E3 Wound management Flashcards
Factors that affect wound healing?
-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
Inflammation is a ______ _______ response to injury or destruction of tissue
localized protective
What are the various processes and stages of wound healing?
- Bring hemostasis
- Inflammatory phase
- Repair/ Remodel (Scar tissue)
What are the 3 key components of skin/wound management?
- Assessment
- Cleansing
- Protection
What should you note during Wound assessment?
- Appearance: Red, Yellow Black
- Length, Width, Death (sinus tracts, tunnels, redness/swelling around)
- Closed wounds: skin edges should be ‘well approximated’ (staples, sutures, tissue adhesives)
- Note drains or tubes present
- Pain around the incision (Controlled?)
- Odor
Wound measurements are made in ____
cm
Describe how you would measure a wound
- Head to toe
- Side to side
- Depth (if any)
- 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
How would you chart tunneling or undermining?
Charted in respect to a clock with 12 o’clock being toward the patients head.
Is wound drainage normal?
Yes and No
Accumulates during the inflammatory and proliferative phases of healing
How would you document wound drainage?
Amount
Odor
Consistency
Color
Note integrity of surrounding skib
For an accurate measurement:
Weigh the dressing
1g =
1mL
Serous drainage
portion of blood (serum) that is watery and clear or slightly yellow in appearance (think what is in blisters)
Sanguineous drainage
Serum and RBCs, thick/appears reddish
Brighter= active bleed
Darker= older bleed
Serosanguinous drainage
Contains serum and blood, watery, looks pale/pink (New Wound)
Purulent drainage
Result of infection, thick, contains WBCs, tissue debris, and bacteria
-Yellow, tan, green, brown
Nursing interventions for patients with wounds
-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
What kind of diet should a patient with wounds be on?
-High protein, carbohydrates, & vitamins w/ moderate fat intake
What are the nutrition labs?
Albumin & Prealbumin levels
Woven guaze (sponges)
absorb exudate
Non-adherent material
Doesn’t stick to wound bed
Wet-to-Dry
-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
Self-adhesive, transparent: Ex. Tegaderm
Careful bc they will pull off good skin
Hydrocolloid wound dressing
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
Hydrogel wound dressing
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
What type of wound would you use a hydrogel dressing on?
Infected, deep wounds or necrotic tissue
What type of wound would you not use a hydrogel dressing on?
Wound with alot of drainage
Aliginates wound dressing
Nonadherent dressing that conform to wounds shape, and absorb exudate
Collagen
Powders, paste, granules, gels
-Stop bleeding and promote healing
Vacuum-assisted closure system: Wound Vac
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
A wound Vac helps with
-Tissue generation
-Decrease swelling
-Enhance healing in moist, protective environment
-Wounds not healing naturally, dehiscent wounds, or perineal wounds
Complications of wound healing
- Adhesions
- Contractions
- Hemorrhage
- Dehiscence
- Evisceration
- Fistula formation
- Infection
- Excessive granulation tissue
- Keloid formation
Hemorrhage is caused by
-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)
Internal bleeding may present with
swelling, distention in area, and may cause sanguineous drainage (& initially, subtle change in V.S.)- Increase HR & BP
What is a Hematoma?
a local area of blood collection that appears as red or blue bruise
What is Dehiscence?
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
What is Evisceration?
A dehiscence that involves the protrusion of visceral organs through wound opening
Manifestations of Evisceration
-Significant increase in flow of serosanguinous fluid on the wound dressing
-Straining
-Sudden change or ‘Pop’ or ‘Giving way’
Risk factors for dehiscence and evisceration
-Chronic disease
-Advanced age
-Obesity
-Invasive abdominal cancer
-Vomiting
-Excessive straining, coughing, sneezing
-Dehydration, malnutrition
-Ineffective suturing
-Abdominal surgery
-Infection
Dehiscence/ Evisceration Nursing Management
-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
Risk factors of infection and surgical wounds
-Age extremes
-Immune suppression
-Impaired circulation/ oxygenation
-Wound Condition & nature
-Malnutrition
-Chronic Disease
-Poor wound management
Manifestations of infection and surgical wounds
2-11 days after injury or surgery
-Pain
-Redness, edema, & purulent drainage (around wound)
-Fever & Chills
-Odor
-Increased pulse & RR
-Increased WBC
Nursing interventions for wound infection
-Prevent infection using aseptic technique with dressing changes
-Provide optimal nutrition
-Provide adequate rest
-Administer antibiotic therapy after culture and sensitivity test
