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Hand/UE 3 > Wound Care > Flashcards

Wound Care Flashcards

1
Q

phases of healing (3)

A
  1. inflammatory phase
  2. proliferation phase
  3. maturation phase
    * all overlapping
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2
Q

inflammatory phase

A
  • begins the moment of injury and lasts 2 days to 2 weeks
  • initial vasoconstriction to control blood loss
  • protein-based fluid leaks out of vessels and swelling begins along with clean-up cells
  • within 30 minutes mast cells release histamine to cause vasodialation
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3
Q

proliferation phase

A
  • begins once injured area being clean and free of damaged tissue, foreign matter, and bacteria and last several weeks
  • consists of granulation, angiogenesis, wound contraction, and epithelialization
  • moist wound bed desired
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4
Q

maturation phase

A

“remodeling phase”

  • water and amino acids squeezed out of the granulation tissue matrix
  • collagen fibers produced, forms scar
  • can last up to 2 years
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5
Q

scar vs skin strength

A

scar is 80% as strong as skin at full maturity

*scar management is important

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6
Q

factors that affect healing (9)

A
  1. circulation
  2. debris in wound bed
  3. infection
  4. chemical stress
  5. temperature of wound bed
  6. amount of moisture in/around wound bed
  7. medications and other medical conditions
  8. nutrition
  9. age
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7
Q

debridement

A

the removal of necrotic tissue from a wound so the healthy tissue is exposed in the wound bed

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8
Q

slough

A

yellow, white stringy tissue
moist composite of fibrin bacteria, dead cells and exudate
*dead tissue

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9
Q

eschar

A

black, hard tissue, occasionally moist in appearance

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10
Q

autolytic debridement

A

when the body breaks down the necrotic tissue on its own

  • can encourage with dressings
  • comfortable and effective, but slower
  • watch for macerated skin
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11
Q

enzymatic debridement

A

use of topical enzymes to break down slough and eschar

  • check state practice act
  • collagenase ointment - needs Rx
  • may cause discomfort
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12
Q

sharp debridement

A

use of sharp instrument (scissors/scalpel) to selectively remove necrotic tissue

  • check state practice act
  • need to be skilled
  • fastest and most effective method
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13
Q

mechanical debridement

A

remove of dead tissue using methods like whirlpool agitation, high pressure fluid irrigation, or wet-to-dry dressings
**NOT RECOMMENDED

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14
Q

hypergranulation tissue

A

looks like shiny, deep-red balls of tissue that grow taller than the wound margin

  • soft, bleeds easy
  • treat with nitrate sticks (do with dressing changes/turns tissue gray)
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15
Q

wound cleansing frequency

A

wound should be cleansed every time the dressing is changed

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16
Q

best wound cleansing solutions

A

normal saline
sterile water
drinkable tap water

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17
Q

wound cleansing solutions to avoid

A

hydrogen peroxide, Dakin’s solution, povidone iodine/Betadine, soap, bleach
*never use anything you would not be willing to put in your eye

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18
Q

hydrogen peroxide and wounds

A
  • should only be used in home setting to clean cuts/scrapes immediately after injury
  • once wound is free from debris, OH can be toxic to granulation tissues and use can slow wound healing
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19
Q

moisture balance

A

moist wound will heal much faster than a wound that is too wet or too dry

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20
Q

goals of wound dressing

A

keep bacteria out, retain some moisture, but still absorb any excess fluid if needed

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21
Q

non-occlusive dressing

A

allows for free passage of water, vapor, and bacteria

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22
Q

occlusive dressing

A

will not allow passage of water, vapor, and bacteria

23
Q

semi-occlusive dressing

A

falls in the middle

allows passage of water vapor, but not water or bacteria

24
Q

types of dressings (6)

A
  1. transparent film
  2. impregnated low-adherence dressings
  3. hydrogels
  4. gauze
  5. foams
  6. alginates
25
Q

transparent film dressings

A

semi-occlusive
thin, see-through films that adhere right to the skin and can be used as primary or secondary dressing
*can last up to 7 days

26
Q

impregnated low-adherence dressings

A

non-occlusive to semi-occlusive
designed to make contact with wound and reduce sticking and tearing of wound tissue during dressing changes
*requires secondary dressing
*reduces risk of infection

