Wound Care Flashcards
What is included in a wound Ax?
- identify type of wound healing (primary, secondary, tertiary)
- type of tissue at wound base
In wound full-thicnkness, what are phases?
-heal by scar formation
- total loss of skin layer
hemostasis
inflmn
proliferation
remodeling
Hemostasis:
- first 24hrs
- after injury to skin, vascular response
- Clotting factors activate coagulating pathways to stop bleeding
- Clot formation, seals the disturbed vessels stop the bleeding & act as temporary bacterial barrier
- Platelets release growth hormones which attract cells needed to state the repair process.
Inflammation:
- 1-4days
- Vasodilation, edema, erythema & warmth, blood vessels leak plasma and microorganisms into surrounding tissue which helps prevent infection
- Clean up by WBC, Mast Cells & Macrophages.
- The result is a clean wound bed
Proliferation/granulation
4-21days
- Epithelization begins, the edges of the wound are pulled together.
- New capillaries formed restoring the delivery of oxygen and nutrients
- Collagen is synthesized to provide strength and structural integrity of the wound.
Remodelling/maturation
- up to 2yrs
- Realignment of collagen to become stronger and to provide tensile strength to the wound
- Scar tissue forms and becomes thicker over time.
- Skin’s ability to stretch and return to shape will be only 70-80% as strong as before the injury.
Factors that impact wound healing
- impaired perfusion
- adequate nutrition
- infxn prolongs inflmn
- DM
- Corticosteroid therapy
- advanced age
Healing by primary intention:
- edges of clean surgical incision remain close togehter
- heals uickly
- tissue loss minimal or absent
- smooth surface join at suture line
- heals by epitheliazation
healing by secondary intention
- left open and healed by scar formation this results in inc. risk of infxn
- tissue loss, open wound edges
- cap between edges
- granulation begins to fill
- severe laceration, massive surgical intervention with skin loss
- heals by granulation
Healing by tertiary intention (delayed primary intention or closure)
- surgical wounds not closed immediately
- left open 3-5days to allow edema infxn to diminish
what type of tissue indicates healing?
- granulation
what type of tissue indicates delayed healing?
- black brown or tan (eschar or sough) which should be removed
what factors affect wound healing process?
- locatin
- severity
- extent of injury
- tissue layers involved
How does partial thickness loss heal by?
- process of regeneration
- limited to epidermis and possible dermis
What is NPWT (negative pressure wound therapy) used for?
- subatmospheric (negative) pressure to a wound through suction to facilitate healing and collect wound fluid
How does NPWT enhance wound healing?
- eliminate chronic exudate
- maintains moist wound bed
- reduced edema = inc. profusion
- macrodeformation
- microformation
- stretch on cells in wound bed activating healing
macrodeformation
- traction on side of wound that promotes contraction of wound edges
Debridement
- removal of non-viable tissue
- topical therapy and component of wound healing
methods of debridement?
- enzymatic
- mechanical
- autolytic
- sharp
what does the type of debridement depend on?
- condition of the wound
- goal of wound tx
- pt’s overall condition
True or false, does the type of suture increase risk for surgical site infxn?
false
enzymatic debridement?
- topical application of enzymes
- collagenese moiture rententive dressing used to soften the tissue
safety guidelines:
- do not remove dressing unless there is an order
- analgesics 30min prior
- consider age
- consider nutritional status
- consider risks of obesity
- consider dec. oxygenation
- know medications
- know presence of chronic disease (DM or radiation)
How do meds affect wound healing?
- steroids reduce inflammatory response and slow collagen synthesis
How do you clean a drain?
- circular stroke
1st. next to drain
2nd. new swab, a little further out
What is the TIME framework used for and what does it stand for?
- address barriers to wound healing and indientifies key clinical assessments and tx options
T: tissue management
I: inflmn/infxn
M: moisture
E: edge
What does tissue management refer to?
- involves debridement
What does Inflmn/infxn refer to
- identify/ treat infxn
What does moisture refer to
goal is to keep surface moist, not wet
What does edge refer to
- goal is to have a proliferative wound edge
key priniciples to a healthy wound envirnment
- adeqaute moisture
- temp. control
- pH
- control of bacteria
4 outcomes of dressing
- reduces volume of exudate and amount of necrotic tissue
- resolves or prevents periwound erythema
- reduces wound dimensions or depth of sinus tract
- reduces pain intensity during dressin changes
what is a priority in wound care management
- pt comfort
what are two ways you can prevent pain
- moisture rententive dressing
- analgesic
polyurathene film dressesing affective in..
- reducing infxn
sacral border silicone dressing effective in..
- provides absorption and reduces friction, shear and moisture
silicone foam fdressing..
- prevent pressure injuries
how often should silicone foam dressings be applied?
- every 3 days
4 different types of wound drainage
Serous: clear watery plasma
Sanguineous: fresh birght red bleeding
serosanguineous: pale red and more watery
purulent: thick yellowgreen brown tan
indications for dry gauze dressing
primary intention with little wound drainage
- abraisons
- nondraining post-operative
dry dressings provide…
- protect wound from injury
- reduce discomfort
- speed healing
disadvantages of dry dressing
- moisture evaporates quickly = frequent dressing change
purpose of impregnated gauze
- hydration
- absorbs exudate
- deliver antimoicrobials
What should you do if the dry gauze adheres to eschar?
- moisten gauze with NS or sterile water to remove
What is the order of suture/staple removal?
remove all at once or everyother as the first phase and then the remaining as the 2nd
how long until suture/staples are removed?
7-14days
What does removal of suture/stables require?
- sterile stable removal
- aseptic technique
What should the nurse do when there is any sign of suture line separation?
- leave remaining ones in place and document
What should the nurse do after suture/staples are removed?
- steri-strips over the incision to provide support
How long do steri-strips last and when can they be removed?
- loosen around 5-7 days
- can be removed when half of the strip is no longer attached to skin
What are you assessing the incision for prior to removal?
- closure of edges
- normal color
- absence of drainage
- absence of inflmn
What should the nurse do prior to removal?
- clean with antiseptic swabs starting at the sides of suture line then on suture line
What should you document on?
- appearance and size of wound
- characteristics of drainage
- presence of necrotic tissue
- dressing applied
- pt’s response to dressing change
- level of comfort
- pt/family understanding of dressing change
- anything unexpected
phases of partial thickness wound healing
- inflammatory
- 3-5days, hemostasis, controls bleeding and cleans)
- proliferation and migratin
- 3-24 days, wound contraction, epithelialization
- remodelling
- up to 2 years
Which will heal better, a moist or dry wound?
- a moist wound will heal in 4 days; whereas, a dry wound will heal in 5-7 days because epithlial cells only migrate across a moist surface
acute wound
- proceeds orderly and timely
- trauma, surgical incision
- edges clean and intact
- easily cleaned and repaired
chronic wound
- fails to proceed orderly and timely
- chronic inflmn, repeated insults to injury
how long to the edges of a normal wound appear red and inflammed?
2-3 days
how many days does it take for a normal wound to resurface with epithelialization and edges close?
7-10 days
complications of wound healing
- hemorrhage or hematoma
- infection
- Dehiscence 3-11days after injury
- Evisceration (protrusion of visceral organs through wound opening)
- Fistula (abn passage between two organs or organ and outside of body)
