Complex Wound Care Flashcards
1
Q
Can student nurses perform VAC dressing changes or sharp wound debridement?
A
no
2
Q
how often do Braden Scales need to be completed to be effective?
A
every shift or every 24hrs
3
Q
what will a Braden scale help you determine?
A
risk pt has for skin breakdown so early intervention can reduce risk
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)
5
Q
as pressure ulcers heal they are not down staged, instead they are what?
A
classified granulated stage
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
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
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
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
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
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
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
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
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
15
Q
How do you treat a stage 1 pressure ulcer?
A
- relieve pressure
- protect with barrier cream
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
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
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
19
Q
How do you treat a stage X pressure ulcer?
A
surgical
- debridement to remove eschar
non-surgical
- keep dry/ prevent infection
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
21
Q
What is inadine?
A
antimicrobial povidone impregnated gauze
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
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
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
25
if you suspect a deep tissue injury what do you need to maintain?
- moisture balance and keep peri wound dry
- wound protection
26
what are the signs of a SYSTEMIC infection that might lead you to the clinical reasoning to obtain a C&S?
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
27
what are the signs of a LOCAL infection that might lead you to the clinical reasoning to obtain a C&S?
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
28
when might antibiotics be ordered if a wound infection is suspected?
before or after results are back
29
Why might antibiotics be ordered if a wound infection is suspected?
to treat with wound care products to reduce the bacteria in wound
30
if fluid for wound irrigation needs to be warmed to meet client needs, what do you use?
use a bowl of warm water do not microwave as this can cause burns
31
what must a wound have in order to irrigate?
a known endpoint
32
What temperature should fluid be when irritating a wound?
room temperature
33
what are some options that can be used to irrigate a wound?
- sterile normal saline
- sterile water
- potable water
- commercial cleansing agent
- topical antiseptic agents
34
define wound irrigation
application of fluids into a wound that removes items without adversely impacting cellular activity to the wound healing process
35
when irrigating a wound what can be removed?
- exudate
- debris
- bacterial contaminants
- dressing residue
36
describe an irrigation tip
- single use
- latex free
- soft flexible plastic
37
what is the pressure that comes through the irrigation tip?
7-8 psi
38
what are some indications for an irrigation tip to be used?
- deep wounds with wide openings
- wounds with narrow opening/ sinus or tunnelling
39
How should you position a patient when irrigating a wound?
position patient for gravity drainage or irrigation fluid
40
how do you irrigate a wound that has a deep/ wide opening?
- hold tip 2.5cm above upper end of wound
- gently flush using continuous pressure
- repeat until runs clear
41
how do you irrigate a wound that has a small opening or sinus or tunnel?
- gently insert tip and pull out 1cm
- gently flush with continuous pressure
- repeat until runs clear
42
What PPE do you need to wear when irrigating a wound?
dependent on size/ depth of wound and potential for splashing
43
What is the purpose of wound packing?
- loosely fill dead space in wound
- encourage growth of granulation tissue from base of wound
- prevent premature closure/ abscess formation
44
what does wound packing assist with?
healing as material absorbs drainage > allows for faster healing from inside out
45
in regards to wound packing, why does the material protect the wound?
without packing wound may close at the top without healing at the deeper areas
46
describe a tunnelling wound or a sinus tract
narrow opening or passageway underneath skin that can extend in any direction through soft tissue
47
what can a tunnelled wound or sinus tract result in?
dead space potential for abscess formation
48
What are undermine wounds?
wounds that extend in one or multiple directions into subcutaneous tissue under skin
49
what causes an undermine wound?
- infection
- pressure that has caused lack of blood flow
- improper wound treatment
50
true or false
wounds heal much more effectively when they are moist
true
51
can you tell the actual amount of damaged tissue just by looking at an undermine wound?
no, damaged tissue is much bigger than it appears by just looking at the surface of the wound
52
what are some products that can be used to a pack a wound?
- gauze (dry or moist)
- impregnated ribbon dressing
- hydrofibre dressing
- alginates dressing
- antimicrobial dressing
- negative wound pressure therapy foam
53
define wound packing
process of loosely filling a wound cavity or dead space with gauze or other material
54
can you use multiple pieces when packing a wound?
