Wound Care Flashcards
What are the three types of healing?
Primary intention
Secondary intention
Tertiary intention
What is part of primary intention healing?
Tissue surfaces approximated
Minimal or no tissue loss
Minimal granulation tissue and scar
Surgical incision
What is part of secondary intention healing?
Edges cannot or should not be approximated
Repair time longer
More scarring and risk of infection
What is part of tertiary intention healing?
Left open for 3-5 days and then closed
Allows edema to resolve exudate to drain
Closed with sutures, staples, or adhesive skin closures
“Delayed primary intention”
What are the phases of wound healing?
Hemostasis phase
Inflammatory phase
Proliferative phase
Maturation phase (remodeling)
What are some complications of wound healing?
Hemorrhage
Infection
Dehiscence
Evisceration
What are some modifiable factors for wound healing?
Nutrition
Lifestyle
Medications
What happens in the hemostasis phase?
Cessation of bleeding
Vasoconstriction and formation of clot
- Scab inhibits infection
- Epithelial cells migrate into wound- prevent entry of microorganisms
What happens in the inflammatory phase?
Blood supply increases
- Erythema and edema
- Exudate cleanses wound
- Neutrophils first 24 hours
- Replaced by macrophages
- Phagocytosis
- Crucial to healing
What happens in the proliferative phase?
Day 3-4 to 21 days
- Fibroblasts synthesize collagen: adds strength to wound
- Capillaries grow across wound, bring fibrin
- Granulation tissue forms
- Light red or pink
What happens in the maturation phase?
From day 21 up to 1-2 years
- Fibroblasts continue to synthesize collagen
- Wound site is remodeled and contracted
- Scar becomes stronger
-
What happens with a hemorrhage complication?
May bleed uncontrollably: emergency
Apply pressure
Surgery may be needed
Hematoma under wound may obstruct blood flow to area
What happens with an infection complication?
- Microbes compete for oxygen and nutrition: impairs wound healing
- Change in wound color, pain, drainage
- May occur during injury, surgery, or post-op
- Confirmed by culture
- May have fever, elevated WBC
- Immunosuppressed increased risk
What happens with a dehiscence complication?
- Partial or total rupture of sutured wound
- Cover with sterile saline gauze
- Patient to bed with knees bent
- Notify doctor
What happens with an evisceration complication?
- Protrusion of internal viscera through an incision
- Cover with large sterile dressing
- Patient in bed with knees bent
- Notify surgeon immediately
What are some risk factors for evisceration?
Obesity Poor nutrition Trauma Failure to suture Coughing Vomiting Straining
When does evisceration usually occur?
4-5 days post-op
Prevention: Nutrition
Protein CHO's Lipids Vitamins A and C Iron Zinc Copper
Prevention: Lifestyle
Regular exercise leads to better circulation
Smokers at risk for delayed healing
Prevention: Medications
Anti-inflammatory
Anti-neoplastic
Prolonged antibiotics
What is serous exudate?
Clear, thin, watery plasma.
Normal during inflammatory: in small amounts Moderate to heavy amount may indicate a high bioburden.
What is sanguineous exudate?
Fresh bleeding
In deep partial-thickness and full-thickness wounds.
Small amount may be normal during the inflammatory stage
What is Serosanguineous exudate
Thin, watery, and pale red to pink in color
The pink tinge indicates damage to the capillaries with dressing changes
What is a clinical manifestation of wounds?
Exudate
What is purulent exudate?
Thick and opaque
Tan, yellow, green, or brown in color
Never normal in a wound bed.
What are the different types of exudate?
Serous
Serosanguineous
Sanguineous
Purulent
Why are elderly patients at risk for impaired wound healing?
Impaired liver function Nutritional deficiencies Chronic illness Vascular changes Delayed inflammatory response Slowed collagen synthesis
What is a diagnostic test for wounds?
Wound culture and sensitivity
When would there be a need for an emergency surgery for wounds?
Life threatening
Repair tissue or vessels
When would there be a non-emergency surgery for wounds?
Ineffective healing
What are some types of non-emergency surgeries?
Debridement for infected necrotic tissue
Abscess- incision and drain
Escharotomy to remove eschar
What is the difference between necrotic tissue and eschar?
sret
What is involved in pharmacologic therapy?
Antibiotics
Topical gels or injectable meds with growth factors
Opioids and NSAIDS
What is involved in non-pharmacologic therapy?
Nutrition Compression Vacuum-assisted closure Hyperbaric oxygen therapy Stem cells Maggots Alternative
What is part of the nursing care for wounds?
Maintain moist wound healing
Promote optimal nutrition and hydration
Prevent infection
Position to minimize pressure on the wound
According to EBP, what is best for dry wound s?
Hydrocolloid dressings
Why are hydrocolloid dressings used?
Impermeable to oxygen, moisture, and bacteria
Maintain moist environment
Support autolytic debridement
According to EBP, a dry wound with no drainage should have what?
Transparent film
According to EBP, an exudative wound should have what?
Example?
Absorptive dressings
Hydrofiber (Aquacel)
What is the purpose of drains?
Allow excessive fluid, purulent drainage to drain
Assists with granulation tissue formation
What should the drain be labeled with?
Type of drain
Date
Initials
What is part of the nursing care for drains?
Maintain suction as needed
Assess and document drainage
What some types of drains ?
Jackson-Pratt (JP)
Hemovac
What is a wound V.A.C?
Continuous or intermittent negative pressure
Removes fluid and exudate
Prepares the wound for healing and closure
What should patients be evaluated for ?
Risk for bleeding
What are some complications of a wound V.A.C?
Hemorrhage from suction with anticoagulant therapy
Wound infection from dressing pieces left in wound
When should a VAC be stopped?
When bright red blood is seen
Apply pressure and notify doctor
Sutures can either be what
Absorbable
Non- absorbable
What are staples used for?
Close skin
How should staples and stitches be removed?
Ever other one
