Surgical Wounds Flashcards
Describe a clean/ contaminated wound
Surgical wounds of the genitourinary, respiratory or alimentary/oropharengeal cavity. Contaminated by resident flora. No reaction by host
Describe a clean wound
Wounds made under aseptic surgical aseptic technique. No clinical signs of infection. Don’t enter genito urinary, respiratory or alimentary tracts/ oropharengeal cavity
Describe a contaminated wound
Contaminated by bacteria. Honest reaction. No pus.
Describe an infected wound
Clinical signs of infection (pain, heat,swelling,redness,^exudate). Increased leukocyte and macrophages. Chronic wound infection signs.
List the signs of a chronic wound infection
New or increased pain. Delayed healing. Friable, bright red hyper granulation. Pocketing/irregular deposition of granulation tissue, bridging tissue. Malodour and ^exudate.
List the surgical methods for primary wound healing
Sutures, staples, surgical tape, tissue glue (histacryl)
List the surgical wound healing methods for delayed primary intention
Suture after 3-10 days
What are the two types of natural sutures?
Absorbable and non-absorbable
Describe the two types of Natural absorbable sutures
Natural - purified collagen.
Catgut (plain or chromic)
- plain: rapidly absorbed, tensile strength, lasts 7-10 days.
-chromic: treated with chromium salt solution to resist enzymes, last 10-14 days.
Describe Non-absorbable sutures
Silk
Linen
Stainless steel
What are the four types of synthetic sutures?
Absorbable e.g. polyglycolic acid, polyglactin
Non absorbable e.g. Polyamide,polyester,polypropylene
Vicryl e.g. Tensile strength 65@14days ,40%@21 days10%35days
Poly dioxane e.g. Tensile strength 70%@14days,50%@28days. Absorption complete by 180 days.
Name the four types of suture techniques
Simple square, interrupted sutures, mattress sutures, continuous sub cuticular sutures and tension sutures
Describe simple square interrupted sutures
Inserted 1cm apart and 1cm across
Describe mattress sutures
Less pressure/tension on wound opening.
Vertical: in,under wound, out other side, then in,back across, out, knotted.
Horizontal: same as above, only sit parallel with incision line
Describe continuous subcuticular suture
One piece of suture. Start by going into SC inside wound, come up , leave a stitch, go into skin, across other side, repeat
Describe tension sutures
Inserted into deep tissue, provide additional support, nylon sutures covered with polyurethane cove to prevent cutting into skin.
Describe wound closure strips
Adhesive strips. Eg. Steri strips or leukocyte-strips
What are the principles for wound healing by primary intention?
Protect the wound from physical or pathogenic assault Absorb exudate Maintain wound temperature Maintain body temperature Oxygenation Avoid stress-pain relief Observe suture line for complications
What can you use to dress a suture line?
Keep dressing on for 24-48 hours (unless there is a drain ) Dry low-adherent dressings Island dressings Semi permeable film Hydro colloid Foam
What are the indications for a drainage tube
Abscesses cavity-prevent premature closure
Insecure intra abdo wound- compromised healing, malnourished
Anticipated exudate
Risk of peritonitis -bowel, gastric, biliary
Extensive dissection- large collections
Traumatic injury- to drain contaminants
List the 3 types of drains
Capillary wicking:Penrose, corrugated,ported
Attached negative pressure suction devices: redivac, Jackson Pratt, sump,axiom
Percutaneous: biliary, nephrostomy
What are the indications for percutaneous tubes?
Gastrostomy - feeding or decompression Jejunostomy- feeding Nephrostomy - draining urine Supra public catheter -draining urine Biliary-draining bile
Describe peri tubular skin care
Keep skin clean and dry
Peri tubular leakage -indicates width of tube is too small for fistula track
Hypergranulation around tubes indicates friction - secure tube
What is a Biliary T-Tube?
Inserted into the biliary track to drain bile following a cholecystectomy.
What are the principles of drain management?
Client/carer support and education Secure drain Maintain patency Maintain skin integrity Contain exudate Observe type and amount of exudate Prevent infection Observe for complications -infection,discomfort, dislodgement,blocksge. If on -ve pressure -loss of suction, loss of skin integrity
List the types of surgical wound complications
Haemorrhage- primary or secondary Haematoma Seroma Oedema Infection Occlusion blood supply- necrosis Dehiscence / evisceration Adhesions
What is the aetiology of dehiscence?
Heamatoma, seroma,infection, trauma
What is a sinus?
A track or opening into tissues
What is a fistula?
An abnormal track connecting one viscus to another viscus or to the skin surface
What is the aetiology of a fistula?
