Lab 2 Flashcards
(141 cards)
1
Q
what is the purpose of wound mngmt (3)
A
- clean a wound to remove debris & dirt
- treat infection to prepare the wound for healing
- protect wound from trauma
2
Q
for wounds that heal by primary intention, what is commonly used in wound mngmt (2)
A
- cover incision w a dry, sterile dressing that is removed as soon as the drainage stops in 2-3 days
- may use protective sprays or wipes
3
Q
describe wound healing mngmt by secondary intention (3)
A
- depends on the cause of the wound & type of tissue in the wound
- utilizes the red-yellow-black concept of wound care
- utilizes transparent film dressings or other dressings
4
Q
what is a “red wound”? what are examples
A
- wound that is superficial or deep, clean, red or pink
ex. skin tears, pressure ulcers, second degree burns
5
Q
what is the goal of treatment for red wounds (2)
A
- gentle cleansing
- protection of the wound
6
Q
describe wound mngmt for red wounds (5)
A
- keep slightly moist
- protect from trauma
- may use systemic antibiotics if infected
- cover w sterile dressing
- avoid unnecessary manipulation during dressing changes (may destroy granulation tissue & break down fibrin formation)
7
Q
what type of dressings are helpful w red wounds (2)
A
- transparent films
- clear acrylic dressings
(are semi-occlusive and can be permeated by oxygen)
8
Q
what is a “yellow wound”
A
- wound w nonviable necrotic tissue
9
Q
what is the goal of treatment for a yellow wound (2)
A
- removal of nonviable tissue
- absorption of excessive drainage
10
Q
what type of dressings may be used for mngmt of yellow wounds (3)
A
- hydrogel
- absorptive dressings
- hydrocolloids
11
Q
what impact does hydrogel or absorptive dressings have on the wound
A
- facilitates autolytic debridement (selective process in which the body’s own enzymes are used to selectively rehydrate, soften, and liquefy slough
12
Q
what impact does hydrogel or absorptive dressings have on the wound
A
- facilitates autolytic debridement (selective process in which the body’s own enzymes are used to selectively rehydrate, soften, and liquefy slough
13
Q
describe the impact of hydrocolloids on yellow wounds
A
- the inner component interacts w exudate, forming a hydrated gel over the wound
- when the drsg is removed, the gel separates and remains w the wound
14
Q
how long can dressings for yellow wounds stay in place
A
- up to 7 days or until leakage occurs around the dressings
15
Q
what can be used to eliminate nonviable necrotic tissue from the wound in yellow wounds
A
- enzymatic debridement
16
Q
what is a black wound? what are examples
A
- wound covered w thick, dry, necrotic tissue (eschar) that is black, brown, or grey
ex. full thickness burns, gangrenous ulcers
17
Q
describe the risk of infection w black wounds
A
- increases in proportion to the amt of necrotic tissue present
18
Q
what is the immediate treatment of black wounds
A
- debridement of the nonviable eschar
19
Q
what are various approaches to debridement (4)
A
- surgical
- mechanical
- autolytic
- enzymatic
20
Q
describe surgical debridement: benefit? when is it indicated? where is it done?
A
- quickest method of debridement
- indiciated when lrg amts of tissue are nonviable & pt has sepsis
- performed in the OR or at the pts bedside
21
Q
when is mechanical debridement used
A
- used when minimal debris
22
Q
what are various forms of mechanical debridement (3)
A
- wet-to-dry dressinga
- pressurized wound irrigation
- whirlpool
23
Q
describe the process of wet-to-dry dressings for mechanical debridement
A
- uses open-mesh gauze which is moistened w NS, packed into the wound surface, and allowed to dry
- wound debris adheres to the dressing
- when the dressing is removed, the debris is trapped in the gauze and mechanically separated from the wound bed
24
Q
what are 2 disadvantages to wet-to-dry debridement
A
- nonselective: destroys some healthy tissue
- painful: pain mngmt before
25
describe the process of pressurized-wound irrigation for debridement
- involves delivery of water at a high or low pressure to remove bacteria, foreign matter, & necrotic tissue from the wound
26
what is an important consideration r/t pressuized-wound irrigation; why is this important?
- ensure the pressure is not too high --> could drive bacteria & debris deeper into the wound and damage granulation tissue
27
describe the process of whirlpool for mechanical debridement
- loosens and removes surface wound debris
| textbook doesnt describe what it is rlly
28
when should mechanical debridement not be used?