- yes but it's best to use 1 piece of packing when possible or must be tied together or secured
55
when packing a wound can the material be wet?
no, should be moist or damp
56
what do you need to document for wound packing?
- number or pieces removed and inserted
57
in regards to wound packing what should you not pack beyond? what else do you need to do this?
do not pack beyond 15cm of opening unless direct orders from MRP or WOC
58
How should you pack a wound?
- loosely fill space with contact to entire base and edges
- do not pack causing stretching or bulging
59
what are the techniques used for wound packing?
- 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
define VAC therapy
non invasive active therapy combining localized negative pressure and moisture to promote healing
61
what does VAC therapy require?
requires an order, then WOC is referred to assess
62
can any nurse complete a VAC dressing ?
no, requires competency/ further training
63
when are VAC dressing changes complete?
- 3 times/ week
- normally mon, wed, fri
64
What does VAC stand for?
Vacuum Assisted Closure
65
What are indications for VAC therapy?
- acute/ traumatic wounds
- abdominal wounds
- cardiothoracic wounds
- orthopaedic wounds
- chronic ulcer wounds
- burns
66
what are some complications associated with VAC therapy?
- infection
- foam retention
- tissue adherence
- bleeding
- pain
67
what are other systems that can be used that have the same purpose as VAC therapy?
- prevena
- PICO
68
describe the other systems that can be used that have the same purpose as VAC therapy.
- small
- battery powered
- portable system
- patients may go home with these
- up to 7 days of therapy
69
describe the type of expected pain patients may feel with prevena and PICO systems
- pulling/ tugging sensation for about 30 minutes after change is completed to one of these systems
70
what is the difference between prevena and PICO systems?
prevena - has small canister
PICO - draws fluid into absorbent covering dressing
71
What are some benefits of VAC therapy?
- 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
Why are VAC therapies cost effective?
- less dressing changes
- decreased nursing time/ home visits
- decreased patient length of hospital stay for wound care
- simplifies treatment
73
What are some contraindications for VAC therapy?
- 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
what must you do to a necrotic wound prior to using VAC therapy?
must treat with ABX or debridement first
75
what are some non-adherent wound care products?
- mepitel
- adaptic
- allevyn
- alldress
- inadine
- restore
- Iodasorb
76
in regard to non-adherent wound care products, describe mepitel
silicone layer
77
in regard to non-adherent wound care products, describe adaptic
cellulose acetate impregnated petroleum
78
in regard to non-adherent wound care products, describe allevyn
hydrocellular foam dressing
79
in regard to non-adherent wound care products, describe alldress
composite dressing
80
in regard to non-adherent wound care products, describe inadine
viscose fabric impregnated with iodine
81
in regard to non-adherent wound care products, describe restore
fine polyester mesh and petroleum-based formula with silver layer
82
in regard to non-adherent wound care products, describe Iodasorb
cadesomer iodine ointment (forms moist gel over wound)
83
What are some absorbent wound care products?
- allevyn/ mepilex border
- nuderm alginate
- aquacel
- silvercel
- mesalt
- mesorb
- gauze
84
in regards to absorbent wound care products, describe allevyn/ mepilex border
hypocellular foam dressing/ non- adherent
85
in regards to absorbent wound care products, describe nuderm alginate
calcium alginate (made from seaweed, has hemostatic properties)
86
in regards to absorbent wound care products, describe aquacel
hydrofiber
87
in regards to absorbent wound care products, describe silvercel
fine polyester mesh and petroleum-based formula with silver
88
in regards to absorbent wound care products, describe mesalt
hypertonic gauze (sat-impregnated gauze)
89
in regards to absorbent wound care products, describe mesorb
absorbent material/ fluid-repelling backing
90
in regards to absorbent wound care products, describe gauze
cotton fabric
91
What are some antimicrobial wound care products?
