*PTA 200- Wound Management Objectives Flashcards
Discuss wound prevention
Prevention includes:
- repositioning every 2 hours
- pressure reduction with positioning or cushions (example: roho pillow)
- shifting weight
- lifting devices
- pillows
- head of bed elevation. (30 degrees for tube feeds, but never at 45 degrees)
Prevention also includes skin care and early treatment of skin:
- inspection of skin
- bathing
- incontinence
- moisturization
Discuss factors that contribute to a patient’s risk of developing a wound
- Malnutrition
- Immobility
- Chronic Illness
- Advanced age
- Incontinence
- Altered Mental Status
- Diminished Sensation
Why is wound prevention a multidisciplinary team effort?
Prevention is a multidisciplinary team effort because it is part of best practices. The collective wisdom of the team results in shorter wound healing times, a lower rate of wound related complications, and fewer amputations.
Describe an abrasion wound:
a wound caused by rubbing or scraping the skin or mucous membrane. Examples; road rash, skinned knee, scrapes, carpet burns.
Describe a puncture wound:
a wound caused by a pointed object or instrument. Examples; stab wounds, gunshot wounds, bites.
Describe a laceration wound:
a cut; a wound produced by the tearing of body tissue.
Describe a burn:
caused when the skin contacts dry heat (fire), moist heat (steam), chemicals, electricity, or radiation. Burns are classified according to their depth and size. (superficial, partial thickness, full-thickness).
Describe an incision and explain what kind of surface area is created by an incisional wound.
a cut made by a sharp instrument such as a scalpel.
The surface area will be really small and will be approximated. It will heal by primary intention.
Describe interventions for pressure ulcers
-prevention is the best intervention for pressure ulcers.
The five steps in pressure ulcer prevention includes:
- Education
- Positioning
- Mobility
- Nutrition
- Management of incontinence
Pressure Ulcer Prevention mnemonics; NO ULCERS, SKIN
N-nutrition and fluid status
O- observation of skin
U-up and walking or assist with position changes. L- lift don't drag C-clean skin and continence care E- elevate heels R- risk assessment S- support surfaces
S-surface selection
K-Keep turning
I- incontinence management
N-nutrition
Interventions for Vascular Insufficiency- venous ulcers
- Initiate healthcare team with patient to address co-morbidities
- Educate patient and caregiver
- wound etiology
- intervention strategies
- risk factor modification
- guidelines for patients with venous insufficiency ulcers. - Treat Cause
- Apply compression if appropriate
- instruct patients in methods to decrease edema - Treat Wound
-Inflammation Control- use topical steroids to decrease inflammation or weeping.
-Infection Control- choose absorptive dressings
and use skin sealants.
-Debridement - Treat Periwound
- moisturize dry, scaling skin
- infection control
- absorb drainage
- debridement
Interventions for vascular insufficiency; arterial ulcers
- Protect Surrounding Skin
- moisturize dry skin
- avoid adhesives
- reduce friction between toes
- provide padding to protect ischemic toes - Address wound bed
- choose dressings to moisten wound bed
- debride necrotic tissue if appropriate - Maximize circulation
- avoid compression
- choose footwear to accommodate for bandages and decrease stress to wound. - Educate patient/caregivers
- wound etiology
- intervention strategies
- risk factor modification
- foot care guidelines
Foot care guidelines for patients with arterial ulcers
- Protect your feet and legs from:
- trauma-inspect your feet, wash and dry carefully, trim nails straight across
- chemicals-do not use home remedies
- excessive heat and cold-do not use heating pads, soak feet in hot water, use heavy socks to protect against the cold.
- any open wounds- wear bandages, do not put pressure on open areas when walking. - Live Healthy
- eat a balanced diet
- exercise regularly
- if you smoke, quit
- control medical conditions such as diabetes
Correctly measure a wound and document in objective in a SOAP format
- Length x width as linear distances from wound edge to wound edge and then multiplied for surface area in one of two ways: Clock method - head being 12 o’clock and landmarks would be defined and the corresponding widest and longest areas of the wound is measured and then surface area is calculated.
