Complex Dressings and Wound Care

Question 1

Stage 1 Pressure ulcer

Answer 1

Intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.

Question 2

Stage 2 Pressure ulcer

Answer 2

• Partial-thickness loss presenting as a shallow open ulcer with a red-pink wound bed, without slough.
• May also present as an intact or open/ruptured serum-filled blister.
• Presents as a shiny or dry shallow ulcer without sloughing or bruising (bruising indicates suspected deep tissue injury).

Question 3

Stage 3 Pressure ulcer

Answer 3

Full-thickness skin loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.

• May include undermining and tunneling.
• The depth of a stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and stage 3 ulcers can be shallow.
• In contrast, areas of significant adiposity can develop extremely deep stage 3 pressure ulcers.
• Bone or tendon is not visible or directly palpable.

Question 4

Stage 4 Pressure ulcer

Answer 4

Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.

• Often includes undermining and tunneling.
• The depth of a stage 4 pressure ulcer varies by anatomical location.
• Stage 4 ulcers can extend into muscle and/or supporting structures (fascia, tendon, or joint capsule), making osteomyelitis possible.
• Exposed bone or tendon is visible or directly palpable.

Question 5

Unstageable Pressure ulcer

Answer 5

• Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, grey, green, or brown) and/or eschar (tan, brown, black) in the wound bed.
• Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined.
• Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural cover” and should not be removed.

Question 6

A partial thickness wound (loss of tissue limited to epidermis and partial dermis) heals by the process of

Answer 6

Regeneration

Question 7

A full-thickness wound (total loss of skin layers as well as some deeper tissues) heals by the process of

Answer 7

Scar formation

Question 8

Phases of wound healing

Answer 8

• Hemostasis
• Inflammatory
• Proliferative
• Remodeling

Question 9

Phases of wound healing: Hemostasis phase

Answer 9

Blood vessels constrict, clotting factors activate the coagulation pathway. Then, growth factors are released which attracts the cells needed to begin the repair process.

Question 10

Phases of wound healing: Inflammatory phase

Answer 10

• Vasodilation occurs, allowing plasma and blood cells to leak into the wound, noted as edema, erythema, and exudate.
• Leukocytes arrive in the wound to begin wound cleanup, and macrophages appear and begin to regulate the wound repair.
• The result of the inflammatory phase is a clean wound bed.

Question 11

Phases of wound healing: Proliferative phase

Answer 11

• Epithelialization (the construction of new epidermis) begins. At the same time new granulation tissue is formed, and new capillaries are created, restoring the delivery of oxygen and nutrients to the wound bed.
• Collagen is synthesized and begins to provide strength and structural integrity to the wound.
• Contraction, which occurs in open wounds, reduces the size of the wound.

Question 12

Phases of wound healing: Remodeling phase (aka maturation phase)

Answer 12

Collagen is remodeled to become stronger and provide tensile strength to the wound. Outer appearance in an uncomplicated wound will be that of a well-healed scar.

Question 13

Systemic factors affecting wound healing:

Answer 13

• Tissue perfusion and oxygenation
• Nutritional status
• Infection
• Diabetes mellitus
• Corticosteroid therapy
• Chemotherapy and radiation
• Age
• Stress
• Immunosuppression
• Systemic conditions that affect health status such as renal or hepatic disease, sepsis, cancer
• Hematopoietic disorders.

Question 14

Types of healing: Primary intention

Answer 14

• Occurs when the edges of a clean surgical incision are pulled together and approximated with sutures, staples, or adhesive tapes, and healing occurs by connective tissue deposition.
• The wound heals quickly, and tissue loss is minimal or absent.
• Skin cells quickly regenerate, and capillary walls stretch across under the suture line to form a smooth surface as they join.

Question 15

Types of healing: Secondary intention

Answer 15

• Occurs when wounds are left open and allowed to heal by scar formation. There is tissue loss and wound edges.
• There is some gap between the edges, and healing occurs by granulation tissue formation and contraction of the wound edges. Connective tissue develops, which supports new capillaries.
• The slowness of this process places a patient at greater risk for infection.
• The percentage and type of tissue in the wound base indicates the extent to which the wound is progressing toward healing.
• Viable tissue is normally red to pink in color and moist in appearance (granulation tissue).
• Black, brown, or tan tissue in the wound is eschar and should be removed before the wound healing can begin.

