Wound Care Flashcards
Standard Precautions
They are “standard” because every patient should be viewed as infected.
Transmission based precautions
- 2nd tier, KNOWN infection
9 elements of standard precautions
- Hand hygiene
- PPE
- Safe handling and disposal of sharps
- Cleaning and decontamination
- Safe handling of waste
- Safe handling of linens
- Respiratory and cough hygiene and etiquette
- Aseptic non-touch technique
- Safe handling of blood and body spillage
Hand hygiene
Single most important
Before and after
15-30 seconds
Turn off tap and open door with paper towel
Nail brush
PPE
If contact with blood or fluids is a possibility
Gloves, gowns, face shields
Safe handling and disposal of sharps
Disposal containers
Cleaning and decontamination
Clean after use, single use, shared items
- visibly dirty to sertilize
Safe handling of waste
Wear appropriate PPE
Don’t smoke or eat
Wash hands
Dispose as appropriate
Safe handling of linens
Always wear gloves
Roll up
Do not carry against body
Designated container (not shared with clean)
Respiratory and cough hygiene and etiquette
Cover your cough, tissue-disposal
Mask
Separation and ventilation as appropriate
Aseptic non-touch technique
Sterile technique
Safe handling of blood and body spillage
PPE as appropriate
Approved cleaner
Red bag
Who is responsible for safety precautions?
Your employer
- Responsible for providing all needed equipment
- Training you
- Developing policies
- Keeping up with infections
* impact to funding
- Treating you if you become infected
You
- Following policy
Transmission-based precautions
When you know a client has a highly transmissible disease (contact, droplet, or airborne)
- depends on disorder
- gloves, gowns, mask as appropriate
Contact precautions
Clean hands before entering and when leaving the room
Put on gloves and gown before room entry. Discard before room exit.
Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person.
Droplet precautions
Clean hands before entering and when leaving the room.
Make sure their eyes, nose, and mouth are fully covered before room entry and remove before exiting.
Airborne precautions
Clean handing before entering and when leaving the room.
Put on a fit-tested N-95 or higher level respirator before room entry and remove after exiting and closing the door.
Door to room must remain closed.
Causes of wounds
Surgery
- incisions
Trauma
- lacerations
- abrasions
- fractures
- burns
- punctures
O2 loss
- pressure sores
*decubitus (can be helped by repositioning to remove pressure)
* bedsore
- gangrene
- infections
Venous failure
- blood stops flowing
- spontaneous
Stages of wound healing
Inflammation
- vascular and cellular responses
- cannot occur in dead tissue
Proliferation
- healing begins
- as early as 48 hours after injury
Maturation
- strengthening and reorganizing of new tissue
- 6 months to 2 years after an injury
- scar tissue is never more than 80% the tensile strength of normal tissue
What happens in the inflammatory stage?
Body immediately responds to control body loss, prevent infection and fluid loss, signals cells necessary for repair.
- transudate
- Localized blood vessels constrict for several minutes-prevent blood loss.
- Platelets aggregate at the site of injury to create a clot.
After 30 minutes
- Excudate is formed
- Histamine and prostoglandins are released, causing redness, warmth, and swelling.
At the cellular level
- margination (call are attracted to walls)
- phagocytosis (bacteria and debris)
- macrophages (secrete enzymes and growth factors)
- mast cells (secrete inflammatory mediators)
Scab begins to form
Cardinal signs of inflammation
Swelling - tumor
Redness - rubor (erythemal)
Warmth - calor
Pain - dolor
Decreased function - functio laesa
Problem with inflammation
Lack of inflammatory response - AIDS and HIV
Chronic inflammation/excessive for injury
How to mediate inflammation
Elevation
Ice
MEM (manual edema mobilization/retrograde massage)
AROM
Compression
Debridement
Meds
Proliferation
Once the cells necessary for repair and regeneration reach the site of injury, the proliferation phase begins.
Can be as quick as 48 hours.
