WEEK 10: Wound care management and dressing

Question 1

What does a black, yellow or red wound mean?

Answer 1

• 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

Question 2

Describe wound irrigation with a WIDE OPENING **KNOW THIS*

Answer 2

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

Question 3

Describe wound irrigation with SMALL OPENING and what is 1 precaution to keep in mind?** KNOW THIS**

Answer 3

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

Question 4

how do we irrigate necrotic wounds and what pressure settings do we use?

Answer 4

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

Question 5

If irrigating a wound with syringe how far above the wound should you do it?

Answer 5

1 inch above wound

Question 6

Describe cleaning wound with handheld shower

Answer 6

• 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

Question 7

What are the 4 wound healing process?

Answer 7

1) Hemostasis
2) Inflammation
3) Proliferation
4) Maturation

Question 8

What is the TIME framework for wound care assessments?

Answer 8

• Tissue management
• Inflammation/infection
• Moisture
• Edge

Question 9

What are the outcomes of using wound dressings?

Answer 9

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

Question 10

What are some characteristics we want in a dressing?

Answer 10

• Keep wound bed moist and surrounding periwound tissues dry and intact

Question 11

If pain meds are needed before wound change how early should you give them?

Answer 11

30 minutes

Question 12

Describe gauze dressings and its use

Answer 12

Description: cotton material
Use: protect surgical or minimally draining wounds or wound packing

Question 13

Describe transparent film dressing and its use

Answer 13

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

Question 14

Describe hydrocolloids dressings and its use

Answer 14

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.

Question 15

Describe hydrogel dressings and its use

Answer 15

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.

Question 16

Describe alginates and hydrofibre dressings and its use

Answer 16

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

Question 17

Describe foam dressings and its use

Answer 17

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.

Question 18

What are 4 types of wounds?

Answer 18

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

Question 19

What dressing is used for primary intention healing?

Answer 19

Dry gauze dressing since it has little drainage (non draining post op incisions)

Question 20

Describe types of debridement (removing dead tissue from wounds)

Answer 20

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

Question 21

Describe packing and its purpose

Answer 21

Packing is used to fill the dead space and avoid potential abscess formation

Question 22

What packing is used for undermining and tunnelling?

Answer 22

Gauze impregnated with hydrogel

Question 23

What packing is used to fill narrow spaces?

Answer 23

ribbon gauze

Question 24

How do we cleanse a wound?

Answer 24

From least to most contaminated

Question 25

Describe pressure bandages and its relation to aseptic technique

Answer 25

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

Question 26

Describe transparent dressing

Answer 26

Prevents tissue dehydration and allows rapid healing and it is also preferred for IV catheter insertion site

Question 27

What are secondary dressings?

Answer 27

bandages

Question 28

Why do we use gauze and elastic bandages?

Answer 28

To secure or wrap hard to cover body areas

Question 29

Describe abdominal binder?

Answer 29

Can either be elastic or cotton and they support large abdominal incisions from tension. Stress. Also lessens pain post-op

Question 30

who benefits from dry gauze dressings?

Answer 30

preferred for primary intention with little drainage, ABRASIONS AND POST OP INCISIONS

dry dressings protect wounds from injury, reduce discomfort

Question 31

how do you beat moisture with dry wound dressings?

Answer 31

frequent dressing changes to keep the wound from drying out or sometimes the gauze will come impregnanted

Question 32

what gauze do you NOT use to debris wounds?

Answer 32

dry gauze

Question 33

who benefits from moist-dry dressings?

Answer 33

moistened gauze increases its ability to collect exudate and used for mechanical debrisment

Question 34

which wound dressing for heavy exduating wounds?

Answer 34

alginate dressing