Wound Care Flashcards
Things to be documented after performing a surgical incision dressing change
- 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?)
Describe 4 different types of exudate
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
Name 5 purposes of a dressing
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
Key factors influencing wound healing for a patient?
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)
Intact skin refers to
surface skin and layers free from disruption or alteration
Skin plays a role in
thermoregulation, sensory impulses, pain, pressure and communication
Is skin related to self esteem?
Indeed it is! Can cause changes in body image and social interaction
What is a clean wound
uninfected, minimal inflm, primarily closed wounds. Not connected to GI, Respiratory, genital or urinary tract
What is a clean contaminated wound
surgical wounds in which GI, Respiratory, genital or urinary tracts have been entered under controlled conditions. NOT infected.
what is a contaminated wound
open, fresh, accidental or surgical wounds that involve break in sterile technique or gross spillage from GI/urinary tract. Acute non purulent inflm present
What is a dirty or infected wound
old/traumatic wounds that retain dead tissue. Involve clinical infection or perforated viscera
what is an acute wound?
one that heals within the expected time frame
what is a chronic wound
break or alteration of skin for a long duration (often over 3 months) or recurs frequently
Name 6 types of wounds
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)
How do you define wound by depth
Partial thickness- confined to dermis and epidermis, heals by regeneration
Full thickness- involves subcutaneous tissue, possibly muscle or bone, requires connective tissue repair
what is a pressure ulcer
clinical sign indicating prolonged or excessive tissue deformation (compression, shear, tension) possibly including ischemic distortion of vasculature
Stages of pressure ulcers
Kozier 1009
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
Primary vs secondary vs tertiary intention
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
Phases of wound healing
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
Steps of dressing change (besides hand washing etc)
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
How to make a solid garbage bag
put a cuff on the top using a quick fold over. Needs to be waterproof material
can you use a solvent if tape if too sticky?
Apparently (Kozier suggests acetone)
whats better: precut or cutting gauze yourself
precut- avoid messy edges that may get gummed up in wound
What vascular factors might reduce healing
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.
Characteristics of black/brown tissue in a wound
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
Characteristics of yellow tissue in a wound
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
Characteristics of Red tissue in wounds
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.
What is negative pressure wound therapy
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
theory behind Negative pressure wound healing?
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
Key principles of wound irrigation
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.
When do you use high pressure vs low pressure when cleaning/irrigating wounds
high pressure is reserved for necrotic tissue, debris, particulate, or bacteria burden or exudate. Low pressure should be used on any viable tissue
What is dehiscence
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
What is evisceration
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.
what is debridement
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.
What kind of debridement is irrigation
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
Types of dressings
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
What is potentially more pain- deep or superficial wounds
Superficial wounds with multiple exposed nerves may be intensely painful, whereas deeper wounds with destruction of dermis should be less painful
Where do you collect a wound drainage sample
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
How to collect C&S of wound
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
Key features of a physiologic wound environment
are adequate moisture, temperature control, pH, and control of bacterial burden
is wet or moist best for healing?
A wound heals best in a moist environment because this favors epithelial cell migration, promotes extracellular matrix formation, reduces fibrosis, and decreases wound infection
