Wound Care

Question 1

Things to be documented after performing a surgical incision dressing change

Answer 1

• Appearance of Incision (color, length, inflm/edema, preowned area?)
• Tissue involved and depth
• Approximation of incision
• If there is drainage (colour, volume, odour)
• Sutures/staples present (Number?)
• Are drains present (what is being drained)
• Solution used to cleanse
• Specific dressing used
• How it was tolerated by patient (analgesic?/response?)

Question 2

Describe 4 different types of exudate

Answer 2

Serous (More Translucent, less Necrotic tissue/WBC)

Purulent (Pus, WBC, Smell, Necrotic, often yellow)

Serosanguineous (Blood,heavy in clearish fluid- PINK)

Sanguineous (hemorrhagic) Bright Red

Question 3

Name 5 purposes of a dressing

Answer 3

maintain moist wound healing
Infection control/prevention
Prevent bleeding (includes prevention of further trauma)
Absorb Exudate or drainage
May reduce pain or provide psychological comfort

Question 4

Key factors influencing wound healing for a patient?

Answer 4

Age (very old or very young have DEC skin strength)
Nutrition
Location of wound (Access, Rubbing or time until found)
Immobility
Cognitive/physical ability for self care
Smoking 
Antibiotics (infection prolongs healing)
Obesity (Dec healing)
Steroids (Dec healing)
Chemotherapy (Dec healing)

Question 5

Intact skin refers to

Answer 5

surface skin and layers free from disruption or alteration

Question 6

Skin plays a role in

Answer 6

thermoregulation, sensory impulses, pain, pressure and communication

Question 7

Is skin related to self esteem?

Answer 7

Indeed it is! Can cause changes in body image and social interaction

Question 8

What is a clean wound

Answer 8

uninfected, minimal inflm, primarily closed wounds. Not connected to GI, Respiratory, genital or urinary tract

Question 9

What is a clean contaminated wound

Answer 9

surgical wounds in which GI, Respiratory, genital or urinary tracts have been entered under controlled conditions. NOT infected.

Question 10

what is a contaminated wound

Answer 10

open, fresh, accidental or surgical wounds that involve break in sterile technique or gross spillage from GI/urinary tract. Acute non purulent inflm present

Question 11

What is a dirty or infected wound

Answer 11

old/traumatic wounds that retain dead tissue. Involve clinical infection or perforated viscera

Question 12

what is an acute wound?

Answer 12

one that heals within the expected time frame

Question 13

what is a chronic wound

Answer 13

break or alteration of skin for a long duration (often over 3 months) or recurs frequently

Question 14

Name 6 types of wounds

Answer 14

Incision- usually intentional, w/ sharp object
Contusion (Bruise, only one considered closed)
abrasion (surface scrape, + pain)
puncture (penetrate to underlying tissue, int. or unint.)
laceration (tissue torn apart, jagged edges
penetrating (unintentional, underlying tissue, think bullet)

Question 15

How do you define wound by depth

Answer 15

Partial thickness- confined to dermis and epidermis, heals by regeneration

Full thickness- involves subcutaneous tissue, possibly muscle or bone, requires connective tissue repair

Question 16

what is a pressure ulcer

Answer 16

clinical sign indicating prolonged or excessive tissue deformation (compression, shear, tension) possibly including ischemic distortion of vasculature

Question 17

Stages of pressure ulcers

Kozier 1009

Answer 17

1) intact skin non plantable redness
2) partial thickness skin loss, open ulcer, w/ red/pink wound bed OR intact/open serum filled blister
3) full thickness, submit tissue visible, WITHOUT bone, muscle or tendon, could be tunneling
4) Exposed bone, muscle or tendon, slough or eschar (dried dead less) in wound bed. Often includes tunnelling

Question 18

Primary vs secondary vs tertiary intention

Answer 18

primary- tissue approximated (closed), minimal tissue loss, often surgical

secondary- involves considerable tissue loss, edges can not or should not be approximated. More scarring, higher likelihood of infection and long healing times

Tertiary- where wound must remain open for some time and approximated later on. Often due to contamination, infection or need to access damaged tissue

Question 19

Phases of wound healing

Answer 19

Hemostasis Phase
Blood vessels constrict; clotting factors activate coagulation pathways to stop bleeding. Clot formation seals the disrupted vessels so blood loss is controlled and acts as a temporary bacterial barrier

Inflammatory- vasodilation and cellular response we know from path)

proliferative- (day 3-21ish) filled with granulation tissue, fragile, bleeds easily

maturation (month to years) collagen, scar (keloid) development

Question 20

Steps of dressing change (besides hand washing etc)

Answer 20

remove old dressing (direction of hair growth if sticky)

clean area- the basics + (don’t remove residue that is difficult to clean off as it will irritate wound)

Assess

New dressing ( be sure ends of dressing taped down well, so they will not catch, tape to intact skin only)

Document

Question 21

How to make a solid garbage bag

Answer 21

put a cuff on the top using a quick fold over. Needs to be waterproof material

Question 22

can you use a solvent if tape if too sticky?

Answer 22

Apparently (Kozier suggests acetone)

Question 23

whats better: precut or cutting gauze yourself

Answer 23

precut- avoid messy edges that may get gummed up in wound

Question 24

What vascular factors might reduce healing

Answer 24

Hypovolemia, hypotension, vasoconstriction, edema, and hypoxia negatively affect wound healing because adequate perfusion and oxygenation are necessary for new vessel development, collagen synthesis, and development of tensile strength.

