Wound Care Flashcards
do nurses stage wounds?
no, b/c of financial implications for the hospital
what causes wounds (6)?
- pressure
- truma
- surgery
- burns
- infections (skin contaminated)
- arterial/venous insufficiency
wounds need to be protected from what three things?
- mechanical injury
- pressure
- microbial contamination
are wounds cared for using “sterile” or “clean” techniques?
it depends, we mostly see clean
what are the 6 objectives wound care is meant to do?
- protect
- enhance healing
- absorb drainage
- splint/immobilize
- prevent premature closure of infected wounds
- debride wound site
after surgery who changes the dressing on surgical incisions for the first time?
physicians, unless otherwise ordered
what is an example of a wound that requires clean technique?
decubitous (pressure injury)
what is an example of a wound that would use sterile technique?
a wound in the abdomen or chest
what is tunneling?
when a wound extends deeper than its surface creating tunnel or channel
what is undermining?
a wound complication where the edges of a wound separate from the healthy tissue around it, creating a pocket of dead space under the skin.
what are the 10 aspects of a wound that might need to be documented?
- location
- size/shape
- appearance/color
- approximation
- drainage
- odor
- undermining/tunneling
- suture/ staples
- dressing type
- drains
what is dehiscence?
separation of wound edges
what is evisceration?
abdominal contents protrude through wound opening
what are some wound complications that require immediate intervention?
dehiscence and evisceration
what are the three types of wound healing?
primary, secondary
and tertiary
what is secondary wound healing?
will not be closed by sutures, heals from the inside out
-wound gaping and irregular
-granulation occurs over time
-epithelium fills in scar (bigger)
what is primary wound healing?
-clean wound (most wounds)
-sutured early
-results in a hairline (small) scar
what is tertiary wound healing?
will be closed by sutures
-wound not sutured but needs to be
-granulating tissue sutured together
what is the Braden scale for?
-used to help predict skin breakdown
-scoring charted each shift
-used to guide care and prevent skin breakdown
what are three causes of pressure wounds?
-pressure (bony prominences)
-compromised blood flow
-shearing forces
what are shearing forces?
friction from moving pt. around
the Braden score assesses which 6 areas?
- sensory perception
- moisture
3.activity - mobility (pt. demo)
- nutrition
- friction and shear
what are some bony prominences to look out for in regards to pressure wounds?
back or side of head
scapulae
elbows
sacrum
heels
knee
ear
malleous (ankle)
hip
shoulder
vertebrae
pelvis
toes
breasts
cheek
with the Braden scale a lower score equals _______ risk
higher
range 6-23
<18 score on the braden scale means what?
at risk for skin breakdown and begin skin preventative interventions
hat are preventative intervention for someone who is at risk for skin breakdown?
turn/ reposition
protect bony prominences
increase activity
nutrition/ HYDRATION
MANAGE MOISTURE
use pressure redistribution surfaces
Pressure injuries staging 1-4
1 red skin
2 broken skin
3 deep, through sub-q tissue
4 to bone
what is eschar?
eschar is dead tissue that forms a scab-like covering over wounds and eventually falls off
unstageable
describe a stage 1 pressure injury
reddened area
localized
nonblanchable
usually over bony prominence
painful
hard/soft
warmer/cooler
dark skin may be diff.color
describe a stage 2 pressure wound
-partial thickness loss of dermis
-open but shallow
-pink wound bed
describe a stage 3 pressure wound
-deep crater
-full thickness skin loss
-may extend into adipose layer
what are 5 other types of wounds besides pressure?
- skin tears
- arterial ulcers
- venous ulcers
- diabetic foot ulcers
- incontinence associated dermatitis
what are medical devices that can cause skin breakdown?
nasal cannula
o2 face mask
o2 sat probes
tracheostomy parts
feeding tubes
vascular lines/hubs
urinary and fecal tubing
chest tubes
cervical collars
braces/splints/casts
SCDs
bedpans
describe a stage 4 pressure wound
full thickness skin loss
-very deep
- may extend into muscle or bone
- slough/eschar may be present (dead tissue)
who stages pressure wounds and how do they do it?
a wound care expert
photos taken w/ facility camera, measured (tunnels too)
what is undermining/tunneling?
a wider are of wounding that lies beneath the wound opening
who directs wound care?