Leaking surgical anastomoses ,
Spontaneous rupture due to obstruction, disease, trauma or radiotherapy.
Mesenteric ischaemia
Sepsis - diverticulitis & appendicitis
What are the two types of fistula classifications?
Internal fistula - vesicovaginal,enterocolonic,rectovagal
External fistula - enterocutaneous, buccal,vesciocutaneous
What are the principles for fistula management?
Patient comfort and support, fluid and electrolyte replacement, nutritional assessment and supplementation
, prevention and management of infection, maintenance of skin integrity, containment of effluent and odour, cost-effective care.
Describe medication management for fistula’s?
Anti-motility agents e.g. Loperamide, lomotil, opioids.
Cholestyramine e.g. If fistula’s in the duodenum or proximal jejunum and if excess bile salts in the intestine.
Somastatin analogues- enhances fluid and electrolyte absorption.
1t and 2t sugar solution
What is an evisceration of the abdomen?
Spontaneous rupture of the abdominal suture line and intestines protrude through the opening
What are the types of aberrant healing?
Hypergranulation, contracture, hypertrophic scar, keloid
Describe Hypergranulation
Raised granulation tissue above the level of the surrounding skin commonly occurs as a result of;
Friction
Increased bacterial burden in the wound
Infection
Describe contracture
Abnormal scar formation that can inhibit movement or function due to excessive myofibroblast activity.
Describe a Hypertrophic scar
Excessive scar that remains within the perimeter of the original wound
Describe a Keloid scar
Excessive scar that extends outside the perimeter of the original wound
What are the 6 F’s of when not to pack a wound?
Fistula, fascial plane separation,facilitate exudate drainage,foreign bodies,formed track (lined with epithelium) , fear of the unknown
What are the risk factors for burns?
Young children, adult males, elderly.
Indigenous
Alcohol,cigarettes, drug abuse,low socioeconomic status
, residential factors
Describe a thermal burn
Hot surfaces, flames,scalds (e.g hot water) flash injuries from explosions
What is a chemical burn?
Acidic and alkaline substances, household and industrial cleaning agents
What is an electrical burn?
Low or high voltage, lightening
What is a radiation burn?
Over exposure to UV, electromagnetic, x-ray, particulate (alpha/beta or neurons)
What is a cold injury?
Frost bite, tissue hypothermia/freezing, impaired vascular function, tissue necrosis.
What is friction?
Motorbike or treadmill accidents
Name the five burn aetiologies
Thermal, chemical, electrical, radiation and friction
Describe the pathophysiology of a burn
Increased capillary permeability and oedema straight after the burn.
Caused by inflammatory mediators- histamine,prostaglandins, leukotrienes and kinins.
Increased capillary permeability = loss of small protein molecules, odema and fluid loss proportional to TBSA%
TBSA +30% leads to hypovolaemic shock, cardiovascular, respiratory, GI, urinary, metabolic and autoimmune compromise.
Local effects: extent and depth of burn determined by temperature, duration of contact and thickness of skin.
Systemic effects: fluid loss from site, increased metabolism, nitrogen loss, hypothermia, protein loss, gluconeogenesis, impaired insulin production and glucose metabolism = hyperglycaemia
Name Jackson’s zone of burn injury
Zone of ;
Coagulation
Stasis
Hyperaemia
Describe the zone of coagulation
Occurs at the point of maximal damage. Central, inner zone, blood vessel thrombosis, irreversible necrosis
Describe the zone of stasis
Medial zone. Decreased tissue perfusion, potentially salvageable. Tissue can become necrotic due it impaired circulation, release of inflammatory mediators and poor first aid. Main aim = increase tissue perfusion and prevent irreversible damage
Describe the zone of hyperaemia (erythema)
Outermost zone, erythematous due to increased tissue perfusion, tissue heals within 7 days, complications due to infection, ongoing trauma or oedema can hinder healing
Describe a superficial burn
Involves the epidermis. Painful, erythema, blanching on pressure, mild odema, May blister and peel.
3 - 10 days to heel.
Spontaneous healing
Describe a deep partial thickness burn
Extends to reticular or deeper layer of dermis. Fluid filled blisters, erythema, shiny wet surface, sever pain, mild to moderate oedema. Deceased capillary refill.
Heals within 3 weeks, scarring,hypertrophic.
Will require surgical intervention for healing. Excision and skin graft to reduce contracture and scar.
Describe a superficial-partial thickness burn
Involves epidermis, extends to papillary/superficial layer of dermis. Erythema,blisters,exudate, pain, skin blanches.
Heals within. 2 weeks.
