Week 9: Irrigation & Packing of Wounds

Question 1

What is skin grafting?

Answer 1

Skin grafting is a technique in which a section of skin is detached from its own blood supply and transferred as free tissue to a distant (recipient) site.
the most common form of reconstructive surgery.

Question 2

What is skin grafting used for?

Answer 2

Skin grafts are commonly used to repair defects that result from excision of skin tumours, to cover areas denuded of skin (e.g., burns), and to cover wounds in which insufficient skin is available to permit wound closure.

Question 3

Skin grafts may be classified as autografts, allografts, or xenografts. What do these terms mean?

Answer 3

An autograft is tissue obtained from the patient’s own skin.  
An allograft (aka allogeneic or homograft) is tissue obtained from a donor of the same species.  
A xenograft or heterograft is tissue from another species.

Question 4

Grafts are also referred to by their thickness.
A skin graft may be a split-thickness (i.e., thin, intermediate, or thick) or full-thickness graft, depending on the amount of dermis included in the specimen. What do these terms mean?

Answer 4

A split-thickness graft can be cut at various thicknesses
cover large wounds or defects for which a full-thickness graft or flap is impractical
A full-thickness graft consists of epidermis and the entire dermis without the underlying fat.
It is used to cover wounds that are too large to be closed directly.

Question 5

What is the care for a donor site?

Answer 5

A single layer of nonadherent, fine-mesh gauze is placed directly over the donor site.
Absorbent gauze dressings are then placed on top to absorb blood or serum from the wound.
A membrane dressing (e.g., Op-Site) advantages:
It is transparent and allows the wound to be observed without disturbing the dressing, and it permits the patient to shower without fear of saturating the dressing with water.
Extremes in temperature, external trauma, and sunlight are to be avoided for donor sites and grafted areas because these areas are sensitive, especially to thermal injuries.

Question 6

What are the conditions that must be met for a graft to survive?

Answer 6

For a graft to survive and be effective, certain conditions must be met:
• The recipient site must have an adequate blood supply so that usual physiologic function can resume.
• The graft must be in close contact with its bed to avoid accumulation of blood or fluid.
• The graft must be fixed firmly (immobilized) so that it remains in place on the recipient site.
• The area must be free of infection.
May be sutured in place, slit and spread apart to cover a greater area.
The process of revascularization and reattachment of a skin graft to a recipient bed is referred to as a “take.”
may be left exposed or covered with a light dressing or a pressure dressing

Question 7

What are the nursing interventions for a skin graft?

Answer 7

Keep the affected part immobilized as much as possible.
For a facial graft, strenuous activity must be avoided.
A graft on the hand or arm: immobilized with a splint.
A graft on a lower extremity: the part is kept elevated (new capillary connections are fragile and excess venous pressure may cause rupture).
When ambulation is permitted, the patient wears an elastic stocking
Any fluid, purulent drainage, blood, or serum that has collected is gently evacuated by the surgeon, because accumulation of this material would cause the graft to separate from its bed.
When the graft appears pink, it is vascularized.
After 2 to 3 weeks, mineral oil or a lanolin cream is massaged into the wound to moisten the graft.
Loss of feeling or sensation: application of heating pads and exposure to sun are avoided to prevent burns and further skin trauma.

Question 8

What is a flap (list as much as you can remember about them)?

Answer 8

A flap is a segment of tissue that remains attached at one end (i.e., a base or pedicle) while the other end is moved to a recipient area.
Its survival depends on functioning arterial and venous blood supplies and lymphatic drainage in its pedicle or base.
A flap differs from a graft in that a portion of the tissue is attached to its original site and retains its blood supply (except the free flap)
Flaps may consist of skin, mucosa, muscle, adipose tissue, omentum, and bone.
They are used for wound coverage and provide bulk, especially when bone, tendon, blood vessels, or nerve tissue is exposed.
Flaps are used to repair defects caused by congenital deformity, trauma, or tumour ablation (i.e., removal, usually by excision) in an adjacent part of the body.
Flaps offer an aesthetic solution because:
a flap retains the colour and texture of the donor area
is more likely to survive than a graft
can be used to cover nerves, tendons, and blood vessels.
The major complication is necrosis of the pedicle or base as a result of failure of the blood supply.

Question 9

What are free flaps?

Answer 9

A striking advance in reconstructive surgery is the use of free flaps or free-tissue transfer achieved by microvascular techniques.
A free flap is completely severed from the body and transferred to another site.
A free flap receives early vascular supply from microvascular anastomosis (i.e., attachment) with vessels at the recipient site.
The procedure usually is completed in one step, eliminating the need for a series of surgical procedures to move the flap.
Microvascular surgery allows surgeons to use a variety of donor sites for tissue reconstruction.

Question 10

What does wound cleansing involve?

