WEEK 10: Wound care management and dressing Flashcards
What does a black, yellow or red wound mean?
- Black/brown = eschar meaning full thickness tissue destruction: necrotic tissue
- Yellow wounds = slough meaning presence of infection and can be accompanied by purulent drainage
- Red wounds = granulation: this red colour = increasing amount of new blood vessels and thus considered healthy
Describe wound irrigation with a WIDE OPENING **KNOW THIS*
1) Fill a 35mL syringe w/irrigation solution
2) Attach 19-guage angiocathether
3) Hold syringe tip 2.5cm (1inch) above upper end of wound and over area being cleaned
4) Using continuous pressure, flush wound
Describe wound irrigation with SMALL OPENING and what is 1 precaution to keep in mind?** KNOW THIS**
1) Attach soft catheter to filled irrigation syringe
2) Gently insert catheter into opening about 1.3cm (1/2 inch)
3) Do not force the catheter int the wound because this will cause tissue damage. AVOID irrigating when the wound base will not permit effective flushing out of solution
4) Using slow, continuous pressure, flush wound
5) While keeping catheter in place pinch it off just below the syringe
6) Remove and refill syringe and reconnect catheter and repeat until solution draining into basin is clear
how do we irrigate necrotic wounds and what pressure settings do we use?
Pulsatile high-pressure lavage is used for necrotic wounds. Pressure settings set per provider prescription between 4 and 15 psi and shouldn’t be used on skin grafts, exposed blood vessels, muscle, tendon or bone. USE with cautio if pt has coagulation disorder or is taking anticoagulants
If irrigating a wound with syringe how far above the wound should you do it?
1 inch above wound
Describe cleaning wound with handheld shower
- With patient sitting in chair (or standing if condition allows), adjust spray to gently flow, make sure water is warm.
- Shower for 5-10 minutes with shower hear 30cm (12 inches) from wound
What are the 4 wound healing process?
1) Hemostasis
2) Inflammation
3) Proliferation
4) Maturation
What is the TIME framework for wound care assessments?
- Tissue management
- Inflammation/infection
- Moisture
- Edge
What are the outcomes of using wound dressings?
1) Reduces volume of exudate and amount of necrotic tissue
2) Prevents periwound erythema or maceration
3) Reduce dimensions or depth of sinus tract
4) Reduces pain intensity during dressing changes
What are some characteristics we want in a dressing?
- Keep wound bed moist and surrounding periwound tissues dry and intact
If pain meds are needed before wound change how early should you give them?
30 minutes
Describe gauze dressings and its use
Description: cotton material
Use: protect surgical or minimally draining wounds or wound packing
Describe transparent film dressing and its use
Description: waterproof adhesive
Use: best for securing IV tubing and the pro is that you can visualize wound and skin underneath dressing
Prevents tissue dehydration and allows rapid healing
Describe hydrocolloids dressings and its use
Description: gel-forming agents which maintain a moist environment and are waterproof.
Use: debridement of noninfected wounds with slough or necrotic tissue most common pressure injuries stage 2 and above,, Must allow 2-3cm of intact skin around the wound.
Describe hydrogel dressings and its use
Description: glycerin or water based to provide moisture to a dry wound bed,
Use: partial or full thickness wounds and pressure injuries shallow to deep wounds or dry to light exudate: necrotic wounds.
Describe alginates and hydrofibre dressings and its use
Description: when wet the hydrofibre dressing turns into gel which makes it easy to remove from a wound
Use: for moderately to heavily draining wounds. Comes in sheets or ribbon so can be fluffed into a wound bed
Describe foam dressings and its use
Description: absorbent, nonadhesive used to protect wounds and maintain moist healing
Use; moderate to heavily exudate wounds. Used for deep wounds stage 3 and up.
What are 4 types of wounds?
1) Serous: clear watery plasma
2) Sanguineous: fresh bleeding, bright red
3) Serosanguineous: pale, red, more watery than sanguineous
4) Purulent: thick, yellow, green or brown drainage
What dressing is used for primary intention healing?
Dry gauze dressing since it has little drainage (non draining post op incisions)
Describe types of debridement (removing dead tissue from wounds)
1) Autolytic: use of hydrocolloids to help body clear itself of debris
2) Enzymatic: agents applied to wound bed and digest collagen in necrotic tissue. LESS commonly used
3) Surgical : GOLD STANDARD but may not be readily available or appropriate
4) Maggot therapy : used less commonly
Describe packing and its purpose
Packing is used to fill the dead space and avoid potential abscess formation
What packing is used for undermining and tunnelling?
Gauze impregnated with hydrogel
What packing is used to fill narrow spaces?
ribbon gauze
How do we cleanse a wound?
From least to most contaminated
Describe pressure bandages and its relation to aseptic technique
Temporary treatment to control excessive unanticipated bleeding. It stops blood flow to promote clotting.
- Aseptic technique is secondary during an episode of acute bleeding basically stopping bleeding is FIRST PRIORITY as usually you do sterile field first but someone’s life is in danger
Describe transparent dressing
Prevents tissue dehydration and allows rapid healing and it is also preferred for IV catheter insertion site
What are secondary dressings?
bandages
Why do we use gauze and elastic bandages?
To secure or wrap hard to cover body areas
Describe abdominal binder?
Can either be elastic or cotton and they support large abdominal incisions from tension. Stress. Also lessens pain post-op
who benefits from dry gauze dressings?
preferred for primary intention with little drainage, ABRASIONS AND POST OP INCISIONS
dry dressings protect wounds from injury, reduce discomfort
how do you beat moisture with dry wound dressings?
frequent dressing changes to keep the wound from drying out or sometimes the gauze will come impregnanted
what gauze do you NOT use to debris wounds?
dry gauze
who benefits from moist-dry dressings?
moistened gauze increases its ability to collect exudate and used for mechanical debrisment
which wound dressing for heavy exduating wounds?
alginate dressing
