Wound Care Flashcards
Acute wound vs Chronic Wound
Acute wound
- Would follows an orderly and timely healing process
- i.e. surgical incision
Chronic wound
- Would does not heal easily and the skin does not soon return to its normal appearance and function
- i.e. pressure ulcer
Wound healing - primary intention
- Wound with little tissue loss
- i.e. surgical incision
Wound healing - secondary intention
- Wound involving tissue loss
- i.e. could be a surgical wound but took out some tissue; pressure ulcers
Wound healing - teritary intention
- Delayed primary closure
- Wound left open, then closed
Phases of Wound healing - Partial thickness wound
1) Inflammatory response
- First 24hrs
- Inflamed, swollen, red, hot
2) Epithelial proliferation (reproduction) and migration
- Migration of the epithelial cells across the wound bed
3) Re-establishment of the epidermal layers
Phases of wound healing - Full thickness wound
1) Inflammatory phase (Reaction)
- Beings minutes after injury until about 3 days
- Control bleeding, deliver blood and cells to injured area, and epithelial cells form at injured site
2) Proliferative phase (Regeneration)
- Lasts for 3-23 days
- Filling in the wound with granulation tissue, contraction of the wound and resurfacing of the wound by epithelialization
3) Remodelling (Maturation)
- Final stage (may take up to 2 years)
- Collagen fibers (scar tissue) continue to gain strength
Assessment of acute wounds
1) Wound appearance
2) Character of wound drainage
3) Presence of drains
4) Wound closures
5) Palpation of wound
6) Pain
Wound Appearance
1) Edges
- Approximation
2) Size
- Measuring tools, length, width, depth
3) Shape
4) Colour
Wound Drainage
1) Serous
- Light pink or hay coloured
- Very thin kind of fluid
2) Serosanguinous
- Looks mixed with blood
3) Sanguinous
- Is blood
4) Purulent
- Pus, green/yellow, often accompanied by odour
Why are drains used?
- Don’t want to accumulation of fluid in the wound bed, which would inhibit the body to heal
- It takes up space and doesn’t allow for the migration of cells across the wound bed
Jackson-Pratt (JP) Drain
- Suction device
- Bulb at end; other end of line is in wound bed
- When attached it squished, the suction out fills the bulb
- Needs to be measured; becomes part of the ins/outs of the patient care
- Can come out when it stops draining
Hemovac Drain
- Uses suction
- Any kind of tube in the body
- Start at the patient body as work away with the tube if not draining properly and want to assess
Penrose Drain
- Latex tubing
- Often for head and neck surgeries
- Stick out; generally not sutured
- The pin keeps it from going into the body; not pinned to anything just through the tube
- Need to be mindful of the drainage around ti, can cause skin breakdown if left
- Clean around it with gentle circular motions
- Can be pulled out easily
- Take dressing off very carefully
- If you pull it out let the surgeon know
Wound closures
- Sutures
- Staples
- Steri-strips
- Glues
Types of Sutures
1) Intermittent
- Interuppted sutures
2) Continuous
- Goes throughout the skin
3) Blanket continuous
- Single thread but also stitched along side
4) Retention
- Reinforced along places along the wound
Suture removal
- Need sissors and some form of tweezer
- Want to make sure the skin is closed properly
- Want to ensure you are not pulling the outside of the suture through to the inside of the skin; prevent contamination
Staple removal
- Special device used to remove staples
- Crushes the middle, so the ends pop up and out
Palpation of wound
- Observe swelling or separation of wound edges
- Lightly press wound edges to detect areas of tenderness and/or warmth
- May cause fluid to be expressed if there is a pocket of drainage
- Extreme tenderness may signify infection
Wound pain
- Minimize discomfort
- Numeric rating scale; have patient rate their pain before and after wound care
- If needed, administer analgesic 30-45 mins before dressing change
Nursing diagnosis of wounds
- Impaired skin integrity
- Risk of impaired skin integrity
- Impaired tissue integrity
- Risk of infection
- Pain
Interventions to promote wound healing
- Wound dressings
- Debridement; removal of damaged tissue from wound, specialized care
- Principles of dressing changes
- Irrigating and packing wounds
- Other modalities used to manage wound and promote healing
- Culturing wounds
- Application of bandages
- Want wound to maintain moist environment, the less we can change a wound dressing the better
Nutrition and wound care
- Optimal nutrition facilitates wound healing, maintain immune competence, and decreases the risk of infection
- Poor nutrition has been associated with delayed wound healing
Purpose of wound dressings
- Protects from microorganisms
- Aid is hemostasis
- Promote healing by absorbing drainage and supports autolytic debridement
- Support/splint wound
- Protects patient from seeing the wound (if preceived as unpleasant)
- Promote thermal insulation
- Provide moist environment for wound bed
Layers of a traditional wound dressing
1) Contact or primary layer
- Covers the incision
2) Absorbent layer
- Reservoir for additional secretions
3) Outer protective layer
- Prevents external contaminants from reaching the wound surface
Types of wound dressings
1) Dry
2) Moist wound healing
Note: wet-to-dry and moist-to-dry are not recommended as they mechanically debride the wound and can damage healing tissues
Preparation of Client - wound care
- Administer required analgesics so that peak effects occur during the dressing change
- Describe the steps of the procedure to lessen client anxiety
- Gather all supplies required for the dressing change
- Answer questions about the procedure or the wound
- If they ask how it looks; describe what you see (i.e. dimensions of the wound, the healing, the skin around the wound)
Basic skin cleansing
- Cleanse the wound with normal saline
- Cleanse from the least contaminated (wound site) to the most contaminated (surrounding skin)
- Use gentle friction to clean
- Use each cleansing gauze only ONCE
Two methods of cleansing a wound
1) Moving horizontally from incision
2) Going vertically, first along incision then moving away
- Always use nursing judgement to see how much cleaning you have to do
- Do what works for you and what works for the patient
Principles of irrigating a wound
- Fluid should flow out so wound bed is not damaged further
- Solution should flow from least to most contaminated
- Use low pressure (larger syringe will provide lower pressure psi)
Why obtain a wound culture?
