Interventions and Management of Wound Care Flashcards
Commonalities between infection and inflammation:
pain
delayed healing
persistent or increasing exudate
suboptimal granulation tissue (spongy or friable)
induration
When is soap and water appropriate to use on a wound?
non-infected wounds
What is a good cleansing method for infected wounds?
-antiseptic x 2 weeks
-then wash w/ water
-only use as needed
Should hydrogen peroxide be used regularly on wounds?
no
kills healthy cells; don’t use straight out of the bottle
** same with iodine–> cytotoxic; not a long term option
DIMES- infection and topical interventions; ionic vs colloidal silver
ionic silver
-protects the wound from bacterial contamination
colloidal silver
-silver deposits into tissues; blue skin appearance
Silver as an element has proven to be antibacterial and protective against a lot of different kinds of germs and bacteria. Wound healing using silver ions works very efficiently even in low concentration and has been proven to cause faster healing than usual.
What is a risk of using too much neosporin?
-creates antibiotic resistance
-it is an antibiotic ointment
Should a complex wound be left open to the air?
NO
require proper moisture balance and temperature
What is bogginess of a wound?
-softness
-empty end feel
Types of abnormal effects of too much or too little moisture
-maceration
-excoriation
-denuded
Maceration
softening and breaking down of skin due
to prolonged exposure to moisture
Excoriation
chafing, raw irritated lesion
linear erosion of the skin by mechanical
means (scratching, rubbing)
Denuded
Loss of epidermis due to exposure to urine,
feces, body fluids, wound exudate or friction
What should be avoided when it comes to maintaining proper wound moisture?
Depends (adult diapers)
Extra layers (sheets, bed pads)–> adds insulation and holds more fluid
Needs for maintaining proper moisture environment:
toileting schedule
rectal tube
What are passive drains?
Air or fluid moves from an area of high pressure to one of lower pressure (often just “gravity assisted”)
-penrose drain (fluid can exit from deeper spaces)
-pigtail catheter (abdominal/thoracic drain/drainage of pleural fluid)
-gastrostomy
-cystostomy
-nephrostomy
-T-tube
What are active drains?
-negative pressure is used
-connected to a collection device
–> hemovac
–> jackson-pratt
Function of tubes:
-used to remove air and fluids
-provides decompression
-maintains patency of a lumen (keeps the edges open to prevent pocket as the wound heals)
What is a hemovac?
A Hemovac drain is placed under your skin during surgery. This drain removes any blood or other fluids that might build up in this area. You can go home with the drain still in place.
What is a Jackson Pratt Drain?
-held into place with 1-2 stitches internally
-must be under suction
-must unplug, squeeze, replug
JP drains are often placed in wounds during surgery to prevent the collection of fluid underneath the incision site. This is a closed, air-tight drainage system which operates by self-suction. The drain(s) promote healing by keeping excess pressure off the incision and decreasing the risk of infection.
When can collagen be used for wounds?
-can be added into wound, as it is helpful for stalled wounds; promotes healing
When is hyperbaric oxygen used as a wound healing intervention?
-only certain diagnoses: necrotizing fasciitis, non-healing 30 days, crush injuries
-have to show to insurance that other interventions have not worked
Support (DIMES)
Physical therapy involvement in wound care:
-risk assessment
-functional mobility training
-positioning
-pressure redistribution
-exercise
-application of biophysical agents –> pain reduction and tissue healing
-open wound direct management
Electrical stimulation-indications and CIs
Type used:
-high volt
-low intensity- direct current
-microcurrent
** evidence supporting pulsed current, TENS, and PEMI
INDICATIONS
-chronic or recalcitrant (not healing in typical timeline) wounds, clean or infected, granular or necrotic
-pressure, arterial, venous, or neuropathic
-better outcomes for pressure wounds than venous ulcers
CONTRAINDICATIONS
-wounds with osteomyelitis, in combination with topicals containing heavy metal ions, actively bleeding wounds; caution w/patients with sensory neuropathy
-caution with cancer, DVT, pregnancy
HOW IT WORKS
-necrotic tissue has disrupted polarity–> E stim helps to restore the current of injury (bioelectric field and polarity)
-enhanced epithelialization
-stimulates cells to move along an electrical gradient (galvanotaxis)
-stimulates cell proliferation
-Increases blood flow (augmented angiogenesis)
-increased oxygen at wound bed
-Increases bactericidal abilities (attraction of neutrophils and macrophages)
-reduces edema
-facilitates (autolytic) debridement
*electrodes can be placed within wound bed
Ultrasound: purpose, CIs and Indications
PURPOSE
-enhances all phases of wound healing
-increases collagen deposition, granulation tissue formation, angiogenesis
-enhances wound contraction (closure)
-improves scar pliability
-ultrasound waves deliver saline to wound site –> saline acts as “debrider”
INDICATIONS
-for chronic or recalcitrant wounds
CONTRAS
-osteomyelitis
-active bleeding
-severe arterial insufficiency
-DVT
THINGS TO KEEP IN MIND
-don’t touch surface of sound head on skin (hot sound head)
-machine determines how long the ultrasound should last
-dress wound after US treatment
Negative Pressure Wound Therapy
“vacuum assisted wound closure”
PURPOSE:
o Increased local blood flow
o Decrease wound & periwound edema
o Increased granulation tissue formation
o Increased angiogenesis
o Decreased wound bioburden (bacteria)
o Promotes cellular proliferation
o Maintains moist, warm wound environment
INDICATIONS:
-chronic wounds, post-surgical wounds/grafts
CONTRAS
-necrotic wounds, body cavity wounds, osteomyelitis, exposed blood vessels; caution with anticoagulants
Can you use negative pressure wound therapy on necrotic wounds?
