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Interventions > Wound care > Flashcards

Wound care Flashcards

1
Q

primary intention healing (primary union/ first intention healing)

-what it is? Materials? when is it used? examples?

A
  • tissue surfaces are close together
  • stitches, stables, skin glue, tape
  • are used where there is little tissue lose
  • surgical incisions, Iv therapy, lumbar puncture
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2
Q

open wounds vs closed wounds

A

closed: skin integrity remains intact
open: skin integrity is compromised

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3
Q

secondary intention healing

what? when? examples?

A
  • edges of wound are not close together
  • wounds are extensive and have a lot of tissue loss
  • examples: large open wounds (burns, pressure ulcers, venous stasis ulcers
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4
Q

how is secondary intention healing different to primary intention healing

A

secondary intention takes longer to heal, has more scarring, and at higher risk for infection

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5
Q

tertiary intention healing (delayed/ secondary closure)

-why? when? how long? examples?

A
  • indicated if there is a reason to delay suturing or closing a wound ( usually to allow for drainage, edema, or infection to resolve)
  • used for heavy contamination of wound
  • usually cleans and heal open for less the 48hrs. and then surgically closed
  • examples: abdominal wound left open for drainage and closed later, dog bits
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6
Q

wound care assessment

A
  • size: length, width, depth
  • location: nearest anatomic landmark
  • undermining: erosion around wound bed
  • tunneling/sinus tract: passage way to opening in skin in 1 direction
  • tissue in the wound base: eschar, slough, granulation
  • exudate/drainage: amount (scant, moderate, copious), color and type (serious, sanguineous, purulent) Odor
  • peri-wound skin: surrounding skin (pink, excoriated, macerated, reddened)
  • pain: tolerance for dressing change
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7
Q

wound care assessment

A
  • size: length, width, death
  • location: nearest anatomic landmark
  • undermining: erosion around wound bed
  • tunneling/sinus tract: passage way to opening in skin in 1 direction
  • tissue in the wound base: eschar, slough, granulation
  • exudate/drainage: amount (scant, moderate, copious), color and type (serious, sanguineous, purulent) Odor
  • peri-wound skin: surrounding skin (pink, excoriated, macerated, reddened)
  • pain: tolerance for dressing change
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8
Q

eschar

A

dead tissue that appears black and leathery: impairs healing

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9
Q

slough

A

white, yellow, tan, gray, green tissue that is a consequence fo inflammatory phase of wound healing.

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10
Q

granulation

A

contain significant amounts of highly vascularized granulation tissue: red or deep pink color

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11
Q

exudate

A
  • serous: clean watery
  • sanguineous: bright red
  • serasanguienous: pale, red, watery mixture of serious and sanguineous
  • purulent: thick, yellow, green, tan, or brown
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12
Q

epithelialization

A

healing wound tissue

-pink in color

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13
Q

approaches to wound managements: RED

A
  • protect
  • granulation tissue
  • gentle cleansing, use of moist dressings change only when necessary
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14
Q

approaches to wound management: Yellow

A
  • clean
  • slough tissue
  • cleanse tissue, irrigate to remove
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15
Q

approaches to wound management: debride

A
  • eschar tissue

debridement by APRN

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16
Q

healing principles: what is the best healing environment

A
  • moist wound bed:a low for epidermal migration

- surrounding skin dry: prevent skin breakdown

17
Q

healing principles: removal of nonviable tissue

2 things that are done to remove tissues

A

remove microorganism and debris

  • cleansing: approximated: clean to dirty, top to bottom and unapproximated: half circles from center to periphery
  • debridement: can be done through topical application of enzymes to breakdown tissue, dressing or mechinical
18
Q

healing principles: prevent further injury

A

-apply dressing to wound itself to protect
-friction and shear (tissues move past each other ): capillary damage
-

19
Q

healing principles: ensure adequate blood supply

A

-needed for healing: blood increases WBC, RBCs, and platelet to site of injury to remove toxin and debris
- external pressure reduce blood supple (ishemia)
-

20
Q

healing principles: adequate nutrition

A
  • vitamin A,B, C(collagen synthesis, capillary formation, K minerals, trace elements)
  • protein: cell mediated defense (WBC formation)
  • insufficient caloric intake: glucose needed for healing
  • encourage meals
21
Q

Primary dressings

A
  • DPD: dry protective dressing: well approximated wounds, minimal drainainge
  • Hydrocolloids (duoderm): absorb drainage
  • hydrogels (Aquasorb): maintains moist environment
  • transparent (tegaderm): allow oxygen but no bacterial penetration
  • Saline moistened dressing: allows for debridement, moist to dry
22
Q

saline moistened dressings

purpose? cleansing process? packing?

A
  • purpose: promote healing
  • clean from center to periphery or if infected clean from clean to dirty
  • pack lightly but completely unfold the dressing to get better contact with wound bed
23
Q

irritating wounds:

pressure?solutions? how long?

A
  • gentle pressure
  • solutions: salin vs. antiseptic or antibiotic solutions
  • irrigate until solution flows clear
24
Q

what things are not used to irrigate wounds?

A

iodine and hydrogen peroxide because they cause cell death

25
Q

wound culture

A
  • wound biofilms are result of bacteria growing ing clumps, imbedded in a thick, self made, protective, slimy, barrier fo sugars and proteins
  • impair wound healing and lead to increased inflammation
  • remove biofilm
  • yellow/greenish
26
Q

when is the best time to obtain a wound culture?

A
  • eradicate biofilm first

- roll to maximize contact

27
Q

wound drains

purpose?placement? passive or negative pressure? assessment

A

purpose: anticipation that fluid will collect
- placement: decided by surgery, type of wound
- passive/passive pressure drainage: will depends on where it is placed
- assessment: many times during shift, note drainage, site, pain, patient tolerance

28
Q

Penrose drain

A
  • passive drainage
  • not sutured in place
  • pulled out little by little as drainage lessens
  • drainage will passively drain onto the dressing
29
Q

Jackson pratt drain

A
  • gentle negative pressure
  • holds 50-100mL
  • sutured in place
  • empty when 1/2 full
  • protect from pulling
  • located along side wound, coiled inside
  • drainage will drain into collection device
  • secured with safety pin
30
Q

hemovac drain

A
  • negative pressure
  • holds 400-800mL
  • sutured in place
  • emptied when 1/2 full
  • protect from pulling
  • drainage will drain into collection device
31
Q

wound drainage: instruments: Vacuum-assisted closure

A

negative pressure wound therapy

  • applies uniform negative pressure: pull of vacuum increases blood flow to the area
  • fenestrated tube embedded in foam
  • occlusive dressing
32
Q

Negative pressure wound therapy: uses: what type of wounds

A

wide open wounds

  • pressure ulcers
  • diabetic ulcers
  • dehisced wounds
  • graft sites
33
Q

Negative pressure wound therapy: benefits

A
  • promotes wound bed circulation
  • reduces risk of infection
  • promotes wound contraction
34
Q

Negative pressure wound therapy: who should you be careful with?

A
  • anticoagulants
  • immunosuppression
  • bleeding problems
35
Q

Negative pressure wound therapy: contraindications

A
  • active bleeding
  • malignancy
  • exposure nerves
  • tendons or ligaments
  • fistulas.

Interventions (8 decks)

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