Wound Care Flashcards
localized injury to skin and other underlying tissue, usually over a bony prominence as a result of pressure, shear, or friction
Pressure Injury
Two types of pressure injuries
those with loss of tissue and those without
Acute wounds without tissue loss. The skin edges “approximate” and are easily pulled closed with sutures, clips, or “Steri-strips” These wounds heal in an orderly and predictable fashion–all the tissue layers heal at once. These wounds heal quickly (usually within 14 days)
Primary Intention healing
Examples of Primary Intention healing
incisions and lacerations
Tissue is lost, and therefore wound edges can’t be pulled together–there is a “cavity left underneath and a high risk of infection. Thus, the wound has to be left open (not sutured). These types of wounds heal from the “bottom up” as the wound fills with granulation tissue. Healing takes a long time.
Secondary Intention healing
Examples of Secondary Intention healing
burns and pressure injuries
Also called delayed primary closure. A wound in which the edges could be pulled together and closed with sutures or staples but is purposely left open for 3-5 days due to excessive drainage, hemorrhage, or infection in the wound before it is closed.
Tertiary Intention healing
clear and watery clear and watery
Serous
a pale red or pink and watery type of drainage (has some red blood cells in it)
Serosanguinous
drainage that is primarily composed of actual bright red blood-a “thick” type of drainage. If the amount of blood is large, it is termed “hemorrhage”. Occasionally a hematoma (collection of blood beneath the surface of the tissue producing swelling) can form in closed wounds
Sanguineous
“pus”—liquefied necrotic tissue; often indicative of infection
Purulent
if the pressure applied over a capillary exceeds the normal capillary pressure
Pressure intensity
the vessel is occluded for a prolonged period of time; could be low pressure over a prolonged period or high-intensity pressure over a short perio
Pressure duration
The ability of tissue to endure pressure: depends on integrity of tissue & supporting structures & ability of underlying skin structures to help redistribute pressure
Tissue tolerance
an increased amount of drainage from the wound, a change in the wound drainage
erythema
partial separation of wound layers at the surface of the wound. The layers of the skin and tissue separate – this commonly occurs before collagen formation which is 3 to 11 days after injury or surgery.
Dehiscence
Most commonly seen with abdominal wounds / abdominal surgeries. Obese patients are especially at risk (constant strain on the wound, plus the fact that that fatty tissue heals poorly). Patients with poor nutritional status, underlying infection, history of chronic disease such as diabetes or peripheral vascular disease
Dehiscence
total separation of all layers of a wound with protrusion of abdominal organs. Is a medical emergency which requires surgical repair.
Evisceration
If Evisceration occurs, we should
cover the wound with sterile cloths or dressings soaked in sterile saline
Abnormal passageway connecting one epithelial surface with another epithelial surface
Fistula
flexible rubber tube that usually lie under the wound dressing and often a clip is placed to prevent the drain from slipping further into the open wound.
Penrose
bulb device with its own suction when fully compressed used for drainage
Jackson-Pratt (JP)
to ensure an irrigation pressure is within the correct range it is best to use a
35 mL syringe with 19-gauge
means removal of dead tissue
Debridement
is loose, stringy, hydrated tissue that is usually yellow
Slough
is dehydrated, thick, leathery tissue that is usually black
Eschar
Wet-to-dry, Pulsed low-pressure irrigation, Whirlpool treatments
Debridement
covering the wound with a dressing that supports moisture at the would surface
Autolytic
application of a topical enzyme preparation that either dissolve or digest dead tissue
Chemical Debridement
using a scalpel or other sharp instrument to cut away dead tissue
Surgical Debridement
is good for superficial wounds with little drainage. Not absorbent. Also used for autolytic debridement. Can serve as “secondary dressings” over the top of alginates and gauzes.
Self-adhesive, transparent film
the oldest and most common. Most often used to cover surgical incisions, keep them clean, and absorb small amounts of drainage. For routine surgical incisions, the initial dressing should be kept in place for 24-48 hours.
Dry Gauze
A form of mechanical debridement. As the saline soaked dressing dries, it “sticks to” the wound and pulls away dead tissue when it is removed
Wet-to-dry dressings
these really don’t represent the appropriate standard of care anymore. These kinds of dressings are “non-selective”- this means that in addition to stripping out necrotic tissue some viable granulation tissue is inevitably removed.
Wet-to-Dry dressings
If using gauze in a clean, granulating wound that isn’t being debrided, NEVER allow it to dry out
Wet-to-moist dressings
are an occlusive-type dressing impermeable to water, water vapor, and oxygen. Their contact layer also forms a gel with the exudate from the wound and keeps it moist.
Hydrocolloids
available as sheets, impregnated gauze, or gels. They keep dry wounds moist and soothe and cool the wound. Not absorbent Often used for thermal burns and painful wounds.
Hydrogels
An increasingly popular wound care choice. They have a non-adherent, moderately absorbent inner layer, and often a narrow adhesive silicone border all the way around to “seal the dressing shut”.
Foams
made of a highly absorbent material manufactured from seaweed. They can absorb up to 40 times their own weight in fluid. Good for wounds which drain copiously. Do not use on dry wounds!
Alginates
Sutures and staples usually removed _________ (provider’s order needed).
at 7-14 days