4 phases:
1. Angiogenesis
- The formation of new blood vessels (buds)
- Supply nutrients to the wound
- Tiny red dots
2. Granulation
- Debris and bacteria is removed
- Granular tissue provides temporary lattice - later replaced by scar tissue
- Fibroblasts begin to lay down extracellular matrix
3. Wound contraction
- Myofibroblasts pull the wound margins together
- Degree of contraction is based on shape, depth, and size
4. Epithelialization
- Epithelial cells multiply to fill the wound
Problems during proliferation
Hypogranulation
Hypertrophic granulation
General failure
- shear injury
- infection
- maceration: rotting skin
Too wet, too dry
Over cleaning
Maturation and remodleing
Granular tissue laid down in the proliferative phase must be strengthened and reorganized.
- This is called scarring
- This process can take up to 2 years
- Most change occurs in the first 6 months
- A scar that is pink is still remodeling
- A flesh color is finished
Opportunity to affect the scar
Hypertrophy and contracture
Occurs with any wound
- hope to see it soften and flatten after a few weeks
- redness is normal - vascularity decreases by 6 months to 2 years
A scar that is thickening is referred to by many as hypertrophic.
Excessive scaring - raised and outside the boarders of the wound is keloid, some don’t differentiate between hypertrophy and keloid
Reasons for hypertrophy or keloid
Genetics
Race
Depth of burn or injury
Infection
Length of time to heal
What do we do during the maturation and remodeling phase?
Desensitization
- C fibers which carry pain can be overridden by stimulating the large A fibers.
* pressure, rubbing, vibrations, TENS, motion, and function
* typically 10 minute sessions at level of irritation 4-5x a day
Scar management
- pressure
* wraps
*elastomers
*Jobst
- massage
- modalities
*iontophoresis
Surgery
- extremes
- problems
Stages of pressure sores
Stage I: a reddened area on the skin that, when pressed, is “nonblanchable.” This indicates that a pressure ulcer is starting to develop
Stage II: the skin blisters or forms an open sore; the area around the sore may be red and irritated
Stage III: the skin breakdown now looks like a crater where there is damage to the tissue below the skin
Stage IV: the pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints
Stage V: full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed
Factors that will affect healing
Circulation
Sensation
Mechanical stress
Age
Nutrition
Comorbidities
Medication
Behaviors
- alcohol use
- smoking
Superficial first degree burn
Sunburn, brief flash burn, brief chemical or heat burn
Effects epidermis only
Painful, no blisters, only redness
Healing: 3-7 days
No scarring likely
Superficial partial thickness second degree burn
Severe sunburn, contact with stove, prolonged exposure to chemical or heat
Affects epidermis and dermis
Redness, wet, blisters, painful
Healing: 2 weeks
Minimal chance of scarring, usually only if prolonged or infected
Must pop blisters if:
- the fluid isn’t clear
- it’s on a joint
- it significantly impacts function
Deep partial thickness second degree burn
Prolonged exposure to heat or strong chemicals
Epidermis and most of dermis, but enough to heal
Redness, painful, large blisters, often pop up to to shear size
Typically heal in 2-3 weeks
Can convert to full thickness if infection occurs
Likelihood of scarring increases, lack of use, contractures and deformities
Full thickness third degree burn
Extreme heat, prolonged heat
Damage through epidermis and dermis, no viable skin under
Not painful due to damaged nerve endings, but surround tissue (2nd and 1st degree burns) will be painful
Pale in color, nonblanching, dry, black in some cases
Requires surgery (grafting) if over 3x3 (silver dollar)
Scarring very likely
Grafting most likely
Grading a burn: Rule of 9s
Grading a burn: Lund Browder Chart
Zenograft or heterograft
Processed pig
Homograft or allograft
Cadaver
Autograft
From the person
Only permanent graft
Why are grafts used?
to help prevent dehydration
Full thickness (flap) graft
usually small areas
Flap
Rotational/ free
Pedicled
Cultivated
Very expensive and thin
Gangrene
Loss of oxygen
Measuring edema
Standard tape measure - cheapest, least effective
Gulick
Volameter - most expensive, most effective, water displacement
Standard tape measure and Gulick are circumferential measurements
Can use figure 8 for hand measurement
Wound assessment
How did the wound occur?