- sivercel or seasorb AG
- aquacel AG
- acticoat flex 3 or 7
- restore
- inadine
- providing-iodine solution
- Iodasorb
92
in regards to antimicrobial wound care products, describe silvercel or seasorb AG
calcium alginate with silver
93
in regards to antimicrobial wound care products, describe aquacel AG
hydrofiber with silver
94
in regards to antimicrobial wound care products, describe acticoat flex 3 or 7
knitted polyester with silver
95
in regards to antimicrobial wound care products, describe restore
fine polyester mesh and petroleum-based formula with silver layer
96
in regards to antimicrobial wound care products, describe Inadine
viscose fabric impregnated with iodine
97
in regards to antimicrobial wound care products, describe Iodasorb
cadesomer iodine ointment
98
what are some debridement wound care products?
- hypertonic gauze
- iodasorb ointment
- gels
- moistened hydrofiber or calcium alginate
99
what are some hydrocolloid wound care products?
- nuderm hydrocolloid
- tegaderm hydrocolloid
100
What do hydrocolloids do?
absorb small amounts
101
what type of wound care product would you use for a bleeding wound?
calcium alginate
102
what type of wound care product would you use for odor control?
activated charcoal dressing
103
What are some examples of gauze dressings used for wound care?
- gauze pack
- mepore strip dressing
- gauze roll
104
what is an example of an occlusive/ transparent film dressing used for wound care?
tegaderm
105
What do you need to take into consideration when picking products for wound care?
- 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
How long do you leave a post op dressing intact for?
24-48hrs unless otherwise ordered
107
define sutures
tiny threads used to sew body tissue and skin together with intermittent, blanket or continuous technique
108
where are sutures placed?
- deep in the tissue
- superficially to close wound
109
what are the different types of sutures?
- absorbent (dissolvable)
- non-absorbent (must be removed)
110
how long are sutures and staples left in place for?
long enough to establish wound closure with enough strength to support internal tissues and organs
111
when are sutures removed?
5-14 days following surgical procedure depending on type of surgery/ physician
112
what are staples made of?
stainless steel wire
113
why does location sometimes restrict the use of staples?
must be far enough away from organs and structures
114
when are staples removed?
7-14 days following surgical procedure depending on type of surgery/ physician
115
What is first intention for wounds?
wound with:
- little tissue loss
- edges of wound approximate
- slight chance of infection
- heals quickly
116
what is a second intention for wounds?
wound with:
- tissue loss
- edges of wound do not approximate
- wound left open/ fills with scar tissue
- slower healing
- increased risk of infection
117
What is a third intention for wounds?
- occurs where there is delayed suturing of a wound
- wound is sutured after granulation tissue begins to form
118
What are complications of sutures and staples?
- dehiscence
- evisceration
- unable to remove
- patient pain
- infection of incision
119
in regards to complications of sutures and staples, describe dehiscence
splitting open of a wound, stop, sterile-strip, redness and call surgeon
120
in regards to complications of sutures and staples, describe evisceration
- extrusion of organs outside of cavity through an open wound
- blood supply to organs is compromised
121
in regards to complications of sutures and staples, describe what you would do if the patient was experiencing pain
allow small breaks during removal
122
in regards to complications of sutures and staples, describe what an infected incision looks like
- warmth
- redness
- swelling
- pus discharge
- foul odor
- pain
123
prior to removing sutures/ staples you notice your patient has an evisceration. What do you do?
- cover with saline soaked sterile dressing
- do not attempt to reposition organs
- call surgeon
124
what do you need to teach your patients regarding sutures and staple management?
- 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
What do you need to include in your documentation for suture/ staple removal?
- wound assessment
- number of closures removed
- wound care provided
- stern-strips applied
- type of dressing applied
126
What are the steps to removing staples/ sutures?
- 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
when you are removing staples/ sutures what are you assessing for?
- redness
- edema
- ecchymosis
- drainage
- approximation
- # closures
128
when you are removing staples/ sutures what are you assessing when it comes to drainage?
- type
- amount
- consistency
- odor
129
what are the steps for removing a suture?
- grab knot
- cut close to skin
- pull suture from inside out
- keep closures for count at end of procedure
130
what are the steps for removing a suture?
- grab knot
- cut close to skin
- pull suture from inside out
- keep closures for count at end of procedur
131
what are the steps for removing a staple?
- slide remover under staple and push down
- do not pull up on staple
- gently move staple from side to side
