Lab 4- complex dressings Flashcards
when do you perform a Braden scale in acute care
Q 48 hours
prevent skin breakdown and intervene sooner
categories of Braden scale
6
sensory perception
moisture
activity
mobility
nutrition
friction /shear
stages of pressure sores
Stage 1
Stage 2
Stage 3
Stage 4
Stage X or N (unstageable)
Stage SDTI (suspected deep tissue injury)
As pressure ulcers heal they are not
down staged, they are classified granulated stage ___
Category 1 PU
- Non blanchable erythema of intact skin
- discoloration of skin, warmth or hardness also may be indicators
category 2 pressure ulcer
example
- partial thickness loss
- epidermis and or dermis
- viable, pink, or red tissue
- distinct wound margin
abrasion, blister, shallow crate
Stage 3 PU
- full thickness skin loss
- damage or necrosis of subcutaneous tissue
- doesn’t go through fascia
stage 4 PU
- full thickness
- extensive damage
- bone or supporting structures affected
stage X or N
unable to determine depth from presence of thick eschar
SDTI
- usually intact skin
- purple or maroon localized area or blood filled blister
- painful, form or mushy/boggy
treatment of stage 1
relieve pressure protect with barrier cream, prevent from becoming worse, protect
stage 2 PU treatment
- relieve pressure
- no dressing or dressing to absorb drainage - debride slough if present
- protect
stage 3 PU treatment
- relieve pressure
- debride slough/eschar if present
- pack sinus tracts and undermining
- dressing to absorb drainage
- decrease bacterial load
- protect
stage 4 PU treatment
same as 3
ensure there is an assessment for
Risk factors to poor healing and address them
RF for poor healing
advanced age, impaired o2 delivery, poor nutritional status, smoking/substance use, impaired mobility, decreased activity tolerance
moisture, shearing, friction
stage x treatment
surgical
non surgical
surgical debridement to remove eschar
if non surgical keep dry and prevent infection
products for stage X
3
iodine swab or liquid with cotton swab, iodasorb ointment
inadine (antimicrobial povidone impregnated gauze)
SDTI treatment
- depends on the presentation and when or if the wound opens
- may become stage 3 or 4 and then treated as such
What should you do if you suspect a wound infection? What can you do as a third year student?
Obtain a C&S swab after cleansing the wound if 2 or more S&S of local infection are present
S/S of
- local infection
- systemic infection
Local: decreased healing, peri wound warmth, increased exudate, redness, necrotic debris, odor present after cleaning
systemic: altered VS, increase WBC, chills, malaise, pain
What should you anticipate as far as orders if there is a suspected infection?
- ABX may be ordered before or after culture results are back
- treat with wound care products to reduce the bacteria in wound
Wound irrigation is
Application of fluid into a wound that removes: - exudate
- debris
- bacterial contaminants
- dressing residue
without adversely impacting cellular activity to the wound healing process
in order to irrigate a wound it must
have a known end point
temperature of fluid for wound irrigation
room temp
options for irrigation fluid (5)
sterile normal saline
Sterile water
potable water
commercial cleansing agent
topical antiseptic agents
irrigation supplies
- irrigation tip (single use, latex free, soft flexible plastic)
irrigation tip PSI
7-8 psi of pressure to contact wound bed
does not damage wound bed
indication for irrigation (2)
- deep wounds with wide openings
- wounds with narrow opening and/or sinus or tunnelling
Steps for irrigation
- position pt for gravity drainage of fluid
- fill 30 mL syringe with irrigating fluid and attach irrigation tip
if deep/wide opening (irrigate)
3
- hold tip 2.5 cm above upper end of wound
- gently flush using continuous pressure
- repeat until runs clear
if small opening/sinus/tunnel (irrigation)
- gently insert the tip and then pull out about 1 cm
- gently flush with continuous pressure,
- repeat until runs clear
reason for wound packing
- assists with healing as material absorbs any drainage which allows for faster healing from the inside out
packing material protects the wound as
it prevents the wound from closing at the top and not healing the deeper areas
A tunneling wound or sinus tract is _________
results in
- narrow opening or passageway underneath the skins that can extend in any direction through soft tissue
- results in dead space with potential for abscess formation
undermining wounds are wound that
extend in one or multiple directions into subcutaneous tissue under the skin
