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NUR 333 > E3 Wound management > Flashcards

E3 Wound management Flashcards

1
Q

Factors that affect wound healing?

A

-Age
-Loss of skin turgor
-Skin fragility
-Decreased circulation and oxygenation
-Slower tissue regeneration
-Decreased absorption of nutrients
-Decreased collagen
-Impaired immune function
-Dehydration
-Overall wellness
-Infection
-Meds
-Low hemoglobin levels
-Obesity
-Smoking
-Chronic Disease
-Malnutrition

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2
Q

Inflammation is a ______ _______ response to injury or destruction of tissue

A

localized protective

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3
Q

What are the various processes and stages of wound healing?

A
  1. Bring hemostasis
  2. Inflammatory phase
  3. Repair/ Remodel (Scar tissue)
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4
Q

What are the 3 key components of skin/wound management?

A
  1. Assessment
  2. Cleansing
  3. Protection
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5
Q

What should you note during Wound assessment?

A
  1. Appearance: Red, Yellow Black
  2. Length, Width, Death (sinus tracts, tunnels, redness/swelling around)
  3. Closed wounds: skin edges should be ‘well approximated’ (staples, sutures, tissue adhesives)
  4. Note drains or tubes present
  5. Pain around the incision (Controlled?)
  6. Odor
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6
Q

Wound measurements are made in ____

A

cm

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7
Q

Describe how you would measure a wound

A
  1. Head to toe
  2. Side to side
  3. Depth (if any)
  4. Tunneling or undermining

Ex. full-thickness, red wound, 7 x 5 x 3 cm, with 3 cm tunnel at 7 o’clock and 2 cm undermining from 3 o’clock to 5 o’clock

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8
Q

How would you chart tunneling or undermining?

A

Charted in respect to a clock with 12 o’clock being toward the patients head.

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9
Q

Is wound drainage normal?

A

Yes and No
Accumulates during the inflammatory and proliferative phases of healing

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10
Q

How would you document wound drainage?

A

Amount
Odor
Consistency
Color
Note integrity of surrounding skib

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11
Q

For an accurate measurement:

A

Weigh the dressing

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12
Q

1g =

A

1mL

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13
Q

Serous drainage

A

portion of blood (serum) that is watery and clear or slightly yellow in appearance (think what is in blisters)

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14
Q

Sanguineous drainage

A

Serum and RBCs, thick/appears reddish
Brighter= active bleed
Darker= older bleed

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15
Q

Serosanguinous drainage

A

Contains serum and blood, watery, looks pale/pink (New Wound)

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16
Q

Purulent drainage

A

Result of infection, thick, contains WBCs, tissue debris, and bacteria
-Yellow, tan, green, brown

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17
Q

Nursing interventions for patients with wounds

A

-Adequate hydration & nutrition
-Wound cleansing
-Remove sutures and staples as ordered
-Administer analgesics and monitor for pain management
-Administer antimicrobials as ordered and monitor effectiveness
-Document thoroughly

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18
Q

What kind of diet should a patient with wounds be on?

A

-High protein, carbohydrates, & vitamins w/ moderate fat intake

19
Q

What are the nutrition labs?

A

Albumin & Prealbumin levels

20
Q

Woven guaze (sponges)

A

absorb exudate

21
Q

Non-adherent material

A

Doesn’t stick to wound bed

22
Q

Wet-to-Dry

A

-Used to mechanically debride a wound until granulation tissue starts to form
-A moist wound bed supports movement of epithelial cells and helps facilitate wound closure
-Help pull of dead skin cells

23
Q

Self-adhesive, transparent: Ex. Tegaderm

A

Careful bc they will pull off good skin

24
Q

Hydrocolloid wound dressing

A

Occlusive dressing that swells in presence of exudate
Ex. Duoderm
-Helps maintain moist environment but also kind of pull away excessive drainage and also protect it
-Replace in 3 days

25
Q

Hydrogel wound dressing

A

Mostly water, gels after contact with exudate, promotes autolytic debridement, rehydrates and fills dead space
-May need secondary occlusive dressing
-Provides moist wound bed and can reduce pain
-Prevents breakdown in high pressure area
-Need HCP Order

26
Q

What type of wound would you use a hydrogel dressing on?

