Lecture 10 - Wound Care (MEDSURG) Flashcards
What are the three layers of the skin?
Epidermis - Outer protective
Dermis/Corneum - Nourishing Layer
Subcutaneous/Hypodermis - Fatty base layer
What are the six function of skin?
–> Barrier and Protection
–> Immunity
–> Temperature regulation
–> Insulation, fat and water storage
–> Sensory perception
–> Vit D synthesis
–> Sociosexual communication and display
Which individuals are at higher risk for skin breakdown
Older adults + very young population, immunosuppressed, oncology patients, those with diabetes
What are important things to note when document changes in skin?
- New onset or existing
- Location
- Colour, shape, size
- Borders, texture, arrangement, elevation or depressed
- Temperature/altered sensation
What kind of lights are best to accurately inspect dark skin tones?
Natural or halogen light, not fluorescent
–> Inspect and palpate
What products are best for cleansing skin?
A gentle/balance pH product and moisturizer or barrier products as needed
What do we need to avoid to protect skin integrity? Which areas should we pay extra attention to
Very hot water, rubbing & friction.
Frequently check bony prominences, folds, creases, contact points.
What is the decision algorithm for skin tears? (7 steps)
- Stop and control bleeding
- Assess and classify (measure, photograph and document)
- Cleanse
- Approximate edges/recover skin integrity
- Determine goals of treatment
- Select product for dressing
- Document and report
What are the kinds of skin tears?
Type 1 - No skin Loss
–> Flap can be repositions to cover the wound bed
Type 2 - Partial Flap Loss
–> Flap cannot be repositioned to cover the wound bed
Type 3 - Total flap loss
–> Wound bed is completely exposed
What differentiates a chronic or acute wound?
Acute: Healing as expected
Chronic/Persistent: Doesn’t match expected trajectory for the type of wound
What are the steps in the cycle of woundcare?
- Assess
- Set goals
- Assemble the team
- Establish and Implement a Plan of Care
- Evaluate outcomes
Looks a lot like the nursing process
When assessing a wound, what should you assess other than the wound itself?
Risk and causative factors that may impact skin integrity for wound healing
–> Pt, environment, systems
What is the MEASURE tool for wound assessment?
Measure - Length. width, depth, area
Exudate - Color, amount, consistency
Appearance - Tissue type and percentage
Suffering - Pain on valid scale and odour
Undermining - Presence or Absence of undermining and tunelling
Re-evaluate - Onset and ongoing every 1-4 weeks
Edge - Condition of edge and peri-wound area
What unit should you measure a wound size in?
Cm
What is fibrous exudate?
Cloudy, thin, watery.
What is haemopurulent exudate?
Dark red, viscous, sticky
What is granulation tissue?
Granulation tissue: red or bright pink, healthy tissue.
What is hypergranulation tissue?
Hypergranulation: excessive growth of granulation tissue “proud flesh”, raised red.
–> Can occur with high moisture
What is slough?
Slough: yellow stringy tissue – none or loosely adherent.
What is fibrin?
Fibrin: yellow stringy tissue – firmly adherent. May be confused with slough.
What is eschar?
Eschar: soft or firm, black or tan necrotic (devitalized) tissue.
What is epithelialization?
Epithelization: hypopigmented, ie pearly white
–> Often seen on wounds that are contracting and decreasing in width
What can cause odour in a wound?
Infection, dead tissue (necrotic, slough), certain dressing products.
Odour might be present before cleansing wound, but should not be after wound care. Perform wound care before complete odour assessment
What is meant by saying a wound has indistinct edges?
Unable to distinguish wound outline
What is meant by saying a wound’s edges are not attached?
Sides are present, and the wound base is deeper than the edge
What is epibole with wound edges?
When the edge is rolled or curved under, downward and into the wound
What is the VINDICATE tool for identifying risk factors for wounds/healing?
Vascular
Infection/Inflammation
Neoplasm
Drug/Degenerative
Idiopathic/Iatrogenic
Congenital
Autoimmune/anatomic/allergies
Traumatic/Toxic
Endocrine/Environmental/Exposure
What occurs during the hemostasis phase of wound healing? How long does it last?