- Depth - Depth of the wound can be described as the distance from the visible surface to the deepest point in the wound. If the depth varies, you would want to record the deepest site, so you may have to take multiple measurements.Typically, a sterile, cotton-tipped applicator (6”) is used. The applicator is inserted gently into the deepest portion of the wound. The thumb and forefinger grasp the applicator at the point corresponding to the skin surface.
- Tunneling and/or undermining (how deep and time)
- Color
- Slough (% of surface area)
- Any structures such as bone - measure l x w and which bone
- Odor
- Pain if present
- Periwound area (color, epiboly, etc.) (use clock method ex. 3-6 o’clock)
- Drainage- amount, color and consistency (serous-clear, watery plasma, sanguinous- bloody, sero-sanguinous- plasma and red blood cells, purulent- thick, white blood cells may be yellow, green or brown, if infected)
- Which stage (if pressure ulcer) or thickness
- Edema (only if present)
- Maceration (if present)
- Location
Demonstrate the correct application and safe removal of the following dressings on your lab partner’s arm: a dry to dry dressing on an 1 inch imaginary incision area and a semipermeable film dressing to an imaginary ½ inch long superficial skin tear.
Clean skin with “skin prep”, use clean method, make “window pane” with tape, slowly pull tape off to remove or to remove film pull toward you.
When shown a wound picture, identify wound characteristics including but not limited to color, type, stage, infection and etiology.
Color: red, yellow, black, pink, gray, white, etc.
Stage: I, II, III, and VI
Thickness: Superficial, Partial, and Full Thickness
Infection: Necrosis, eschar tissue present
Etiology: Venous insufficiency, DM, burn, poor skin integrity, pressure, etc.
Practice identifying pictures from BB
When shown a wound picture, identify wound characteristics including but not limited to color, type, stage, infection and etiology.
Type: Granular- a collagen matrix which contains different types of cells that contribute to wound healing, such as: endothelial cells, fibroblasts, lymphocytes, platelets, and epidermal cells. This tissue has a red, beefy, shiny, granular appearance.
- Necrotic eschar- a slough produced by gangrene.
- Exudate- a fluid with a high content of protein and cellular debris which has escaped from blood vessels and has been deposited in tissues or on tissue surfaces, usually as a result of inflammation.
- Epithelial tissue- Re-establishment of an epidermis on top of the granulation tissue; epithelial margins will begin to migrate toward the center of the wound; This process is sometimes referred to as a “contraction” of the wound… where the surface area of the wound reduces in size. When epithelialization is complete, a scar results.
- Slough- necrotic fatty tissue in the process of being separated from viable portions of the body.
- Maceration- a term used for moisture saturated skin, usually in the periwound area.
discuss the requirements of and demonstrate the creation of a sterile field.
The field is designed to maintain the sterility of objects contained within the field, such as dressings or bandages, and to prevent contamination of the objects.
- Contamination occurs when any time a sterile item physically contacts a nonsterile item.
- Do not talk, sneeze, or reach across a sterile field
- Do not turn your back to the field
- Do not leave the field unattended
- A 1-inch border along the edges of the field is considered to be nonsterile
- The gloves, front of the gown above waist level, and both sleeves of the gown are the only portions of your protective clothing that are considered sterile.
- Position the items on the field so the items to be used first are nearest you.
- The area below the surface of the sterile field are considered nonsterile.
discuss the requirements of and demonstrate the creation of a clean field.
Preventing the spread of pathogenic microorganisms
- Wash hands
- Utilize gloves, gown, and mask when indicated
- Use clean equipment
- Handling linens in ways that prevent germs from spreading
Discuss the considerations for choosing a dressing, dressing size, various modes of securing wound dressings and precautions regarding tape use at a would site.
Choosing a dressing-
Protection: prevent additional wound contamination, keep microorganisms in the wound from infecting other sites, prevent from further injury, and provide a “barrier”to the outside environment.
Absorption of wound drainage (necrotic tissues, blood, etc.)
Moisture retention
Mechanical debridement (non-specific)
Dressing size- Needs to be at least 2” around wound
Modes of securing wound dressing- tape and secondary dressings holding primary dressing in place.
Tape precautions- injuries and allergies. When securing the dressing, care should be taken to avoid additional insult to the skin from the tape or adhesive. You need to be aware that tape should be applied without excessive pulling or tension; and also ASSESS THE AREA UNDER AND AROUND THE TAPE FOR ANY ALLERGIC REACTION. Paper tape is best.