A

Infected, deep wounds or necrotic tissue

27
Q

What type of wound would you not use a hydrogel dressing on?

A

Wound with alot of drainage

28
Q

Aliginates wound dressing

A

Nonadherent dressing that conform to wounds shape, and absorb exudate

29
Q

Collagen

A

Powders, paste, granules, gels
-Stop bleeding and promote healing

30
Q

Vacuum-assisted closure system: Wound Vac

A

Use of foam strips into the wound bed with occlusive dressing - creates negative pressure (help increase tissue perfusion to area)

Need HCP order to apply, when to change, and what to set pressure to

Usually change ever 3 days/ Becomes part of assessment

31
Q

A wound Vac helps with

A

-Tissue generation
-Decrease swelling
-Enhance healing in moist, protective environment
-Wounds not healing naturally, dehiscent wounds, or perineal wounds

32
Q

Complications of wound healing

A
  1. Adhesions
  2. Contractions
  3. Hemorrhage
  4. Dehiscence
  5. Evisceration
  6. Fistula formation
  7. Infection
  8. Excessive granulation tissue
  9. Keloid formation
33
Q

Hemorrhage is caused by

A

-Clot dislodgement, slipped suture, or blood vessel damage
-Greatest risk 24-48 hrs after injury/surgery
-Can be Emergency: apply pressure dressing, notify HCP, and monitor vital signs (may need fluids to increase BP or blood transfusion)

34
Q

Internal bleeding may present with

A

swelling, distention in area, and may cause sanguineous drainage (& initially, subtle change in V.S.)- Increase HR & BP

35
Q

What is a Hematoma?

A

a local area of blood collection that appears as red or blue bruise

36
Q

What is Dehiscence?

A

Partial or total rupture (seperation) of a sutured wound, usually with a separation of underlying skin layers

-Failure of proper wound healing
-Happens 2-11 days after surgery before collagen formation
-Usually do small wet to dry dressing

37
Q

What is Evisceration?

A

A dehiscence that involves the protrusion of visceral organs through wound opening

38
Q

Manifestations of Evisceration

A

-Significant increase in flow of serosanguinous fluid on the wound dressing
-Straining
-Sudden change or ‘Pop’ or ‘Giving way’

39
Q

Risk factors for dehiscence and evisceration

A

-Chronic disease
-Advanced age
-Obesity
-Invasive abdominal cancer
-Vomiting
-Excessive straining, coughing, sneezing
-Dehydration, malnutrition
-Ineffective suturing
-Abdominal surgery
-Infection

40
Q

Dehiscence/ Evisceration Nursing Management

A

-Notify HCP Immediately due to surgical intervention
-Stay w/ pt
-Cover wound and any protruding organs with sterile towels or sterile dressing soaked with normal saline
-Do not attempt to reinsert organs
-Maintain calm environment
-Position pt supine with hips and knees bent to decrease abdominal tension
-Keep pt NPO

41
Q

Risk factors of infection and surgical wounds

A

-Age extremes
-Immune suppression
-Impaired circulation/ oxygenation
-Wound Condition & nature
-Malnutrition
-Chronic Disease
-Poor wound management

42
Q

Manifestations of infection and surgical wounds

A

2-11 days after injury or surgery
-Pain
-Redness, edema, & purulent drainage (around wound)
-Fever & Chills
-Odor
-Increased pulse & RR
-Increased WBC

43
Q

Nursing interventions for wound infection

A

-Prevent infection using aseptic technique with dressing changes
-Provide optimal nutrition
-Provide adequate rest
-Administer antibiotic therapy after culture and sensitivity test

NUR 333 (15 decks)

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