Staples for
Large incisions
Tissue adhesives for
Used in linear incisions or lacerations
Suture removal in the face
3-5 days
Suture removal in trunk, arms, legs, scalp
7 days
Suture removal in hands, feet, over joints, back
10-14 days
What do u document with sutures ?
Document # of sutures/staples removed andpatient tolerance to procedure
Sutures should be removed before
epidermis
has migrated into
the deeper parts ofthe dermis
Removal of necrotic tissue from a wound to improve or facilitate the healing process
Debridement
Necrotic tissue is typically the result of
Poor blood supply
Prolonged inflammation
Bacterial damage
Dead/necrotic tissue serves as a
inflammatory stimulus and a medium for bacterial growth
Debridement should start when
Within 3 day of Dx
If a patient has a systemic infection, debridement should start
Within 12 hours
Systemic infection signs (5)
Increased temperature Leukocytosis Confusion Agitation Symptoms have no other identified cause
Benefits of debridement (4)
Removal of bacteria
Stimulation of growth factors
Removes senescent cells
Removes hyperprolifeative, nonmigratory tissue
May be yellow, green, gray or black
May be loose and stringy or thick and leathery
Necrotic tissue appearance
2 main types of debridement
Selective and nonselective
3 types of SELECTIVE debridement
Sharp/surgical
Enzymatic
Autolytic
3 types of NONselective debridement
Mechanical
Wound irrigation
Hydrotherapy
Use of scalpel, forceps, scissors, (by trainedPT, RN or PA) to remove dead tissue
Sharp/surgical debride
Quickest method
Sharp debride
Sharp/surgical debride always used when ?
signs of advancing cellulitis or sepsis
Where can sharp/surgical debride be performed
Bedside or OR
Precautions of sharp debride (3)
Caution with sharp debridement if pt has
prolonged bleeding time (check PT, PTT,
INR)
Avoid aggressive debridement if wound does not have adequate blood supply to heal
Only physicians are licensed to cut healthy
tissue – do not attempt to deroof a tunnel or
sinus tract
Topical enzyme agents degrade necrotic tissue
Enzymatic debride
Enzymatic debride is a great option for
non-surgical candidates, pts in LTC, homecare
is often performed
prior to application to increase surface area for contact
Cross-hatching/scoring eschar
Do not use enzymatic debride in conjunction with
Silver dressings
Examples: santyl, medihoney
Enzymatic Debridement
Uses the body’s own enzymes to break down necrotic tissue
Autolytic Debridement
Apply a moisture-retentive dressing; fluid
accumulates which aids in the lysis/softening of necrotic tissue
Autolytic Debridement
What softens the tissues in autolytic debride?
Phagocytic cells and preotelytic enzymes; digested by macrophages
Slowest method of debride
Autolytic
Autolytic debride CANNOT be used with?
Infected wounds
Selectively debride
necrotic tissue
Secrete enzymes that breakdown proteins and digest
bacteria
Maggots
Maggots are applied when?
Every 2-3 days
Maggots are contra-indicated for
limb-threatening wounds,
psychological distress,
bleeding abnormalities,
deep-tracking wounds
Uses an external force to remove necrotictissue
Mechanical debride
What does non-selective mean?
Does not discriminate between viable and nonviable tissue
Mechanical debride may cause ? So you might have to do what for the pt?
May cause pain;
Consider premedicating patient
Examples: wet to dry, water jet
Mechanical debride
Moving water dislodges loose debris; used for large wounds that need aggressive
cleaning/softening of necrotic tissue
Whirlpool
Whirlpool is contraindicated in
Granulating wounds b/c it might macerate the wound bed
Disadvantages of?
Periwound maceration Trauma to wound bed Waterborne infections Cross-contamination Dependent position may increase edema Potential for burns
Whirlpool
Specialized equipment that provides pulsating irrigation, followed by suction; operates with the same principle as a carpet shampooer
Pulses lavage with suction
Disadvantages for Pulsed Lavage with Suction
risk of inhalation of aerosolized particles (requires gown plus eye/face protection); risk of driving organisms deeper into wound; may cause pain
Who can oNLY do sharp debride?