Purulent drainage noted at wound site
Would culture technique
- Cleanse the wound thoroughly with N/S
- Do not culture pus or exudate
- Swab healthiest looking tissue; do not swab over scab or eschar
- Rotate the swab in 1cmx1xm of clean tissue in the open wound
- Apply pressure with the swab to elicit fluid
- Inset the tip of the swab into the appropriate sterile container
Principles to packing a wound
- Pack to eliminate dead space
- Packing should be loose, while contacting all wound surfaces and not mounding above the skin surface
- Assess for undermining, tunneling
- Measure and record wound depth
- Protect integrity of skin around wound to prevent maceration; white and soft area on wound, its skin that can start to breakdown
- Want to precent fluid accumulation in the dead space
- Use cotton tip applicator to assess tunneling in the wound, want to make sure they’re packed as well
- Use clock face to document tunneling
Other modalities in wound care
Sterile leches
- Secrete chemical that stops you blood from clotting while they’re sucking your blood
Maggots
- Will only eat away the dead skin tissue
Why use bandages and binders?
- Creating pressure
- Immobilizing a body part (i.e. sprained ankle)
- Supporting a wound (abdominal binder)
- Reducing or preventing edema
- Securing a splint
- Securing dressings
Complications of wound healing
- Hemorrhage
- Infection
- Dehiscence; where the edges start to pull apart
- Evisceration; parts of the inside start to come through to the outside, commonly found in the abdominal region
- Fistula; opening that’s not supposed to be there between two different parts
Hemorrhage - wound healing
- Some bleeding is expected with a surgical wound
- External; is visible
- Internal; use assessment skills, swelling or distention, more drainage in drain reservoir, may progress to hypovolemic shock
Infection - wound healing
- Pain/tenderness
- Erythema
- Edema
- Inflammation of wound edges
- Purulent discharge
- Warmth at site, fever, chills
- Foul odour
- Increased white blood cells (WBCs)
- Delayed healing
Surgical Site Infections (SSI)
- Occurs in 2-5% of patients undergoing inpatient surgery
- Most common and most costly HAI
- Account for 20% of all HAIs in hospitalized pts
Way to reduce SSIs:
- Perioperative antimicrobial coverage
- Approproate hair removal (no shaving anymore)
- Maintenance of periopertaive glucose control
- Perioperative normothermia (keeping patient cold in OR, but then at a warm temp postOP)
Dehiscence
- Total separation fo wound layers
- Risk behvaiour include: coughing, vomiting, sitting up in a chair (abdominal wounds)
- Risk factos include: obesity, smoking, poor nutrition, multiple traumas, failure of suturing, excessive coughing, vomiting and dehydration
- Nursing interventions to reduce risk: splinting the area with blanket or pillow
Evisceration
- Protrusion of visceral organs through a wound opening
- Medical emergency
- If occurs, place sterile towels that have been soaked in sterile saline over ares
- Patent is NPO
- Observe for signs and symptoms of shock
- Prepare patient for emergency surgery
Fistula
- Poor healing
- Passage developed between two spaces where there shouldn’t be one
- e.g. between vagina and bowel
List activities done by the nurse to prepare a client for a dressing change
- Administer required analgesics so that peak effects occur during the dressing change
- Describe steps of the procedure to lessen patient anxiety
- Gather all supplies required for the dressing change
- Recognize normal signs of healing
- Answer questions about the procedure or the wound
Three principles to follow when cleansing a wound or the area
around the drain
1) Cleanse in a direction from the least contaminated area, such as the wound or incision to the surrounding skin or from an isolated drain site to the surroundings skin
2) Use gentle friction when applying solutions locally to the skin
3) When irrigating, allow the solution to flow from the least to most contaminated area
Hyperemia and how it’s evaluated
An excess of blood in the vessels supplying an organ or other part of the body. Can also be considered redness of the skin due to vasodilation.
