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NRSG 301 > Complex Wound Care > Flashcards

Complex Wound Care Flashcards

1
Q

Can student nurses perform VAC dressing changes or sharp wound debridement?

A

no

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2
Q

how often do Braden Scales need to be completed to be effective?

A

every shift or every 24hrs

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3
Q

what will a Braden scale help you determine?

A

risk pt has for skin breakdown so early intervention can reduce risk

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4
Q

What are the different pressure sore stages?

A
  • stage 1
  • stage 2
  • stage 3
  • stage 4
  • stage X or N (unstageable)
  • stage SDTI (suspected deep tissue injury)
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5
Q

as pressure ulcers heal they are not down staged, instead they are what?

A

classified granulated stage

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6
Q

Why are pressure ulcers classified as granulated stage as they heal?

A

lost muscle, fat and dermis are not replaced, granulation tissue just fills in the defect

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7
Q

describe a category/ stage 1 pressure ulcer

A
  • non blanch able erythema of intact skin
  • discolouration of skin, warmth or hardness also may be indicator
  • with darker pigmented skin, colour of area may differ from adjacent skin
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8
Q

describe a category/ stage 2 pressure ulcer

A
  • partial thickness skin loss involving epidermis and/ or dermis
  • presents as an abrasion, blister or shallow crate
  • partial thickness tissue loss showing viable, pink or red, moist with distinct wound margin
  • may present as intact or ruptured serum filled blister
  • slough/ eschar not present
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9
Q

Describe a category/ stage 3 pressure ulcer

A
  • full thickness skin loss c SC adipose layer exposed
  • involves damage or necrosis of SC tissue may extend down to underlying fascia
  • slough/ eschar initially present
  • healing wounds show granulation tissue
  • rolled edges may be visible in chronic wounds
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10
Q

describe a category/ stage 4 pressure ulcer

A
  • full thickness tissue loss with damage through SC adipose layer, fascia, muscle, tendon, ligament, cartilage or bone
  • slough/ eschar initially may be present
  • healing wounds show granulation tissue
  • rolled edges may be visible in chronic wounds
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11
Q

describe a category/ stage X or N pressure ulcer

A

unable to determine depth of the wound due to presence of thick eschar

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12
Q

describe a suspected deep tissue injury

A
  • usually intact skin
  • can deteriorate rapidly
  • painful
  • firm
  • mushy/ boggy
  • discoloured area of purple/ maroon localized intact skin or blood filled blister > indicates deep tissue damage
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13
Q

if a suspected deep tissue injury is covered with slough/ eschar it is unstageable until when?

A

wound is visible and then restaged as 3 or 4

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14
Q

What risk factors do you need to assess for when treating a pressure ulcer?

A
  • poor healing
  • poor nutritional status
  • advanced age
  • impaired O2 status
  • smoking/ substance use
  • impaired immobility
  • decreased activity tolerance
  • moisture
  • shearing
  • friction
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15
Q

How do you treat a stage 1 pressure ulcer?

A
  • relieve pressure
  • protect with barrier cream
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16
Q

How do you treat a stage 2 pressure ulcer?

A
  • relieve pressure
  • no dressing or dressing to absorb drainage
  • decried slough if present
  • protect
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17
Q

How do you treat a stage 3 pressure ulcer?

A
  • relieve pressure
  • debride slough/ eschar if present
  • pack sinus tracts and undermining
  • dressing to absorb drainage
  • decrease bacterial load
  • protect
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18
Q

How do you treat a stage 4 pressure ulcer?

A

(same as stage 3)
- relieve pressure
- debride slough/ eschar if present
- pack sinus tracts and undermining
- dressing to absorb drainage
- decrease bacterial load
- protect

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19
Q

How do you treat a stage X pressure ulcer?

A

surgical
- debridement to remove eschar

non-surgical
- keep dry/ prevent infection

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20
Q

What products do you use when treating a stage X pressure ulcer?

A
  • iodine swab or liquid with cotton swab
  • iodasorb ointment
  • inadine
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21
Q

What is inadine?