Minimal scar
Pigmentation change to skin
Describe a full thickness burn
Involves epidermis, dermis, SC tissue. Dry, Thick white, brown, tan, bloc leathery skin. Escher doesn’t blanch. Not sensitive to light touch due to nerve damage. May involve muscle, tendons and bones.
Excision and skin graft to reduce scarring and contracture. Hypertrophic scar.
What are the types of burns classifications?
First= superficial Second (superficial) = superficial partial thickness Second (deep) = deep partial thickness Third = full thickness Fourth= sub-dermal
Wallace's rules of nines; Neck and genito perineal= 1% Head, R &L arm= 9% each Back and front of trunk = 18% each R & L leg= 18% each
Age dependent graphs
Lund & browder - good for children and neonates
Burns classified according to age group
Allows for anatomical different at different ages
Describe burn management
First aid: remove safely from source of burn, thermal burn( stop drop roll) , cool clean running water 20mins, resuscitation( 48-72hrs) . Primary survey (ABCDE) and secondary survey (after PS assess for other injuries).
Acute wound healing: inflammation, reconstruction, maturation
Rehabilitation: follow up, bio psychosocial adjustment, scar management, multidisciplinary output
Describe first aid for burns
Remove from source of burn, stop burning process, cool the burn - 20 mins water, no ice can increase depth of burn, irrigate with large amounts of water
Describe primary survey for burns
Airway
Breathing & ventilation : humidified 02 100%, bag ventilation, intubation. Assess for CO poisoning (decreased consciousness, cherry red ) RR>20 is a concern. Eschatology of restrictive skin.
Circulation: pulse strength/ regularity, cap refill <2secs. Control haemorrhage, elevation , cardiac complications with electrical burns.
Disability and neurological status: GCS, pupil reaction, hypoxia,shock.
Exposure and environment: remove jewellery/clothing, prevent hypothermia. Trim stuck clothes.
Fluid resuscitation: IVC in non burnt area, blood samples/cross matching, IVH via ANZBA guidelines/ Baxter formula;
2-4 ml Hartmanns per kg/ per %TBSA= total fluid requirements over 24hrs post burn. 1/2 TF over first 8hrs, 1/4 TF over next 8. Hrs, 1/4 TF over final 8hrs (of first 24hrs).
IDC: dark urine indicates myoglobinuria and acute tubular necrosis.
Pain: full thickness burns are innervated, intact & regenerating nerves trigger pain.
Tetanus prophylaxis
Describe secondary survey for burns
Full body assessment; fractures etc, referral to burn unit, protect wound following cooling,cling wrap to prevent evaporation and heat loss( longitudinal and circumference) , enteral nutrition or parental.
What are the goals of care for burns
Alleviate pain, prevent infection, prevent conversion to deeper wound, achieve wound coverage as early as possible, promote function of healing skin, preserve function of body part, minimise scarring
Describe management of Blisters
Intact provides protection and less pain.
Aspiration to pressure and pain
Small prune like blisters not on joints can be left roofed.
Large and over joints should be de roofed
On palm, should be slit,drained and left roofed for 48hrs before completely de-roofed(reduces pain )
Tense blisters should be de-roofed or aspirated
Opaque indicates infection, de-roofed and dressed.
Define a skin graft
A segment of dermis and epidermis which has been completely separated from its blood supply and donor site and transplanted yo another site.
- speeds up healing
- reduces infection
- deep partial thickness and full thickness undergo surgical debridement and skin grafting
List the types of skin grafts
Autografts , allografts/ homografts, xenografts/ heterografts, tissue culture, bio engineered skin, split skin graft (thin, intermediate, thick) and meshed graft
What is an autograft?
Transfer of tissue from one site to another site on same person
What is an allograft/ homograft?
Transfer of tissue from one person to another
What is a xenografts/heterograft?
Transfer of tissue from one species to another (e.g pig skin)
What is a tissue culture?
Epidermal cells cultured in a lab
What is an example of bioengineered skin?
Dermagraft, apligraf
What is a split skin graft?
Contain epidermis and varying amounts of debris
What is a thin split skin graft?
Epidermis and upper part of papillary layer of dermis.
Contracts within the first few months
no hair
Higher survival rate as vascularisation occurs easily
What is a thick split thickness graft
Epidermis, most of dermis layer, thin layer of reticular dermis. Less contraction. Some hair follicles and sweat glands.
What is an intermediate split thickness graft?
Epidermis, most of papillary layer.
What is a meshed graft?
Allows greater wound surface cover as mesh is stretched. Cultured epidermal cells need to be sprayed between interstices of mesh
What is a full thickness graft?
