Module 7: Advanced Wound Care Flashcards
1
Q
recall principles of sterile technique
A
- absence of microorganisms
- sterile to sterile equipment only to maintain sterility
- used in hospital in comparative to community
- only sterile objects may be placed on a sterile field
- a sterile object of field out of the range of vision or an object below a person’s waist is contaminated
- when a sterile surface comes in contact with a wet contaminated surface the sterile object or field becomes contaminated
- a sterile object or field becomes contaminated by prolonged exposure to air
- fluid flows in the direct of gravity
- the edge of a sterile field or container is considered to be contaminated
- recognize contamination and correct it
2
Q
primary intention
A
- wound is clean with straight edges as in surgical incision
- edges can be approximated with sutures , staples or tape
- healing is rapid and primarily by collagen synthesis
- scar is usually thin and flat
3
Q
Secondary intention
A
- wound is large and irregular with considerable tissue loss, as in pressure ulcer or deep abrasion
- healing evolved inflammation , filling with granulation tissues and epithelialization
- scar is usually large and pronounced
4
Q
Tertiary Intention
A
- wound is left open because of possible contamination of debris
- healing involves some granulation tissue and increase inflammation and risk of infection
- edges are approximated well as possible with sutures once wound is clean
- scar varies with wound
5
Q
Phases of Wound healing
A
- inflammatory phase
- incision to post op (2 days)
- hemostasis, phagocytosis
- mild redness, swelling - Proliferative phase
- day 3 - 14-21
- collagen strengthen wound, produces scar tissue, granulation tissues is highly vascular
- wound bed whitish, then translucent, red/friable, raised healing ridge on sutured wound
- Maturation Phase- Early
- 2-3 to 6 weeks
- collagen reorganize into more orderly structure
- raised scare formation
- Later Maturation phase
- 6 weeks to 2 years
- scare tissue has <80% of original tissue strength
- flat, thin scar
6
Q
Review common wound dressing materials
A
- Gauze
- woven
- useful for packing
- non woven
- non adherent e.g. Tefla
- woven
- Transparent Film dressings
- self adhesive, occlusive
- trap moisture
- small superficial wounds
- Non-adherant Contact
- protects granulation tissue
- allows moisture to evaporate
- Soft Silicone
- removed without trauma to wound or peri-wound
- decreases pain
- Hydrocolloid
- maintains wound bed moisture
- adhesive and occlusive
- can be left in place 5-7 days
- preventive dressing for high friction area
- Hydrogel
- give moisture to wound bed
- absorbs small amount of exudate
- soothing
- softens necrotic tissue
- Foam
- non-adhesive
- left intact for up to 7 days
- useful for large amounts of drainage or autolytic debridement
7
Q
Topical treatment for infected wounds
A
> hypertonic
- contains sodium to pull out ISF
- decreases edema to improve blood flow
cadexomer iodine
- iodine targets bacteria; controlled release
silver
- antimicrobial effects (including MRSA, VRE)
Honey
- antimicrobial
- changes pH to create negative environment for proliferation of bacteria
Negative wound pressure
- uses localized negative pressure to bottom and edges of wound
- speeds heeling
8
Q
Vacuum Assisted closure
A
- negative pressure wound therapy
- for acute and traumatic wounds, pressure ulcers, chronic open wounds burns
- cannot be used with bleeding disorders, infections , malignancies or fistulas
- foam cover by occlusive dressing, with a suction tube attached
- dressing are done every 2-3 days or longer as prn
9
Q
Describe key components of wound assessment, including wounds with drains
A
- wound assessment
- drainage
- wound bed - colour, type, percentage of tissue present
- wound edges
- measurement length x width x depth
- location
- peri wound
- Redness can indicate infection, reaction to skin closures, dressing, tape
- nursing action: circle red area, monitor temperature ad WBC count. Change dressing material/tape, leave exposed if not draining
- Ecchymosis can indicate bruising during or after surgery, coagulopathy
- nursing action: monitor colour, size and tenderness. monitor temperature and abc count and monitor blood work, CBC and coagulation factors
- Edema can indicate infection
- monitor size, monitor temperature and WBC count
- Drainage and gapping of skin (poor approximation) can indicate infection
- monitor type and amount of drainage, monitor temperature, and wbc counts and send for C&S, notify physician
10
Q
Explain the rationale for choice of dressing materials and choice of method for dressing wounds
A
- what is the type of wound to be dressed?
- surgical incision, dehisced incision, laceration, abrasion, ostomy or fistula
- what is the goal for the dressing?
- exudate management, protection, debridement, curative or chronic management
- Wet to dry
- mechanical wound debridement
- disrupts wound bed, pulls healthy granulation tissue with non-viable tissue
- Wet to moist
- frequent dressing changes
- cools wound bed
- disrupts granulation tissue
- frequent dressing changes
11
Q
Identify appropriate wound cleansing solutions and describe steps of wound cleansing
A
- least contaminated to most
- gentle friction to peri-wound
- avoid abrading the wound bed with gauze
12
Q
Describe the steps of wound irrigation and packing of a wound
A
- packing is instilled in a wound via sterile technique to allow the wound to heal from the bottom up
- granulation tissue forms in the wound bed and is red and beefy in appearance healing by secondary or tertiary intention
- absorbs drainage so that an abscess doesn’t form in deep wound while it heals
- wet to damp technique
- wound irrigation
- washing or flushing out the wound using sterile technique
- preparation
- reviews dr order
- review previous wound/dressing documentation
- assess pain
- administer analgesia 30 min prior to procedure if needed
- gather supplies
- solutions used
- normale saline
- antibiotic solutions (sometimes)
- do not use skin cleansers or antiseptic agents unless ordered
- install a steady stream of solution - usually 100-150 ml - irrigate until solution is clear
- use a pressure of 4-15 psi with a 30-60 ml syringe
- hold syringe above wound
13
Q
Penrose Drain
A
- simplest type of drain, soft open tube
- used for thicker drainage
- drainage absorbed into outer dressings
- may or may not be sutured
- sterile safety pin is placed to repent slippage back into wound
- shortened as per physicians orders
14
Q
jackson-pratt Drain
A
- used in a variety of surgeries
- placed in a separate puncture site or at the edge of the surgical wound
- fenestrated tubing attached to a bulb-shaped reservoir container
- bulb is compressed and closed to create negative pressure
- sutured in place
- small volume (100ml)
15
Q
Hemovac
A
- perforated (fenestrated) tubing connected to portable vacuum unit (spring activated)
- compress and close to create negative pressure
- larger volume (400ml)
- used for abdominal and orthopaedic surgeries
