Wound Care 3 Flashcards
3 types of wound drainage
serous
sanguineous
purulent
serous wound drainage
pale yellow or transparent fluid from body cavities
sanguineous wound drainage
color of blood or containing blood
purulent
possible infection
production of pus
When should odor be assessed?
after debridgement and rinsing
should be described as present of not present
What is Turgor?
sign of dehydration
you pull up skin on back of hand for few seconds and see how quickly it returns to normal
Color-hyperpigmentation
long standing venous insufficiency
color-blue
prolonged ischemia
Color-lighter/paler
means decreased blood supply or newly formed scar tissue
What does it mean if wound is nonblanchable?
ischemic damage due to unrelieved pressure
What is induration?
firm edema
Measuring Temperature
measure with dorsum of hand after pt has rested in supine for 5 min.
compare to proximal body segments
Increased temp=inflammation or infection
Purposes of debridement
decrease bacterial concentraion/infection risk
increase effectiveness of topical antimicrobials
improve bactericidal activity of leukocytes
shorten the inflammatory phase of wound healing
decrease energy required by body for wound healing
What does black wound bed indicate?
covered in eschar
indicates full thickness wound probably
should be debrided
Yellow wound means what?
draining wound covered with slough
may result from partially removed eschar of black wound or may represent more superficial wound.
moisture=bacteria growth and maceration
Red wound means what?
granular wound (red and ready to heal)
should not be debrided
should be protected in a warm, moist environment
Should calluses be debrided?
yes possibly
if large fluid filled blisters, over joint, or burn blisters, they may need to be debrided.
Contraindications for PT debridement
red, granular wounds surgical debridement (deep tissues, undermining stage 4, electrical burns, and gangrenous tissue
Two types of debridement
selective
non selective
4 methods of debridement
sharp (selective)
autolytic (selective)
enzymatic (selective)
mechanical (non selective)
Sharp debridment
selective
fastest, most aggressive method outside of surgery
may be done by PTs but not PTAs
When is sharp debridement indicated?
large amount of necrosis
advancing cellulitis
advancing sepsis
wounds w/necrotic tissue
When is sharp debridement contraindicated?
area can’t be seen because of tunneling/undermining
material to be debrided can’t be identified
on uninfected ischemic ulcers
Definition of Autolytic debridement (selective)
uses body’s own enzymes, including collagenase to digest necrotic tissue by applying moisture retentive dressing and leaving it in place several days
Facts about autolytic debridement
most conservative, least invasive, least painful
takes min. time
reduces cost over long term
easy to teach pts/clinicians
doesn’t allow frequent visual of wound bed and you have to wait a few days for it to work
Indications for autolytic debridement
wound that contains necrotic tissue
pt who can’t tolerate other forms of tx
Contraindications for autolytic debridement
infected wounds
wounds needing sharp or surgical debridment
What is enzymatic debridment? (selective)
use of topical exogenous enzyme to remove devitalized tissue
can be done by PTA
About enzymatic debridement
need physicians prescription don't need as much skill less painful than others (beside autolytic) can be expensive/time consuming less effective
Types of enzymatic debridement
proteolytics-family of proteins that degrade necrotic debris
fibrinolytics=breaks down blood clot
collagenases-promote cellular response to injury
Indications for enzymatic debridement
infected and uninfected wounds w/necrotic tissue
pts who can’t tolerate sharp debridement
adjunct to sharp or mechanical debridement between sessions
home care or LTC settings
Contraindications
wounds w/exposed deep tissues when sharp or surgical debridement is required facial burns wounds with no necrotic tissue wounds being autolytically debrided
What is mechanical debridement?
nonselective
use of force to remove devitalized tissue, foreign material, and debris.
What is Wet-to-dry mechanical debridement
applying single layer of fluffed saline moistened gauze to necrotic wound, covering w/more gauze, then allowing to dry 8-24 hours.
When it’s dry, it’s torn away at right angle.
About wet to dry mechanical debridement
removes viable AND nonviable tissue
risk of perwound maceration and fungal infection
less effective than enzymatic and autolytic
only indicated in wounds with 100% devitalized wound beds.
What is mechanical “scrubbing” debridement?
use of sponge, brush, or gauze along with a fluid to break the adherence of devitalized tissue and debris from wound bed.
About “scrubbing” debridement
can remove or traumatize viable tissues as well
contraindicated for granulating wounds
high porosity sponge and LITTLE force is recommended.
begin at wound center and work out to avoid contaminating cleansed areas.
What is wound cleansing?
delivery of wound cleanser to wound surface using mechanical force to remove lightly adhered necrotic tissue, debris, and bacteria.
Facts about wound “cleanser”
cleansers often contain antiseptic and have antimicrobial properties.
They aren’t FDA approved
they have been found to contain cytotoxic agents that delay wound healing.
7 main purposes of whirlpool
debride loosely adherent devitalized tissues
soften necrotic tissue and eschar
hydrate the wound bed/ promote healing
promote circulation
reduce pt pain complaints during wound care
ease ROM
can soak off adherent dressings
Indications for whirlpool
infected wound
nondraining wound
wound with thick eschar
wound with loosely adherent necrotic tissue
Contraindications for whirlpool
clean, granulating wounds
tunneling wounds or wounds w/undermining
wounds in areas of skin folds
What is pulsed lavage w/concurrent suction?
delivery of wound irrigant under pressure by an electrically powered device and removal of irrigant with negative pressure.
Advantages of pulsed lavage
removal of irrigant decreased tx cleanup portable shorter tx time lower cost less risk of cross contamination less physiological stress less painful than whirlpool better ergonomics for clinician
Disadvantages of pulsed lavage
one time use tubing and wound tips=increased cost
not appropriate for extensive wounds
Indications for pulsed lavage
cleansing or debriding wounds due to arterial insufficiency, venous insufficiency, diabetes, pressure, small burns, surgery, or trauma
contraindications for pulsed lavage
near exposed arteries, nerves, tendons, bones in body cavities facial wounds recent grafts or surgical procedures wounds that are actively bleeding
What is Negative pressure wound therapy?
subatmospheric pressure to wound using electrical pump to intermittently or continuously convey pressure through connecting tubing to a specialized wound dressing to promote healing.
Advantages of negative pressure wound therapy
moist wound environment establish fluid balance removal of slough reduction in edema and 3rd space fluids potential decrease in wound bacteria increase blood to wound increase growth factors by approximation promotion of white cells and fibroblasts in wound
Disadvantages of negative pressure wound therapy
one time use for tubes and supplies
not ideal for all pts
Indications for negative pressure wound therapy
pressure ulcers stage 3 &4 ortho trauma wounds diabetic ulcers post op flaps open abdominal and surgical dehisced wounds partial thickness wounds
Contraindications for negative pressure wound therapy
malignancy untreated osteomyelitis exposed blood vessels necrotic tissue with eschar or slough nonenteric or unexplored fistula bleeding disorder untreated malnutrition