All of epidermis and dermis. Donor site has to be directly closed or grafted.
What Are the reasons for grafting?
Wounds deficient in surface covering may require closure with skin graft or skin flap. E.g skin cancer, burns.
Exceptions;
Bone, tendon, cartilage and nerve
Name the processes involved in the vascularisation of skin grafts
Plasmatic imbibition, inosculation of blood vessels and true circulation
Describe Plasmatic inhibition
First step in SG vascularisation. Occurs in first 48 hrs, plasma like fluid absorbed into graft, fibrin network established between graft and recipient bed to hold graft in place.
Describe innoculation of blood vessels
In the first 48 hours, vascular buds grow into fibrin network, anchors graft to bed
Describe the establishment of true circulation?
Angiogenesis within 4-7 days, lymphatic establishment
What are the factors that inhibit graft take?
Poorly vascularised recipient bed, shearing movement, fluid collection beneath the graft (e.g haematoma, seroma, pus,debris), infection, inadequate graft support when dependent, patient intrinsic or extrinsic factors
Describe shearing movement and nursing interventions to prevent this
Movement between the graft and the recipient bed cusses damage to the capillaries growing into the graft and prevents revascularisation.
- splinting (e.g thermoplastic splints)
- patient education (e.g keeping graft site immobilised)
- dressings (e.g tie over, compression)
How does infection inhibit graft take? What are some nursing interventions to prevent this?
Pre-graft recipient bed preparation
Post grafting - bacteria can destroy migrating epithelial cells and increase exudate .
Identify signs and symptoms of infection , compliance with treatment plan if infected, graft care: removal of accumulated exudate and crusts, trimming of graft once taken.
How does inadequate graft support affect graft uptake? What are interventions to prevent this?
Increased graft hydrostatic pressure when graft site is dependent, may cause fragile new capillaries to rupture and bleed resulting in blistering, haematoma, and possible loss of graft.
Graft support (compression dressing)
Staged mobility regime
Observation of the graft following mobilisation
Describe care of skin grafts
Palpate for fluid collection
Nick with fine point scissors and dab excess fluid
Protect with silicone or tulle gras dressing
Fill defect with fluffed quaze
Describe patient factors affecting graft uptake
Non-compliance : lack of education/ understanding
Impaired healing: e.g anaemia, immunosuppression, diabetes, malignancy, radiotherapy, chemotherapy, PVD, smoking and poor nutritional status
Describe interventions for incomplete graft uptake
Regrafting
Healing by secondary intention and using moist wound healing principles
Treatment of any Hypergranulation with antiseptic dressings to control any infection
List the skin graft donor site dressings
Alienates, hydro colloids, acrylic, silicone impregnated
What is the ongoing management for skin grafts
Support, ambulation regimes, education, continuing wound awareness, keep skin supple, massage gently, observation, treat all breakdown as it arises
Define a flap
Surgical relocation of tissue from one part of the body to another part in order to reconstruct a primary defect.
Flaps are described as skin or cutaneous flaps and composite flaps
What are the two different type of flaps?
Skin or cutaneous: consisting of skin and superficial fascia.
Composite tissue:
- fasciocutaneous flap= skin, SC, underlying and deep fascia & muscle
-myocutaneous= skin! underlying fascia, muscle, bone
-osteomyocutaneous= skin, underlying fascia, muscle,bone
What is a free flap?
Relocation of skin and subcutaneous tissue as a complete segment with an anastomosis of the blood supply
What is a pedicle flap?
Transfer of skin and tissue to another site. Blood supply to the flap is maintained via a vascular pedicle.
What is a rotational flap?
Z-plasty, flap rotated to cover adjacent tissue
What flap observations would you conduct as a nurse?
Vitals,fluid intake, UO, 02 therapy, exudate, pain, warmth, change in tissue turgor (prune like or hollow if arterial occlusion. Tense, swollen and distended if venous occlusion) , skin colour changes, bleeding, cap refill, doppler -arterial, venous force, regularity
How do certain medications effect flaps?
Diuretics: cause sudden change in flap perfusion
Aspirin: can inhibit aggregation of platelets
Heparin: can inhibit thrombin clot formation
Caffeine: is a cardiac stimulant and diuretic
Nicotine: inhibits oxygenation of tissues
What is a skin tear?
Traumatic wound occurring on older adults as a result of friction or shearing which separates epidermis from dermis or both from underlying structures.
Describe features of ageing skin
Thinning and flattening of epidermis Decreased epidermal proliferation Cells in horny layer loose elastin Atrophy of the dermis = decreased contraction Changes to and loss of collagen Decreased vascularity of dermis Decreased number of oil and sweat glands Vascular response is compromised Altered or reduced sensation Fragility
What is the name of the skin tear classification system?