A

antimicrobial povidone impregnated gauze

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22
Q

How do you treat a suspected deep tissue injury (SDTI)?

A
  • depends on presentation/ when or if the wound opens
  • may become stage 3 or 4 ulcer and then treat as such
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23
Q

prior to treating a pressure ulcer what do you need to do?

A
  • address pain concerns
  • assess client education level of strategies to reduce pressure/ monitor risk, reduce risk and early detection of wounds
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24
Q

if you suspect a deep tissue injury what protocol, techniques do you need to adhere to?

A
  • hand hygiene protocols
  • aseptic technique
  • wound cleansing procedures
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25
Q

if you suspect a deep tissue injury what do you need to maintain?

A
  • moisture balance and keep peri wound dry
  • wound protection
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26
Q

what are the signs of a SYSTEMIC infection that might lead you to the clinical reasoning to obtain a C&S?

A

obtain C&S after cleansing the wound and if 2 or more of the following are present:
- altered VS
- increase WBC
- chills
- periwound warmth
- malaise
- pain

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27
Q

what are the signs of a LOCAL infection that might lead you to the clinical reasoning to obtain a C&S?

A

obtain C&S after cleansing the wound and if 2 or more of the following are present:
- decreased healing
- increased exudate
- redness
- necrotic debris
- odor present after cleaning

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28
Q

when might antibiotics be ordered if a wound infection is suspected?

A

before or after results are back

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29
Q

Why might antibiotics be ordered if a wound infection is suspected?

A

to treat with wound care products to reduce the bacteria in wound

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30
Q

if fluid for wound irrigation needs to be warmed to meet client needs, what do you use?

A

use a bowl of warm water do not microwave as this can cause burns

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31
Q

what must a wound have in order to irrigate?

A

a known endpoint

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32
Q

What temperature should fluid be when irritating a wound?

A

room temperature

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33
Q

what are some options that can be used to irrigate a wound?

A
  • sterile normal saline
  • sterile water
  • potable water
  • commercial cleansing agent
  • topical antiseptic agents
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34
Q

define wound irrigation

A

application of fluids into a wound that removes items without adversely impacting cellular activity to the wound healing process

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35
Q

when irrigating a wound what can be removed?

A
  • exudate
  • debris
  • bacterial contaminants
  • dressing residue
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36
Q

describe an irrigation tip

A
  • single use
  • latex free
  • soft flexible plastic
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37
Q

what is the pressure that comes through the irrigation tip?

A

7-8 psi

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38
Q

what are some indications for an irrigation tip to be used?

A
  • deep wounds with wide openings
  • wounds with narrow opening/ sinus or tunnelling
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39
Q

How should you position a patient when irrigating a wound?

A

position patient for gravity drainage or irrigation fluid

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40
Q

how do you irrigate a wound that has a deep/ wide opening?

A
  • hold tip 2.5cm above upper end of wound
  • gently flush using continuous pressure
  • repeat until runs clear
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41
Q

how do you irrigate a wound that has a small opening or sinus or tunnel?

A
  • gently insert tip and pull out 1cm
  • gently flush with continuous pressure
  • repeat until runs clear
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42
Q

What PPE do you need to wear when irrigating a wound?

A

dependent on size/ depth of wound and potential for splashing

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43
Q

What is the purpose of wound packing?

A
  • loosely fill dead space in wound
  • encourage growth of granulation tissue from base of wound
  • prevent premature closure/ abscess formation
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44
Q

what does wound packing assist with?

A

healing as material absorbs drainage > allows for faster healing from inside out

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45
Q

in regards to wound packing, why does the material protect the wound?

A

without packing wound may close at the top without healing at the deeper areas

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46
Q

describe a tunnelling wound or a sinus tract

A

narrow opening or passageway underneath skin that can extend in any direction through soft tissue

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47
Q

what can a tunnelled wound or sinus tract result in?

A

dead space potential for abscess formation

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48
Q

What are undermine wounds?