PTs
When do you NOT debride?
-Stable heel wounds with firmly adherent eschar
-Do not debride necrotic arterial wounds
-Do not debride in patients who are at risk for
bleeding (check PT, PTT, INR)
-Systemic infection
- Unidentified structures in wound bed
Dry gangrene
Debridement may be delayed in patients whoare critically ill, unstable or severely neutropenic, as long as it is not infected
Why not debride stable eschar onheels?
Less blood flow
Small amount of subcutaneous tissue over calcaneus
Highly susceptible to infection
Takes longer time to heal
Selective versus nonselective
Location, type and amount of necrosis present
Type and amount of necrotic tissue removed
Instruments used and settings used if
applicable
Documentation for debride
Most amputations are performed for
Ischemic disease of LE
Pathophys of amputations
PVD Trauma Tumor Infection Congenital limb deficiency
removes toe and corresponding metatarsal bone
Ray amputation
removes forefoot
Transmetatarsal amputation
cuts
through ankle joint
Symes amputation
Complications with amputations (4)
Infection
Dehiscence
Excessive wear of prosthesis causing breakdown
Phantom limb pain
Post recovery ambulation rate for hip disarticulation
0-10%
Post Recovery Ambulation Rate for AKA
38-50%
Post Recovery Ambulation Rate for knee disarticulation
31%
Post Recovery Ambulation Rate for BKA
80%
Causes: Violating lifting precautions or excess Wound infection Tight sutures which cut off blood flow to wound edges leading tonecrosis Decreased skin integrity
Dehiscence
What is dehiscence
Surgical complication where the wound ruptures along the incision
Sutures break, stretch or cutthrough tissue, knots slip,
suture too thin, insufficient
number of sutures
Dehiscence due to technical factors
Age >65, emergency operation,cancer, hemodynamic
instability, intra-abdominal
sepsis, wound infection,
hypoalbuminemia, obesity, use of steroids, heavy coughing,
ascites
Dehiscence due to patient Factors
Lacerations how do you fix it?
Irrigate/debride to remove debris
Abnormal opening between 2 epithelial surfaces
Fistula
External fistulas empty into?
The environment like skin
Internal fistulas empty into?
Other organs
Esophageal fistula
Clear or white output
Gastric fistula
Green output
Small bowel fistula
Light brown or tan output
Internal organ protrudes from the wound
Evisceration
If evisceration occurs, what do you do?
1- stay calm 2- keep it moist 3- keep pt NPO for immediate surgery 4- lower head of bed less than 20 deg 5- monitor vitals and assess for Signs/Sx of shock
Beta-hemolytic Streptococcus
pyrogenes Develops following a breach in the mucous membranebarrier
Necrotizing fasciitis
Early signs of necrotizing fasciitis includes
Early signs include reddened,
swollen, extremely painful area of cellulitis; fever
With progression of necrotizing fasciitis, dark red
induration of epidermis and bullae filled with ? And then?
Blue/purple fluid and then As progression continues, skin becomes blue, maroon, or black
How does necfasc happen?
Bacteria make protein that destroys tissue directly
Toxins released
Immune system destroys healthy tissue in fight against bacteria
Diagnosed via tissue culture, ESR, WBC,ultrasound, CT scan
Nec fasc
Treatment for nec fasc
Treatment includes early, aggressive surgical
debridement and broad-spectrum IV antibiotics.
Wound is packed and kept moist; often requires daily debridement
This skin graft Includes the epidermis and part of the
dermis; more fragile; more
contraction; smoother/shinier; abnormally pigmented
Split thickness skin graft
This skin graft includes the epidermis and the entire
dermis; better cosmesis; less contraction
Full thickness skin graft