STAR
Describe the classification of a STAR 1A skin tear
Edges CAN be realigned to normal position without stretching
Skin or flap is NOT pale,dusky or darkened
Describe the classification of a STAR 1B skin tear
Edges CAN be realigned to normal without stretching
Skin or flap IS pale, dusky or darkened
Describe the classification of a STAR 2A
Edges CANNOT be realigned
Flap colour is NOT pale,dusky or darkened
Describe the classification of a STAR 2B skin tear
Edges CANNOT be realigned
Flap colour IS pale, dusky or darkened
Describe a STAR 3 skin tear
Skin tear where flap is completely absent
Describe the management of skin tears
Control bleeding
Realign
Assess tissue loss and colour
Assess SS for swelling, discolouration, bruising
If dusky reassess in 24-48 hrs
Use silicone dressing for fragile skin, draw an arrow to indicated dressing removal direction
Define debridement
Removal of all foreign material, contaminated and devitalised tissue from or adjacent to a traumatic or infected lesion, until healthy tissue is exposed.
What is the rationale for debridement
Necrotic tissue hinders assessment, granulation, contraction, epithelial migration, causes bacteria risk and is odorous
List the methods of debridement
Surgical, conservative sharp, enzymatic, autolytic, mechanical, chemical, parasitic/larval, low frequency ultrasound
Describe surgical debridement
Aseptic, in theatre by surgeon
Done when there is extensive tissue damage or infection, prep for skin graft, comprising factors from enviro/client
What is conservative sharp debridement?
Removal of loose,avascular tissue without pain or bleeding
Aseptic conditions in clinical setting
Performed by competent RN
What is enzymatic debridement?
Enzymes to promote lysis of necrotic tissue, blood clots and fibrinous tissue
What is autolytic debridement
Rehydrating or moisture retention dressings or agents assist
Physiological response to presence of devitalised tissue and cellular debris
Hydrogels and honey facilitate by adding fluids
Hydro colloids and semi permeable films facilitate moist healing
What is mechanical debridement
Removal via mechanical means- wet to dry dressings, pressure irrigation.
Short term goal
What is chemical debridement?
Chemical agents for control or removal
Sodium hyper chlorite and hydrogen peroxide are NOT recommended as cytotoxic to healthy skin.
Cadexomer iodine- is non toxic, assists control of bacterial burden
What is parasitic/larval debridement
Bio surgical or myasitic larval therapy Deliberate infestation of lab raised maggots Lucilia sericata(green bottle fly) Enzymes from maggot breaks down tissue, maggots ingest tissue
What is low frequency ultrasound debridement?
Ultrasonic frequencies 20-100khz
Mechanical - converts electrical currents to vibrations
Give examples of safe chemical debridement agents
Cadexomer Iodine, hypertonic saline, wound honey
What are the contraindications for conservative wound debridement
Densely adherent necrotic tissue
When interface between viable and non viable tissue cannot be clearly identified
Impaired clotting mechanism
Increased risk of bleeding .e.g malignant wound
Non infected ischaemic ulcer covered with dry Escher when tissue oxygenation is insufficient to support infection control and wound healing
What is a sinus?
A cavity or track into the tissues
How do we heal a sinus?
Aim is to heal from base upward in order to eliminate dead space. Gently packed to facilitate wound closure
What is a dehiscence ?
Separation of tissue layers in a surgical wound as a result of infection, haematoma, fluid collection or localised trauma
What is an evisceration?
Protusion of viscera or bowels through a surgical incision or traumatic wound.
Keep covered with sterile moistened pads or drapes
A surgical emergency
What is the host- bacterial relationship?
Infection = organism number x virulence / host resistance
What is critical colonisation?
Increased exudate, static edges, friable granulation, bridging tissues, increased or new pain
When would you use an aseptic technique?
If individual , their wound and healing environment is compromised
I.e client is auto immune suppressed, wound entered a sterile cavity, enviro is unhygienic
When is a clean technique acceptable?
Acceptable if individual, their wound and healing enviro is not compromised
What is a compromised wound?
Acute surgical or traumatic wound
Wounds enters a sterile,cavity, exposed bone or tendon
Infection evident
Ischaemia of tissues
What is the rationale for packing a wound ?
Control wound closure and bleeding
Keep a narrow sinus opening patent
Avoid dead space in wounds to eliminate risk of abscess
Prepare wound prior to skin grafting- mechanical debridement for reduction of bacteria
