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NURS 3532 - Skills 4 > Lab 2 > Flashcards

Lab 2 Flashcards

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
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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
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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
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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

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5
Q

what is the goal of treatment for red wounds (2)

A
  • gentle cleansing

- protection of the wound

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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)
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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)

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8
Q

what is a “yellow wound”

A
  • wound w nonviable necrotic tissue
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9
Q

what is the goal of treatment for a yellow wound (2)

A
  • removal of nonviable tissue

- absorption of excessive drainage

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10
Q

what type of dressings may be used for mngmt of yellow wounds (3)

A
  • hydrogel
  • absorptive dressings
  • hydrocolloids
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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
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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
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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
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14
Q

how long can dressings for yellow wounds stay in place

A
  • up to 7 days or until leakage occurs around the dressings
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15
Q

what can be used to eliminate nonviable necrotic tissue from the wound in yellow wounds

A
  • enzymatic debridement
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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
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17
Q

describe the risk of infection w black wounds

A
  • increases in proportion to the amt of necrotic tissue present
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18
Q

what is the immediate treatment of black wounds

A
  • debridement of the nonviable eschar
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19
Q

what are various approaches to debridement (4)

A
  • surgical
  • mechanical
  • autolytic
  • enzymatic
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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
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21
Q

when is mechanical debridement used

A
  • used when minimal debris
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22
Q

what are various forms of mechanical debridement (3)

A
  • wet-to-dry dressinga
  • pressurized wound irrigation
  • whirlpool
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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
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24
Q

what are 2 disadvantages to wet-to-dry debridement

A
  • nonselective: destroys some healthy tissue

- painful: pain mngmt before

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25
Q

describe the process of pressurized-wound irrigation for debridement

A
  • involves delivery of water at a high or low pressure to remove bacteria, foreign matter, & necrotic tissue from the wound
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26
Q

what is an important consideration r/t pressuized-wound irrigation; why is this important?

A
  • ensure the pressure is not too high –> could drive bacteria & debris deeper into the wound and damage granulation tissue
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27
Q

describe the process of whirlpool for mechanical debridement

A
  • loosens and removes surface wound debris

textbook doesnt describe what it is rlly

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28
Q

when should mechanical debridement not be used?

A
  • for clean, granulating wounds
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29
Q

describe the use of topical antimicrobials and bactericidals in wound care

A
  • use w caution bc can damage the new epithelium of healing tissue
  • never use to treat clean granulating wounds
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30
Q

what is used in autolytic debridement

A
  • use of hydrogels, semiocclusive dressings, or occlusive dressings to promote softening of dry eschar by autolysis
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31
Q

describe the process of autolytic debridement (4)

A
  • slow
  • selective
  • painless
  • enables body’s own endogenous enzymes to break down necrotic tissue
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32
Q

autolytic debridement is used for…

A
  • noninfedcted wounds w necrotic tissue and adequate circulation
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33
Q

what is an imp consideration w autolytic debridement

A
  • use of a skin protectant around the wound to prevent maceration
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34
Q

describe the process of enzymatic debridement

A
  • 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
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35
Q

what is the only product for enzymatic debridement available in Canada

A
  • Santyl collagenase
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36
Q

what must the wound pH be between? what implication does this have

A
  • between 6-7

- cleansing products w detergants or heavy metals (ex. mercury or silver) should not be used

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37
Q

what is negative pressure wound therapy

A
  • involves the application of negative pressure (suction) to the wound bed
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38
Q

what wound types are sutiable for negative pressure wound therapy (5)

A
  • chronic, acute, traumatic, and dehisced wounds
  • partial-thickness burns
  • ulcers
  • flaps
  • grafts
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39
Q

describe use of gauze as a wound dressing (4); what is an examples

A
  • 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
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40
Q

describe the use of nonadherent dressings (4) what are examples

A
  • woven or unwoven dressings
  • may be impregnated w petroleum or antimicrobials
  • minimally absorbent
  • used on minor wounds or skin tears
    ex. adaptic, jelonet
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41
Q

describe the use of transparent film dressings (4)