Evaluate the area of hyperemia by pressing a finger over the affected area. If the area blanches and the redness return when you remove your finger, hyperemia is transient and is an attempt to overcome the ischemic episode, this it is called blanching hyperemia. However, if the erythematous area does not blanch when you apply pressure, deep tissue damage is probable.
Pressure intensity; for pressure injuries
Capillary closing pressure is the minimal amount of pressure required to collapse a capillary; therefore pressure is applied over a capillary exceeds the normal capillary pressure and the vessel is occluded for a prolonged period of time, tissue ischemia, or reduction of blood flow, can occur. If the patient has decrease sensation and does not have the cue of discomfort to prompt shifting pressure, tissue death may result.
Pressure duration; for pressure injuries
Two considerations are related to duration of pressure. Low pressures over a prolonged time period and high-intensity pressure over a short period of time can both cause tissue damage. Extended pressure occludes blood flow and nutrients and contributes to cell death.
Tissue intolerance; for pressure injuries
The ability of tissue to endure pressure depends on the integrity of both the tissue and supporting structures. The extrinsic factors of shear, friction, and moisture affect the ability of the skin to tolerate pressure; the greater the degree to which these factors are present, the more susceptible the skin will be to damage from pressure. Another factor related to tissue tolerance pertains to the ability of the underlying skin structures (blood vessels, collagen) to assist in resdistributing pressure. Systemic factors such as poor nutrition, age, and low blood pressure affect tissue tolerance to externally applied pressure.
Factors that put clients at risk for pressure injuries
- Impaired sensory perception
- Impaired mobility
- Alteration in level of consciousness
- Shear
- Friction
- Moisture
- Nutrition
- Tissue perfusion
- Infection
- Pain
- Age
- Psychosocial impact of wound
What does a suspected deep tissue injury look like
Purple of maroon localized area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure or shear or both. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
What does a Stage I pressure injury look like
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area.
What does a Stage II pressure injury look like
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or an open or ruptured serum-filled blister.
What does a Stage III pressure injury look like
Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
What does a Stage IV pressure injury look like
Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
What does a unstageable pressure injury look like
Full thickness loss in which the base of the ulcer is covered by slough (yellow, tan, grey, green, or brown) or eschar (tan, black, or brown), or both, in the wound bed.
Venous ulcer
- Result of poor circulation and occur in the lower extremities.
- Account for 80% of leg wounds.
- They are superifcial and are irregular in shape.
- Usually have a large amount of exudate cause by edema in the surrounding tissue.
- Related to weak vein walls in the legs and limited range of motion in the ankles.
- This decreased the ability to the calf to pump; serum and RBCs leak into the surrounding tissue which causes the characteristic brownish hemosiderin staining of the tissue and skin.
Arterial ulcer
- Also called ischemic ulcers
- Are caused by inadequate blood flow to the lower extremity (unlike venous ulcers which are caused by poor blood return).
- They have a “punched out” appearance that is deeper and smaller than venous ulcers.
- Often located on the feet, over the tips of the toes, or one the toe joints.
- They may be necrotic in appearance or have very pale wound beds.
- The legs of someone with arterial ulcers are thin and have shiny, taut, and hairless skin with an almost translucent appearance.
- Considered a “maintenance” wound where the goal is to provide comfort and protection from infection.
Diabetic ulcer
- Diabetic ulcers occur because of neuropathic changes related to diabetes.
- They are most commonly found over body prominences located on the plantar surface of the foot, over the metatarsal heads, and beneath the heels.
- These changes include sensory neuropathy, loss of protective sensations, autonomic neuropath, or absence of swearing leading to dry skin fissures, cracks, and calluses over pressure points (heels and ball of the foot)
- Motor neuropathy, resulting in changes in muscle contractions leading to high arches and crocked-up “hammer” toes. These contribute to pressure point, creating calluses.
Malignant or fungating wound
- Cancer tumors may extrude through the skin as swollen masses with numerous fissures that drain purulent
- Often very malodorous exudate, that sometimes bleed when cleansed or touched.
- Typical sites for fungating wounds are the side of the face or neck and the breast or groin area.
- They are malignant wounds that will not heal, but the tumors may be reduced in size with radiation or chemotherapy.