A

wounds that extend in one or multiple directions into subcutaneous tissue under skin

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49
Q

what causes an undermine wound?

A
  • infection
  • pressure that has caused lack of blood flow
  • improper wound treatment
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50
Q

true or false

wounds heal much more effectively when they are moist

A

true

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51
Q

can you tell the actual amount of damaged tissue just by looking at an undermine wound?

A

no, damaged tissue is much bigger than it appears by just looking at the surface of the wound

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52
Q

what are some products that can be used to a pack a wound?

A
  • gauze (dry or moist)
  • impregnated ribbon dressing
  • hydrofibre dressing
  • alginates dressing
  • antimicrobial dressing
  • negative wound pressure therapy foam
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53
Q

define wound packing

A

process of loosely filling a wound cavity or dead space with gauze or other material

54
Q

can you use multiple pieces when packing a wound?

A
  • yes but it’s best to use 1 piece of packing when possible or must be tied together or secured
55
Q

when packing a wound can the material be wet?

A

no, should be moist or damp

56
Q

what do you need to document for wound packing?

A
  • number or pieces removed and inserted
57
Q

in regards to wound packing what should you not pack beyond? what else do you need to do this?

A

do not pack beyond 15cm of opening unless direct orders from MRP or WOC

58
Q

How should you pack a wound?

A
  • loosely fill space with contact to entire base and edges
  • do not pack causing stretching or bulging
59
Q

what are the techniques used for wound packing?

A
  • review wound care plan
  • position pt for gravity drainage
  • organize supplies, irrigating fluid/ packing material
  • remove old dressing/ packing with clean gloves and blue forceps, soak if adheres and count peices
  • complete wound assessment/ measurements
  • may need to use peri wound skin barrier
  • secure packing tail to periwound with steristrip
  • document
60
Q

define VAC therapy

A

non invasive active therapy combining localized negative pressure and moisture to promote healing

61
Q

what does VAC therapy require?

A

requires an order, then WOC is referred to assess

62
Q

can any nurse complete a VAC dressing ?

A

no, requires competency/ further training

63
Q

when are VAC dressing changes complete?

A
  • 3 times/ week
  • normally mon, wed, fri
64
Q

What does VAC stand for?

A

Vacuum Assisted Closure

65
Q

What are indications for VAC therapy?

A
  • acute/ traumatic wounds
  • abdominal wounds
  • cardiothoracic wounds
  • orthopaedic wounds
  • chronic ulcer wounds
  • burns
66
Q

what are some complications associated with VAC therapy?

A
  • infection
  • foam retention
  • tissue adherence
  • bleeding
  • pain
67
Q

what are other systems that can be used that have the same purpose as VAC therapy?

A
  • prevena
  • PICO
68
Q

describe the other systems that can be used that have the same purpose as VAC therapy.

A
  • small
  • battery powered
  • portable system
  • patients may go home with these
  • up to 7 days of therapy
69
Q

describe the type of expected pain patients may feel with prevena and PICO systems

A
  • pulling/ tugging sensation for about 30 minutes after change is completed to one of these systems
70
Q

what is the difference between prevena and PICO systems?

A

prevena - has small canister
PICO - draws fluid into absorbent covering dressing

71
Q

What are some benefits of VAC therapy?

A
  • improved wound bed preparation/ enhanced granulation tissue growth
  • removal of excess interstitial fluid
  • increase local vascularity
  • decreased bacterial colonization
  • accurate wound drainage assessment
  • maintenance of moist wound environment
  • increased rate of epithelialization
  • cost effective
72
Q

Why are VAC therapies cost effective?

A
  • less dressing changes
  • decreased nursing time/ home visits
  • decreased patient length of hospital stay for wound care
  • simplifies treatment
73
Q

What are some contraindications for VAC therapy?

A
  • insufficient vascularity
  • necrotic wounds
  • untreated osteomyelitis
  • malignancy in wound
  • sinus tracts that are unpack able
  • fistula
  • allergy to dressing material
  • high risk of bleeding
  • can’t get appropriate seal
74
Q

what must you do to a necrotic wound prior to using VAC therapy?