- for clean, granulating wounds
29
describe the use of topical antimicrobials and bactericidals in wound care
- use w caution bc can damage the new epithelium of healing tissue
- never use to treat clean granulating wounds
30
what is used in autolytic debridement
- use of hydrogels, semiocclusive dressings, or occlusive dressings to promote softening of dry eschar by autolysis
31
describe the process of autolytic debridement (4)
- slow
- selective
- painless
- enables body's own endogenous enzymes to break down necrotic tissue
32
autolytic debridement is used for...
- noninfedcted wounds w necrotic tissue and adequate circulation
33
what is an imp consideration w autolytic debridement
- use of a skin protectant around the wound to prevent maceration
34
describe the process of enzymatic debridement
- applies a topical ointment containing proteolytic enzymes to the necrotic tissue in the wound
- then convered w a moist dressing (ex. NS moistened gauze) and changed daily
35
what is the only product for enzymatic debridement available in Canada
- Santyl collagenase
36
what must the wound pH be between? what implication does this have
- between 6-7
| - cleansing products w detergants or heavy metals (ex. mercury or silver) should not be used
37
what is negative pressure wound therapy
- involves the application of negative pressure (suction) to the wound bed
38
what wound types are sutiable for negative pressure wound therapy (5)
- chronic, acute, traumatic, and dehisced wounds
- partial-thickness burns
- ulcers
- flaps
- grafts
39
describe use of gauze as a wound dressing (4); what is an examples
- provide absorption of exudate
- supports debridement if applied & kept moist
- used to maintain moistness of wound surface
- can be used as filler dressings in sinus tracts
ex. NuGauze
40
describe the use of nonadherent dressings (4) what are examples
- woven or unwoven dressings
- may be impregnated w petroleum or antimicrobials
- minimally absorbent
- used on minor wounds or skin tears
ex. adaptic, jelonet
41
describe the use of transparent film dressings (4)
- semipermeable membrane that permits gaseous exchange between wound bed & enviro
- minimally absorbent so that enviro is kept moist in presence of exudate
- bacteria do not penetrate membrane
- use for dry, noninfected wounds, wounds w minimal drainage, stage 1 pressure ulcers to prevent friction or shear
ex. tegaderm, mefilm
42
describe the use of acrylic clear dressings
- used for superficial and partial-thickeness wounds w light drainage
ex. tegaderm absorbent
43
describe the use of hydrocolloid dressings
- occlusive dressing that does not allow O2 to diffuse from atmosphere to wound bed
- occlusion does not interefere w wound healing and supports debridement
- used for superficial & partial thickness wounds w light to mod drainage
ex. tegasorb
44
describe the use of foam dressings (4)
- many shapes & sizes
- absorbs mod to heavy amt of exudate
- for partial or full thickness wounds
- for infected wounds
ex. tegaderm, mepilex, hydrasorb
45
describe the use of alginate, calcium alginate, and hydrofibre dressings (6)
- absorbs lrg amt of exudate
- dressing forms gel-like substance that supports autolytic debridement and maintains moisture of wound surface
- fills wound cavities and obliterates dead space
- for partial or full-thickness wounds
- for infected wounds w lots of exudate
- requires a secondary dressing
ex. aquacel, seasorb
46
what type of wounds should alginate dressings not be used in
- not for lightly draining or dry wounds bc can desiccate the wound bed
47
describe the use of hypertonic dressings (3)
- sheet, ribbon, or gel impregnated w NaCl concentrate
- not for dry wounds (treat w hydrogel)
- may be painful on sensitive tissue
48
describe the use of hydrogel (5)
- gently eliminates necrotic tissue by autolytic debridement
- maintains moistness of wound surface
- provides limited absorption of exudate
- cooling effect on wound = effective in mnging pain
- for partial or full thickness wounds w minimal drainage & necrotic wounds
49
describe the use of charcoal dressings
- contains odour-absorbent charcoal
50
describe the use of antimicrobial dressings
- broad spectrum against bacteria
- contains silver, PHMB, cadexomer iodine
ex. iodosorb
51
describe the use of biological dressings (5)
- living human fibroblasts in sheets at ambient or frozen temp
- extracellular matrix
- collagen-containing preparations
- hyaluronic acid
- do not use on wounds w infections or sinus tracts, excessive exudate, or if hypersensitivity to product
52
describe wound assessment in stable settings & w surgical wounds (3)
- assess to determine healing process
- if wound is covered by a dressings and the dressing is intact & not saturated w drainage, do not directly inspect the wound unless suspect complication or you're changing the dressing
- inspect the dressing and external drains
53
when should dressings be changed in stable settings & w surgical wounds (3)