no
Process of applying wound vac (negative pressure wound therapy):
1) clean wound bed
2) cut foam to size of wound bed
3) put foam into wound bed
4) attach suction tube to foam and make sure there is a hole in center
5) want foam to look like dried raisin appearance
Hyperbaric Oxygen Therapy - purpose, indications, contras
Average treatment time: 90-120 minutes, 2-3 days/week, 20-60 sessions, 75,000 dollars
PURPOSE
o Increases oxygen
o May reduce bacterial growth
o May enhance angiogenesis, collagen synthesis, granulation tissue formation, epithelialization, wound
contraction
o May reduce edema
INDICATIONS
gangrene, acute traumatic peripheral ischemia, acute peripheral arterial insufficiency, crush injury, Grade 3 or worse LE diabetic wounds, progressive necrotizing infection, chronic refractory osteomyelitis, osteoradionecrosis, preparation & preservation of compromised grafts & flaps
CONTRAS
DVT, CHF, severe arterial insufficiency; caution with claustrophobia, COPD, pregnancy
IRRIGATION, purpose contras and indications
PURPOSE
* Promote healing
* Reduce infection risk
* Maintain healthy wound
* Remove foreign material
** fine balance of how much pressure to use (aggressive enough but not too aggressive)
INDICATIONS
-acute and chronic wounds
-wounds undergoing suturing, surgical repair, or debridement
CONTRAS
-may not be needed for highly vascularized area (scalp)
-wounds with fistulas or sinuses with unknown depths –> be careful
-irrigation can include wound anesthesia with lidocaine, bipivacaine, etc
Irrigation cleansing agent types and solutions:
CLEANSING AGENTS:
povidone, iodine, chlorhexadine, polxamer 188 (soap like)
SOLUTIONS:
-normal saline - similar tonicity to cells
-sterile water - hypotonic (cell lysis)
-potable water- not preferred, no difference between sterile water for infection rates
-commercial surfactant cleansers
-commercial antimicrobial cleansers
Other modalities used for wound care:
UV light
laser therapy
monochromatic infrared energy
Education on venous wounds:
-control medical con
-exercise regularly- activate venous pump
-no smoking
-healthy diet
-wear clean, smooth socks
-avoid constrictive clothing
-wear well fitting shoes
-compression hosiery
-elevation of wound
-avoid prolonged sitting/standing
-avoid crossing legs
-skin lubrication
Compression for venous wounds TEDS vs SCDs
-TEDS - for bed
(thrombo-embolytic deterring device) –> prevents DVT, NOT edema
- TEDs provides10 mmHg at popliteal vein –> does not prevent DVT when working against gravity (better in supine)
SCDs- sequential compression devices
–> standard DVT prevention combined with anticoagulation
What intervention should be avoided with venous wounds?
