Wound Care Flashcards
3 categories of chronic wounds
Venous disease wounds
Arterial disease wounds
Neuropathic disease wounds
Days 1-4 of acute wound healing
- redness
- Edema
- Exudate
- Epithelial closure by day 4
Days 5-14 of acute wound healing
- Bright pink
- Edema and exudate resolve by day 5
- Staples/sutures removed between days 9 and 14
Days 15-1 year
- Pale pink
- Scar tissue forms
What is primary intention?
Wound edges are approximated, which prevents granulated tissue formation
What is secondary intention?
Wound edges are not approximated, such as in a pressure injury
Heals by granulation tissue formation and re-epitheliazation
What is tertiary intention?
Wound is left open and closed at a later time
Negative Pressure Wound Therapy/Vacuum Assisted Closure
- Applies continuous or intermittent suction to wound
- removes bacteria and exudate
- Promotes granulation
- Not for areas of poor perfusion
Open drainage system
- Penrose drains (absorbent dressing with collapsable tube)
- Pros: protects surrounding skin, provides drainage
- Cons: difficult to assess the amount of drainage and to control microbes
Closed drainage system
- Use compression/suction to remove drainage in reservoir
- Pros: accurate measurement of drainage and prevents infection
Types of closed drains
- Self-contained drainage system (bulb)
- Portable wound suction device
Describe components of wound assessment
- Location, shape, size (width by length by depth in mm), color
- Erythema (blanchable or nonblanchable (structural damage))
- Temperature (cold indicates low perfusion vs expected warmth)
- Odor (helps identify certain microorganisms)
presence of exudate, slough, or eschar - Signs of impaired healing (necrosis, tunneling, undermining, edema)
- Signs of good healing (clean edges or granulating tissue)
- Condition of the area around the wound
- Psychosocial: body image, esteem, sex, socialization
What are dry dressings used for?
Wounds with little or no exudate
(use sterile or clean technique, self-adhered or held by gauze and tape)
Wet-to-dry dressings
- Saline soaked gauze that is squeezed
- Pulls healthy and necrotic tissue out of wound when it dries
- Do not use on clean wound with granulation
Chemically impregnated dressings
- Silver, povodine iodine, petrolatum, collagen, or antibiotics
- Speed healing process
- Make sure using appropriate dressing for wound/microbe type
Foam dressings
- Absorbent and provide more support for boney prominences
- Mild to moderate exudate
- Self-adherent or nonadherent
Alginate dressings
- Made from seaweed
- Provides moist healing environment, absorbs exudate, and promotes hemostasis
- Doesn’t adhere to wound and needs second dressing
- Good for lots of exudate or packing deep wounds
* Do not use on dry wounds
Hydrogel dressings
- Promotes moist environment and absorbs exudate
- No effect on hemostasis
- Swells with exudate and requires secondary dressing on top
- Good for necrosis and infection and dry wounds
* Do not use on excessive exudate
Wound fillers
- Gels, powders, beads
- Soften tissue to facilitate debridement
- Do not use on dry wounds
Transparent dressing
- No absorption, but provides barrier, moist environment, oxygen, and visualization of wound
- Good for necrotic tissue and superficial tears
Hydrofiber dressings
- Moderate to high exudate wounds
- Hemostasis and very absorptive, less maceration than alginate
- Can stay in place for several days
Hydrocolloid dressings
- Autolytic debridement, make moist wound bed, bacteriostatic, and stimulate cell growth
- Can’t see through and can look like purulent drainage
- Good for small abrasions, superficial burns, pressure injuries, postoperative wounds
* Do not use on dry wounds, and some infected wounds
Types of antiseptic agents
Provodine iodine
Silver
Hydrogen peroxide
Chemical debridement gels
For pressure injuries with eschar or slough, or uneven edges
Use only on necrotic tissue
Types of wound cleansing
Pressurized irrigation
Passive irrigation
Mechanical cleansing
Pressurized irrigation
8 psi through syringe or catheter
Start at top edge and hold syringe 1 inch away from wound
Irrigation and packing
Mechanical cleansing
gauze and solution to clean wound
Passive irrigation
0.9 % sterile saline solution and gravity
Solution runs top-to-bottom
Types of debridement
Mechanical
Autolytic
Chemical
Surgical
What is mechanical debridement
Either wet-to-dry dressing or pressurized irrigation
What is autolytic debridement?
Dressings help wound fluids self-digest necrotic tissue
What is chemical debridement?
Topical enzymes
Examples of pressure relief devices
Only work in combo with turning and skin care
Heal protectors, pillows, foam surfaces, specialized beds
What types of wounds can electrical stimulation be used for?
Stage 2, 3, or 4 pressure injuries
Stimulates granulation and decreases pain
What types of wounds are negative pressure wound therapy used for?
