Interventions and Management of Wound Care

Question 1

Commonalities between infection and inflammation:

Answer 1

pain

delayed healing

persistent or increasing exudate

suboptimal granulation tissue (spongy or friable)

induration

Question 2

When is soap and water appropriate to use on a wound?

Answer 2

non-infected wounds

Question 3

What is a good cleansing method for infected wounds?

Answer 3

-antiseptic x 2 weeks
-then wash w/ water

-only use as needed

Question 4

Should hydrogen peroxide be used regularly on wounds?

Answer 4

no

kills healthy cells; don’t use straight out of the bottle

** same with iodine–> cytotoxic; not a long term option

Question 5

DIMES- infection and topical interventions; ionic vs colloidal silver

Answer 5

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.

Question 6

What is a risk of using too much neosporin?

Answer 6

-creates antibiotic resistance

-it is an antibiotic ointment

Question 7

Should a complex wound be left open to the air?

Answer 7

NO

require proper moisture balance and temperature

Question 8

What is bogginess of a wound?

Answer 8

-softness
-empty end feel

Question 9

Types of abnormal effects of too much or too little moisture

Answer 9

-maceration

-excoriation

-denuded

Question 10

Maceration

Answer 10

softening and breaking down of skin due
to prolonged exposure to moisture

Question 11

Excoriation

Answer 11

chafing, raw irritated lesion

linear erosion of the skin by mechanical
means (scratching, rubbing)

Question 12

Denuded

Answer 12

Loss of epidermis due to exposure to urine,
feces, body fluids, wound exudate or friction

Question 13

What should be avoided when it comes to maintaining proper wound moisture?

Answer 13

Depends (adult diapers)

Extra layers (sheets, bed pads)–> adds insulation and holds more fluid

Question 14

Needs for maintaining proper moisture environment:

Answer 14

toileting schedule
rectal tube

Question 15

What are passive drains?

Answer 15

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

Question 16

What are active drains?

Answer 16

-negative pressure is used

-connected to a collection device
–> hemovac
–> jackson-pratt

Question 17

Function of tubes:

Answer 17

-used to remove air and fluids
-provides decompression
-maintains patency of a lumen (keeps the edges open to prevent pocket as the wound heals)

Question 18

What is a hemovac?

Answer 18

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.

Question 19

What is a Jackson Pratt Drain?

Answer 19

-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.

Question 20

When can collagen be used for wounds?

Answer 20

-can be added into wound, as it is helpful for stalled wounds; promotes healing

Question 21

When is hyperbaric oxygen used as a wound healing intervention?

Answer 21

-only certain diagnoses: necrotizing fasciitis, non-healing 30 days, crush injuries

-have to show to insurance that other interventions have not worked

Question 22

Support (DIMES)

Answer 22

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

Question 23

Electrical stimulation-indications and CIs

Answer 23

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

Question 24

Ultrasound: purpose, CIs and Indications

Answer 24

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

Question 25

Negative Pressure Wound Therapy

Answer 25

"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

Question 26

Can you use negative pressure wound therapy on necrotic wounds?

Answer 26

no

Question 27

Process of applying wound vac (negative pressure wound therapy):

Answer 27

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

Question 28

Hyperbaric Oxygen Therapy - purpose, indications, contras

Answer 28

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

Question 29

IRRIGATION, purpose contras and indications

Answer 29

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

Question 30

Irrigation cleansing agent types and solutions:

Answer 30

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

Question 31

Other modalities used for wound care:

Answer 31

UV light laser therapy monochromatic infrared energy

Question 32

Education on venous wounds:

Answer 32

-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

Question 33

Compression for venous wounds TEDS vs SCDs

Answer 33

-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

Question 34

What intervention should be avoided with venous wounds?

Answer 34

whirlpool -problematic with infection -can increase edema

Question 35

Arterial wound intervention:

Answer 35

-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

Question 36

Exercise for arterial wounds

Answer 36

-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)

Question 37

Compression amounts for arterial wounds based on ABI:

Answer 37

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

Question 38

Interventions (support) for neuropathic wounds

Answer 38

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

Question 39

Support for pressure injuries (DIMES)

Answer 39

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

Question 40

Various mattresses for reducing pressure:

Answer 40

-can detect pressure and change position of patient -some have built in pressure maps -alternating pressure

Question 41

Pressure injury prevention timeline:

Answer 41

-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

Question 42

What should you absolutely not do with an ETT?

Answer 42

tape any items to it (NG tube, small bore feeding tube)

Question 43

Mnemonic for education to prevent pressure injuries (NO ULCERS, SKIN)

Answer 43

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

Question 44

What are the purposes of dressings?

Answer 44

-mimics functions of the skin -creates/maintains a moist environment -provides thermal insulation

Question 45

Most occlusive dressings:

Answer 45

semipermeable foam (least) hydrogels hydrocolloids latex (most)

Question 46

Least occlusive dressings

Answer 46

calcium alginates fine-weave gauze loose-weave gauze air (least)

Question 47

Gauze

Answer 47

highly permeable loose knit wet to dry (old technique) inexpensive primary or secondary dressing make sure fibers don't get left behind

Question 48

What is impregnated gauze?

Answer 48

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.

Question 49

Films (type of wound dressing)

Answer 49

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

Question 50

Hydrogels

Answer 50

-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

Question 51

Foams (wound dressing)

Answer 51

-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

Question 52

Alginates (wound dressing type)

Answer 52

-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

Question 53

Composites (wound dressing type)

Answer 53

-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

Question 54

Hydrocolloids (dressing)

Answer 54

-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

Question 55

What are different types of wound fillers?

Answer 55

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

Question 56

Silicone gel sheets (dressings):

Answer 56

** 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

Question 57

Collagen dressings

Answer 57

-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

Question 58

Cloth tape

Answer 58

◦ Soft surgical cloth ◦ No latex; hypoallergenic ◦ Porous ◦ Good for areas that stretch (elbow) ◦ Good for wear & tear, repeated re-dressings ◦ Good for delicate skin

Question 59

Silicone tape

Answer 59

◦ Can remove and re-apply (less pain) or skin irritation ◦ Breathable

Question 60

Foam tape

Answer 60

◦ Has cushion ◦ Flexible ◦ Waterproof ◦ Good for high moisture wounds

Question 61

Silk tape

Answer 61

◦ 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

Question 62

Paper tape

Answer 62

◦ repeated applications on sensitive skin possible ◦ good for elderly patients ◦ moisture evaporation occurs ◦ breathable ◦ minimal adhesive residue left behind

Question 63

Clear plastic surgical tape

Answer 63

◦ Latex-free and hypoallergenic ◦ Transparent ◦ Perforated ◦ Strong adhesive ◦ Bi-directional tearing ◦ Water resistant ◦ can handle more moisture and drainage

Question 64

What should be included in a wound dressing label?

Answer 64

-date -time -initials -number of pieces in wound -info like removal direction -limit time open to air

Question 65

What should you wear if there is any chance of splash or spray from wound?

Answer 65

mask goggles/face shield

Question 66

Order of PPE to put on

Answer 66

gown mask goggles gloves - always headlamp or light

Question 67

Clean technique vs sterile technique

Answer 67

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

Question 68

Where should sharps be disposed?

Answer 68

*Contains blood or other biological waste – red bio bag * No blood/bio – regular trash

Question 69

When she pictures of a wound be taken?

Answer 69

- before and after debridement -Ideally done with the patient in the same position each time -Include a reference for appropriate dimensions

Question 70

How does billing work for wound care?

Answer 70

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)