MD order supersedes
PT/RN wound specialist
what are some types of wound dressings that are commonly used?
transparent adhesive wound barriers (tegaderm)
impregnated npn-adherent dressings (adaptic or vaseline gauze, xeroform)
what are some different types of gauze?
2x2
4x4
fluffs
kerlix
ABD pads
split drain sponge
what are some example s of hydrocolloids? why is it not used often?
mepilex
duoderm
must be specifically ordered. not used often due to possible damage upon removal
used for bedsores (mildly exuding wounds) maintain moisture and protect from bacteria
what is hydrogel and how does it help wounds?
it is a 90% water in a gel base.
creates a moist healing environment and fills in dead space
what does hydrogel promote?
-granulation
-epithelialization
-autolytic debridement (enzymes break down necrotic tissues)
can hydrogel be used with infection present?
yes
should hydrogel be applied directly to wounds or to dressings?
can do both
what are some wound irrigation solutions?
normal saline
hydrogen peroxide (full/partial strength)
dakins solution
what are the 8 steps in wound care planning?
- review order
- determine clean vs. sterile
- pre-medicate
- source doc.
- explain procedure/consent
- necessary supplies to rm.
- extra help?
- lucky gloves
it is important to move from ________ to __________ areas in wound care
Clean to contaminated
pressure injuries are considered __________, so we use ____________ with them
colonized
clean technique
a wound itself is considered what?
sterile
what is the purpose of wet-to-dry dressings?
to gently debride the area
wet to dry dressings are actually supposed to be what?
moist to dry
avoid placing wet dressing on healthy skin, it will macerate (break down)
what is the procedure for changing a wound dressing? 14 steps
- hand hygiene
- prepare sterile field
- add necessary sterile supplies
- pour cleansing solution
- remove outer dressing with clean gloves
- remove inner dressing with sterile tweezers
- discard tweezers/ non-sterile gloves
- apply sterile gloves/use new suture kit
- insert guaze w/ sterile tweezers/sterile q tips and gloves
- DO NOT TOUCH OUTSIDE OF WOUND
- fill entire wound with gauze
- cover wound with absorbent pad/gauze
13.cover with protective dressing - secure dressings
what are three ways to secure dressings?
tapes
wraps
montgomery straps
what are three kinds of tape?
paper
plastic
cloth
what are three kinds of wraps?
gauze
stretch netting
ace bandage
what is sanguineous drainage?
bloody
what is serous wound drainage?
watery
what is serosanguineous drainage?
watery/bloody
what are abdominal binders commonly used for?
to help pt. feel better and supported after surgery
how to wrap ace bandage?
diagonally back and forth, secure with hooks
what are the two suture types?
plain interrupted
plain continuous
when removing plain interrupted sutures what part do the tweezers hold onto?
the knot side
what are three ways to close a wound?
sutures
staple
cyanoacrylate glue (derma bond)hat is
a penrose drain?
drain that allows for open drainage through capillary action to skin surface through tube, drainage absorbed in dressing (not for lg. amts. of drainage)w
What is a JP suction drain?
and what does it do?
(jackson pratt)
provides gentle suction
must be compressed
150 mL max (sm amt.)
keep track of amt.
what is a hemovac? and what does it do?
used for lg. volumes
placed in vascular cavity
must be compressed
stronger and larger than JP
what is cold therapy good for? what does it do?
-controls bleeding
-decreases edema
-pain control
-anti-inflammatory effect
what is heat therapy good for? what does it do?
-facilitates soft tissue -repair
-relaxes skeletal muscles
-increases blood flow to area
what are the safety factors with heat therapy?
order required
intact sensory function
assess response
what are the safety factors for cold therapy?
order required
not applied directly to skin
discontinue when numbness is achieved
assess response
15 min on/ 15 min off
what is generally applied first to a wound? hot or cold therapy?
cold therapy for about 2 days then move on to hot therapy