Answer 10

Wound cleansing involves removing debris, excess slough, necrotic tissue, bacteria and other Microorganisms

Question 11

What is the goal of wound cleansing?

Answer 11

Goal of wound cleansing is to minimize chemical and mechanical trauma and provide a clean wound bed

Question 12

Povidone-iodine, hydrogen peroxide, alcohol are commonly used to clean wounds (T or F)

Answer 12

Povidone-iodine, hydrogen peroxide, alcohol were commonly used to clean wounds but are now considered cytotoxic

Question 13

When cleaning move from the most contaminated to least contaminated area (T OR F)

Answer 13

Major principle of wound cleansing is to move from area of least contamination to most

Question 14

Irrigation pressure ranges from Irrigation pressure ranges from ___ psi to ___ psi

Answer 14

Irrigation pressure ranges from 4 psi to 8 psi

Question 15

30-60 mL syringe with 18/19 gauge is used for approx ___psi

Answer 15

8 PSI

Question 16

What are the frequently used irrigation solutions?

Answer 16

Frequently used irrigation solutions: NS, RL, antibiotic solutions

Question 17

What are the disadvantages to using dry gauze?

Answer 17

Disadvantage to gauze:
moisture evaporating quickly, causing a dressing to dry out.
Frequent dressing changes are usually needed,
Increased infection rates when compared with semiocclusive dressings

Question 18

What is dry gauze used for?

Answer 18

Dry gauze dressings are for wound healing by primary intention with little drainage

Dry gauze dressings are commonly used for abrasions and non-draining postoperative incisions

The dressing protects the wound from injury, reduces discomfort, and speeds healing

Question 19

What are dry dressings not appropriate for?

Answer 19

Dry dressings are not appropriate for debriding wounds.
When gauze adheres to drainage on a wound surface, the seal can cause you to pull off healthy tissue when the gauze is removed.
If gauze does adhere to a wound, moisten the dressing with sterile normal saline or sterile water before removing it to minimize wound trauma.

Question 20

What are some different types of gauze ?

Answer 20

Impregnated gauze can hydrate a wound and absorbed exudate or deliver antimicrobial agents.
Dry gauze dressings are commonly used for abrasions and nondraining postoperative incisions
Telfa gauze dressings contain a shiny, nonadherent surface on one side that does not stick to a wound.
Drainage passes through the nonadherent surface to the outer gauze dressing.

Question 21

What is a moist-to-dry dressing?

Answer 21

Moist-to-dry dressings (also called wet-to-dry or damp-to-dry) are gauze moistened with an appropriate solution.

The primary purpose is to mechanically debride wounds, specifically full-thickness wounds healing by secondary intention and wounds with necrotic tissue

The moistened gauze increases the absorptive ability of the dressing to collect exudate and wound debris.

This layer dries and adheres to dead cells, thus debriding the wound when removed.

Use a sterile isotonic solution such as normal saline or lactated Ringer’s to moisten dressings.

The outer absorbent layer is a dry dressing that protects the wound from invasive organisms.

Question 22

What does the outer, dry layer do on a wet-to-dry dressing?

Answer 22

The outer absorbent layer is a dry dressing that protects the wound from invasive organisms.

Question 23

What are autolytic and enzymatic debriding agents?

Answer 23

Autolytic debriding products are applied to wounds to allow enzymes to self-digest dead tissue.
Enzymatic debriding agents applied directly to a wound bed act by digesting collagen in necrotic tissue
Both autolytic and enzymatic products are used in combination with moist gauze but may also come as prepackaged dressings that do not require any additional gauze.

Question 24

What is the purpose of packing a wound?

Answer 24

The purpose of packing a wound is to fill dead space and avoid the potential of abscess formation by a wound closing too soon

Question 25

What are the different types of gauze used for packing and why?

Hint: impregnated, strip, damp

Answer 25

Impregnated gauze is useful when there is undermining
Strip gauze is useful for filling the narrow areas in the channel so the complete dressing can be removed easily during a dressing change
Damp gauze is useful for packing exudative wounds.
If a wound is dry, use hydrating packing material such as hydrogel impregnated or saline-moistened gauze to keep it moist.

Question 26

What is some general wound care terminology?

Answer 26

Undermining – A separation of tissue that occurs underneath the intact skin of the wound perimeter
Sinus /tunnel – A channel that extends from any part of the wound and tracks into deeper tissue.
Fistula – An abnormal track connecting an organ to the skin surface or wound bed or to another organ.
Dead space – The space left in the body as a result of tissue loss; the wound area that is packed.
Packing – The process of loosely filling a wound cavity or dead space with gauze sponges, gauze strips or other appropriate packing material
Irrigation –Is the application of fluid to a wound to remove exudate, slough, necrotic debris, bacterial contaminants, and dressing residue without adversely impacting cellular activity which is vital to the wound healing process.