Final Flashcards
Stages of Wound Healing
Hemostasis ( first 24h)
Inflammation (1-4 days)
Proliferation or granulation (4- 21 days)
Remodelling or maturation (up to 2 years)
It is important to identify what stage the wound is to create the appropriate care plan and appropriate wound care products.
Wound assessment
Location and type > acute or chronic? Pressure ulcer? venous or arterial? surgical? Skin tear?
Wound bed/base: pink, eschar, granulation, slough, ..
Exudate type and amount
Wound measurements (length x width x depth)
Presence of: sinus tract, undermining (clock method)
Periwound area
Acute and Chronic Wounds
All wounds start as acute
Acute wound: heals within an expected time frame (within 21 days)
Chronic wound: one in which the normal process of wound healing is disrupted at one or more points in the healing process. (eg. pressure ulcers, venous ulcers, arterial ulcers, diabetic foot ulcers)
General Nursing Care of the Patient with chronic wounds
Thorough Assessments Hx - lifestyle (ETOH, hygiene)
Treatment depends on the type of ulcer
Assess for presence of infection
Assess nutrition
Comorbidities: PVD, diabetes, immunocompromised, smoking, obesity, phlebitis, ..
Pressure ulcers
Clinical site indicating tissue damage as a result of pronlonged and excessive tissue deformation (compression, shear and tension)
Serious and costly
Preventable
Maintaining wound healing is important to avoid progression and further complications
Stages 1 - 5?
Pressure Ulcers
Stage I - non blanchable erythema signals potential ulceration; skin is intact
Stage 2- partial thickness; skin loss
Stage 3- full thickness skin loss to subcutaneous tissue
Stage 4- full thickness skin loss exposed muscle, tendon or bone
Unstageable - ulcer is covered by slough or eschar - requires advanced interventions
Pressure Ulcers contributing factors
mechanical loads (tear and friction) immobility inadequate nutrition fecal and/ or urinary incontinence decreased LOC Diminished sensation Excessive body heat age and comorbidities (eg diabetes, PVD)
How to prevent pressure ulcers?
Complete Braden scale on admission
HTT - focus on integ upon admission
Hx and identify patients with poor circulation
Assess and monitor labs
Maintain good skin hygiene and avoid skin trauma
Frequent repositioning (if bedridden q2h)
Multidisciplinary approach and individualized care plan
Provide local wound care
Optimize wound healing
Arterial Ulcer - think ischemia
Claudication, painful++ smooth/regular shaped orders Minimal drainage Non-bleeding Weak pulse or non palpable Pale or black Very hard to tx d/t poor perfusion of o2 and nutrients Goal is to eliminate restrictive clothing, protect from cold, heat or trauma; elevate HOB, flat legs (dangle legs)
Venous Ulcer (usually caused by disease - eg CHF)
Dull ache to moderate pain edema irregular borders copious drainage Pulses present Bleeds easily Tx: compression, diuretics, elevate legs, restore skin integrity, increase mobility
Diabetic Foot Ulcer
due to hyperglycemia, motor or sensory neuropathy, PVD can be prevented by: protective shoes and good hygiene care frequent inspection relieving pressure lifestyle changes (no smoking)
general interventions:
assess wound, identify the cause and treat
individualized pt care plan and TEACHING
interdisciplinary approach to address glycemic control, prevent infection, offloading pressure and localized wound care
Principles to promote optimal wound bed
Protect healthy granulation tissue
Provide moist environment
Remove excess exudate, debris and dead tissue
Cleanse with non cytotoxic agents
Prevent infection
Maintain normothermia
Address pain (before and after drsg change)
Dressing changes accordingly to wound healing stage
Regular nursing assessment and documentation
General guidelines for caring for chronic wounds
Use aseptic technique: no touch or sterile
Know what type of wound and goal of tx plan
Use moist sterile probe to measure sinuses, tunnels, undermining and vacity wounds
Assess Pt as a whole and not just the hole
Documentation
Pt teaching (nutrition diet, avoid smoking as it delays healing)
Wound irrigation
application of fluid to a wound to:
- remove exudate, slough, debris, bacterial contaminants and dressing residue
- debride large open cavities
- apply warmth
- administer medication
without perturbing the granulation tissue
Principles of irrigation
- Slow continuous flow of pressure
- Cleansing with at least 100 mL of sterile solution at room temperature
- Undermining sinuses and tunnels that extend 15 cm of length are not to be irrigated and must be directed by a physician
- Protect intact skin in periwound area
- Wear PPE
