Lab 2 Flashcards
what is the purpose of wound mngmt (3)
- clean a wound to remove debris & dirt
- treat infection to prepare the wound for healing
- protect wound from trauma
for wounds that heal by primary intention, what is commonly used in wound mngmt (2)
- 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
describe wound healing mngmt by secondary intention (3)
- 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
what is a “red wound”? what are examples
- wound that is superficial or deep, clean, red or pink
ex. skin tears, pressure ulcers, second degree burns
what is the goal of treatment for red wounds (2)
- gentle cleansing
- protection of the wound
describe wound mngmt for red wounds (5)
- 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)
what type of dressings are helpful w red wounds (2)
- transparent films
- clear acrylic dressings
(are semi-occlusive and can be permeated by oxygen)
what is a “yellow wound”
- wound w nonviable necrotic tissue
what is the goal of treatment for a yellow wound (2)
- removal of nonviable tissue
- absorption of excessive drainage
what type of dressings may be used for mngmt of yellow wounds (3)
- hydrogel
- absorptive dressings
- hydrocolloids
what impact does hydrogel or absorptive dressings have on the wound
- facilitates autolytic debridement (selective process in which the body’s own enzymes are used to selectively rehydrate, soften, and liquefy slough
what impact does hydrogel or absorptive dressings have on the wound
- facilitates autolytic debridement (selective process in which the body’s own enzymes are used to selectively rehydrate, soften, and liquefy slough
describe the impact of hydrocolloids on yellow wounds
- 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
how long can dressings for yellow wounds stay in place
- up to 7 days or until leakage occurs around the dressings
what can be used to eliminate nonviable necrotic tissue from the wound in yellow wounds
- enzymatic debridement
what is a black wound? what are examples
- wound covered w thick, dry, necrotic tissue (eschar) that is black, brown, or grey
ex. full thickness burns, gangrenous ulcers
describe the risk of infection w black wounds
- increases in proportion to the amt of necrotic tissue present
what is the immediate treatment of black wounds
- debridement of the nonviable eschar
what are various approaches to debridement (4)
- surgical
- mechanical
- autolytic
- enzymatic
describe surgical debridement: benefit? when is it indicated? where is it done?
- quickest method of debridement
- indiciated when lrg amts of tissue are nonviable & pt has sepsis
- performed in the OR or at the pts bedside
when is mechanical debridement used
- used when minimal debris
what are various forms of mechanical debridement (3)
- wet-to-dry dressinga
- pressurized wound irrigation
- whirlpool
describe the process of wet-to-dry dressings for mechanical debridement
- 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
what are 2 disadvantages to wet-to-dry debridement
- nonselective: destroys some healthy tissue
- painful: pain mngmt before
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
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
describe the process of whirlpool for mechanical debridement
- loosens and removes surface wound debris
textbook doesnt describe what it is rlly
when should mechanical debridement not be used?
- for clean, granulating wounds
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
what is used in autolytic debridement
- use of hydrogels, semiocclusive dressings, or occlusive dressings to promote softening of dry eschar by autolysis
describe the process of autolytic debridement (4)
- slow
- selective
- painless
- enables body’s own endogenous enzymes to break down necrotic tissue
autolytic debridement is used for…
- noninfedcted wounds w necrotic tissue and adequate circulation
what is an imp consideration w autolytic debridement
- use of a skin protectant around the wound to prevent maceration
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
what is the only product for enzymatic debridement available in Canada
- Santyl collagenase
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
what is negative pressure wound therapy
- involves the application of negative pressure (suction) to the wound bed
what wound types are sutiable for negative pressure wound therapy (5)
- chronic, acute, traumatic, and dehisced wounds
- partial-thickness burns
- ulcers
- flaps
- grafts
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
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
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
describe the use of acrylic clear dressings
- used for superficial and partial-thickeness wounds w light drainage
ex. tegaderm absorbent
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
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
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
what type of wounds should alginate dressings not be used in
- not for lightly draining or dry wounds bc can desiccate the wound bed
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
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
describe the use of charcoal dressings
- contains odour-absorbent charcoal
describe the use of antimicrobial dressings
- broad spectrum against bacteria
- contains silver, PHMB, cadexomer iodine
ex. iodosorb
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
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
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
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
describe the appearance of a puncture wound (2)
- small, circular
- edges come together towards the center
if a surgical wound is healing by primary intention, describe the wound appearance
- clean, well approximated edges
what should you do if wound edges are separated
- assess for complications such as dehiscence & evisceration
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
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
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
describe the assessment of wound drainage
- note the amt, odor, color, and consistency
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)
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
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
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)
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
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
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
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
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
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
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
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
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)
how might surgical wounds be closed (3)
- suture
- staples
- wound closures
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
how long are staples left in place
7-10 days
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)
over tight suture material may cause?