- if dressing is contaminated w external drainage (feces, urine)
- if dressing is saturated
- when ordered
54
describe considerations when completing dressing changes in stable settings & w surgical wounds (3)
- take care to avoid accidental removal or displacement of drains
- assess need for & give analgesics 30 min before
55
describe the appearance of a puncture wound (2)
- small, circular
| - edges come together towards the center
56
if a surgical wound is healing by primary intention, describe the wound appearance
- clean, well approximated edges
57
what should you do if wound edges are separated
- assess for complications such as dehiscence & evisceration
58
describe the outer edges of a normal wound throughout time
- inflamed for first 2-3 days, which slowly disapears
| - within 7-10 days, a normally healing wound resurfaces w epithelial cells & edges close
59
describe abnormal findings in a primary intention wound (5)
- wound's incision line poorly approximated
- drainage present more than 3 days after closure
- inflammation decreased in first 3-5 days
- no epithelialization of wound edges by day 4
- no healing ridge by day 9
60
describe abnormal findings in a secondary intention wound (6)
- pale or fragile granulation tissue
- granulation tissue excessively dry or moist
- necrotic or sloughy tissue in wound base
- epithelialization not continuous
- fruity, earthy, or putrid odour present
- presence of fistulas, tunnelling, undermining
61
describe the assessment of wound drainage
- note the amt, odor, color, and consistency
62
describe ways to record the amt of drainage in a wound (2)
- can weigh the dressing and compare it w the same clean & dry dressing (1g = 1mL)
- chart # of dressings used and freq of changes (an increase or decrease in number or freq will indicate a relative increase or decrease in wound drainage)
63
describe appearance of serous fluid,what does it mean
- clear, watery plasma
- typically seen in early stages of inflammation or w minor injury
- result of fluid that has few cells or protein content
64
describe the appearance of purulent drainage & what it means
- thick, yellow, green, tan, brown
- contains WBC, microorganisms, liquified dead cells, debris
- likely indicates infection = notify surgeon
65
describe the appearance of serosanguinous fluid & what it means
- pale, red, watery, mixture of clear (serous) & red fluid (blood)
- considered normal from a new surgical wound as long as there are no other abnormal findings (ex. low BP)
66
describe the appearance of sanguinous fluid and what it means
- bright red
- may or may not be a normal finding depending on type of surgery
- indicated active bleeding
67
what should you do if you observe sanguinous fluid
- if bleeding is not active & is a new wound, complete further monitoring
- if bleeding continuous, unable to stop by nursing interventions (pressure, etc.), or wound is >24 h old = notify surgeon
68
why are drains used in some wound
- if a large amt of drainage is anticipated
| - the accumulation of blood & body fluids in wound bed = delayed healing, bacterial growth
69
what is a penrose drain
- open drainage system
- soft, flexible tube made of latex
- drain that is left inside the site of surgery and lies under the dressing, the fluid then drains onto the dressing
70
what is a safety consideration used w the penrose drain
- a pin or clip is placed thru the drain to prevent it from slipping further into the wound
71
what is the nurse's responsibility r/t penrose drains
- to pull or advance the drain as drainage decreases to permit healing deep within the wound site
72
describe the assessment on drain systems (6)
- observe the security of the drain and its location with respect to the wound
- note character of drainage
- if uses a collectin device, measure the drainage volume
- look for drainage flow thru the tubing (if patent or not)
- assess # of drains
- if connected to suction, assess the system to ensure the ordered pressure is being exerted
73
what does a sudden decrease in drainage through the tubing possibly indicate? what should you do?
- may indicate a blocked drain, which may require surgical revision
- contact the physician
74
what should you do if evacuator devices (ex. hemovac or JP) if unable to maintain a vacuum on its own
- notify the surgeon , who will then order a secondar-vacuum system (ex. wall suction)
75
how might surgical wounds be closed (3)
- suture
- staples
- wound closures
76
what is the benefit of staples to close surgical wounds (4)
- more strength than nylon or silk sutures
- less irritation to tissue
- faster to apply
- less r/o infection
77
how long are staples left in place
7-10 days
78
describe assessment of sutures, staples, and wound closures (3)
- look for irritation around staples & sutures
- note whether closures are in tact
- look for continued swelling (normal for first 2-3 days but longer than this = closures too tight)
79
over tight suture material may cause?
