Wound Care Flashcards
Gauze
Absorbs exudate
Damp to damp
4x4 that remains damp to mechanically debride wound until granulation begins to form
Self adhesion/transparent film
Tergaderm and biolusive
Secondary skins ideal for small superficial wounds
Hydrocolloid
Duoderm and exuderm Occlusive bandage that forms seal Made up of gelatin and pectin Maintains granulation bed May stay in place for seven days
Hydrogel
Hypergel and intrasite gel Gel after contact Promotes debridement and cooling Rehydrated and fills dead space Can stay in place for three days
Inflammatory stage
Injury to 3/6 days
Blood supply brings WBCs, O2 and nutrients
Macrophages do phagocytosis
Proliferative stage
3 to 24 days
Granulation, connective or collagen replaces lost tissue
Edges begin to contract
Maturation stage
Day 21+ up to a year
Strengthening of collagen scar
Return to normal appearance
How much hydration should you add for wound management
2000-3000 mL
How can albumin levels indicate a delay in healing
Albumin levels below 3.5 indicate lack of protein which increases delay and infection risk
Name seven cleaning interventions
Clean from least to most contaminated
Use gentle friction when cleaning or applying solutions
Isotonic solutions are preferred cleaning agents
Never use same gauze
Do not use cotton balls or anything that sheds
Use a piston syringe to irrigate
Clean with saline, lactated rings or antibiotic solution
What should you administer in wound care
Analgesics and antimicrobials