A
  • 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
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42
Q

describe the use of acrylic clear dressings

A
  • used for superficial and partial-thickeness wounds w light drainage
    ex. tegaderm absorbent
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43
Q

describe the use of hydrocolloid dressings

A
  • 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
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44
Q

describe the use of foam dressings (4)

A
  • many shapes & sizes
  • absorbs mod to heavy amt of exudate
  • for partial or full thickness wounds
  • for infected wounds
    ex. tegaderm, mepilex, hydrasorb
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45
Q

describe the use of alginate, calcium alginate, and hydrofibre dressings (6)

A
  • 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
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46
Q

what type of wounds should alginate dressings not be used in

A
  • not for lightly draining or dry wounds bc can desiccate the wound bed
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47
Q

describe the use of hypertonic dressings (3)

A
  • sheet, ribbon, or gel impregnated w NaCl concentrate
  • not for dry wounds (treat w hydrogel)
  • may be painful on sensitive tissue
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48
Q

describe the use of hydrogel (5)

A
  • 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
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49
Q

describe the use of charcoal dressings

A
  • contains odour-absorbent charcoal
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50
Q

describe the use of antimicrobial dressings

A
  • broad spectrum against bacteria
  • contains silver, PHMB, cadexomer iodine
    ex. iodosorb
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51
Q

describe the use of biological dressings (5)

A
  • 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
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52
Q

describe wound assessment in stable settings & w surgical wounds (3)

A
  • 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
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53
Q

when should dressings be changed in stable settings & w surgical wounds (3)

A
  • if dressing is contaminated w external drainage (feces, urine)
  • if dressing is saturated
  • when ordered
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54
Q

describe considerations when completing dressing changes in stable settings & w surgical wounds (3)

A
  • take care to avoid accidental removal or displacement of drains
  • assess need for & give analgesics 30 min before
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55
Q

describe the appearance of a puncture wound (2)

A
  • small, circular

- edges come together towards the center

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56
Q

if a surgical wound is healing by primary intention, describe the wound appearance

A
  • clean, well approximated edges
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57
Q

what should you do if wound edges are separated

A
  • assess for complications such as dehiscence & evisceration
58
Q

describe the outer edges of a normal wound throughout time

A
  • inflamed for first 2-3 days, which slowly disapears

- within 7-10 days, a normally healing wound resurfaces w epithelial cells & edges close

59
Q

describe abnormal findings in a primary intention wound (5)

A
  • 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
Q

describe abnormal findings in a secondary intention wound (6)

A
  • 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
Q

describe the assessment of wound drainage

A
  • note the amt, odor, color, and consistency
62
Q

describe ways to record the amt of drainage in a wound (2)

A
  • 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
Q

describe appearance of serous fluid,what does it mean

A
  • 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
Q

describe the appearance of purulent drainage & what it means

A
  • thick, yellow, green, tan, brown
  • contains WBC, microorganisms, liquified dead cells, debris
  • likely indicates infection = notify surgeon
65
Q

describe the appearance of serosanguinous fluid & what it means

A
  • 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
Q

describe the appearance of sanguinous fluid and what it means

A
  • bright red
  • may or may not be a normal finding depending on type of surgery
  • indicated active bleeding
67
Q

what should you do if you observe sanguinous fluid

A
  • 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
Q

why are drains used in some wound

A
  • if a large amt of drainage is anticipated

- the accumulation of blood & body fluids in wound bed = delayed healing, bacterial growth

69
Q

what is a penrose drain

A
  • 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
Q

what is a safety consideration used w the penrose drain

A
  • a pin or clip is placed thru the drain to prevent it from slipping further into the wound
71
Q

what is the nurse’s responsibility r/t penrose drains

A
  • to pull or advance the drain as drainage decreases to permit healing deep within the wound site
72
Q

describe the assessment on drain systems (6)

A
  • 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
Q

what does a sudden decrease in drainage through the tubing possibly indicate? what should you do?