Question 16

Types of healing: Tertiary intention

Answer 16

• Sometimes called delayed primary intention or closure.
• Occurs when surgical wounds are not closed immediately but left open for 3 to 5 days to allow edema or infection to diminish.
• Then the wound edges are sutured or stapled closed.
• Scarring is minimal.

Question 17

Wound colors: Black/brown

Answer 17

• Eschar
• Represents full-thickness tissue destruction.
• Black is necrotic tissue or desiccated tissue such as tendon. It is also related to gangrenous lesions secondary to peripheral vascular disease.

Question 18

Wound colors: Yellow

Answer 18

• Slough
• Represents nonviable tissue and in some cases the presence of an infection.
• It is often yellow, cream-colored, or gray slough, which is usually accompanied by purulent drainage.

Question 19

Negative pressure wound therapy (NPWT)

Answer 19

• A mechanical wound care treatment that uses controlled negative pressure to assist and accelerate wound healing.
• The most common commercial brand is called vacuum-assisted closure (V.A.C.)
• Supports wound healing by optimizing blood flow, removing wound fluid, and maintaining a moist environment.
• Chronic wounds such as pressure ulcers, diabetic ulcers, traumatic wounds, and venous stasis ulcers are approved for NPWT

Question 20

Principles of basic wound irrigation:

Answer 20

• Cleanse in a direction from the least contaminated area to the most contaminated (the area you are cleansing is considered “clean” and the surrounding skin surfaces are considered “contaminated” even if the wound is not infected).
• When irrigating, all the solution flows from the least contaminated to the most contaminated area (both distal and lower).
• A suture line is the “least contaminated” area and must be cleansed first when a drain is present as well.

Question 21

An infected acute wound usually demonstrates signs of

Answer 21

• Inflammation
• Redness and warmth in the area
• Presence of drainage
• Pain or tenderness
• Unusual odor

Question 22

Dehiscence

Answer 22

• A failure of wound healing in which the surgical wound breaks, separates, and opens to the fascial level; occurs 4 to 14 days after surgery.
• Factors contributing to surgical wound dehiscence include anemia, malnutrition, obesity, and use of steroids.

Question 23

Evisceration

Answer 23

-Also a failure of wound healing, but with total separation of the layers of the wound and protrusion of the internal organs through the wound.

Question 24

Types of wound exudate:

Answer 24

• Serous: clear, watery plasma.
• Sanguineous: fresh bleeding.
• Serosanguineous: pale, more watery drainage than sanguineous.
• Purulent: thick, yellow, green or brown drainage.

Question 25

Wound Assessment:

Answer 25

• Location: anatomical position of the wound on the body.
• Type of wound: surgical, pressure, trauma. If possible, note the etiology of the wound.
• Extent of tissue involvement: full-thickness, partial-thickness. If it is a pressure ulcer, use the staging system.
• Type and percentage of tissue in wound base: granulation, slough, eschar, and also the approximate amount.
• Wound size: width, length, and depth according to agency policy (cm).
• Wound exudate: amount, color, consistency.
• Presence of odor. Also note if the dressings were either saturated, slightly moist, or had no drainage.
• Periwound area: color, temperature, texture, and a description of any areas that are open, stripped, or have a rash (skin integrity).
• Of course, amount and level of pain on the 1-10 scale.

Question 26

Wound irrigation:

Answer 26

• Pressure needs to be high enough to remove debris and low enough to avoid traumatizing tissue.
• Promotes wound healing through removing debris from a wound surface, decreasing bacterial counts, and loosening and removing eschar.
• Two types: high pressure and pulsatile high-pressure lavage (machine that delivers intermittent high-pressure irrigation).
• Pressure ranging from 4-15 pounds per square inch.
• Normal saline or sterile water.
• 30-35 ml syringe with 18-19 gauge needle=approx 8-11 psi.

