Wk 4 Wound Management Flashcards
What is a potential cause of fragile skin?
A patient who has been on long-term systemic steroids
What is an example of decreased circulation and oxygen as a cause of impaired wound healing?
peripheral vascular disease
What are 9 factors that affect wound healing?
Age
Loss of skin turgor
Skin fragility
Decreased circulation and oxygenation
Slower tissue regeneration
Decreased absorption of nutrients
Decrease in collagen
Impaired immune function
Dehydration
What 3 types of medications can affect wound healing?
Chemotherapy
Anti-inflammatories
Steroids
What 2 labs can affect wound healing?
Decreased WBC
Low hemoglobin levels
What 3 lifestyle factors can affect wound healing?
Obesity
Smoking
Malnutrition
Wound impair skin __
Integrity
What is inflammation?
A localized protective response to injury or destruction of tissue
What are the 3 components of managing a patient’s wound?
Assessment
Cleansing
Protection
What does red color typically mean on a wound?
Healthy regeneration of tissues
What does yellow typically mean concerning wounds?
Purulent
What does black typically mean for wounds?
Eschar
What is eschar?
A dry, dark scab or falling away of dead skin, typically caused by a burn
Eschar __ wound healing
impairs
What should be noted when assessing a patient’s wound?
L x W x D
Sinus tracts
Tunnels
Redness/swelling around the wound
Drains
Pain
Closed wounds that are healing by primary intention, skin edges should be…
Well approximated
What are 3 ways skin edges are together by way of primary intention?
Staples
Sutures
Tissue adhesives
What does approximated mean?
Edges are budding together (like a surgical incision)
How do you measure tunneling?
Take q-tip and see if it goes into the wound (measure)
What is undermining?
When there is a “lip” or a hangover of the wound
What phases of healing does wound drainage accumulate?
Inflammatory and proliferative phases
What should be documented about wound drainage? (5)
Amount
Odor
Consistency
Color
Integrity of surrounding skin
If asked to measure drainage, how much is 1 ml of drainage?
1 gram
What is copious amount?
Large area or volume
Portion of serum that is watery and clear, or slightly yellow in appearance (like what is in blisters)
Serous exudate
Serum + red blood cells, appears thick and red
Sanguineous exudate
Exudate that contains serum and blood, watery, looks pale pink
Serosanguinous
Describe purulent drainage
Result of infection
thick
contains WBC
tissue debris and bacteria
yellow, tan, green, brown
Without adequate __ a wound will not heal
nutrition
A patient with a wound will need what type of diet?
High protein, high carbohydrate
High vitamin
Moderate fat intake
What two labs to monitor nutritional status?
Albumin
Pre-albumin
What is something you may want to do before changing a wound dressing?
Administer analgesics and monitor for pain management
What does a wet-to-dry wound dressing do?
You put it on the wound wet, and when it is dry and you remove it, it mechanically debrides the wound
Example of a self-adhesive, transparent dressing
Tegaderm
What is a hydrocolloid dressing?
Occlusive dressing that swells in the presence of exudate
What is an example of a hydrocolloid dressing?
Duoderm
What is a hydrogel wound dressing?
Mostly water, gels after contact with exudate
Promotes autolytic debridement, rehydrates and fills dead space
What are hydrogel wound dressings used for?
Infected, deep wounds, or necrotic tissue
What are hydrogel wound dressings not used for?
Wounds that drain a lot
What are 2 advantages of hydrogel wound dressings?
Provides moist wound bed and can reduce pain
Prevents skin breakdown in high-pressure areas
What are alginate wound dressings?
Nonadherent dressing that conform to wounds shape and absorb exudate
What are collagens?
Powders, pastes, granules, gels
What is a wound vac?
Use of foam strips into the wound bed with occlusive dressing, creates negative pressure to occur once the tubing is connected
What does a wound vac help with?
Tissue generation
Decrease swelling
Enhance healing in moist, protective environment
What are two advantages of wound vacs?
Can infused antibiotics
Counts output