A

must treat with ABX or debridement first

75
Q

what are some non-adherent wound care products?

A
  • mepitel
  • adaptic
  • allevyn
  • alldress
  • inadine
  • restore
  • Iodasorb
76
Q

in regard to non-adherent wound care products, describe mepitel

A

silicone layer

77
Q

in regard to non-adherent wound care products, describe adaptic

A

cellulose acetate impregnated petroleum

78
Q

in regard to non-adherent wound care products, describe allevyn

A

hydrocellular foam dressing

79
Q

in regard to non-adherent wound care products, describe alldress

A

composite dressing

80
Q

in regard to non-adherent wound care products, describe inadine

A

viscose fabric impregnated with iodine

81
Q

in regard to non-adherent wound care products, describe restore

A

fine polyester mesh and petroleum-based formula with silver layer

82
Q

in regard to non-adherent wound care products, describe Iodasorb

A

cadesomer iodine ointment (forms moist gel over wound)

83
Q

What are some absorbent wound care products?

A
  • allevyn/ mepilex border
  • nuderm alginate
  • aquacel
  • silvercel
  • mesalt
  • mesorb
  • gauze
84
Q

in regards to absorbent wound care products, describe allevyn/ mepilex border

A

hypocellular foam dressing/ non- adherent

85
Q

in regards to absorbent wound care products, describe nuderm alginate

A

calcium alginate (made from seaweed, has hemostatic properties)

86
Q

in regards to absorbent wound care products, describe aquacel

A

hydrofiber

87
Q

in regards to absorbent wound care products, describe silvercel

A

fine polyester mesh and petroleum-based formula with silver

88
Q

in regards to absorbent wound care products, describe mesalt

A

hypertonic gauze (sat-impregnated gauze)

89
Q

in regards to absorbent wound care products, describe mesorb

A

absorbent material/ fluid-repelling backing

90
Q

in regards to absorbent wound care products, describe gauze

A

cotton fabric

91
Q

What are some antimicrobial wound care products?

A
  • sivercel or seasorb AG
  • aquacel AG
  • acticoat flex 3 or 7
  • restore
  • inadine
  • providing-iodine solution
  • Iodasorb
92
Q

in regards to antimicrobial wound care products, describe silvercel or seasorb AG

A

calcium alginate with silver

93
Q

in regards to antimicrobial wound care products, describe aquacel AG

A

hydrofiber with silver

94
Q

in regards to antimicrobial wound care products, describe acticoat flex 3 or 7

A

knitted polyester with silver

95
Q

in regards to antimicrobial wound care products, describe restore

A

fine polyester mesh and petroleum-based formula with silver layer

96
Q

in regards to antimicrobial wound care products, describe Inadine

A

viscose fabric impregnated with iodine

97
Q

in regards to antimicrobial wound care products, describe Iodasorb

A

cadesomer iodine ointment

98
Q

what are some debridement wound care products?

A
  • hypertonic gauze
  • iodasorb ointment
  • gels
  • moistened hydrofiber or calcium alginate
99
Q

what are some hydrocolloid wound care products?

A
  • nuderm hydrocolloid
  • tegaderm hydrocolloid
100
Q

What do hydrocolloids do?

A

absorb small amounts

101
Q

what type of wound care product would you use for a bleeding wound?

A

calcium alginate

102
Q

what type of wound care product would you use for odor control?

A

activated charcoal dressing

103
Q

What are some examples of gauze dressings used for wound care?

A
  • gauze pack
  • mepore strip dressing
  • gauze roll
104
Q

what is an example of an occlusive/ transparent film dressing used for wound care?

A

tegaderm

105
Q

What do you need to take into consideration when picking products for wound care?

A
  • need to increase aborption to remove exudate
  • need to increase in a dry wound to promote a healing environment
  • type of tissue/ goal of wound care
106
Q

How long do you leave a post op dressing intact for?

