WOUND CARE Flashcards
medical clean asepsis/ clean technique
Reduce or prevent the spread of microorganisms
surgical asepsis/ sterile technique
Eliminate microorganisms
clean
Removal of all soil from an object or surface
disinfect and antiseptic
Elimination of many germs from inanimate objects (disinfect) or living surfaces (antiseptic)
sterilization
Elimination of germs from inanimate objects
leukocytosis
high white blood cells. have infection or inflammation
neutropenia
decrease white blood cells. risk of infection/ disease
WBC range
4500-11000
identify wound
Surgical, Traumatic, Pressure, Burn, Other (dermatitis, vascular, arterial, etc.)
determine size of wound
Measure length (head to toe), width (left to right), depth (use cotton tip) cm
Note any tunneling, undermining
wound cleaning
If ordered, follow orders
If not ordered, you may use a commercially available wound cleanser, an isotonic solution such as 0.9% Sodium Chloride (Normal Saline) to clean the wound
Generally clean from areas of least contamination to areas of greater contamination
- Use a new swab or cloth for each stroke
remember to dry peri-wound skin
incision cleaning
clean down the incision line then moving away from the incision
open wound cleaning
clean from the center of the wound outward in circles
purpose of irrigation
To clean the area and promote healing
To instill antiseptic solution or medication
To remove excess drainage or other materials
isotonic solutions
No antibacterial action **
Removes exudates
Moisturizes wound surfaces
Commonly used to cleanse wounds
- ex. Sterile normal saline or Lactated ringers
chlorhexidine gluconate
Skin antiseptic
Kills bacteria, spores, viruses, fungi
- Toxic to granulation tissue. **
Used preoperatively, before invasive procedures and sometimes daily
Can be used as a weaker concentration to irrigate wounds
Other names: CHG, hibiclens, chloraprep
hydrogen peroxide
Used for mechanical debridement of open wounds
Causes too much trauma with effervescent action for deep tunneling wounds
Removes blood clots → but we do want the blood to clot so it can heal
No sustained antiseptic action
Not used in full strength
Half strength is half specimen cup of sterile water and the other half hydrogen peroxide
is wound irrigation clean or sterile procedure
Sterile procedure
simple dressing
dry sterile dressing DSD
complex/ deep dressing
Packing
Wet to dry
Damp to dry
Dry
Negative pressure/ vacuum
simple dressing do what
Wound with little 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
wounds that are dry are typically packed…
with wet or moist gauze
wounds that are draining will usually be packed…
packed with dry gauze
wounds with slough will be…
mechanically debrided with gauze that is placed in the wound wet, and left in place until it is dry. As it is removed, some non-viable tissue will come out with the gauze
negative pressure or vacuum dressings
Requires an order and special equipment (often rented)
Assists in wound closure by applying negative pressure to draw the edge of the wound together
- Accelerates healing
- Reduces edema
- Improves circulation
- Reduces bacterial counts in the wound
wound vacuum
Clear tape will go over the wound and a tube will go inside the tape/wound and will provide negative pressure and it will pull and collapse the foam into the wound.
Helpful for pt. With complex wounds
pressure dressing
Used for temporary control of the excessive bleeding following
Trauma
Surgery
Puncture
may stop bleeding
may be combined with sandbag use
intentional dressing
sandbags on the groin after cardiac catheterization to ensure a hematoma does not form
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
gauze pads
2 x 2’s, 4 x 4’s, gauze squares
Can be used sterile or clean
Gauze is a primary dressing
- Used on top of the wound
Special types: Iodoform, Vaseline, Xeroform, Nuguaze
fluffed or rolled gauze
May be referred to as: Kerlex, Fluff, Bulkee
Large or long pieces of loosely woven gauze
Can be layered or folded to absorb drainage
Used for packing wounds or wrapping extremities
ABD pads
Sometimes referred to as Combine Pads or Combination Pads
Large, absorbent pads
Generally used as a secondary dressing (over another dressing)
hydrocolloid dressings
Brand name: Duoderm
Soft wafer that can be cut to fit
Absorbs small amounts of drainage
Provides protection for autolytic debridement of small wounds
- Keeps wound, warm moist and allows to heal on own
Can be used to protect the skin from tape
Can be used to prevent or treat Stage I & II pressure injuries
Maintains an adequate moist environment for healing clean, shallow wounds
Can remain in place for 5 -7 days if kept clean and dry
non-adherent dressings
The brand name is Telfa (and Band-aide!)