Location of the wound
Size of the wound
- Direct measurement
* length x width = wound surface
* depth
* always measure in CM
* sterilize or dispose
- Wound tracing
- Photograph
Wound closure
Primary closure
- stitches, staples, or steri strips
* internal, external, or dissolvable
- edges are approximated
- deep wounds
Z plasty
- dupytren’s contractures
Secondary closure
- left open
- shallow wounds
- infected
- surgical preference
Tertiary intention
- delayed primary
- usually surgical wounds or deep lacerations
Issues with measuring wounds
Wound must be probed to determine if there is any
- tunneling: small tunnel due to a break down in tissue
- undermining: small opening leading to a large area
Both may require packing
- pack too tightly is will stop the healing
- gauze
- hydrogel
Measure with probe
How to describe wound bed
Pink or red and granular
Pale or faded and granular
Slough - yellow gunk
Eschar
Describe any exposed structures
Describe this wound
Defined edges
Granular tissue around edges with majority of wound covered with disconnected eschar
How do you describe wound edges
Indistinct
Distinct or well defined
Scarring or rolled edges (epibole)
- won’t heal
ADD PICTURES
Maceration
Skin rotting
To help with this:
- adjust bandage
- remove topical agent
- skin barrier
ADD PICTURE
Crust
The yellow center
Tissue that’s beginning to be a problem
ADD PICTURE
Wound drainage
Excudate - anything coming out of the wound
Consistency - thick or thin
Amount:
- none
- minimal: 1 pad/day
- moderate: 2 pads/day
- copious: 3+ pads/day
Types of excudate
Serous - clear or pale yellow
Sanguinous - light pink
Hemorrhagic - produces blood
Purulent or pus
- by itself may not be infection
- yellow; sterile, noninfected; accumulation of dead cells
Pseudomonas - blue/green
Wound odor
When describing: present or absent
Odor can be linked to infection, but may also be
- body odor
- dirty bandage
- bandage and topical solution
- proteus infection: smells like ammonia
- pseudomonas infection: sickly sweet
Inflammation vs. infection
Inflammation
- Rubor (color)
* well defined boarders, redness is ok
* proportionate to size and extent of wound
- Calor (temp)
* wam around the wound
- Tumor (edema)
* mild, proportionate to size of wound
- Functio laesa (function)
* temporary in affected area
- Drainage
* thin, serous or serosanguinous
Infection
- Rubor
* poorly defined boarders - “runners”
* redness is beyond extend of injury
* streaks
- Calor
* warm away from wound
* fever
- Tumor
* extensive and excessive
- Functio laesa
* malaise
* pt feels sick
* extreme pain
- Drainage
* copious amounts
* thick, purulent, or creamy
* white, yellow, green, or blue
* distinctive odor
Reasons to do a debridement
Decrease risk of infection
Increase effectiveness of topical agents
Improve activity of leukocytes
Decrease the energy required by the body for wound healing
Shorten the inflammatory phase
Decrease odor
When to do a debridement
If there is necrotic tissue or purulent tissue
Foreign material
Scabs
Blisters
Residual topical agents
When not to do a debridement
Healthy, red granular tissue
Very deep, surgical
Massive infection
- gangrene
Selective debridement
Sharp - forceps, scissors, and scalpel (license issues)
- serial (forceps and scissors)
* only remove what is willing to go with you
* bleeding and pain should be minimal
- selective sharp (scalpel)
Autolytic - using the body
- no necrosis or infection
Enzymatic
Leaches
Maggots
Non-selective debridement
Pressure irrigation/ pulsed lavage
Whirlpool
- 92º
Scrubbing
Wet to dry dressing
Cellulitis
Infection of the cellulite
Often occurs with small injuries, but can occur with major injuries too
What do topical agents do?