Identify primary and secondary dressings and suggest appropriate dressing(s) when given a wound example.
Primary dressing: next to wound
Secondary dressing: often serve to hold primary dressing in place
Stage I- (re-positioning)
Stage II- Hydrocolloid
Stage III- Calcium alginate
Stage IV- gauze or calcium alginate
Skin tear- semipermeable film or impregnated (vaseline) gauze and roll gauze (as secondary dressing) (if skin integrity is in question)
Neuropathic/Diabetic ulcer- hydrogel with secondary gauze
Arterial ulcer- hydrogel with secondary gauze
Venous ulcer- semipermeable foam or calcium alginate with short stretch bandage
Red wound- collagen wound bandage
Identify the various topical solutions used in conjunction with dressings.
Sterile Saline Solution: frequently used in the irrigation of wounds; doesn’t sterilize or disinfect or harm, just moistens. It is commonly used with gauze dressings. (Not considered a topical agent but included here for convenience.)
Povidone-Iodine Solution (Betadine): Antimicrobial, used on necrotic tissue, some sources say that this product has really lost it’s value that it once had claimed.
Sodium Hypochlorite Solution (Household Bleach): Used as an antimicrobial agent in controlling sepsis; used in whirlpool baths in a .25 percent to .5 percent solution. Can be cytotoxic if not properly diluted.
Chloramine-T (Chlorazene) Less irritating than sodium hypochlorite. Chlorazene products are available pre-packaged for use in specific-sized whirlpool tanks.
Dakin’s Solution Mixture of sodium hypochlorite and boric acid. (Clorox and baking soda) This solution is bactericidal. Should never be used more than 1 week and some sources say 4 days. Dakins can cause maceration. For wounds w/ excessive slough.
Acetic Acid Solution
Neosporin Ointment, Silvadene, and Furacin
Hydrogen Peroxide: Because of it’s effervescent action, H2O2 is a mechanical cleansing agent and a non-specific debriding agent.
Hydrogen peroxide has little bactericidal actions, but it may be helpful to loosen dried exudate or debris on a superficial wound surface/approximated wound incision. It shouldn’t be applied to “clean wounds” because it may destroy granulation tissue. Also, it should never be “poured” into wound tunnels, because of the gas build-up potentially causing an air embolus.
Describe intervention for diabetes/neuropathy ulcers
As with other ulcers, neuropathic ulcer treatment consists of coordination, communication, and documentation of patient/client related instruction and individual procedural interventions.
Interventions might include:
- patients must be throughly informed of the disease process and medical management of diabetes.
- pt must be educated in proper shoe wear and foot care guidelines.
- local wound care; daily application of petrolatum-based moisturizer to feet
- modalities such as negative pressure wound therapy, ultrasound, and e-stim, as well as growth factors (oasis), may be useful for wounds that are slow to heal.
- total contact casting is efficient for treating grades 1 and 2 for neuropathic ulcers. Total contact casts are essentially modified short leg casts.
- patients with fragile skin may benefit from a walking splint.
- patients not meeting criteria for total contact casting may benefit from a padded ankle-foot orthoses or walking shoes.
- therapeutic exercise- gait and mobility training. Patients should be taught how to ambulate by using a non-weight bearing pattern to eliminate continued trauma to the affected area. More commonly pt is taught partial weight bearing due to lack of strength/endurance.
- range of motion exercises- specifically targeting great toe extension, talocrural dorsiflexion and subtalar joint motions.
- temporary inserts for shoes made of felt or foam can be customized to unweight ulcerated areas and better distribute forces over surfaces of the foot.
Describe and discuss wound classification by thickness
Classification by thickness- designed for use with wounds whose primary cause is something other than pressure. This is typically the classification system for burns, skin tears, lacerations, surgical wounds, and vascular ulcers. (superficial, partial, full)
Classification by thickness-
superficial- into only the dermis
partial-wounds extends through the first layer of skin (epidermis) and into, but not through the second layer (dermis)
full- extend through the epidermis and dermis, and may involve subcutaneous tissue, muscle, and possibly bone. (grafting/flaps are necessary).