- cut into the skin = wound separation or dehiscence
80
what is the benefit of early suture removal (2)
- reduces formation of defects along the future line
| - minimized chances of unattractive scar formation
81
describe the use of tissue adhesives for wound closure (3)
- form a strong bond across apposed wound edges = allows normal healing to occur below
- can be used to replace small suture for incisional repair
- applied across the approximated wound edges, which are then held together until the solution dries = adhesive closure
82
what are tissue adhesives usually used for (30
- small, superficial lacerations
- may be used for larger wounds, where subcut suture are needed
- after suture/staple removal to provide additional support for few days post-removal
83
what is an example of a tissue adhesive
- dermabond
84
what education should be given to pts r/t steri-strips (tissue adhesives)
- keep on til they fall off
| - do not scrub them in shower but they can get wet
85
describe palpation of wounds (2)
- use sterile gloves to lightly press the wound edges to detect localized areas of tenderness or drainage collect
- observe for swelling or separation of wound edges
86
describe abnormal findings when palpating a wound (2)
- if fluid is expressed w pressure --> note the character of drainage
- extreme tenderness (may = infection) (the pt is normally sensitive to palpation, but not extremely)
87
what needs to be done if you detect purulent or suspicious looking drainage
- may need to obtain a specimen of the drainage for culture
88
describe considerations w wound cultures (4)
- never collect a wound culture sample from old drainage
- clean a wound to remove skin flora before taking culture
- swab a wound from the healthiest looking tissue to obtain results consistent w the infectious condition of the wound
- also approp to swab areas of undermining
89
what is the gold standard of wound culture
- tissue biopsy
90
what are 5 potential complications of wound healing
- hemorrhage
- infection
- dehiscence
- evisceration
- fistula
91
hemorrhage that occurs after hemostasis (usually occurs several minutes after initial trauma) may indicate? (4)
- a slipped surgical suture
- a dislodged clot
- infection
- erosion of a blood vessel by a foreign object (ex. drain)
92
how can you detect internal bleeding (3)
- look for distension or swelling of the affected body part
- change in the type & amt of drainage from a surgical drain
- signs of hypovolemic shock
93
what is a hematoma
- a localized collection of blood underneath the tissues
94
how can a hematoma be detected (5)
look for:
- swelling
- change in color
- change in sensation
- change in warmth
- mass that takes on bluish discoloration
95
what danger is associated w hematomas near a major artery or vein
- the pressure obstructs blood flow
96
how can external hemorrhage be detected
- assess the dressing for bloody drainage
97
at what point is the risk for hemorrhage the greatest
- the first 24-48 hrs after surgery
98
what is the second most common healthcare associated infection
- wound infection
99
what differentiates between contaminated wounds & infected wounds (3)
- the amt of bacteria present
- all chronic wounds are considered contaminated w bacteria
- infected = more than 100,000 organisms per gram of tissue
100
what increases the risk of wound infection (3)
- necrotic tissue
- when contaminants are in or near the wound
- when blood supply & local tissue defences are reduced
101
what impact does bacterial infection have on wound healing?
- impairs wound healing
102
what are signs of a wound infection (6)
- fever
- tenderness
- pain at wound site
- elevated WBC
- edges of wound appear inflamed
- odourous, purulent drainage
103
at what point might you see signs of infection in a wound
- some contaminated or traumatic wounds show signs early: within 2-3 days
- surgical wound infection may not show until day 4 or 5
104
what is dehiscence
- partial or total separation of wound layers
105
what increases the risk of dehiscence (4)
- pts at risk of poor healing --> ex. poor nutrition, infection, obesity, DM< chronic or acute conditions
- obese pts due to pressure on the wound & poor healing qualities of fat
- granulation tissue that is not strong enough to hold wound edges together
- infection causing an inflam. response
106
what does dehiscence involve? what may cause it?
- abdominal wounds
| - may occur after a sudden strain (ex. coughing, throwing up, sitting up)
107
how do pts describe dehiscence
- " something has given way"
108
what are signs of dehiscence (3)
- increased amt of serosanguinous drainage
- pt's report
- visual appearance
109
what is a strategy to avoid dehiscence (3)
- support the area
- use a folded blanket or pillow over the abdominal wound when the pt is coughing
- reduce abdominal pressure by having pt bend knees up
(this splints and supports healing tissue when coughing)
110
when does most dehiscence occur after surgery
- 4-14 days after, with a mean of 8 days
111
what is evisceration
- protrusion of visceral organs thru a wound opening w total separation of wound layers
- emergency that needs surgical repair!