Seconds-Hours
–> Vasoconstriction, platelet aggregation, leukocyte migration
What are the goals of wound care?
Prevention & Healing
For non-healing - maintenance
Palliation - First focus of QoL + symptom management
How often are measurements redone for wounds?
Usually weekly
What occurs during the Inflammatory phase of wound heal? How long does it last?
Hours-Days
–> Starts with neutrophils and ends with macrophages
–> Phagocytosis and removal of foreign bodies/bacteria
What are the stages of wound healing? How long do they last?
Hemostasis - seconds to hours
Inflammatory phase - hours to days
Proliferative phase - days to week
Remodeling - Week to months (could be up to 2 years)
Who would we want to contact to assemble the team for wound care?
NSWOCC - A nurse specialized in wounds, ostomies, and Continence Canada
Physio - mobility
OT - Equipment & positioning
Dietician - Optimizing nutrition
Speech Language Pathology - swallowing
Physicians
Pt & Family
Nurse coordinates and provides care
What are the different kinds of wound closure techniques?
Primary Intention- closing wound from top edges (skin)
Secondary Intention- closing wound from bottom and letting it heal upwards (bottom up)
Tertiary Intention - Wound is left open for a period of time and then closed using primary intentions (mixed)
At what point should a surgical incision be bright pink instead of red? When should it start moving to pale pink or scar tissues?
Pink by day 10-14
Scar tissue developed by 15 days- 2 years
What are some uncontrollable pre-operative risks?
–> Advanced age
–> Previous experience with anesthesia
–> Comorbidities (Diabetes, over or underweight, altered immune system, skin conditions
–> Medications
What are some controllable pre-operative risk factors?
–> Anxiety, stress, fear
–> Nutritional status
–> Hb, sugar, oxygenation
–> Smoking
–> Hygiene & hair removal
–> Pre-existing infections
What is an important question to ask cardiac surgery patients before the operation?
Up to date dental work - prevent infection following surgery
What are some uncontrollable intra-operative risk factors?
The site, duration, and complexity of the surgery
What are some controllable intra-operative risk factors?
Prophylactic antibiotics, instrument processing, safe surgical attire for staff, performing surgical checklist.
Maintain normothermia and tissue perfusion/oxygenation
What lack of progression in a post-operative wound should be noticed early?
Seroma, hematoma, or infection.
What are the top three kinds of nosocomial infections?
UTI, Pneumonia, wound
What products would we use for primary intention cover dressings?
Non-adherent dressings with some absorbency
–> Negative pressure wound therapy
–> Island Telfa
–> Foam and films
When would an island Telfa adhesive dressing be indicated? What is the wear time?
For primary intention cover dressing with scant or small exudate
–> Inexpensive, with a weat time of 3 days
When would a combo (foam and film) dressing be used?
For primary intention cover dressing with scant to moderate exudate
–> Very water resistant and more expensive than telfa adhesive
When should negative pressure therapy be used for primary intention?
For wounds with a high risk of dehiscence (splints wound)
–> Can be very costly and limit accessibility
How often do you change a primary intention wound covering?
As long as possible to promote healing - It takes 4-8 hours for the wound to heal form removing the dressing.
Are mucosal membrane pressure injuries staged?
No - but MDRPIs are
What does a stage 1 pressure injury look like?
Non-Blanchable erythema of intact skin
Brown or Black skin may present with changes in temperature, be very shiny, changes in sensation, itching.
What change in skin temp will indicate perfusion related injury?
drop of 3° C
A serum filled blister is what stage pressure injury?
Stage 2 - has not entered highly vascularized tissue below skin yet.
What is a stage 2 pressure injury?
Partial thickness loss with exposed epidermis
–> Viable wound bed, may be serum filled blister
What does not count as a stage 2 pressure injury?
Moisture-Associated Skin Damage
–> Incontinence Associated Dermatitis
–> Intertriginous dermatitis
Medical Adhesive Related Skin Injury
Traumatic Wounds
What is a stage 3 pressure injury? What does it look like?