- cut into the skin = wound separation or dehiscence
what is the benefit of early suture removal (2)
- reduces formation of defects along the future line
- minimized chances of unattractive scar formation
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
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
what is an example of a tissue adhesive
- dermabond
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
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
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)
what needs to be done if you detect purulent or suspicious looking drainage
- may need to obtain a specimen of the drainage for culture
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
what is the gold standard of wound culture
- tissue biopsy
what are 5 potential complications of wound healing
- hemorrhage
- infection
- dehiscence
- evisceration
- fistula
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)
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
what is a hematoma
- a localized collection of blood underneath the tissues
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
what danger is associated w hematomas near a major artery or vein
- the pressure obstructs blood flow
how can external hemorrhage be detected
- assess the dressing for bloody drainage
at what point is the risk for hemorrhage the greatest
- the first 24-48 hrs after surgery
what is the second most common healthcare associated infection
- wound infection
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
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
what impact does bacterial infection have on wound healing?
- impairs wound healing
what are signs of a wound infection (6)
- fever
- tenderness
- pain at wound site
- elevated WBC
- edges of wound appear inflamed
- odourous, purulent drainage
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
what is dehiscence
- partial or total separation of wound layers
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
what does dehiscence involve? what may cause it?
- abdominal wounds
- may occur after a sudden strain (ex. coughing, throwing up, sitting up)
how do pts describe dehiscence
- ” something has given way”
what are signs of dehiscence (3)
- increased amt of serosanguinous drainage
- pt’s report
- visual appearance
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)
when does most dehiscence occur after surgery
- 4-14 days after, with a mean of 8 days
what is evisceration
- protrusion of visceral organs thru a wound opening w total separation of wound layers
- emergency that needs surgical repair!
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
what is a fistula
- an abnormal passage between 2 organs or between an organ and the outside of the body
what increases the risk of fistula formation (6)
- do to poor wound healing
- complication of disease (ex. Crohns)
- trauma
- infection
- radiation
- cancer
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
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
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
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
what is a con of NPWT
- expensive
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
what is the nurses role w NPWT or a wound VAC
- placed and maintained by nursing
how can drainage evacuation be achieved?
- use a drain alone
2. drainage tube w continuous suction
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
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
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
what is the jackson pratt (JP) drain
- closed system that uses a bulb to collect drainage
what is the jackson pratt (JP) drain
- closed system that uses a bulb to collect drainage
how much fluid can a JP drain hold
- up to 100cc
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
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
describe the freq of emptying & dressing changes w a JP drain
- surgeon may give orders
- but monitor carefully
what should drainage in a JP drain be assessed for (3)
- color
- vol
- accumulation rate
describe the expectation of drainage in a JP drain
- expected to decrease over time
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
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
what is a hemovac
- closed drainage system that is used when larger amt of exudates are anticipated
how much exudate can a hemovac hold
- up to 400 cc
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
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)
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)
danielle recommended reviewing the NSO modules but I am not making cards on those
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