112
what should you do when evisceration occurs (5)
- quickly place sterile towels/gauze soaked in sterile saline over the extruding tissue to reduce the chance of bacterial invasion and drying of the tissues
- contact the physician
- pt NPO
- observe for S&S of shock (VS)
- prep pt for emergency surgery
113
what is a fistula
- an abnormal passage between 2 organs or between an organ and the outside of the body
114
what increases the risk of fistula formation (6)
- do to poor wound healing
- complication of disease (ex. Crohns)
- trauma
- infection
- radiation
- cancer
115
what is the risk associated w fistulas (3)
- increased risk of infection
- fluid & electrolyte imbalances d/t fluid loss
- predispose to skin breakdown thru chronic drainage of fluids
116
what is negative pressure wound therapy
- use of a machine that applied localized negative pressure to the surface and margins of large open wounds
= pulls up the base of the wound
117
what is negative pressure wound therapy (NPWT)
- use of a machine that applied localized negative pressure to the surface and margins of the wound
= pulls up the base of the wound
ex. VAC
118
what is the benefit of NPWT (6)
- enhances healing rates
- decrease the requirement for health care resources
- enhance QOL
- increases circulation
- decreases edema
- prevents wound from external contamination
119
what is a con of NPWT
- expensive
120
what else is NPWT used for? how does this work?
- enhance the viability of split-thickness skin grafts by placing it over the graft intraoperatively
= decreases the ability of the graft to shift & evacuates fluids that build up under the graft
121
what is the nurses role w NPWT or a wound VAC
- placed and maintained by nursing
122
how can drainage evacuation be achieved?
1. use a drain alone
| 2. drainage tube w continuous suction
123
what should be applied around drain sites
- special skin barriers (ex. hydrocolloid dressings) so drainage flows on the barrier but not directly on the skin
124
what are drainage evacuators
- convenient, portable units that connect to tubular drains lying within a wound bed & exert safe, constant, low-pressyre vacuum to remove and collect drainage
125
what should you do once the drainage evacuator fills (3)
- assess the character of the drainage
- empty into a gradulated cylinder to measure
- immediately reset the evacuator to apply suction
126
what is the jackson pratt (JP) drain
- closed system that uses a bulb to collect drainage
127
what is the jackson pratt (JP) drain
- closed system that uses a bulb to collect drainage
128
how much fluid can a JP drain hold
- up to 100cc
129
how is suction maintained w JP drain
- the plug is opened
- the bulb is pressed flat
- the plug is replaced
- the bulb expands as it fills w fluids
130
describe the tubing of a JP drain
- fenestrated (has little holes) that allows the fluid to go into the tubing and flow into the bulb
131
describe the freq of emptying & dressing changes w a JP drain
- surgeon may give orders
| - but monitor carefully
132
what should drainage in a JP drain be assessed for (3)
- color
- vol
- accumulation rate
133
describe the expectation of drainage in a JP drain
- expected to decrease over time
134
when should you notify the surgeon in relation to a JP drain (3)
- if there is a significant increase in bloody drainage after it had begun to taper off
- changes to types of drainage such as bloody or purulent
- if no drainage immed after surgery
135
describe the dressing for a JP drain
- tubing may be sutured in or not
| - a simple dressing covers the tubing that comes outside of the body to keep it in place and prevent pulling
136
what is a hemovac
- closed drainage system that is used when larger amt of exudates are anticipated
137
how much exudate can a hemovac hold
- up to 400 cc
138
describe the suction of a hemovac (2)
- similar to JP, must be compressed for suction
| - check orders: may not always use suction, may instead drain by gravity
139
describe the removal of sutures & staples (4)
- physicians order needed
- but nurses can remove
- remove every second stitch/staple, then the remainder if all looks good
- clean the incision site before & after removal (NS, chlorhexidine, povidone depending on institution practice)
140
what is an important consideration w removal or sutures and staples
- never allow the exposed portion of the suture to be brought back thru the underlying tissue (prevents microorganisms from going back into the sterile body = prevent infection)
141
danielle recommended reviewing the NSO modules but I am not making cards on those
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