Prevent dryness
Promote healing
Keep moist
Growth factor
Sterile technique
No microbes left
Prolonged soaking or autoclave
Kept in sterile field
Sterile gloves
Standard for surgical setting, burns, and fragile wounds
Clean technique
Significantly reduces number of microbes
Anything that touches the client is sterile
Gloves, table, etc. are not
Now the standard for most wound care
Purpose of dressing and bandages
Decrease pain
Keep wound at proper temperature
Barrier to outside microbes
Keep good microbes in
Fill in dead space (packing)
Debridement
- wet to dry dressing
Types of dressings and bandages
Wet to dry
Damp to damp
Occlusive – tent over wound that doesn’t let anything in or out
Absorbent gauze
Nonabsorbent gauze (nonstick)
Impregnated gauze – usually a Vaseline product is in it
Semipereable
Hydrogels
Foams
Alginates
Rigid
Applying a bandage
Firm to hold in place the dressing
Should not cut of circulation or cause edema
Be cautious of tape
Don’t limit AROM
Special types
- Fingers, feet, faces
- Applicators
Cylindrical wrap distal to proximal
With all dressings, bandages, etc
- In most cases, less is more
Other things to help wound care
Whirlpool/hubbard tanks/showering
Pulsed lavage
Nutrition-protein
Estim
Ultrasound
Barrier
Wound treatments
O2-hyperbaric chamber
Exercise within pain free parameters increases circulation
WoundVac pumps
- Negative pressure wound therapy
Ultraviolet
- Promise for venous insufficiency-needs more research
Laser-also needs more research
Attitude
- Positive attitude, prayer
Removing stitches
Typically, 8-14 days
There will be a knot
Pull the knot up and cut one side
Pull other side
Removing steri strips
When they let go, it’s time to remove
Or if the edges are approximated
Removing staples
Use a staple pull
Slide under
Squeeze
Staple will pop up
Don’t pull
Do one at a time
Water and removal
- Stitches and Staples
- Safe to submerge and get dirty, 24-48 hours after removal
Care of surgical pins or external fixators
Do not disturb
Don’t allow skin to stick
Daily cleaning
- Hydrogen peroxide
Cover as needed for protection
Watch activities that will endanger
- Wood working etc
Cover during ADL’s as appropriate
How to apply a bandage
- Have all equipment and supplies close by
- Position pt so they are comfortable and you can see wound bed
- Explain what you are doing to pt
- Wash hands and put on gloves (clean or sterile depending on technique)
- Remove old bandage
- dispose as indicated
- adhesive bandages: stretch longitudinally to break seal
- remove adhered gauze by soaking with saline, unless wet to dry - Remove gloves
- Open any packages you will need
- Put on clean gloves
- Inspect the wound, rinse as needed with saline, do any interventions
- debridement
- modalities - Note any changes in the wound once you are done
- decreased size
- pain
- smell
- tissue removed - Apply
- nothing
- topical agent
- skin sealant or moisture barrier - Remove soiled gloves
- Apply new gloves
- Apply bandage
- Remove gloves
- Many places initial and date the new bandage
- Wash hands
- Educate pt
- Document
Clean up
Red bag anything with fluids
Remove gloves inside out
Clean work areas
Sterilize instruments
What should you do when you see a pink/red granular wound bed?
Debride only necrotic tissue
Protect the bed
What should you do when you see a moist wound bed?
Absorb moisture from wet bed - gauze, semipermeable
Keep covered
What should you do when you see a dry wound bed?
Add moisture - use product
Avoid toxic agents
What should you do when you see a dead space?
Lightly fill cavity, check for undermining and tunnels
What should you do when you see an infection?
Prevent it
Keep it covered
Use universal precautions
Use sterile technique
Contact physician
What should you do when you see a healthy periwound and skin?
Moisturize if dry, skin sealant if maceration
What should you do when you see slow healing?
Modalities, growth factors, nutrition, activity
What should you do when you see eschar or loose skin and tissue?
Pick what comes with you
What should you do when you see a dirty wound?
Selective of nonselective debridement as indicated