whirlpool
-problematic with infection
-can increase edema
Arterial wound intervention:
-if wound has significant ischemia–> vascular surgery
PT ROLE:
-gait training (NWB)
-education on footwear
-with dry gangrene:
–> may auto amputate
–> offload wound
–> educate on auto-amputation, home care, signs/symptoms, emergent nature of conversion to wet gangrene
–> educate on feet protection, protect from extreme temps, protect open wounds, control medical cons, exercise regularly, quit smoking, eat balanced diet, keep nails trimmed straight, clean and smooth socks, avoid constrictive clothing, well-fitting shoes, protect and moisturize surrounding skin
- a lower ABI can lead to decrease in global strength, decrease in global endurance, decrease in SL balance
Exercise for arterial wounds
-individualized, progressive, monitored exercise for lower levels of arterial compromise
-promotion of angiogenesis
GAIT TRAINING IMPROVES:
-perceived walking speed
-walking distance
-stiar climbing
-SF-36 score (HRQOL)
Compression amounts for arterial wounds based on ABI:
ABI >0.8 –> high pressure: 40-50 mmHg, moderate pressure: 30-40
ABI 0.5-0.8 –> low to moderate pressure: 25-33 mmHg
ABI > 0.5 –> low pressure compression: 18-24 mmHg
** NEVER APPLY COMPRESSION IS ABI <0.5 : could be dangerous and lead to impaired arterial perfusion and cutaneous microcirculation –> could lead to acral necrosis, lower leg pain, pain with walking
Interventions (support) for neuropathic wounds
PT ROLE:
-gait training
-equipment
-prevention
-education
EXERCISE:
-150 min/week, 5x/week, 30 minutes per session (moderate to vigorous)
-strength training 2x/week
FOOTWEAR:
-wide toe box
-look at how their shoes are wearing down
-medicare covers pair of shoes and orthotics/year
CASTING:
-total contact casting may be needed with ulcer
Support for pressure injuries (DIMES)
PREVENT:
-shear forces
-friction forces
-pressure forces
-moisture
3 PILLOW RULE
HOB 30 degrees or less
POSITIONING:
-reposition every 2 hours
-use pressure reduction devices on beds and chairs, and under heels
-use lift sheet or device to reduce shear and friction
DAILY CARE
-look at it daily , report red areas
-keep skin dry
-help person eat well and drink fluids
Various mattresses for reducing pressure:
-can detect pressure and change position of patient
-some have built in pressure maps
-alternating pressure
Pressure injury prevention timeline:
-risk assess within 6 hours of admin
-skin assess performed with each repositioning
-turning with clock - every 2 hours
-increased involvement of rehab team for pressure relief
-pressure relief dressing of bipap, cpap, ETT, trach
-manage moisture/incontinence
What should you absolutely not do with an ETT?
tape any items to it (NG tube, small bore feeding tube)
Mnemonic for education to prevent pressure injuries (NO ULCERS, SKIN)
NO ULCERS
-nutrition and fluid status
-observation of skin
-up and walking or assist with position changes
-lift, don’t drag
-clean skin and continence care
-elevate heels
-risk assessment
-support surfaces
SKIN
-surface selection
-keep turning
-incontinence management
-nutrition
What are the purposes of dressings?
-mimics functions of the skin
-creates/maintains a moist environment
-provides thermal insulation
Most occlusive dressings:
semipermeable foam (least)
hydrogels
hydrocolloids
latex (most)
Least occlusive dressings
calcium alginates
fine-weave gauze
loose-weave gauze
air (least)
Gauze
highly permeable
loose knit
wet to dry (old technique)
inexpensive
primary or secondary dressing
make sure fibers don’t get left behind
What is impregnated gauze?
Impregnated gauze is a wound dressing that is saturated with a solution, emulsion, oil, or other compound. The agents that are most common include saline, oil, zinc salts, petrolatum, 3% bismuth tribromophenate, or scarlet red.
Films (type of wound dressing)
thin and flexible
impermeable to bacteria - vapor and gas passage
elastic
does not stick well to periwound skin; sticks well to dry skin but NOT wound bed
inexpensive
INDICATIONS:
-prevents friction in an area
-good for wounds with little/no exudate
-covers donor sites, lacerations, or abrasions
-protect intact blisters
-promotes autolytic debridement (good for necrotic wounds)
CONTRAS
-wounds with moderate –> heavy exudate
-not ideal of infected wounds
-full-thickness burns
Hydrogels
-change every 1-2 days
-good space filler
-can come in bandages/dressings
-permeable to gas/water
-rehydrate with saline
-good for autolytic debridement
INDICATIONS
-partial and full thickness wounds that are dry or moist
-granulating wounds
-wounds with necrosis
-minor burns, skin tears, donor sites
-infected wounds
CONTRAS
-moderate to heavy exudate
-full thickness burns
**need secondary dressing with this
Foams (wound dressing)
-can hold fluid
-can have silver
-adhesive or none
-lasts 3-5 days
INDICATIONS
◦ Partial- and full-thickness wounds
◦ Minimal to heavy exudative wounds (depending on brand)
◦ Softened necrotic tissue
◦ Can also be used to fill dead space or under compression
◦ Can be used for reduction of hypergranulation tissue
CONTRAS
◦ Dry wounds- takes moisture away
◦ Third degree or full thickness burns
◦ Sinus tracts- can break into tunnel
Alginates (wound dressing type)
-made from brown seaweed
-highly absorbant (stays wet)
-helps track bacteria in wound bed
-contributes to collagen production in wound bed
-permeable
-mobile
-can act as space filler
-MUST HAVE SECONDARY DRESSING
-change 1–2 days
INDICATIONS
◦Partial and full thickness wounds with moderate to heavy exudates
◦ Bleeding wounds
CONTRAS
◦ Third degree and full thickness burns
◦ Eschar covered wound
◦ Minimal exudate or dry wounds
Composites (wound dressing type)
-somewhat like a bandaid
-different shapes and sizes
-surgical/graft sites
LAYERS:
-innermost: nonadhesive
-middle: foam–> absorbs
-outer- adhesive, less permeable
-can cut them apart
Hydrocolloids (dressing)
-can last several days
-usually has gelatin and pectin
-can put powder and past on
-impermeable to water, air, bacteria
INDICATIONS
-partial and full thickness wounds with or without necrotic tissue
-skin tears
-lacerations
-HELPS WITH: autolytic debridement
CONTRAS
-burns or dry wounds
-wounds with heavy exudate
-tunneling or sinus tracts
-infected wounds
-wounds with exposed tendon or bone
-wounds with fragile periwound skin
-may encourage hypertrophic granulation
-could contribute to maceration bc can carry a lot of fluid
What are different types of wound fillers?
