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242 > Wound Care > Flashcards

Wound Care Flashcards

1
Q

What is included in a wound Ax?

A
  • identify type of wound healing (primary, secondary, tertiary)
  • type of tissue at wound base
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2
Q

In wound full-thicnkness, what are phases?

A

-heal by scar formation
- total loss of skin layer
hemostasis
inflmn
proliferation
remodeling

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3
Q

Hemostasis:

A
  • 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.
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4
Q

Inflammation:

A
  • 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
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5
Q

Proliferation/granulation

A

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.
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6
Q

Remodelling/maturation

A
  • 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.
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7
Q

Factors that impact wound healing

A
  • impaired perfusion
  • adequate nutrition
  • infxn prolongs inflmn
  • DM
  • Corticosteroid therapy
  • advanced age
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8
Q

Healing by primary intention:

A
  • edges of clean surgical incision remain close togehter
  • heals uickly
  • tissue loss minimal or absent
  • smooth surface join at suture line
  • heals by epitheliazation
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9
Q

healing by secondary intention

A
  • 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
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10
Q

Healing by tertiary intention (delayed primary intention or closure)

A
  • surgical wounds not closed immediately

- left open 3-5days to allow edema infxn to diminish

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11
Q

what type of tissue indicates healing?

A
  • granulation
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12
Q

what type of tissue indicates delayed healing?

A
  • black brown or tan (eschar or sough) which should be removed
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13
Q

what factors affect wound healing process?

A
  • locatin
  • severity
  • extent of injury
  • tissue layers involved
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14
Q

How does partial thickness loss heal by?

A
  • process of regeneration

- limited to epidermis and possible dermis

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15
Q

What is NPWT (negative pressure wound therapy) used for?

A
  • subatmospheric (negative) pressure to a wound through suction to facilitate healing and collect wound fluid
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16
Q

How does NPWT enhance wound healing?

A
  • eliminate chronic exudate
  • maintains moist wound bed
  • reduced edema = inc. profusion
  • macrodeformation
  • microformation
  • stretch on cells in wound bed activating healing
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17
Q

macrodeformation

A
  • traction on side of wound that promotes contraction of wound edges
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18
Q

Debridement

A
  • removal of non-viable tissue

- topical therapy and component of wound healing

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19
Q

methods of debridement?

A
  • enzymatic
  • mechanical
  • autolytic
  • sharp
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20
Q

what does the type of debridement depend on?

A
  • condition of the wound
  • goal of wound tx
  • pt’s overall condition
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21
Q

True or false, does the type of suture increase risk for surgical site infxn?

A

false

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22
Q

enzymatic debridement?

A
  • topical application of enzymes

- collagenese moiture rententive dressing used to soften the tissue

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23
Q

safety guidelines:

A
  • 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)
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24
Q

How do meds affect wound healing?

A
  • steroids reduce inflammatory response and slow collagen synthesis
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25
Q

How do you clean a drain?

A
  • circular stroke
    1st. next to drain
    2nd. new swab, a little further out
26
Q

What is the TIME framework used for and what does it stand for?

A
  • address barriers to wound healing and indientifies key clinical assessments and tx options

T: tissue management
I: inflmn/infxn
M: moisture
E: edge

27
Q

What does tissue management refer to?

A
  • involves debridement
28
Q

What does Inflmn/infxn refer to

A
  • identify/ treat infxn
29
Q

What does moisture refer to

A

goal is to keep surface moist, not wet

30
Q

What does edge refer to

A
  • goal is to have a proliferative wound edge
31
Q

key priniciples to a healthy wound envirnment

A
  • adeqaute moisture
  • temp. control
  • pH
  • control of bacteria
32
Q

4 outcomes of dressing

A
  • 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
33
Q

what is a priority in wound care management

A
  • pt comfort
34
Q

what are two ways you can prevent pain

A
  • moisture rententive dressing

- analgesic

35
Q

polyurathene film dressesing affective in..

A
  • reducing infxn
36
Q

sacral border silicone dressing effective in..

A
  • provides absorption and reduces friction, shear and moisture
37
Q

silicone foam fdressing..

A
  • prevent pressure injuries
38
Q

how often should silicone foam dressings be applied?

A
  • every 3 days
39
Q

4 different types of wound drainage

A

Serous: clear watery plasma
Sanguineous: fresh birght red bleeding
serosanguineous: pale red and more watery
purulent: thick yellowgreen brown tan

40
Q

indications for dry gauze dressing

A

primary intention with little wound drainage

  • abraisons
  • nondraining post-operative
41
Q

dry dressings provide…

A
  • protect wound from injury
  • reduce discomfort
  • speed healing
42
Q

disadvantages of dry dressing

A
  • moisture evaporates quickly = frequent dressing change
43
Q

purpose of impregnated gauze

A
  • hydration
  • absorbs exudate
  • deliver antimoicrobials
44
Q

What should you do if the dry gauze adheres to eschar?

A
  • moisten gauze with NS or sterile water to remove
45
Q

What is the order of suture/staple removal?

A

remove all at once or everyother as the first phase and then the remaining as the 2nd

46
Q

how long until suture/staples are removed?

A

7-14days

47
Q

What does removal of suture/stables require?

A
  • sterile stable removal

- aseptic technique

48
Q

What should the nurse do when there is any sign of suture line separation?

A
  • leave remaining ones in place and document
49
Q

What should the nurse do after suture/staples are removed?

A
  • steri-strips over the incision to provide support
50
Q

How long do steri-strips last and when can they be removed?

A
  • loosen around 5-7 days

- can be removed when half of the strip is no longer attached to skin

51
Q

What are you assessing the incision for prior to removal?

A
  • closure of edges
  • normal color
  • absence of drainage
  • absence of inflmn
52
Q

What should the nurse do prior to removal?

A
  • clean with antiseptic swabs starting at the sides of suture line then on suture line
53
Q

What should you document on?

A
  • 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
54
Q

phases of partial thickness wound healing

A
  • inflammatory
    • 3-5days, hemostasis, controls bleeding and cleans)
  • proliferation and migratin
    • 3-24 days, wound contraction, epithelialization
  • remodelling
    • up to 2 years
55
Q

Which will heal better, a moist or dry wound?

A
  • 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
56
Q

acute wound

A
  • proceeds orderly and timely
  • trauma, surgical incision
  • edges clean and intact
  • easily cleaned and repaired
57
Q

chronic wound

A
  • fails to proceed orderly and timely

- chronic inflmn, repeated insults to injury

58
Q

how long to the edges of a normal wound appear red and inflammed?

A

2-3 days

59
Q

how many days does it take for a normal wound to resurface with epithelialization and edges close?

A

7-10 days

60
Q

complications of wound healing

A
  • 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)

242 (6 decks)

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