Patient with Wounds

Question 1

What factors affect wound healing?

Answer 1

Age
Loss of skin turgor
Skin fragility
Decreased circulation and oxygenation
Slower tissue regeneration
Decreased nutrient absorption
Decreased collagen
Impaired immune function
Dehydration
Decreased WBC --> increased risk of infection
Low Hgb
Smoking
Obesity
Chronic disease
Malnutrition
Medications (Chemo/ anti-inflammatory/ steroids)

Question 2

What does inflammation of a wound serve?

Answer 2

Localized protective response to injury or destruction of tissue

Question 3

3 components of management of wounds

Answer 3

Assessment
Cleansing
Protection

Question 4

What do you look for when you assess a wound?

Answer 4

Appearance –> red (healthy regeneration), yellow (purulent), black (eschar)?
Length, width, depth (cm) –>sinus tracts, tunnels, redness/swelling around? (Chart by using clock positions to describe location)
Closed wounds –> edges well approximated? Note number of staples and sutures, tissue adhesives
Drains/tubes present
Pain around incision

Question 5

What should you include documenting wound drainage?

Answer 5

Amount of drainage
Odor
Consistency
Color of drainage from drain or dressing

Question 6

What should you look for when you clean wound drainage?

Answer 6

Observe skin around drain for irritation or skin breakdown

Question 7

How do you find out how much drainage there is?

Answer 7

Weigh the dressing (1g = 1mL of drainage)

However, often just describe as scant, moderate, large, or copious

Question 8

On a dressing you note watery yellowish clear drainage. What kind of exudate is this called?

Answer 8

Serous

Question 9

What does serosanguinous exudate look like?

Answer 9

Contains serum and blood —> watery pale/pink

Question 10

What does darker sanguineous blood indicate?

Answer 10

Older bleeding

Question 11

What does brighter sanguineous blood indicate?

Answer 11

Active bleeding

Question 12

What does purulent exudate indicate? What does it look like?

Answer 12

Infection —> thick, contains WBCs, tissue debris, and bacteria
Yellow, tan, green, brown —> depends on organism present

Question 13

What are interventions for patient’s with wounds is important to promote healing?

Answer 13

Adequate hydration and nutrition (without adequate nutrition a wound will not heal!)
High protein, CHO, vitamins with moderate fat intake

Question 14

What are wet to dry wound dressings used for?

Answer 14

Mechanically debride a wound until granulation tissue begins to form

Question 15

What does hydrocolloid wound dressings do?

Answer 15

Occlusive dressing that swells when exposed to exudate

Question 16

What are hydrogel wound dressings used for?

Answer 16

Gels after contact with exudate —> promotes autolytic debridement, rehydrates and fills dead space
For deep wounds, infected, or necrotic tissue

Question 17

What are hydrogel wound dressings not used for?

Answer 17

Wounds with a lot of exudate

Question 18

What is an alginate dressing?

Answer 18

Non-adherent dressing that conform to the shape of the wound and absorbed exudate

Question 19

Why use a hydrogel wound dressing?

Answer 19

Moist wound bed and reduces pain

Prevents skin breakdown in high pressure area

Question 20

How does wound vacs help wound healing?

Answer 20

Helps with tissue regeneration, decrease swelling, and enhance healing in moist, protective environment

Question 21

What are some complications of wound healing?

Answer 21

Adhesions, contractions, hemorrhage, dehiscence, evisceration, fistula formation, infection, excessive granulation tissue, keloid formation

Question 22

When is hemorrhage is at greatest risk of occurring for surgical wounds?

Answer 22

24-48 hrs after surgery/injury

Question 23

What can cause surgical wound hemorrhage complications?

Answer 23

Slipped suture
Clot dislodgment
Blood vessel damage

Question 24

What are some signs and symptoms of internal bleeding?

Answer 24

Swelling, distention in area and may cause sanguineous drainage and initial subtle changes in VS

Question 25

What should you do if a patient starts to hemorrhage?

Answer 25

Can be an emergency —> pressure dressing, notify HCP, and monitor VS

Question 26

What is a surgical wound dehiscence?

Answer 26

Partial or total separation of a sutured wound (usually with separation of underlying skin layers)

Question 27

What are the clinical manifestations of evisceration?

Answer 27

Significant increase serosanguineous fluid from wound dressing
Immediate hx of sudden straining
Patient reports sudden change or “popping” or “giving away” in wound area
Viscera are visible

Question 28

Risk factors of evisceration and dehiscence

Answer 28

Chronic disease
Old age
Obesity
Invasive abdominal cancer
Vomiting
Excessive sneezing/coughing/straining
Dehydration and malnutrition
Ineffective suturing
Abdominal surgery 
Infection

Question 29

Evisceration or dehiscence occurs, what should you do?

Answer 29

Contact HCP —> surgical intervention needed
Stay with the patient
Cover wound and organs, if applicable, with sterile towels/dressings soaked with sterile NS
Position patient supine with hips and knees bent
Keep patient NPO —> return to surgery

Question 30

Risk factors for infection of surgical wounds

Answer 30

Age extremes, immune suppression, impaired circulation/ oxygenation, wound condition and nature, poor wound care, malnutrition, chronic disease

Question 31

When does manifestations of surgical wound infections usually occur?

Answer 31

2-11 days after surgery

Question 32

How does a surgical wound infection present?

Answer 32

Pain, fever and chills, 
Redness, edema, purulent drainage around the wound
Odor
Increased pulse and respiratory rate
Increased WBC

Question 33

What are some interventions to prevent surgical wound infections?

Answer 33

Aseptic technique during dressing changes
Adequate nutrition
Rest
If infection occurs —> administer antibiotic therapy after C&S results