A
  • may indicate a blocked drain, which may require surgical revision
  • contact the physician
74
Q

what should you do if evacuator devices (ex. hemovac or JP) if unable to maintain a vacuum on its own

A
  • notify the surgeon , who will then order a secondar-vacuum system (ex. wall suction)
75
Q

how might surgical wounds be closed (3)

A
  • suture
  • staples
  • wound closures
76
Q

what is the benefit of staples to close surgical wounds (4)

A
  • more strength than nylon or silk sutures
  • less irritation to tissue
  • faster to apply
  • less r/o infection
77
Q

how long are staples left in place

A

7-10 days

78
Q

describe assessment of sutures, staples, and wound closures (3)

A
  • 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
Q

over tight suture material may cause?

A
  • cut into the skin = wound separation or dehiscence
80
Q

what is the benefit of early suture removal (2)

A
  • reduces formation of defects along the future line

- minimized chances of unattractive scar formation

81
Q

describe the use of tissue adhesives for wound closure (3)

A
  • 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
Q

what are tissue adhesives usually used for (30

A
  • 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
Q

what is an example of a tissue adhesive

A
  • dermabond
84
Q

what education should be given to pts r/t steri-strips (tissue adhesives)

A
  • keep on til they fall off

- do not scrub them in shower but they can get wet

85
Q

describe palpation of wounds (2)

A
  • 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
Q

describe abnormal findings when palpating a wound (2)

A
  • 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
Q

what needs to be done if you detect purulent or suspicious looking drainage

A
  • may need to obtain a specimen of the drainage for culture
88
Q

describe considerations w wound cultures (4)

A
  • 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
Q

what is the gold standard of wound culture

A
  • tissue biopsy
90
Q

what are 5 potential complications of wound healing

A
  • hemorrhage
  • infection
  • dehiscence
  • evisceration
  • fistula
91
Q

hemorrhage that occurs after hemostasis (usually occurs several minutes after initial trauma) may indicate? (4)

A
  • a slipped surgical suture
  • a dislodged clot
  • infection
  • erosion of a blood vessel by a foreign object (ex. drain)
92
Q

how can you detect internal bleeding (3)

A
  • 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
Q

what is a hematoma

A
  • a localized collection of blood underneath the tissues
94
Q

how can a hematoma be detected (5)

A

look for:

  • swelling
  • change in color
  • change in sensation
  • change in warmth
  • mass that takes on bluish discoloration
95
Q

what danger is associated w hematomas near a major artery or vein

A
  • the pressure obstructs blood flow
96
Q

how can external hemorrhage be detected

A
  • assess the dressing for bloody drainage
97
Q

at what point is the risk for hemorrhage the greatest

A
  • the first 24-48 hrs after surgery
98
Q

what is the second most common healthcare associated infection

A
  • wound infection
99
Q

what differentiates between contaminated wounds & infected wounds (3)

A
  • the amt of bacteria present
  • all chronic wounds are considered contaminated w bacteria
  • infected = more than 100,000 organisms per gram of tissue
100
Q

what increases the risk of wound infection (3)

A
  • necrotic tissue
  • when contaminants are in or near the wound
  • when blood supply & local tissue defences are reduced
101
Q

what impact does bacterial infection have on wound healing?

A
  • impairs wound healing
102
Q

what are signs of a wound infection (6)

A
  • fever
  • tenderness
  • pain at wound site
  • elevated WBC
  • edges of wound appear inflamed
  • odourous, purulent drainage
103
Q

at what point might you see signs of infection in a wound

A
  • some contaminated or traumatic wounds show signs early: within 2-3 days
  • surgical wound infection may not show until day 4 or 5
104
Q

what is dehiscence

A
  • partial or total separation of wound layers
105
Q

what increases the risk of dehiscence (4)

A
  • 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
Q

what does dehiscence involve? what may cause it?

