Patient with Wounds Flashcards
What factors affect wound healing?
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)
What does inflammation of a wound serve?
Localized protective response to injury or destruction of tissue
3 components of management of wounds
Assessment
Cleansing
Protection
What do you look for when you assess a wound?
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
What should you include documenting wound drainage?
Amount of drainage
Odor
Consistency
Color of drainage from drain or dressing
What should you look for when you clean wound drainage?
Observe skin around drain for irritation or skin breakdown
How do you find out how much drainage there is?
Weigh the dressing (1g = 1mL of drainage)
However, often just describe as scant, moderate, large, or copious
On a dressing you note watery yellowish clear drainage. What kind of exudate is this called?
Serous
What does serosanguinous exudate look like?
Contains serum and blood —> watery pale/pink
What does darker sanguineous blood indicate?
Older bleeding
What does brighter sanguineous blood indicate?
Active bleeding
What does purulent exudate indicate? What does it look like?
Infection —> thick, contains WBCs, tissue debris, and bacteria
Yellow, tan, green, brown —> depends on organism present
What are interventions for patient’s with wounds is important to promote healing?
Adequate hydration and nutrition (without adequate nutrition a wound will not heal!)
High protein, CHO, vitamins with moderate fat intake
What are wet to dry wound dressings used for?
Mechanically debride a wound until granulation tissue begins to form
What does hydrocolloid wound dressings do?
Occlusive dressing that swells when exposed to exudate
What are hydrogel wound dressings used for?
Gels after contact with exudate —> promotes autolytic debridement, rehydrates and fills dead space
For deep wounds, infected, or necrotic tissue
What are hydrogel wound dressings not used for?
Wounds with a lot of exudate
What is an alginate dressing?
Non-adherent dressing that conform to the shape of the wound and absorbed exudate
Why use a hydrogel wound dressing?
Moist wound bed and reduces pain
Prevents skin breakdown in high pressure area
How does wound vacs help wound healing?
Helps with tissue regeneration, decrease swelling, and enhance healing in moist, protective environment
What are some complications of wound healing?
Adhesions, contractions, hemorrhage, dehiscence, evisceration, fistula formation, infection, excessive granulation tissue, keloid formation
When is hemorrhage is at greatest risk of occurring for surgical wounds?
24-48 hrs after surgery/injury
What can cause surgical wound hemorrhage complications?
Slipped suture
Clot dislodgment
Blood vessel damage
What are some signs and symptoms of internal bleeding?
Swelling, distention in area and may cause sanguineous drainage and initial subtle changes in VS
What should you do if a patient starts to hemorrhage?
Can be an emergency —> pressure dressing, notify HCP, and monitor VS
What is a surgical wound dehiscence?
Partial or total separation of a sutured wound (usually with separation of underlying skin layers)
What are the clinical manifestations of evisceration?
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
Risk factors of evisceration and dehiscence
Chronic disease Old age Obesity Invasive abdominal cancer Vomiting Excessive sneezing/coughing/straining Dehydration and malnutrition Ineffective suturing Abdominal surgery Infection
Evisceration or dehiscence occurs, what should you do?
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
Risk factors for infection of surgical wounds
Age extremes, immune suppression, impaired circulation/ oxygenation, wound condition and nature, poor wound care, malnutrition, chronic disease
When does manifestations of surgical wound infections usually occur?
2-11 days after surgery
How does a surgical wound infection present?
Pain, fever and chills, Redness, edema, purulent drainage around the wound Odor Increased pulse and respiratory rate Increased WBC
What are some interventions to prevent surgical wound infections?
Aseptic technique during dressing changes
Adequate nutrition
Rest
If infection occurs —> administer antibiotic therapy after C&S results
