Wound Care Flashcards
What should you check on the package to check for sterility?
expiration date, if it was previously opened, and if it is wet
What are wounds that need “complex dressing?”
-wounds with drains or tubes
-deep open wounds
-venous, arterial, and mixed etiology wounds
-wounds that require packing
All of these require sterile technique!
List the type of wound drains
- Hemovac (3 spring drain)– closed, suction, single suture
- Jackson-Pratt (JP)– closed, suction, single suture
- Penrose– open, passive, sterile safety pin
What is the purpose of a wound drain?
to collect/measure excessive drainage from wound to prevent formation of abscess, protect the skin, and remove secretions from the surgical site
What is a stent?
a tube placed in the body to create a passage between 2 spaces
What causes an ulcer?
circulatory impairment– interruption of the circulation to the tissue resulting in localized ischemia, the ischemia deprives cells of oxygen and nutrients and the waste products of metabolism accumulate. The tissue dies because of the anoxia.
What are the types of ulcers?
-venous stasis ulcers
-pressure ulcers
-arterial ulcers
-diabetic ulcers
What is a skin tear?
a wound associated with friction and shearing
What impacts an ulcer?
-moisture
-nutrition
-perfusion
-comorbidities
What are the key predisposing risk factors for developing a pressure injury?
-previous history of pressure ulcers
-malnutrition
-immobility
-impaired circulation
-age (premature infants and those over 70)
-body build
-decreased sensory perception/altered mental status
-skin moisture (perspiration, exudate, incontinence, etc.)
-co-existing health conditions
-and extrinsic factors such as treatment protocols, restraints, medications, etc.
What causes venous ulcers
-caused by chronic venous disease/insufficiency
-most common leg ulcer
-a history of deep vein thrombosis, stroke, obesity, or multiple pregnancies can increase risk
-can be treated using compression therapy and wound care management
What does a venous ulcer look like?
-medial/lateral malleolar area, posterior calf
-irregular border, shallow
-pink/red base may be covered with yellow fibrous tissue
-exudate often large amounts “weeping”
-pain is mild but may be severe
What does primary intention refer to?
when the wound edges are neatly approximated (ex. surgical incision or paper cut)– neat edges and minimal tissue loss
What does secondary intention refer to?
wounds with wise or irregular wound margins which are not/cannot be “well approximated” (ex. pressure injury or traumatic injury)– greater inflammatory response and the site heals from bottom up and from the sides in, creating a bigger scars
What does tertiary intention refer to?
delayed wound closure– the wound is intentionally left open to heal as it would not heal, or healing would be impaired by contamination, infection, edema or poor circulation– a good ex. is compartment syndrome
What is exudate?
discharge that signals infection
What are the ways of classifying a wound?
-depth of tissue effected (superficial, partial, full thickness)
-acute vs chronic
-open vs closed
-superficial vs penetrating
What are the 3 ways of classifying the depth of tissue affected?
1) superficial wound– only epidermis is affected, ex. lightly skinning the surface
2) partial thickness– a wound that extends into the dermis, ex. road rash from falling off bike
3) full thickness– extends further than the dermis into the subcutaneous tissue and deeper
What is the difference between superficial and penetrating?
superficial means only involving the epidermal layer (ex. skin tear)
penetrating means a break in the epidermis, dermal, and deeper tissues and organs (ex. stab wound)
What is dehiscence?
the partial or total rupturing of a surgical wound, it usually involves abdominal wounds where the layers below the skin also separate– factors that increase risk of dehiscence are obesity, smoking, poor nutrition, multiple traumas, failure of suturing, sneeze, excessive coughing, vomiting, and dehydration
What is evisceration?
the protrusion of the internal viscera through an incision– the patient needs to immediately be supported with large sterile dressings, soaked in normal saline, and placed in bed with their knees bent
What are adhesions?
internal scar tissue (collagen) around or between organs due to disturbance of the tissue or organs– can result in more surgeries
What are contractures?
wound contracture is normal (final stage of healing by primary intention)– when in excess it can cause deformity, commonly seen in burn patient’s when the burn is over a joint
What are hypertrophic scars?
also called Keloids, they are when excessive collagen makes the scar lumpy and large
What is the acronym NERDS used for and what does it stand for?
NERDS is used to identify and classify infection
N– nonhealing wound
E– exudate
R–red and friable tissue (red and bleeds easily)
D– debris
S– smell after cleaning
having 3 or more of the criteria indicates the need for antimicrobial dressing