Used directly on the wound bed or incision to prevent injury to granulation tissue when dressings are removed
May be impregnated with petroleum or antimicrobial ointment
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 the adhesive side is applied to the skin
skin protectants/ barriers protect skin from…
Drainage
Urine
Stool
Tape
tape
Various widths
Variety of materials
- Paper
- Silk
- Plastic
- Adhesive
Steri-strips: Used to approximate incisions of lacerations not requiring stitches
drains
Promotes wound healing
Enhance the flow of drainage out of the wound
hemovac
Spring activated self suction → pulls fluid out of body
Empty every 4-8 hours
Jackson-pratt JP drain
Bulb activated self suction
penrose
Passive drainage only, no collection device
Like a tourniquet so the driangae can passively have blood drip into the gauze. Bobby pins keep it from going back inside the body.
stage 1 sanguineous
bloody , thick drainage, not transparent
Interventions:
Relieve pressure, protective dressing, hygiene, moisturizing the skin, nutrition of pt.
stage 2: sero-sanguineous
Blood and serum, red-pink, thinner than sanguineous, thicker than serous
Interventions:
Apply silicone dressing to help create the auto lytic debridement. , offloading devices (wedges, heel pads), nutrition, educate Notify the provider because it has become a never event.
stage 3: serous
Serum from the body, pale yellow, watery, fluid blister-like
Interventions:
- Need expert opinion on how to handle wound. Speciality surface (therapeutic bed to reduce pressure all over bed) nutrition physician, educate pt. Will need packing and dressing changes several times throughout the day.
stage 4: purulent
Pus, pale yellow to green, white blood cells, infection
Interventions:
Graph to heal, huge nutritional demand to regrow tissue. Extensive dressing changes and the most available intensive pressure relieving services.
burns: first degree
Least severe
Reddened area (sunburn)
burns: stage 2
Blisters form/ painful
Moderate to deep partial thickness
Involves epidermis and portions of the dermis
buns: stage 3
No pain
Skin is charred or non-existent
Severe fluid loss, nerve destruction
Full thickness
- Destruction of epidermis and demis
- Requires debridement and grafting
burns: 4th degree
Deep brun necrosis
Extensive damage involving fascia, muscles or bone
nutrition for healing
Vitamins A & C, Minerals
Protein
Calories
Adequate hydration
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, Kling) or Ace wrap
assessment before applying the wrap
Inspect the skin
- Abrasions, edema, discoloration, or exposed wound edges
Cover exposed wounds or open abrasions with a sterile dressing
- Assess the condition of underlying dressings and changing if soiled
Assessing the 5 “P’s”
- Neurovascular assessment
- Circulation, Movement, Sensation (CMS) assessment
the 5 P’s
Assess the extremity distal to the bandage for:
1. Pallor: paleness
2. Paresthesia: numbness or tingling
3. Pain: nerve function
4. Pulselessness: circulatory function
5. Paralysis: motor and nerve function
Assess before and after applying bandage
implementation of wraps
Wraps need not be sterile
Wrap tight enough to hold without constricting blood flow
Apply wrap distal to proximal
- Facilitates venous return → towards heart**
Avoid bandaging over wrinkled dressing to prevent pressure
Avoid bandaging over soiled dressings
Prolonged heat & moisture on skin may cause epithelial cells to deteriorate
- Avoid unnecessarily thick bandages
slings and braces
Fasten slings off-center, behind the neck to avoid rubbing on the cervical vertebra
- Distal extremity should be elevated to prevent edema
Place & support the body part to be bandaged in normal functioning position
- Prevents deformities and discomfort and enhances circulation
Place pins or knots well away from wound, tender areas, or pressure points
Frequently assess skin where there is contact with the brace for irritation or damage from friction
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
application of cold
Causes vasoconstriction
Used in early wound management
- Reduces hemorrhage
- Reduces edema
- Reduces muscle spasm
- Reduces pain
Alternate ½ hr cold, then ½ hr warm to reduce swelling, pain, increase perfusion.
Apply for 30 mins, let the blood rebound and apply an hour or so later.
indications for cold application
Trauma
- Puncture wounds
- Sprains
- Sports injuries
- Fractures
- Lacerations
- Muscle strains
Arthritis: apply after activity to reduce hematoma or edema from occurring
application of heat
Causes vasodilation/dilates peripheral blood vessels to dissipate heat.
- Promotes healing by increasing oxygen, nutrients & leukocytes to tissue
- 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
indications for heat
Arthritis: apply before activity to get circulation following
Muscle spasms
Cramps
Low back pain
Surgical wounds
Hemorrhoids
Episiotomies
Phlebitis
IV Infiltration
safe use of cold or heat
Age of the patient/Sensory deficits
Level of consciousness
Circulatory impairment
Skin integrity
Patient diagnosis
Degree of heat and cold applied
Amount of body surface covered by the application
clean or sterile irrigation?
if in doubt, sterile is always acceptable
ear irrigation purpose
To remove objects (cerumen) or foreign bodies; or to instill medication. Do not irrigate if there is a suspected perforated membrane
is ear irrigation clean or sterile
clean because we are touching the outside and the ear drum protects
how do you position the pt. with ear irrigation
sitting or laying down
cold or warm solution for ear irrigation
Warm the solution to body temperature
straighten the ear canal
Adult: pull pinna up and back
Child: pull pinna down and back
STOP irrigation if…
the patient reports severe pain or dizziness
eye irrigation purpose
To remove foreign bodies (sand, fiberglass, dirt), injurious fluids, or secretions (conjunctivitis)
is eye irrigation sterile or clean?
sterile procedure
how do you position pt. during eye irrigation
Supine or
With head turned with the eye to be irrigated down
where do you introduce the sterile irrigation fluid in the eye?
Introduce sterile irrigation fluid into lower conjunctival sac at inner canthus
Solution and syringe tip remain sterile
evaluation
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
