Lab 6 - Wound Care Flashcards
list what you should assess during assessment of pressure ulcer development (6)
- sensory perception (ability to respond to pressure related discomfort)
- moisture (degree to which skin is exposed to moisture)
- activity lvl (degree of physical activity)
- mobility (ability to change & control body position)
- food & fluid intake (nutrition and hydration)
- friction & shear
what is an assessment tool that can be used to assess pressure ulcer risk
- braden scale
how often should you assess the risk of pressure ulcer development
- on admission
- if any change in status occurs
- on a regular basis according to instutional policy
what does a high braden score mean? low?
- low = high risk
- high = low risk
describe what a stage 1 pressure ulcer looks like
- intact skin
- nonblanchable redness of a localized area over a bony prominence
- presence of blanchable erythema or changes in sensation, temp, or firmness may preced visual changes
- does NOT include purple or maroon discolorations
- may be painful, warm, soft, firm, or cooler when compared to adjacent tissue
describe a stage 2 pressure ulcer
- partial thickness loss of dermis
- shallow, open ulcer
- red, pink, moist wound bed
- no granulation tissue, eschar, or slough
- adipose & deeper tissues not visible
describe a stage 3 pressure ulcer
- full thickness tissue loss
- subcut fat may be visible but bone, tendon, and muscle are not exposed
- may have undermining or tunnelling
- slough, granulation tissue, and epibole (rolled edges) may be present
describe a stage 4 pressure ulcer
- full thickness tissue loss
- exposed bone, muscle, tendon
- often includes undermining, tunneling, and epibole
- slough, eschar, or both may be present
describe an unstageable pressure ulcer
- full thickness tissue loss
- base of ulcer is covered by slough, eschar, or both in the wound bed
- once slough or eschar is removed, will see stage 3 or 4
describe what a suspected deep tissue injury looks like
- nonblanchable purple or maroon localized area of discolored, intact skin
- intact or not intact
what is serous drainage
- clear, watery plasma
what is purulent drainage
- thick, yellow, green, tan, or brown drainage
what is serosanguinous fluid
- pale, red, watery
- mix of clear & red fluid
what is sangeinous fluid? what does it indiciate
- bright red
- indicates active bleeding
describe what you should assess prior to treating a pressure ulcer
- assess lvl of comfort and need for pain med
- check allergies
- review order for dressing
- close door/curtain
- position pt appropriately for location of wound
- assess pressure ulcer
- assess periwound skin
what should you note when assessing the pressure ulcer
- color, type. and % of tissue in wound base
- measure width and length
- measure depth of ulcer and any undermining using a sterile cotton tip
what should you assess regarding the periwound skin
- maceration
- redness
- denuded areas
describe how to clean/treat a pressure ulcer
- hand hygeine
- put on gloves
- cleanse ulcer w NS or cleansing agent
- apply topical agents as prescribed
- remove gloves, dispose of soil supplied
- hand hygeine
list 3 types of topical agents that may be applied to pressure ulcer
- enzymes
- hydrogel
- calcium alginate or hydrofibre
describe how to apply enzymes to a pressure ulcer
- apply thin, even layer over necrotic areas only
- protect periwound skin
- apply secondary nonadherent gauze dressing directly over ulcer
- tape in place
describe how to apply hydrogel to a pressure ulcer
- cover surface of ulcer with thin layer of hydrogel using applicator or gloves hand
- apply secondary nonadherent gauze dressing or transparent dressing over wound & adhere to intact skin
describe how to apply calcium alginate or hydrofiber to a pressure ulcer
- lightly pack wound with alginate or hydrofibre using applicator or gloved hands
- apply secondary dressing of nonadherent gauze, absorbent pad, or foam over alginate
- tape in place
what age-related changes occur in an older adult’s skin (6)
- reduced skin elasticity
- decreased collagen
- thinning of underlying muscle & tissues
- flattening of the attachment between the demris & epidermis
- diminished inflammatory response
- hypodermis decreased in size
what do the age-related changes of skin in an older adult cause? (5)
- skin can be easily torn
- decreased wound healing
- slowed epithelialization
- more prone to skin breakdown
- increased risk of pressure ulcer development
what is an acute wound
- a wound that proceeds thru an orderly and timely reparative process
- results in sustained restoration of anatomical and functional integrity
what are 2 common causes of acute wounds
- trauma
- surgical incision
what do acute wounds often look like; what implication does it have on healing
- wound edges clean & intact
- easily cleaned & repaired
what is a chronic wound
- would that fails to proceed thru an orderly and timely process to produce anatomical & functional integrity
what are 3 causes of chronic wounds