A
  • abdominal wounds

- may occur after a sudden strain (ex. coughing, throwing up, sitting up)

107
Q

how do pts describe dehiscence

A
  • ” something has given way”
108
Q

what are signs of dehiscence (3)

A
  • increased amt of serosanguinous drainage
  • pt’s report
  • visual appearance
109
Q

what is a strategy to avoid dehiscence (3)

A
  • 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
Q

when does most dehiscence occur after surgery

A
  • 4-14 days after, with a mean of 8 days
111
Q

what is evisceration

A
  • protrusion of visceral organs thru a wound opening w total separation of wound layers
  • emergency that needs surgical repair!
112
Q

what should you do when evisceration occurs (5)

A
  • 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
Q

what is a fistula

A
  • an abnormal passage between 2 organs or between an organ and the outside of the body
114
Q

what increases the risk of fistula formation (6)

A
  • do to poor wound healing
  • complication of disease (ex. Crohns)
  • trauma
  • infection
  • radiation
  • cancer
115
Q

what is the risk associated w fistulas (3)

A
  • increased risk of infection
  • fluid & electrolyte imbalances d/t fluid loss
  • predispose to skin breakdown thru chronic drainage of fluids
116
Q

what is negative pressure wound therapy

A
  • 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
Q

what is negative pressure wound therapy (NPWT)

A
  • 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
Q

what is the benefit of NPWT (6)

A
  • enhances healing rates
  • decrease the requirement for health care resources
  • enhance QOL
  • increases circulation
  • decreases edema
  • prevents wound from external contamination
119
Q

what is a con of NPWT

A
  • expensive
120
Q

what else is NPWT used for? how does this work?

A
  • 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
Q

what is the nurses role w NPWT or a wound VAC

A
  • placed and maintained by nursing
122
Q

how can drainage evacuation be achieved?

A
  1. use a drain alone

2. drainage tube w continuous suction

123
Q

what should be applied around drain sites

A
  • special skin barriers (ex. hydrocolloid dressings) so drainage flows on the barrier but not directly on the skin
124
Q

what are drainage evacuators

A
  • 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
Q

what should you do once the drainage evacuator fills (3)

A
  • assess the character of the drainage
  • empty into a gradulated cylinder to measure
  • immediately reset the evacuator to apply suction
126
Q

what is the jackson pratt (JP) drain

A
  • closed system that uses a bulb to collect drainage
127
Q

what is the jackson pratt (JP) drain

A
  • closed system that uses a bulb to collect drainage
128
Q

how much fluid can a JP drain hold

A
  • up to 100cc
129
Q

how is suction maintained w JP drain

A
  • the plug is opened
  • the bulb is pressed flat
  • the plug is replaced
  • the bulb expands as it fills w fluids
130
Q

describe the tubing of a JP drain

A
  • fenestrated (has little holes) that allows the fluid to go into the tubing and flow into the bulb
131
Q

describe the freq of emptying & dressing changes w a JP drain

A
  • surgeon may give orders

- but monitor carefully

132
Q

what should drainage in a JP drain be assessed for (3)

A
  • color
  • vol
  • accumulation rate
133
Q

describe the expectation of drainage in a JP drain

A
  • expected to decrease over time
134
Q

when should you notify the surgeon in relation to a JP drain (3)

A
  • 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
Q

describe the dressing for a JP drain

A
  • 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
Q

what is a hemovac

A
  • closed drainage system that is used when larger amt of exudates are anticipated
137
Q

how much exudate can a hemovac hold

A
  • up to 400 cc
138
Q

describe the suction of a hemovac (2)

A
  • similar to JP, must be compressed for suction

- check orders: may not always use suction, may instead drain by gravity

139
Q

describe the removal of sutures & staples (4)

A
  • 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
Q

what is an important consideration w removal or sutures and staples

A
  • 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
Q

danielle recommended reviewing the NSO modules but I am not making cards on those

A

..

NURS 3532 - Skills 4 (4 decks)

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