Wound Care Flashcards
What are the stages of healing
hemostasis
inflammatory
proliferative
maturation
What dose the hemostasis consist of
Stop bleeding
Platelets
Thrombin
Cytokines
Growth factors
What dose the inflammatory healing stage?
Remove debris
Redness without significant warmth
Neutrophils: destroy bacteria
Macrophage: mediate transition to proliferation, secrete growth factors, and cytokines
what dose proliferative stage consist of?
Produce collagen and epithelial tissue
Granulation: fills wound bed
Fibroblasts migration
Angiogenesis – capillary sprouts
Contraction
what dose maturation stage consist of?
Remodel and increase tensile strength
Collagen reorganizes
Decrease in fibroblasts
First 12 week are critical
what are the wound types
I&D
Wound dehiscence
Abrasions
Burns
Skin tears
Lacerations
Blisters
Bites
Stasis ulcers
Diabetic ulcers
Pressure injuries
Arterial insufficiency ulcers
Moisture associated wounds
what is slough mean?
A yellow fibrous tissue that consists of fibrin, pus, and proteinaceous material
Can be found on the surface of a previously clean wound bed.
Thought to be associated with bacterial activity.
Sanguineous
Blood or bleeding
Serosanguineous
Thin bloody looking or pink
Serous
Thin yellow, green, tan or brownish
Can form crusting if dry
Purulent
Yellow/greenish, thick
wound infection
10^4 or 10^5 organisms per gram of tissue causing a systemic response
wound infection
Red, pain, heat, swelling, purulent drainage, drainage odor, discoloration
Delayed healing
Abnormal odor
Friable granulation tissue
New edema
Induration
Increased serous exudate
Change in granulation color or hypertrophy
Change in wound bed color
Increase pain at wound site (check blood flow
What is the acid mantle
skins pH of 4 to 5.5
inhibits bacteria and fungi
protects skin from elements
dog bites (who, risk of infx, type of injury, and microbes)
Males 6-17
Risk of infection 5-25%
Crush injury
Pasturella multocida or dagmatis or canis
Capnocytophaga canimorsus
cat bites (who, risk of infx, type of injury, and microbes)
Females 20-35
Risk of infection 30-50%, Lymphangitis
Puncture injury
Pasturella multocida or dagmatis or canis
Cat scratch fever: bartonella henselae
human bites (risk of infx, type of injury, and microbes)
High risk of infections 15-25
Oval or semilunar hematoma and or abrasions
Direct: occlusion bite leave impression of teeth
Indirect: blow from a fist to someone’s teeth
Streptococci, staphylococcus, eikenella corrodens, HIV, HBV, HCV
management of bites
Asses depth, location, type, immune status, chronic disease
Irrigation with saline with no pressure
Debridement
Tetanus or rabies
Antibiotic: amoxicillin-clavulanate or doxycycline
Clindamycin if anaerobic
Culture after washing
blisters
Something from the outside rubs against the skin
Deep partial thicknes
which pressure injury stage is this and how to treat?
stage 1
Painful
Non-blanchable redness
Shorten decrease in blood flow
Oxygen users, elbows on wheelchairs
Take pressure off
which stage of pressure injury is this and how to treat
Stage 2
Breaks the skin
Non Granular skin
Moist dressing
Take off pressure
what stage of pressure injury is this and how to treat?
stage 3
In subcutaneous tissue
Stop pressure
Moist wound dressing
Granulation tissue and no slough
what stage of pressure injury is this and how to treat?
Stage 4
Tendon or bone is exposed
Keep it moist
what stage of pressure injury is this?
Deep tissue injury
Complication: Eventually open up
What stage of pressure injury is this?
Unstageable
Filled with eschar
what are the cleansing agents for wounds?
Soap and water: hand or arm
No-Rinse Skin and Wound Cleanser and warm water
Chloroxylenol 3% impregnated scrub brush: feet and legs
Chlorhexidine: new acute wound, soaking an area prior to a procedure, or mixed with water for feet
Prontosan: Soak gauze and leave on wound for 10 min, rinse with water
Normal Saline: abscess only, fistule, undermining
primary dressing
cover the wound directly, manage oozing or bleeding
secondary dressing
covers the primary dressing, helps secure
What gauze are avalaibe for wounds?
Loose open wave
Non-woven
Non-adherent (telfa)
Petrolatum
Rolled fluff
Conforming/stretch
¼” and ½” packing – plain or iodoform
What type of absorbent dressings are used?
Calcium alginate fluff or pads: venous ulcers
Silver impregnated alginates
Hydrofibers: breaks down biofilms
Foam: retain body heat
* “Allevyn/mepilex” (silicon covering)
* Hydrophilic
Abdominal pads
Super absorptive pads (ex. Exu-Dry)
what types of contact dressing are used?
Silicon dressing
Transparent film
Hydrocolloid
Wound closure strips
What topicals are used for wounds?
Mupirocin: staph
Silver sulfadiazine: moisturizer, sulfa
Gentamicin sulfate
Clindamycin phosphate
Medihoney
“Xeroform” gauze
Cadexomer iodine gel (iodosorb)
Lidocaine – injection, ointment, cream and viscous
Hydrogel
Petrolatum
Hydrophor/aquaphor
Triamcinolone Ointment
Hydrocortisone Ointment
Miconazole
A&D Ointment
“Calmoseptine”
Zinc oxide
No sting barrier film
what is used to secure wounds?
island dressings/border gauze
Tape – Hypafix tends to be gentler on skin
Clear adhesive dressing (Tegaderm)
Cotton tubular dressing (Stockinette)
Tubular elastic dressing (Surgi-last)
Self adherent wrap (Coban)
Adhesive bandages (Band-aids)
Tubular elastic support (Surgi-grip)
what are the barriers to healing?
Edema
Oxygenation/circulation and blood flow
Diabetes
Nutrition: Protein, Vitamin C, Vitamin A, Zinc, Arginine, Glutamine, Fish oil
Osteomyelitis
Moisture
Temperature
Smoking
Bacterial burden
mechanical debridement
Wet to dry e.g.
Pressurized saline
Scrubbing, irrigation, pulse lavage, whirlpool, wet to dry
Painful
Don’t do with epithelialization or granulating wounds
Non-selective
Autolytic debridment
selective
uses the body’s own enzymes.
better with an occlusive dressing
Painless
Non-invasive
Slow
Safe for pts on blood thinners or terminally ill
Don’t use with infection, extensive necrotic issue, patients that are immunocompromised
Hydrocolloid and transparent film, honey
Enzymatic debridement
selective, slow
collagenase, daily
Not harmful to healthy tissue
Dissolves/denatured collagen anchored to wound
Can be used with other methods but NOT other topical products or silver products
Collagenase (Santyl)
Slough not thick
Expensive
Biological debridement
selective
sterile maggots
CI: Allergies to Brewer’s Yeast, fly larvae, soy
Special storage requirements for some
Sterile or wild type
Sharps debridment
selective/non-selective, fast
Scalpel, scissors, curette, forceps, laser
CI: Bleeding D/O, ischemia, arterial insufficiency, dry gangrene, malignant wounds, unidentifiable structures, stable eschar
Caution: Anticoagulant tx, immunocompromised, smokers, hands/face, pain tolerance