Question 27

Common wound dressing categories:

Answer 27

• Hydrogel: composed of water or glycerin and provides moisture to wound bed; they may also absorb a small amount of exudate.
• Alginate: highly absorbent, nonwoven calcuim-sodium alginate fibers that form moisture-retentive gel on contact with wound fluid.
• Foams: adhesive or nonadhesive.
• Gauze: cotton or synthetic material of woven or nonwoven construction.
• Hydrocolloids: made of gelatin, pectin, and carboxymethylcellulose particles suspended in adhesive base; maintains a moist environment; considered semiocclusive dressing.
• Transparent films: adhesive membrane dressings that are waterproof, impermeable to fluids and bacteria, and allow oxygen and moisture vapor exchange.
• Dry dressings.
• Wet-to-dry dressings
• Telfa gauze dressings.
• Thin, self-adhesive elastic film dressings.

Question 28

How to make normal saline

Answer 28

8 teaspoons of salt in 1 gallon of distilled water and keeping it refrigerated for 1 month.

Question 29

Suture and staple removal

Answer 29

• Generally removed within 7 to 10 days after surgery if healing is adequate.
• Cut suture as close to the skin as possible, away from the knot.
• Remove suture and never pull contaminated stitch/knot through the tissues.

Question 30

Obtaining wound drainage specimens:

Answer 30

• Never collect a wound culture sample from old drainage.
• Empty drainage devices and collect fresh drainage for the specimen.
• Separate techniques are used to collect specimens for measuring aerobic versus anaerobic microorganisms.
• Cleanse wound with sterile or saline water, remove slough and debris, and swab healthiest looking tissue in the wound bed.
• Place swab end at a 45 degree angle pressing firmly to elicit cellular fluid; rotate swab 360 degrees.
• Aerobic organisms grow in superficial wounds exposed to the air (culture tube with swab).
• Anaerobic organisms grow deep within body cavities, where oxygen is not normally present (tubes contain carbon dioxide or nitrogen gas).

Question 31

Recording and reporting:

Answer 31

• Appearance of dressing and wound color, odor, drainage, and wound characteristics.
• Cleaning solution used.
• Dressing material used to redress.
• Client tolerance.

Question 32

Types of wound infection:

Answer 32

• Aerobic wound infection.
• Anaerobic wound infection.
• Signs and symptoms: localized inflammation, tenderness, warmth, odor, purulent drainage, chills, malaise, increased white blood cell count.

Question 33

1-Keloid 2-Erythema

Answer 33

1-An overgrowth of scar tissue at the site of skin injury, such as a wound or surgical incision.
2-Redness or inflammation of the skin or mucous membranes, result of dilation and congestion of superficial capillaries, blanching and non-blanching.

Question 34

Principles for packing a wound:

Answer 34

• Use the wound characteristics to decide what type of packing is appropriate.
• Make sure the packing material can be safely used to pack a wound.
• Moisten the packing material with a noncytotoxic solution such as normal saline. Never use cytotoxic solutions to pack a wound.
• If using woven gauze, fluff it before packing it into the wound.
• Loosely pack the wound.
• Do not let the packing material drag or touch the surrounding wound tissue before putting it into the wound.
• Fill all the wound dead space with the packing material.
• Pack the wound until you reach the wound surface; never pack a wound higher than the wound surface.

Question 35

Types of dressings and functions:

Answer 35

• Primary (right on wound) and secondary (on top of primary)
• Maintenance of a moist environment; protection from outside contaminants; protection from further injury; prevention of spread of microorganisms; increased client comfort; control of bleeding; absorption of drainage, and debridement.

Question 36

Factors to consider when deciding which type of dressing to apply:

Answer 36

• Ease of application
• Conformity to body contours
• Durability and flexibility
• Cost-effectiveness
• Ability to absorb or contain
• Ease of removal without damaging healing surface
• Acceptable in appearance

Question 37

The perfect dressing:

Answer 37

• Easily removed
• Removes excess exudate and toxins
• Provides thermal insulation
• Is free of particulates
• Allows gaseous exchange
• Protects from secondary infection
• Maintains humidity at interface

Question 38

Nerds & Stones (Whether you need to take a swab for c&s or not)

Answer 38

Superficial: Deep:
N-Non-healing S-Size is bigger
E-Exudate T-Temperature increases
R-Red & bleeding O-Os (exposed opening)
D-Debris N-New breakdown
S-Smell E-Exudate,erythema,
edema
S-Smell