wound care Flashcards
basic terminology
medical asepsis/clean technique
reduce or prevent the spread of microorganisms
basic terminology
surgical asepsis/sterile technique
eliminate all microorganisms
basic terminology
clean
removal of all soil from an object or surface
basic terminology
disinfect and antiseptic
elimination of many germs from inanimate objects (disinfect) or living surfaces (antiseptic)
basic terminology
sterilization
elimination of germs from inanimate objects
basic terminology
leukocytosis
- increased WBC
- > 11000
- likely fighting infection
neutropenia
- decreased WBCs
- increased risk for infection
basic terminology
normal range for WBC
4500-11000
describe wound assessment
-identify type of wound (surgical, traumatic, pressure, burn, other)
-identify location using anatomical location or bony prominence
-remove dressing and examine wound (visual and olfactory assessment)
-observe for drainage, signs of infection, signs of healing
-determine size of wound, especially important for pressure ulcers (measure length (head to toe), width (left to right), depth); note any tunneling, undermining
-observe the wound edges and surrounding skin
what is the basic dressing change procedure
-check order
-medicate and position PRN
-gather supplies
-move garbage can close to bed
-wash hands
-don clean gloves
-remove old dressing
-assess wound
-doff used gloves
-wash hands
-open all supplies
-don gloves (sterile or clean)
-cleanse wound
-dry surrounding skin
-dress wound
-date, time and initial dressing
-remove used gloves
-wash hands
-document
describe wound cleansing
-if ordered, follow orders
-if not ordered, you may use a sommerically available wound cleanser such as normal saline to clean the wound
-generally clean from areas of least contamination to areas of greater contamination (use new swab for each stroke)
-remember to dry peri-wound skin
how do you clean incisions
clean down the incision line then moving away from the incision
how do you clean open wounds
clean from the center of the wound outward in circles
what is the purpose of irrigation
-to clean the area and promote healing
-to instill sntiseptic solution or medication
-to remove excess drainage or other materials
what syringes are used for irrigation
-asepto or bulb syringe
-piston syringe
-catheter tip syringe
-bulb syringe aspirator
describe isotonic solutions
-no antibacterial action
-removes exudates
-moisturizes wound surfaces
-commonly used to cleanse wounds
-sterile normal saline (SNS)
-lactated ringers (LR)
-gentle on granulation tissue
describe chlorohexadine gluconate
-skin antiseptic (kills bacteria, spores, viruses, fungi)
-used preoperatively, before invasive procedures, and sometimes daily
-toxic to granulation tissue (nonselective debrider)
-can be used as a weaker concentration for wounds
-other names: CHG, hibiclens, chroraprep
describe hydrogen peroxide (H2O2)
-used for mechanical debridement of open wounds
-causes too much trauma with effervescent action for deep tunneling wounds
-removes blood clots
-no sustained antseptic actions
-not used at full strength
is irrigation a clean or sterile procedure?
sterile
how do you position the pt when irrigating a wound?
-position pt with wound exposed
-place waterproof pad under area to be irrigated
describe preparing supplies for irrigation
-open syringe container
-pour irrigating solution into sterile container
-open supplies needed for dressing change
-place collection basin distal to the wound to catch contaminated fluid
describe where to direct the solution when irrigating
-direct solution to all areas of the wound from superior to inferior edges
-allow gravity to drain fluid from superior to inferior edges
-keep tip of syringe at least 1 inch away from wound
-use consistent pressure
describe the wound irrigation procedure
-position pt with wound exposed
-don clean gloves, remove existing dressing, inspect wound
-doff gloves, perform hand hygiene
-prepare supplies
-perform hand hygiene, don sterile gloves, consider other PPE
-fill syringe with sterile solution
-direct solution to all areas of the wound from superior to inferior edges
-flush until all debris is cleared or until the ordered volume is instilled
-dry surrounding skin with sterile gauze
-apply sterile dressing
what are some different types of dressings
-simple (dry sterile dressing)
-complex/deep (packing, negative pressure/vacuum)
-pressure
describe simple dressings
-wound with luttle to no drainage
-protects wound from injury
-prevents introduction of bacteria
-reduces discomfort
-speeds healing
-used on abrasions, non draining post op incisions
-moisten with SNS to reduce trauma when removing dressing if it is adhered to the wound
describe complex or deep dressings
-long pieces of gauze or dressing materials are used to fill the wound bed
-keeps wound moist or helps absorb excess drainage
-packing is then covered by a DSD
-negative pressure or vacuum dressings
describe using long pieces of gauze or dressing materials to fill a wound bed
-open or unroll gauze
-fluff it loosely, but completely fill the wound bed
wounds that are dry will usually be packed with…
wet or moist gauze
wounds that are draining will usually be packed with…
dry gauze
describe putting and taking out gauze in a wound with slough
-wounds with slough will be mechanically debrided with gauze that is placed into the wound wet and left in plae until it is dry