- vascular compromise
- chronic inflammation
- repetitive insults to the tissue
what implication do chronic wounds have on healing
- continued exposure to insult impedes wound healing
what are the 3 types of healing
- primary intention
- secondary intetion
- tertiary intention
what is healing by primary intetion
- healing occurs by epithelialization, when a wound is closed or the edges are well approximated
- heals quickly w minimal scarring
- wound edges are pulled together and approximated
what are two types of wounds that heal via primary intention
- surgical incision
- stapled or sutured wound
what is healing by secondary intention
- healing that occurs in wounds where edges are not well aproximated
- would heals by granulation tissue formation, wound contraction, and epithelialization
what are 2 types of wounds that heal via secondary intention
- pressure ulcers
- surgical wounds that have tissue loss
what is healing by tertiary intention
- healing where the wound is left open for several days, then wound edges are approximated
- closure of wound is delayed until risk of infection is involved
what type of wounds are healed via tertiary intention
- wounds that are contaminated & require observations for signs of inflammation
what is the goal of effective wound management
- maintenance of a physiological local wound enviro
how can we maintain a healthy wound enviro
- prevent and manage infection
- cleanse the wound
- remove nonviable tissue
- manage exudate
- maintain the wound in a moist enviro
- protect the wound
why is it important to prevent and manage infection of a wound
- a wound will not move thru the stages of healing if it is infected
prevention of wound infection includes.. (3)
- irrigation
- cleansing
- removal of nonviable tissue
what is used to clean wounds
noncytotoxic wound cleansers:
- NS
- commercial wound cleansers
why must we use noncytotoxic wound cleansers to clean wounds
- will not damage or kill fibroblasts & healing tissue
what are 4 cytotoxic solutions to absolutely avoid for granulating wounds
- sodium hypochlorite dolution
- acetic acid
- povidone-iodine
- hydrogen peroxide
what is irrigation
- common method of delivering the wound cleansing solution to the wound
- uses a syringe to apply the cleansing solution
what is used to ensure an irrigation pressure within the correct range
- use a 35 mL syringe with a 19-gauge angiocatheter or a single 100 mL saline squeeze bottle
what pressure should be applied to wounds during irrigiation to provide adequate removal of bacteria while avoiding trauma to the bed
- 4-15 psi
what is debridement? why do we do it?
- removal of nonviable, necrotic tissue
- is necessary to rid the ulcer of source of infection, enable visualization of the wound bed, and provide a clean base for healing
what is an excpetion to debridement
- dry necrotic heel
- only debride if infected
what are 6 methods of debridement
- mechanical
- biological
- autolytic
- chemical
- sharp
- surgical
what is important to manage during debridement
- pain
what is mechanical debridement
- “wet-to-dry” saline gauze dressing
why is mechanical debridement not considered appropriate for pressure ulcers
- nonselective in its removal of devitalized vs viable tissue
what is biological debridement
- use of maggot therapy
- sterile maggots used in the wound bed to ingest the dead tissue while not impairing granulation
what is chemical debridement
- involves the use of enzymes which breakdown necrotic tissue
- depending the type, it either digests or dissolves tissue
what is an important consideration for chemical debridement
- only apply to the wound bed, avoid the periwound skin
what is the current best practice treatment option for debridement of pressure ulcers
- autolytic
- sharp /surgical debridement
what is autolytic debridement
- debridement which uses synthetic dressings over a wound to maintain a moist enviro
- allows the eschar and fibrinous slough within the wound to be self digested thru the action of enzymes that are present in wound fluids
what are 2 types of dressing that support moisture at the wound surface ? why is this important
- hydrogel & hydrocolloid
- allows the movement of epithelial cells & facilitates wound closure
what is the consequence of excessive exudate
- supports bacterial growth
- macerates the periwound skin
- slows the healing process
which type of dressing should be used if there is an excessive amt of exudate
absorptive dressing:
- calcium alginate
- hydrofibre
- foam
what is sharp/surgical debridement
- debridement that uses a scalpel, scissors, or other sharp instruments
why/when is surgical debridement used
- most efficient way to reach vitalized tissue at the base of a wound
- when sepsis is localized or excised
who is allowed to do surgical/sharp debridement
only HCP with knowledge, skill, and competence to perform the skill:
- physicians
- advanced practice nurses (NP)
the wound will not heal, regardless of the use of topical therapy, unless….