medihoney, iodosorb, packing gauze
helps with autolytic debridement
INDICATED
-partial and full thick wounds
-infected
-draining wounds
-deep wounds
CONTRA
-dry wounds
EX; SILVISOR: 0.25 oz for $35–> expensive
Silicone gel sheets (dressings):
** can trap moisture–> maceration
-soft and pliable
INDICATED FOR:
- Prevention or improvement of appearance of old
and new hypertrophic and keloid scars
CONTRAINDICATED FOR:
◦ Patients with silicone allergy/sensitivity
◦ Unhealed, open wounds
Collagen dressings
-helps add collagen into wound bed
-soft and pliable
-sheet, paste, powder
-NOT good for bovine products
-helps maintain wound moisture
INDICATED
◦ Chronic non-healing wounds
◦ Partial and full thickness wounds
◦ Granulating or necrotic wounds
◦ Infected and non-infected wounds
◦ Tunneling wounds
◦ Wound with minimal to heavy exudate
CONTRAS
◦ Wounds with heavy eschar
◦ Third degree burns
◦ Sensitivity to bovine products
Cloth tape
◦ Soft surgical cloth
◦ No latex; hypoallergenic
◦ Porous
◦ Good for areas that stretch (elbow)
◦ Good for wear & tear, repeated re-dressings
◦ Good for delicate skin
Silicone tape
◦ Can remove and re-apply (less pain) or skin irritation
◦ Breathable
Foam tape
◦ Has cushion
◦ Flexible
◦ Waterproof
◦ Good for high moisture wounds
Silk tape
◦ economical
◦ high strength and adhesive
◦ hypoallergenic
◦ good for bulky dressings and tubing
◦ breathable, can conform to different surfaces
◦ bi-directional tearing
** not good for delicate skin
Paper tape
◦ repeated applications on sensitive skin possible
◦ good for elderly patients
◦ moisture evaporation occurs
◦ breathable
◦ minimal adhesive residue left behind
Clear plastic surgical tape
◦ Latex-free and hypoallergenic
◦ Transparent
◦ Perforated
◦ Strong adhesive
◦ Bi-directional tearing
◦ Water resistant
◦ can handle more moisture and drainage
What should be included in a wound dressing label?
-date
-time
-initials
-number of pieces in wound
-info like removal direction
-limit time open to air
What should you wear if there is any chance of splash or spray from wound?
mask
goggles/face shield
Order of PPE to put on
gown
mask
goggles
gloves - always
headlamp or light
Clean technique vs sterile technique
CLEAN
* reduce microorganism number and transmission
* Handwashing
* Clean gloves, dressings
* Sterile instruments
* Clean field
* Prevention of direct contamination
of materials & supplies
STERILE
* Maintain and reduce microorganisms
* Handwashing
* Use of sterile field
* Sterile gloves, dressings & instruments
* Avoid sterile materials touching any nonsterile surface/product
Where should sharps be disposed?
*Contains blood or other biological waste – red bio bag
- No blood/bio – regular trash
When she pictures of a wound be taken?
-
before and after debridement
-Ideally done with the patient in the same position each time
-Include a reference for appropriate dimensions
How does billing work for wound care?
Billing is procedure based
SELECTIVE
Must measure total opening of the wound bed and how much is debrided
NON-SELECTIVE
- Measure area of wound bed (ex: negative pressure wound therapy)