Full thickness skin loss with visible adipose tissue
–> Visible granulation tissue and epibole (rounded edges) with possible slough or eschar
–> Undermining and tenneling may be present
Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed
What is a stage 4 pressure injury? What does it look like?
Full thickness skin and tissue loss
–> Exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone on wound bed.
–> May be slough or escahr present
–> Epibole, undermining, tunelling often occur
If slough and eschar obscured the extent of tissue loss visible this is considered unstageable
What kind of injury is a blood filled blister?
Deep Tissue Pressure Injury (DTPI)
If you can touch the bone of a stage 4 pressure injury, what are the chances they also have osteomyelitis?
80%
What is a deep tissue pressure injury?
Intact or non-intact skin with localized area of persistent non-blanchable, deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister.
Pain a temperature changes will often precede changes in skin colour - discoloration may occur differently in darkly pigmented skin
What is a medical device pressure injury? Should they be staged?
Pressure injury from use of diagnostic or therapeutic devices - clues can be found in the shape or pattern.
Should be staged using regular system for pressure injuries
How should stable eschar be treated in an unstageable pressure injury?
Should not be softened or removed - paint with PVI and allow to dry
What kind of ulcers can be caused by pregnancy, previous DVT, recurrent phlebitis, and varicose veins?
Where do usually occur and what do they look like?
Venous Ulcers
–> Usually occur between lower calf and median malleolus
–> Shallow and flat margins with moderate to heavy exudate. Slough at base with granulation tissue
What kind of ulcer is usually associated with diabetes, HTN, smoking, and previous vascular disease?
What does this kind of ulcer look like and where does it occur?
Arterial
–> Occurs on pressure points, toes and feet, lateral malleolus and tibial areas
–> Looks like punched out and deep irregular shape with unhealthy wound bed. Presence of necrotic tissue, minimal exudate unless infected
What kind of ulcer is usually caused by diabetes, trauma, and prolonged pressure?
Where is it usually on the body and what what does it look like?
Neuropathic
–> On plantar aspect of foot, tip of toe, and lateral to fifth metatarsal
–> Deep, surrounded by callus, and insensate
What is the VIPS tool for diabetic foot ulcer management?
Vascularity - Pulses, doppler
Infection/Inflammation - Rule out bc they will stall healing
Pressure - Relieve pressure
Sharps/Surgical Debridement
What test can be used to test sensation of the feet in those with diabetic neuropathy?
Monofilament test
What are Marjolin’s Ulcers?
a rare, aggressive, and malignant skin cancer that develops in areas of chronic wounds, scars, or previously injured skin
What are possible risk factors for arterial leg ulcers?
Hyperlipidemia, PAD, HTN, diabetes, smoking, advanced age, positive family history, obesity, inactivity
Previous leg trauma or extensive surgery
What does an arterial leg ulcer look like?
Punches hole, small and deep, well defined borders
May see pallor, coolness, faint pulses
Intermittent claudication - pain with walking
How can severe arterial leg ulcers be treated?
Surgical reperfusion is necessary is circulation is interrupted.
What are the 6Ps are arterial insufficiency?
Pain, pulselessness, pallor, paresthesia, paralysis, poikilothermia
What is ABPI?
Ankle Brachial Pressure Index
–> non-invasive test that measures the ratio of blood pressure in the ankle to the blood pressure in the arm. It’s used to assess vascular health and diagnose peripheral artery disease
What kind of solution should you irrigate with?
A sterile non-cytotoxic solution
When should you not irrigate a wound?
When there is an unknown point of tunnels, sinuses, or undermining/fistulas
When is debridement contraindicated?
With stable a dry eschar when:
–> Perfusion is not adequate and
–> Very close to bone or cartilage, for examples on the heels or scalp.
Instead, paint with iodine solution
Surgical debridement can only be performed by…
What should you be aware of before?
A physician or trained nurse
Ensure hemostatic agents readily available if bleeding occurs
What is a bulla skin lesion?