Stage 3 or 4 pressure injury
Drains removed when drainiage is 30–100 mL within 24 hr
Hyperbaric oxygen therapy
100% oxygen stimulates cell growth for burns and necrosis
Growth factors
Plasma rich in platelets stimulates fibroblasts to activate cell growth
How does ultrasound therapy work to heal wounds?
Stimulates granulation, decreases pain, and decreases infection rate
Describe eschar
Black/brown
Firmly attached
Can be soft
Describe slough
Tan, yellow, white
Stringy and soft
Firmly attached
Describe fibrin
Yellow, white
Stringy and soft
Loosly attached clumps
Describe hyperkeratosis
White, grey
Hard or soft
Firmly attached surrounding edges
Describe gangrene
Black, brown
Hard
Firmly attached
Braden scale components
Braden Scale (score 6–23 where lower is bad)
Perception
Moisture
Activity
Mobility
Nutrition
Friction/shearing
Why do chronic wounds heal slowly?
They have more cytokines, which slow new cell proliferation
How should shearing be prevented?
Raise HOB to 30 degrees maximum
4 stages of healing
Hemostasis (vasoconstriction)
Inflammatory phase
Proliferative phase
Maturation/remodeling phase
Describe components of the inflammatory phase
- **Begins after the skin is injured and lasts 3–6 days
- Heat, swelling, color changes, pain, loss of function, fever
- Presence of neutrophils, lymphocytes, macrophages, mast cells, plasma proteins, complement system **
Neutrophils: first to arrive, phagocytosis
Macrophages: phagocytosis, release of nitric oxide, autolytic debridement, and secretion of growth factors (attract collagen-synthesizing fibroblasts)
Mast cells secrete histamine (vasodilation=edema, and collagen formation)
Describe components of the proliferative phase
- Begins 3 days after injury and lasts 24 hours
- **Fills in the wound with new tissue
- Angiogenesis=creation of new blood vessels
- Bleeding and edema due granulation tissue (fragile capillaries and tissue)**
Epitheliazation: temporary protection, keratinocytes move inward from edges
Begins at the edges and moves upward
Fibroblasts synthesize collagen to form scaffolding for scar formation
Myofibroblasts cause contraction of wound edges
Risk of evisceration because scar is immature
Components of maturation/remodeling phase
- Completion of wound healing can take more than 1 year
- Collagen is replaced with stroger collagen
- Myofibroblasts continue to secrete proteins to cause contraction and wound closure
- Color of scar changes from pink/red to white, or be more pigmented in melanated skin
- Thinner and reduced need for blood
Skin problems in children
maceration and dermatitis
Skin tears, pressure injuries, diaper rash
Skin problems in elderly
thinning of skin, collagen loss, decreased blood supply and hydration
Skin tears, pressure injuries, dryness, infections
Skin problems with chronic illness
(reduced immune system, decreased oxygenation)
Skin tears, pressure injuries, infection, lesions caused by moisture
Skin problems with reduced sensation
Skin tears, pressure injury, infection, incontinence related dermatitis
Extrinsic factors related to wound formation
Medications
Radiation and chemo
Inflammation and decreased blood supply
(Delayed wound healing, dermatitis, infections, pressure iinjuries)
Nutrition
Stress reduces immune response
Damage, repeat trauma, illness can lengthen healing
Moisture associated skin damage
- dermatitis develops when skin is exposed to urine, feces, sweat, stoma effluent, wound drainage
- sweating, skin folds, abnormal skin pH are risk factors
Types of Biological Debridement
Collegenase (targets necrotic tissue only)
Bromelain and papain
Fly larvae secrete enzymes that liquifies necrotic tissue, which larvae eat
When are sterile dressings applied to a wound?
After surgery and kept in place for 24-48 hrs
Open dressings
- gauze
- Used to pack wounds with saline (wet to dry)
Semi-open dressings
- 3 layers: fine knit gauze with therapeutic ointment, middle absorptive layer, and adhesive layer
- Do not control drainage well and can cause poor wound healing
Semi-occlusive dressings
Most diverse in options:
Hydrocolloid
Hydrogel
Alginate
Foam
Hydrofiber
Polymeric membranes
Films
Signs of wound infection
cellulitis
warm skin
redness around the wound
exudate
foul odor
Define Surgical Site Infection (SSI)
infections that occur near a surgical site incision in the 30 days after surgery (superficial) or 30-90 days after surgery (deep)
How should a wound culture be taken?
Apply saline top to bottom of wound to prevent contamination of culture with skin microflora
Use cotton tipped applicator to swab wound without touching edges
Dehiscence
The complete or partial separation of the suture line and underlying tissues that occurs when a wound fails to heal properly from poor surgical technique, foreign material in the wound, or infection.