causes of undermining (3)
- infection
- pressure that has caused a lack of blood flow,
- improper wound treatment
wound heal more efficiently when they are
moist
when packing best to
use 1 piece of packing when possible or tied together or secured
packing wetness
moist or damp but not wet (wring out)
do not pack causing
stretching or bulging
documenting packing
number of pieces removed and inserted
do not pack beyond
15 cm of opening unless direct orders from MRP or WOC
Wound packing technique
- review WCP
- position patient for gravity drainage of wound
- organize supplies, irrigating fluid and packing material
- remove old dressing and packing (clean gloves and blue forceps), soak if adheres and count pieces
- Make sure to do wound assessment including measurements
- May need to use a peri wound skin barrier
- Ensure that a tail of packing is visible and secured with steristrip to periwound
- Documentation is key to determine if plan is working or needs reassessment
Documentation is key to
determine if plan is working or needs reassessment
VAC therapy
- non invasive, active therapy combining localized negative pressure and moisture to promote healing
VAC therapy requires an
order- then WOC is referred to assess if appropriate and for initiation
Wounds that could use VAC therapy
- Degloving injury
- post debridement of necrotizing fasciitis
- compartment syndrome fasciotomies
- Dehisced or extensive non healing
- Dehisced sternal wound or non healing bypass graft site
- Exposed bone, hardware or tendon
- Pressure, diabetic, arterial insufficiency
- Full thickness burns, graft stabilization
VAC indications
6
acute/traumatic wounds
abdominal wounds
cardiothoracic wounds
orthopedic wounds
chronic ulcer wounds
burns
complication of VAC
5
- infection
- foam retention
- tissue adherence
- bleeding
- pain
Prevena and PICO
- small, battery powered, portable system,
- patients may go home with these, up to 7 days therapy
VAC therapy benefits (8)
- wound bed preparation and granulation tissue growth
- Removal of excess interstitial fluid
- Increase vascularity
- Decreased bacteria
- Accurate wound drainage assessment
- moist wound environment
- Increased rate of epithelialization
- Cost effective
VAC contraindications (8)
Insufficient vascularity
Necrotic wounds- need debridement 1st
Untreated osteomyelitis
Malignancy in the wound
Sinus tracts that is unpackable or fistula
Allergy to dressing material
High risk of bleeding
cant manage it
Non adherent products
mepitel – silicone layer
adaptic – cellulose acetate fabric impregnated with petroleum
allevyn - hydrocellular foam dressing
alldress - composite dressing
inadine - viscose fabric impregnated with iodine
restore – fine polyester mesh and petroleum-based formula with silver layer
Iodasorb - cadesomer iodine ointment (forms moist gel over wound)
Mepitel
adaptic
allevyn
- silicon layer
- cellulose acetate fabric impregnated with petroleum
- hydrocellular foam dressing
allress
inadne
restore
- composite dressing
- viscose fabric impregnated with iodine
- fine polyester mesh and petroleum-based formula with silver layer
iodasorb
cadesomer iodine ointment (forms moist gel over wound)
absorbent products
- allevyn/mepilex border – hydrocellular foam dressing/ non-adherent
- nuderm alginate – calcium alginate (made from seaweed; has hemostatic properties)
- aquacel – hydrofiber (carboxymethylcellulose fibers)
- silvercel – fine polyester mesh and petroleum-based formula with silver
- mesalt - hypertonic gauze (salt-impregnated gauze)
- mesorb – absorbent material/fluid-repelling backing
- gauze – cotton fabric
antimicrobial products
- silvercel or seasorb AG (calcium alginate with silver)
- aquacel AG (hydrofiber with silver)
- acticoat flex 3 or 7 (knitted polyester with silver)
- restore (fine polyester mesh and petroleum-based formula with silver layer)
- Inadine (viscose fabric impregnated with iodine)
- povidine-iodine solution
- Iodasorb (cadesomer iodine ointment)
products for debridement
- hypertonic gauze
- iodasorb ointment
- gels
- moistened hydrofiber or calcium alginate
Hydrocolloids (_____)
(small amount)
- nuderm or tegaderm hydrocolloid
Wound products for dry wounds
gels and hydrogels (eg. intrasite gel)
bleeding wounds product
calcium alginate
odor control
activated charcoal dressing
occlusive/transparent film dressing
tegaderm IV 9semi permeable)
gauze dressing
gauze packing
- 1/4 inch
- 1/2 inch
- 1 inch
- 2 inch
mepore strip dressing
choosing the appropriate product
questions to ask (6)
Is the wound healable?
