Wound Care Flashcards
What are the 7 types of wounds?
- abrasion
- incision
- puncture
- pressure ulcer
- venous ulcer
- arterial ulcer
- diabetic ulcer
Describe wounds with primary intention.
- clean, straight line
- little loss of tissue
- well-approximated
- minimal scarring
- commonly with sutures
Describe wounds with secondary intention
- large
- considerable tissue loss
- not well-approximated
- granulation healing
- longer healing time
- greater risk of infection and scars
- open to air healing
Describe a wound with tertiary intention
- combo of primary and secondary
- left open for edema or infection to resolve or for drainage
- closed with sutures after exudate is drained and granulation occurs
What are some signs of wound infection?
- swelling and redness
- hot to palpation
- increased drainage
- foul smelling
Describe the types of wound drainage
serous : clear, watery plasma
serosanguineous: pale, red, watery: mix of blood and plasma
sanguineous: bright red, active bleeding
purulent: thick, yellow, green, tan, or brown = pus
Describe undermining, tunneling, and sinus tracts.
undermining: surface tissue is intact, but underlying tissue has eroded
tunneling: erosion of tissue that creates a tunnel
sinus tract: deep tunnel and undermining. may require incision of overlying tissue to allow for secondary intention healing
How are wounds measured?
size, depth, presence of tunneling
What are the different types of tissues associated with wounds?
necrotic slough: yellow, wet, stringy
necrotic eschar: black, brown, hard
epithelial: pink
granulation: beefy red
What are the risk factors for the development of pressure ulcers?
immobility, impaired skin integrity, increased moisture
1. aging skin
2. chronic illness (perfusion, skin integrity, oxygenation)
3. immobility
4. malnutrition
5. incontinence
6. altered LOC
7. spinal cord/brain injury
8. NM disorders
How do pressure ulcers develop?
external pressure compressed blood vessels, which can impede blood flow and cause ischemia of tissue.
Increased friction or shearing causes tearing of blood vessels, epidermis, and dermis.
What are common locations of pressure ulcers?
bony prominences: heels, tailbone, elbow, shoulder, back of head, ankles, knees, hips, ears, buttocks
What does the Braden scale assess? What are the possible scores?
- sensory perception
- moisture
- activity
- mobility
- nutrition
- friction/shear
= 6 - 23
What are the four stages of a pressure ulcer?
- permanent redness. does not blanch. may feel warm, hard, or slightly swollen.
- superficial ulcer. No slough. Minimal depression.
- ulcer penetrates the dermis and may affect subcutaneous tissue. May include undermining. No bone involvement
- ulcer is deep and damages muscles or bone. Undermining or tunneling is common.
What are common causes of diabetic foot ulcers?
poor glycemic control, peripheral neuropathy, PVD, poor footcare/wear, infection by staphylococcus
What are the differences between arterial and venous ulcers?
Arterial: caused by decreased blood flow and ischemia. Pulses are diminished or absent. Sharp stabbing pain or claudication. Black looking ulcers.
Venous: decreased blood return causes blood stasis. Pulses are present. Edema. Ulcers are red and shiny. Surrounding tissue is dusky and irregular.
What are the purposes of wound dressing?
- Provide physical, psychological, and aesthetic comfort
- Remove necrotic tissue
- Prevent, eliminate, or control infection
- Absorb drainage
- Maintain a moist environment
- Protect wound and surrounding skin
Hydrocolloid dressings
- impermeable to water
- stays on for 3-7 days
- absorption of drainage causes yellowish, foul-smelling covering over wound
Calcium alginate dressings
- seaweed product
- used for packing wounds
- autolytic debridement - forms gel-like substance
- irrigate with sterile saline when changing dressing
- stays for 3-7 days.
Calcium alginate dressings
- seaweed product
- used for packing wounds
- autolytic debridement - forms gel-like substance
- irrigate with sterile saline when changing dressing
- stays for 3-7 days.
Negative pressure/Wound Vac therapy
- promotes wound healing through vacuum
- closed system
- reduces bacteria
- removes excess fluid
- provides moist environment
- creates mechanical tension to stimulate cell proliferation and blood flow
- used for deep wounds or surgical incisions.
When can ineffective wound healing most commonly be seen?
5-10 days postop
In which direction should irrigation flow and cleansing?
from least to most contaminated
Penrose drain
Ind: abdominal surgery
passive drainage
not sutured in place
Jackson-pratt drain
Ind: abdominal or breast surgery
creates low negative suction pressure
sutured in place
empty every 4-8 hours
Hemovac
Ind: deep or surgical wounds
creates negative suction pressure
describe the types of dressings: woven gauze, telfa, self-adhesive, montgomery strap
woven gauze: causes little irritation, absorbent (ex: 4x4 gauze)
telfa: non adherent dressing used over clean wounds
self-adhesive: traps moisture and acts as second skin (ex: Tegaderm)
montgomery strap: abdominal binder that keeps dressing in place
Describe the steps of wound irrigation.
- use 100-150mL of NS
- sterile technique
- flow directly over the wound (clean to dirty)
What do you need to know prior to changing dressings?
- type of dressing
- presence of drains or tubes
- supplies needed
- provider order
- solution needed
- frequency
- ointments needed
- wound documentation
What are interventions for wound dehiscence?
- use pillow or binder to guard wound to prevent dehiscence.
- cover with moist, sterile gauze to prevent infection
- apply pressure
- notify provider
What are the interventions for wound evisceration
- cover are with moist, sterile gauze to prevent infection
- apply pressure
- notify provider
- keep patient in low fowlers and prepare for surgery