-as it removed, some nonviable tissue will come out with the gauze
describe negative pressure or vacuum dressings
-requires an roder and special equipment (often rented)
-assists in wound closure by applying negative pressure to draw the edge of the wound together
-accerlerates healing
-reduces edema
-improves circulation
-reduces bacterial counts in the wound
describe a pressure dressing
-used for temporary control of excessive bleeding following trauma, surgery, puncture (intentional and unintentional)
-may stop bleeding
-may be combined with sandbag use
name some different dressing materials
-gauze
-ABD pads
-hydrocolloids/silicone dressings
-trannsparent films
-skin barriers
-tape
-cleansing solutions
-advanced dressing supplies
name some advanced dressing supplies
-hydrogels
-alignates
-collagens
-composites
-contact layers
-silver
-honey
what is the purpose of dressings
-protecting a wound from microorganism contamination
-aiding hemostasis
-promoting healing by absorbing drainage and debriding a wound
-supporting or splinting the wound site
-promoting thermal insulation of the wound surface
-providing a moist environment
describe gauze pads
-2x2s, 4x4s, gauze squares
-can be used sterile or clean
-gauze is primary dressing, used on top of wound
-special types: lodoform, vaseline, xeroform, nugauze
describe fluffed or rollled gauze
-may be referred to as: kerlex, fluff, bulkee
-large or long pieces of loosely woven gauze
-can be layerd or folded to absorb drainage
-used for packing wounds or wrapping extremities
describe ABD pads
-sometimes referred to as combine pads or combination pads
-large, absorbent pads
-generally used as a secondary dressing (over another dressing)
what is the brand name for hydrocolloid dressings
duoderm
what is a hydrocolloid dressing and what does it do
-soft wafer that can be cut to fit
-absorbs small amounts of drainage
-provides protection for autolytic debridement of small wounds
-can be used to protect skin from tape
-can be used to treat stage 1 and 2 pressure injuries
-maintains adequate moist environment fo healing clean, shallow wounds
how long can a hydrocolloid dressings remain in place when kept clean and dry
5-7 days
describe nonadherant dressings
-brand name is telfa (and band aid)
-used directly on the ound bed or incision to prevent injury to granulation tissue when dressings are removed
-may be impregnated with petroleum or antimicrobial ointment
describe transparent dressings
-brand names: opsite, tegaderm
-used to manage superficial wounds or provide skin protection
-allows visualization of wound or IV insertion site
-it is moisture and vapor permeable (allows gas to pass through dressing)
-leave top, supportive paper on the dressing until after adhesive side is applied to the skin
what different forms may skin protectants/skin barriers come in
-solutions
-pastes
-powders
-wafers
what are skin protectants/skin barriers used for
to protect skin from:
-drainage
-urine
-stool
-tape
describe tape
-various widths
-variety of materials (paper, silk, plastic, adhesive)
-steri strips
what are steri strips used for
used to approxiate incisions of lacerations not requiring stitches
name some different drains
-hemovac
-jackson-pratt (JP)
-penrose
what do drains do
-promotes wound healing
-enhance the flow of drainage out of the wound
describe hemovac
-spring activated self suction
-empty every 4-8hrs
describe JP drain
bulb activated self suction
describe penrose drain
passive drainage only, no collection device
name 4 drainage types
-sangioneous
-sero-sanguineous
-serous
-purulent
describe sanguineous drainage
-bloody
-thick drainage
-not transparent
describe sero-sanguineous drainage
-blood and serum
-red-pink
-thinner than sanguineous, thicker than serous
describe serous drainage
-serum from the body
-pale yellow
-water
-fluid blister like
describe purulent drainage
-pus
-pale yellow to green
-white blood cells
-infection
what interventions would be used for stage 1 pressure injuries
-relieve pressure
-may apply protective dressing
-be vigilant of hygiene
-turn Q2hrs
-pay attention to nutrition
-educate
what interventions would be used for stage 2 pressure injuries
basically the same as stage 1
what interventions would be used for stage 3 pressure injuries
-need expert opinion -> usually infected and complicated
-therapeutic bed
-dietary consult
-extensive education
-most likely needs packed with gauze and require dressing changes several times a day
what interventions would be used for stage 4 pressure injuries
-usualy require sharp debridement by a provider
-may require a graft
-huge nutritional demand and educational demand
-super duper frequent dressing changes and super duper pressure relieving surfaces
describe unstageable pressure injuries
-full thickness tissue loss
-wound covered by slough or eschar
-must be debrided to remove slough or eschar before it can be staged
describe 1st degree burns
-least severe
-reddened area (ex. sunburn)
describe 2nd degree burns
-blisters form/painful
-moderate to deep partial thickness
-involves epidermis and portions of the dermis
describe 3rd degree burns
-skin is charred or nonexistent
-no pain
-severe fluid loss, nerve destruction
-full thickness
-destruction of epidermis and dermis
-requires drebridement and grafting
describe 4th degree burns