27
Q

hydrogel dressings

A

non-occlusive to semi-occlusive
designed to hydrate wounds and promote autolytic debridement
*requires secondary dressing
*needs to be changed every 24-72 hours

28
Q

gauze dressings

A

non-occlusive
most widely available and commonly used
can be used to clean, pack, or cover wounds
*as primary dressing it cannot easily create moist wound environment and also tends to shed fibers
*good secondary to keep other dressings in place

29
Q

foam dressings

A

semi-occlusive
mosty polyurethane and used to absorb moderate amounts of exudate and provide cushioning
*can be primary or secondary depending on brand
*doesn’t conform well to hand

30
Q

alginate dressings

A

non-occlusive to semi-occlusive
derived from seaweed
highly absorbent and made for moderate-large amounts of exudate
*as alginate absorbs fluid, it is converted to a gel that provides moisture to the wound bed
*requires secondary dressing

31
Q

primary intention

A

wound is closed with sutures or staples

*wound heals by fibrous adhesion and little to no granulation tissue

32
Q

secondary intention

A

the wound is left open and left to heal through the granulation process
*requires close monitoring

33
Q

tertiary intention

A

“delayed primary wound closure”

wound is left open initially then closed a few days later

34
Q

patient education on wound care and smoking

A
  • educate them that nicotine decreases the delivery of O2 to tissue and can increase the risk for wound healing complications
  • 1 cigarette can reduce blood flow to hand
  • encourage clients to temporarily stop smoking until wound is healed (or at least cut back)
35
Q

eval - location of wound

A

when describing the location of a wound, be precise do so in terms of anatomical position
ex. “The wound is on the anterior medial aspect of the distal forearm, 2 cm proximal to the pisiform”

36
Q

eval - size of wound

A

length, width, depth recorded in mm or cm

clock method or length and width at longest points

37
Q

eval - wound depth

A

depth measure by inserting a moistened sterile cotton-tipped applicator into the deepest part of the wound
*look for tunneling

38
Q

tunneling

A

a narrow and deep hole that runs away from the main part of the wound

  • creates “dead space” and increases risk of abscess formation
  • record depth and location using clock face method
39
Q

eval - wound margins

A

note color and condition of edges of the wound

  • healthy: pink and flat, firmly attached to tissue underneath
  • watch for undermining
40
Q

undermining

A

space under the wound margins

*sign that wound is not healing effectivley

41
Q

eval - periwound skin

A

note color and condition of skin around the wound

  • should be skin-colored or maybe a little pink
  • redness, inflammation or hardening could indicate infection
  • small lesions could indicate damage from adhesive dressings
  • soft, white indicates skin has absorbed too much fluid
42
Q

macerated skin

A

soft, white skin that results from wound exudate not being adequately absorbed by the wound dressing
*fragile and easily damaged

43
Q

denuded skin

A

when the epidermis around the wound starts to breakdown

44
Q

eval - wound characteristics

A

describe wound using “red-yellow-black” system and document with digital photos to record wound healing progression

45
Q

“red-yellow-black” system

A

estimate what % of the wound is colored by each color

red: healthy
yellow: slough
black: eschar

46
Q

photographing wounds

A

helpful in documenting

always do at same point of treatment, same camera, same settings, same distance, NO FLASH

47
Q

eval - wound exudate

A

describe color, consistency, odor and amount of discharge

*hydrocolloid dressings produce foul odor; this is normal so assess after cleaning

48
Q

serous

A

clear and watery exudate

*normal

49
Q

serosanguinous

A

thin and pink exudate

*normal

50
Q

sanguinous

A

thin and bright red exudate

*may or may not be normal depending on amount and type of tissue in wound bed

51
Q

purulent

A

thick or thin, tan to yellow exudate

*sign of possible infection

52
Q

foul purulent

A

thick, yellow to green exudate with bad odor

*sign of infection

53
Q

signs of infection (9)

A
  1. pain
  2. foul odor
  3. pus drainage
  4. redness
  5. warm to touch
  6. hardening around wound
  7. lymphangitic streaking/red streaks
  8. malaise
  9. fever
54
Q

wound care clinical reasoning (5)

A
  1. moist wound healing is best
  2. create a clean wound bed
  3. wound bed is fragile
  4. infection must be identified
  5. do no harm

Hand/UE 3 (7 decks)

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