What is the goal?
Is the wound flat or deep? Require packing?
Do you need to add moisture or remove moisture?
Are there signs of infection? Need antimicrobial?
What is the main color of the wound? Red? Yellow? Black?
promote healing environment product
intrasite gel
sterile field principles
- never
- do not
- moisture caries
- do not
- position
- field height
- ensure sterile
- ensure
Never turn back of field
Do not talk over
Moisture carries bacteria
Do not reach over
Position in triangle with patient, field, garbage
Field height above incision, do not drop hand
Ensure sterile handling of all items adding to fields below field
Ensure 1 inch sterile border
Leave post op drsg intact for
24-48hrs unless otherwise ordered
sutures are
tiny threads used to sew body tissue and skin together with intermittent, blanket or continuous technique
where sutures placed
deep in the tissue and/or superficially to close a wound
types of sutures
Absorbent (dissolvable) or non-absorbent (must be removed)
sutures left in place long enough to establish
wound closure with enough strength to support internal tissues and organs
when to removal of sutures
usually 5-14 days following the surgical procedure depending on the type of surgery and the physician
beyond 14 days sutures in place causes
skin to grow around
staple are made of _____ and provide _______
stainless steel wire and provide strength for wound closure
location considerations for staples
sometimes restricts use because they must be far enough away from organs and structures
staples left in place enough to establish
wound closure with enough strength to support internal tissues and organs
when to removal of staples
usually 7-14 days following the surgical procedure depending on the type of surgery and the physician
dehiscence=
action
the splitting open of a wound,
stop, steri-strip, redress and call surgeon
Evisceration=
action
Extrusion of organs outside of cavity through an open wound
blood supply to organs is compromised
stop, cover with saline soaked sterile dressing, do not attempt to reposition organs, call surgeon
if unable to remove closures
ask for help
if patient in pain during removal
allow for small breaks during removal
infection of incision s/s
warmth, redness, swelling, pus discharge, foul odor, pain
patient education for incision
- May shower, no bathing or hot tub/pools for 4-6 weeks, keep clean and dry
- Wash your hands before touching incision
- Do not pull of steri-strips, will come off naturally 1-3 weeks
- Watch for signs and symptoms of infection
- Importance of not straining, adequate rest, fluids and nutrition, as well as ambulation for optimal wound healing
drainage assessment
type, amount, consistency, odor
peri wound skin assessment
color, temperature, edema, ecchymosis, maceration
Apply steri-strips extending _____inches on each side of incision
1.5-2 ich
what do document with closure removal
Wound assessment
Number of closures removed
Wound care provided
Steri-strips applied
Type of dressing applied
what depth can we pack a wound
1cm or greater
Do not pack a wound if the sterile ___ cm cotton tip applicator or probe
15
does not reach the end of the wound
further assessment will need to be done
if sterile irrigation tip not available use
18-19 G catheter tip
wounds that can be irrigated
2
- undergoing moist wound healing
- known end point
where to hold the catheter above the wound
10-15 cm
Dressing types form need to increase absorption to need to add moisture
wet wound —> dry wound
Foam
Hydrofiber
Alginate
Hydrocolloid
Gel
FHAHG