you control or eliminate the causative factors
- malnourishment
- friction
- shear
- pressure
- moisture
why is continued reassessment of wounds important
- as the wound goes thru the steps of healing, the treatment plan must be altered
- key to supporting the wound thru the phases of wound healing
what is another important factor regarding wound healing
- must explain the process of wound healing to the pt and family
when should you administer pain meds for irrigation
30-45 min before starting the irrigation
describe the steps of wound irrigation prior to actual treatment
- assess pain & give meds if appropriate
- review orders
- assess recent S+S r/t to the wound to get a baseline
- explain procedure to pt
what recent S+S of wound should you assess prior to irrigation
- conditon of the skin & wound
- elevation of body temp
- drainage from wound (amt, color)
- odour
- consistency of drainage
describe how to irrigate a wound
- perform hand hygeine
- position pt
- set up garbage bag
- put on appropriate PPE
- irrigate wound
- obtain any needed cultures
- dry wound edges w gauze
- apply appropriate dressing
- remove gloves & dispose of equipment
how should you position a pt for irrigation
- so it permits gravitational flow of the irrigating solution thru the wound and into the collecting receptacle
describe how to irrigate a wound with a wide opening
- fill 35mL syringe with irrigation solution
- attach 19-gauge needle or angiocatheter
- hold syringe tip 2.5 cm above upper end of wound and over area being cleansed
- use continuous pressure and repeated until solution draining into the basin is clear
describe how to irrigate a deep wound with a very small opening
- attach soft angiocatheter to filled irrigating syringe
- lubricate tip of catheter with irrigating solution, then gently insert tip of catheter and pull out about 1cm
- use slow, continuous pressure to flush the wound
- pinch off catheter just below syringe while keeping catheter in place
- remove & refill syringe
- reconnect to catheter & repeat until solution draining into basin is clear
what should you immediately report to the physician regarding irrigation
any evidence of:
- fresh bleeding
- sharp increase in pain
- retention or irrigant
- signs of shock
what are the recommendations for standardized techniques for wound cultures
- clean wound surface with a nonantiseptic solution (NS, or sterile water)
- use a sterile swab for the culturette tube
- rotate the swab in 1cm of clean tissue in the open wound
- apply pressure to the swab to elicit tissue fluid
- insert the tip of the swab into the appropriate sterile container & transport to the lab
describe the use of tap water for cleaning a wound
- no particular risk if from safe municpal water sources
- however, tap water from rural areas or unknown sources can cause potential contamination
- therefore, should err on the side of caution & use sterile water or NS
define fistula
- abnormal connection between 2 body parts
what is purulent drainage associated with?
- infection or high bacteria lvls
define hemostasis
- process of the body stops bleeding from a cut or injury
define ischemia
- condition in which blood flow (and thus O2) is restricted or reduced in part of the body
define slough
- necrotic tissue that needs to be removed from the wound for healing to take place
- yellow or tan in appearance
define necrotic
- death of cells in living tissue caused by external factors
define maceration
- softening of tissues by soaking and enzymatic digestion
define evisceration
- extrusion of viscera outside of the body
- specifically thru surgical incision
define debridement
- medical removal of dead, damaged, or infected tissue to improve healing in the remainging healthy tissue
define approximated edges
- wounds that fit neatly together
define granulation
- part of the healing process in which lumpy, pink tissue containing new CT and capillaries forms around the edges of a wound
define erythema
- reddening of the skin that is common but nonspecific sign of skin irritation, inflammation, or injury
- caused by dilation of superficial blood vessels in the skin
define dehiscence
- wound dehiscence is the separation of the edges of a surgical wound
define eschar
- dead tissue found in a full thickness wound
when might we see eschar tissue (6)
- burn injury
- gangrenous ulcer
- fungal infection
- necrotizing fascitis
- spotted fevers
- exposure to cutaneous anthrax
define epitheliazation
- restoration of epithelium over a denuded area by natural growth or plastic surgery
define laceration
- wound that is produced by the tearing of soft body tissue
- irregular & jagged
- often contaminated with bacteria & debris from whatever caused it
define incision
- cut made into the body during surgery
define hypergranulation
- over-granulation or proud flesh
- excess granulation tissue that fills the wound bed to a greater extent than what is required
- goes beyond the height of the surface of the wound = raised tissue mass
define dermatitis
- inflammation of the skin
define exudate
- fluid that leaks out of blood vessels into nearby tissues
- made of cells, proteins, and solid materials
define undermining
- occurs when the tissue under the wound edges becomes eroded = pocket beneath the skin at the wound’s edge
define tunneling
- channels that extend from a wound into & thru subcutaneous tissue or muscle
- often difficult to manage
- may persist for long period of time
define nonviable
- aka necrotic or devitalized
- avascular tissue that has lost normal cellular structure & physical properties required of living tissue