One that is filled with serum (clear fluid)
What is a macule skin lesion?
A color change that is not palpable
What is a papule skin lesion?
A solid or cystic raised spot on the skin that is less than 1 cm wide
–> typically raised, firm, flesh-colored bumps with a pearly or smooth shiny appearance.
What is a pustule skin lesion?
A lesion filled with purulent drainage
What is an ulcer skin lesion?
Crater-like sores that develop due to decreased or absent perfusion
What is a vesicle skin lesion?
A fluid filled lesion that will first burst, scab over, and then heal
–> Associated with HS1
What is a wheal skin lesion?
a patch on the skin that is elevated, discolored, changes shape, and often itches
–> d/t insect bite, eczema, etc.
What are the ABCDEs of melanoma?
Asymmetry
Border
Colour
Diameter
Evolving
How should odour of a wound be described?
None
Noticeable before dressing removal and disappears when dressing discarded
Odour noticed on entering the room
What is meant when a wound’s edges are fibrotic?
When they are scarred, hard, or rigid.
What drug use should you assess for when identifying possible risks for a wound?
Steroids, NSAIDS, chemo meds, alcoholism
What occurs during the proliferative phase of wound healing? How long does it last?
Days-Weeks
–> Fibroblast proliferation & Collagen synthesis
–> ECM reorganization
–> Angiogenesis, granulation tissue formation, epithelialization
What occurs during the remodeling phase of wound healing? How long does it last?
Weeks-months
–> Remodeling, continued epithelialization
–> ECM remodeling
–> Increased tensile strength of wound
At what point should the surrounding tissue of a surgical cease to be inflamed?
Days 5-6
What is the timeline for progression of surgical incision drainage?
Days 1-4
–> Sero-sanguineous of small to moderate amount
Days 5-9
–> Scant serous
Should be absent by day 10-14
What is the timeline for closure material and drains of surgical wounds?
They can begin to be removed around days 4-9.
By day 10-14 they’re removed and replaced by Steristrips, protective cover, or binders
What is the timeline progression of a healing ridge?
Should be present by day 9.
The Braden scale considers what factors?
Sensory perception, moisture, activity, mobility, nutritional status, and friction/shear risk
–> High scores indicate lower risk (severe risk is less than 9)
Why might an ABPI be falsely elevated?
In those with diabetes and renal failure d/t calcification of blood vessels.
What is the gold standard treatment for venous leg ulcers?
Compression
–> only if adequate perfusion
Avoid in Pts with untreated organ failure, DVT, untreated wound infections or other unsafe factors
What is best practice for taking a wound culture?
Cleans wound thoroughly first and then obtain sample using Levine technique
Cultures are different than screening swabs, they are used to determine the type of microorganism, not for diagnosis of infection. Cultures are only useful when obtained from tissue fluid (not purulent drainage)
What are the different kinds of debridement?
Sharp, mechanical, autolytic, enzymatic, biological
What is mechanical debridement? Why is it a short term strategy?
Uses wet to dry saline gauze dressing to remove slough.
–> Can be very painful, must be done frequently and is cost effective
What is autolytic debridement? When is it not recommended?
Helps to trigger the body’s proteolytic, fibrinolytic, and collagenolytic enzymes to digest devitalized tissue
–> Not recommended for infected wounds or those with large amount of necrotic tissue, significant tunneling or undermining
–> Not recommended for pts who are immunocompromised
What is enzymatic debridement? When is it contraindicated?
Uses Collagenase Santyl to digest collagen in dead tissue - ointment available by prescription in Canada
–> Avoid using with silver or iodine dressings that can inactivate the collagenated
Indicated with bleeding is a concern with sharp debridement
What is biological debridement? What should we be aware of when using it?
Use of living organisms to debride wound - can be expensive, but painless and fast
–> Protect healthy skin because larvae secrete enzymes that can cause damage
Acute wounds close in approximately 3 days. What should be a concern when a wound stalls?
Rule out infection
The probability of a wound infection occurring are based on which factors?