A

24-48hrs unless otherwise ordered

107
Q

define sutures

A

tiny threads used to sew body tissue and skin together with intermittent, blanket or continuous technique

108
Q

where are sutures placed?

A
  • deep in the tissue
  • superficially to close wound
109
Q

what are the different types of sutures?

A
  • absorbent (dissolvable)
  • non-absorbent (must be removed)
110
Q

how long are sutures and staples left in place for?

A

long enough to establish wound closure with enough strength to support internal tissues and organs

111
Q

when are sutures removed?

A

5-14 days following surgical procedure depending on type of surgery/ physician

112
Q

what are staples made of?

A

stainless steel wire

113
Q

why does location sometimes restrict the use of staples?

A

must be far enough away from organs and structures

114
Q

when are staples removed?

A

7-14 days following surgical procedure depending on type of surgery/ physician

115
Q

What is first intention for wounds?

A

wound with:
- little tissue loss
- edges of wound approximate
- slight chance of infection
- heals quickly

116
Q

what is a second intention for wounds?

A

wound with:
- tissue loss
- edges of wound do not approximate
- wound left open/ fills with scar tissue
- slower healing
- increased risk of infection

117
Q

What is a third intention for wounds?

A
  • occurs where there is delayed suturing of a wound
  • wound is sutured after granulation tissue begins to form
118
Q

What are complications of sutures and staples?

A
  • dehiscence
  • evisceration
  • unable to remove
  • patient pain
  • infection of incision
119
Q

in regards to complications of sutures and staples, describe dehiscence

A

splitting open of a wound, stop, sterile-strip, redness and call surgeon

120
Q

in regards to complications of sutures and staples, describe evisceration

A
  • extrusion of organs outside of cavity through an open wound
  • blood supply to organs is compromised
121
Q

in regards to complications of sutures and staples, describe what you would do if the patient was experiencing pain

A

allow small breaks during removal

122
Q

in regards to complications of sutures and staples, describe what an infected incision looks like

A
  • warmth
  • redness
  • swelling
  • pus discharge
  • foul odor
  • pain
123
Q

prior to removing sutures/ staples you notice your patient has an evisceration. What do you do?

A
  • cover with saline soaked sterile dressing
  • do not attempt to reposition organs
  • call surgeon
124
Q

what do you need to teach your patients regarding sutures and staple management?

A
  • can shower
  • no baths/ hot tubs for 4-6 weeks
  • wash hands before/ after touching incision
  • do not pull off sterile-strips > come off naturally in 1-3 weeks
  • watch for S&S of infection
  • do not strain
  • adequate rest, fluids, nutrition
  • ambulate
125
Q

What do you need to include in your documentation for suture/ staple removal?

A
  • wound assessment
  • number of closures removed
  • wound care provided
  • stern-strips applied
  • type of dressing applied
126
Q

What are the steps to removing staples/ sutures?

A
  • look for physician’s order
  • set up sterile field, supplies
  • remove old dressing
  • assess drainage on dressing/ wound
  • cleanse incision/ assess prior to removal
  • assess site
  • remove alternating closures/ watch for dehiscence
  • cut/ remove sutures/ staples
  • cleanse incision/ dry well
  • apply ste-strips
  • repeat procedure to remove remaining closures if ordered
  • apply sterile covering dressing
  • document
127
Q

when you are removing staples/ sutures what are you assessing for?

A
  • redness
  • edema
  • ecchymosis
  • drainage
  • approximation
  • # closures
128
Q

when you are removing staples/ sutures what are you assessing when it comes to drainage?

A
  • type
  • amount
  • consistency
  • odor
129
Q

what are the steps for removing a suture?

A
  • grab knot
  • cut close to skin
  • pull suture from inside out
  • keep closures for count at end of procedure
130
Q

what are the steps for removing a suture?

A
  • grab knot
  • cut close to skin
  • pull suture from inside out
  • keep closures for count at end of procedur
131
Q

what are the steps for removing a staple?

A
  • slide remover under staple and push down
  • do not pull up on staple
  • gently move staple from side to side

NRSG 301 (5 decks)

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