Question 25

Characteristics of black/brown tissue in a wound

Answer 25

Black or brown tissue is eschar, which represents full-thickness tissue destruction. Black is used to describe necrotic tissue or desiccated tissue such as tendon. It is also related to gangrenous lesions secondary to peripheral vascular disease. Often requires debridement

Question 26

Characteristics of yellow tissue in a wound

Answer 26

Yellow tissue represents nonviable tissue and in some cases the presence of an infection. It is often yellow, cream colored, or gray slough, which is usually accompanied by purulent drainage. the use of moisture-retentive dressings enhances debridement of the yellow tissue

Question 27

Characteristics of Red tissue in wounds

Answer 27

Red tissue represents the presence of granulation tissue. The red color is the result of an increasing amount of new blood vessels in the wound and is considered healthy. The goal in management of a red granulated wound is to select a dressing that maintains a clean and moist wound environment and minimizes damage to healing tissue.

Question 28

What is negative pressure wound therapy

Answer 28

A suction device is placed over the dressing; and the dressing, suction, and wound area are covered with a transparent dressing, which provides the airtight seal necessary for NPWT. The dressing is changed on a scheduled basis, usually no earlier than 48 hours. Chronic wounds such as pressure ulcers, diabetic ulcers, traumatic wounds, and venous stasis ulcers are approved for NPWT (see

Question 29

theory behind Negative pressure wound healing?

Answer 29

blood flow increases because of the removal of wound fluid and angiogenesis (develop- ment of new blood vessels) and that it stimulates the production of new blood vessels via a mechanical stretch of the tissue (Netsch, 2012). The removal of fluid from the wound decreases tissue edema, which increases dermal perfusion. The dressing placed into the wound maintains a moist environment to facilitate healing

Question 30

Key principles of wound irrigation

Answer 30

1) Cleanse in a direction from the least contaminated to the most contaminated area. 2) When irrigating, verify that all the solution flows from the least contaminated to the most contaminated area.

Question 31

When do you use high pressure vs low pressure when cleaning/irrigating wounds

Answer 31

high pressure is reserved for necrotic tissue, debris, particulate, or bacteria burden or exudate. Low pressure should be used on any viable tissue

Question 32

What is dehiscence

Answer 32

the failure of wound healing in which the surgical wound separates and opens to the fascial level. It occurs fairly early after surgery, by postoperative day 5 to 8 in patients in whom normal healing responses lag. Note: The wound edges open, and serosanguineous drainage is present. These wounds are then allowed to heal by secondary intention

Question 33

What is evisceration

Answer 33

a failure of wound healing, with total separation of the layers of the wound and protrusion of the internal organs through the wound. NOTE: This is a surgical emergency, and you need to cover the wound with a moist sterile saline dressing, notify the surgeon immediately, and prepare the patient for emergent surgery.

Question 34

what is debridement

Answer 34

Debridement, the removal of nonviable tissue from the wound, is an essential objective of topical therapy and a critical component of optimal wound management NTOE: Methods of debridement include enzymatic, mechanical, autolytic, or sharp.

Question 35

What kind of debridement is irrigation

Answer 35

mechanical NOTE: High-pressure irrigation is the cleansing of a debris-filled wound with irrigating fluid delivered at 4 to 15 psi with a 35-mL syringe and a 19-gauge angiocatheter

Question 36

Types of dressings

Answer 36

Gauze- Cotton or synthetic material; woven or nonwoven construction. Often Primary intention Transparent films- Adhesive membrane dressings; waterproof, impermeable to fluids and bacteria; allow oxygen and moisture vapor exchange Hydrocolloids- Adhesive dressings that contain gel-forming agents; mold to body contours, considered semiocclusive dressings hydrogels- Glycerin-or water-based dressings designed to maintain clean, moist wound; may also absorb small amount of exudate (burns) Alginates- Highly absorbent, nonwoven material that forms gel when exposed to wound drainage; fibrous product derived from brown seaweed foam dressings- Absorbent, nonadherent polyurethane or film-coated layer used to protect wounds and maintain moist healing environment

Question 37

What is potentially more pain- deep or superficial wounds

Answer 37

Superficial wounds with multiple exposed nerves may be intensely painful, whereas deeper wounds with destruction of dermis should be less painful

Question 38

Where do you collect a wound drainage sample

Answer 38

Always collect a wound culture sample from fresh exudate from the center of a wound after removing old drainage. Resident colonies of bacteria on the skin grow in wound exudate and may not be the true causative organisms of infection

Question 39

How to collect C&S of wound

Answer 39

1- wash wound with sterile saline and debrided superficially with swab. 2) apply saline to clean swap to aid in bacteria adherence 3) Zig zag swab over center area of wound, rotating as you go. centre towards sides, firm pressure (may be painful) 4) repeat process if there is a sinus or pocket

Question 40

Key features of a physiologic wound environment

Answer 40

are adequate moisture, temperature control, pH, and control of bacterial burden

Question 41

is wet or moist best for healing?

Answer 41

A wound heals best in a moist environment because this favors epithelial cell migration, promotes extracellular matrix formation, reduces fibrosis, and decreases wound infection