(Number of organisms x virulence) / Host resistance
Clinical manifestations of wound infections often reflect the host’s response to invasion and tissue injury except…
In patient with chronic wounds or if immunocompromised
Classic signs may be absent in those who use steroids or have DM too.
What are the five classic signs of inflammation?
Erythema, pain, warmth, swelling, and impaired function
What are the steps of the IWII Wound Infection Continuum?
- Contamination
- Colonization
- Local Wound Infection (may be covert or overt)
- Spreading infection
- Systemic Infection
What are the signs of a covert local wound infection?
Hypergranulation, friable tissue, epithelial bridging and pocketing in granulation tissue, increasing exudate or bleeding
Delayed healing beyond expectations
The ideal antimicrobial agent has which qualities?
It penetrates the tissue or eschar, is broad spectrum, and does not interfere with wound healing.
It should have minimal systemic absorption and toxicity
What are different kinds of antimicrobial agents used for wounds?
Iodine, silver, Medical grade honey, PHMB, Gentian Violet/Methylene Blue
With whom should be use iodine as an antimicrobial agent with caution? With whom should we avoid it entirely? What is appropriate dosing?
Use caution in those with thyroid disease and avoid in those who are pregnant/breastfeeding
–> Each application should not exceed 50g and should be no more than 150g/week.
When are iodine solutions indicated? When should they be changed?
Have broad spectrum activity and address chronic biofilms
–> Change from orange/brown to white is change is needed
Which antibacterial agent is effective against 150 pathogens including MRSA and VRE?
What should you avoid with this dressing? When is it indicated?
Silvercel
–> Has hemostatic properties and absorbs moderate to large amounts of exudate
Avoid packing tunnels or undermining with minimal drainage and do not premoisten
Aquacel Extra AG is also useful against yeast - but should not be packed or put in tunnelling wounds
Which antimicrobial is useful against Gram +/-, MRSA, VRE and pseudomonas?
What else is it useful for?
PHMB dressings
–> Useful for deep and tunnelling wounds
What can be used as a primary absorbent dressing?
Alginates: Silvercel, Biatain
Hydrofibers: Aquacel AG
Nonadherent foams: Allevyn
What can be used as a secondary absorbent dressing?
Foam and composite dressings: Tegaderm foam adhesive, aquacel foam, allevyn
What should we put on a a stage 1 pressure injury?
Leave open to air, or use a liquid or film
What should you put on a stage 2 pressure injury?
Foams, thin hydrocolloids, absorbent films, zinc oxide paste for difficult to dress areas
When is a hydrogel indicated? When should we use caution?
When a wound is excessively dry, use caution in wounds with infection.
What kind of dressing should be used for excessively moist wounds?
Hypertonic or alginate dressings, secondary highly absorbent dressings may also be beneficial
What are indications, precautions, and contraindications for NPWT?
Indications
–> Reduces edema, promotes granulation tissue and perfusion, removed exudate and infectious material
Precautions
–> Enteric fistulas, spinal cord injury, anticoagulation, and concern for damaged BVs.
Contraindications
–> Unresolved bleeding, untreated osteomyelitis, necrotic tissue with eschar, exposed organs or vessels, malignancy
Which dressings can reduce protease levels in chronic wounds and help repair tissue and rebuild ECM?
Collagen dressings.
What kind of debridement are hydrogels and hydrocolloids? When are they used?
Autolytic
–> Autolytic is used to soften dry eschar. Used in non-infected wounds with necrotic tissue and adequate circulation
When is enzymatic debridement used?
What pH must it be used under?
Used for necrotic tissue, pH must be between 6-8 and silver/iodine dressing should not be used in conjunction to prevent inactivation of enzymes
How can electrical stimulation be used to promote wound healing?
Can be used in conjunction with regular wound care to promote closure in stalled stage 2,3,4 pressure injuries that do not respond to other interventions.
During which phase of healing is a wound resistant to infection? Why?
Granulation Phase (part of proliferative phase)
–> Protective functions of granulation tissue