-deep burn necrosis
-extensive damage involving fascia, muscles, and/or bone
describe nutrition for healing
-vitamins A and C, minerals
-protein
-calories
-adequate hydration
what are some possible nursing diagnoses for wound care
-risk for infection
-pain
-impaired skin integrity
-impaired tissue integrity
-body image disturbance
-imbalanced nutrition (less than body requirement)
-risk for injury
-ineffective thermoregulation
-hyperhtermia
-hypothermia
-auditory sensory deficit
what is the purpose of wraps
-creating pressure over a body part
-immobilizing a body part
-supporting a wound
-reducing or preventing edema
-securing a splint
-securing a dressing
usually rolled gauze (kerlix) or ace wrap
describe assessment before applying a wrap
-inspect the skin (abrasions, discoloration, or exposed wound edges)
-cover exposed wounds or open abrasions with sterile dressing (assess condition of underlying dressings and changing if soiled)
-assessing the 5 Ps
what are the five Ps
-assess the extremity distal to bandage for:
pallor
paresthesia (numbness/tingling)
pain
pulselessness
paralysis
-assess before and after applying bandage
describe implementation of a wrap
-wrap does not need to be sterile
-wrap tight enogh to hold without constricting blood flow
-apply wrap distal to proximal (facilitates venous return)
-avoid bandaging over wrinkled dressing to prevent pressure
-avoid bandaging over soiled dressings
-prolonged heat and moisture on skin may cause epithelial cells to dteriorate (avoid unnecessarily thick bandages)
describe slings and braces
-fasten slings off center, behind the neck to avoid rubbing on cervical vertebra (distal extremity should be elevated to prevent edema)
-place and support the body part to be bandaged in normal functioning position (prevents deformities and discomfort and enances circulation)
-places pins or knots well away from wound, tender areasm or pressure points
-frequently assess skin where there is contact with the brace for irritation or damage from friction
describe binders
-used to support, immobilize, or splint
-used around the chest, abdomen, or pelvis
-used to hold a dressing in place
-generally made of cloth or elastic material
true or false:
blood vessels in the skin dilate to dissipate heat
true
what does application of cold do to the blood vessels
causes vasoconstriction
what is the application of cold used for
used in early wound management
-reduces hemorrhage
-reduces edema
-reduces muscle spasm
-reduces pain
describe application of cold
-alternated 1/2 hr cold then 1/2 hr warm to reduce swelling, pain, and increase perfusion
what are some indications for cold application
-trauma (puncture wounds, sprains, sports injuries, fractures, lacerations, muscle strains)
-arthritis
why is cold used 30mins at a time
to prevent trauma to the skin
what does the application of heat do
-causes vasodilation/dilates peripheral blood vessels
-promotes healing by increasing O2, nutrients, and leikocytes to tissues
-eliminates toxic waste products that accumulate in swollen areas (can reduce swelling by increasing circulation
-relieves pain from muscle spasms or injured joints. reduces muscle tension/promotes muscle relaxation
-increases tissue metabolism
what are some indications for application of heat
-arthritis
-muscle spasms
-cramps
-low back pain
-surgical wounds
-hemorrhoids
-episiotomies
-phlebitis
-IV infiltration
what is important to consider for safe use of cold or heat
-age of pt/sensory deficits
-LOC
-circulatory impairment
-skin integrity
-patient diagnosis
-degree of heat and cold applied
-amount of body surface covered by the application
when is sterile irrigation used
-eye
-urinary bladder
-wounds (both traumatic and surgical)
if in doubt, sterile is always acceptable
when is clean irrigation used
-ear
-GI track (stomach and bowel)
what is the purpose of ear irrigation
-to remove objects (cerumen) or foreign bodies
-instill med
is ear irrigation clean or sterile
clean
should you irrigate if there is a suspected perforated membrane (eardrum)
no
what position should the pt be in for ear irrigation
sitting or laying down
what temo should the solution be for ear irrigation
warm - body temp
describe the ear irrigation procedure
-warm solution
-tilt head forward and away from the side to be irrigated
-straighten ear canal (up and back for adults and dwn and back for kids)
-direct tip of the syringe toward top of ear canal (use circular motion to aid in the evacuation of contents)
-STOP if pt reports severe pain or dizziness
-irrigate until canal is clean, or ordered volume is instilled
what is the purpose of eye irrigation
to remove foreign bodies (sand, fiberglass, dirt), injurious fluids, or secretions (conjunctivitis)
is eye irrigation clean or sterile
sterile
describe pt position for eye irrigation
-supine
-or with head turned with the eye to be irrigated down
describe the eye irrigation procedure
-place kidney basin beneath eye
-retract lower eyelid with gloved hand
-introduce sterile irrigation fluid into lower conjunctival sac at inner canthus
-slution and syringe tip remain sterile
describe evaluation of wound care
-prevention of skin damage
-evidence of healing (epithelialization)
-absence of infection
-minimization of edema, pain, bleeding
-no compromise to circulation or nerve function
-reduction of pain
-removal of debris
-return of function
