Wound care Flashcards
primary intention healing (primary union/ first intention healing)
-what it is? Materials? when is it used? examples?
- tissue surfaces are close together
- stitches, stables, skin glue, tape
- are used where there is little tissue lose
- surgical incisions, Iv therapy, lumbar puncture
open wounds vs closed wounds
closed: skin integrity remains intact
open: skin integrity is compromised
secondary intention healing
what? when? examples?
- 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
how is secondary intention healing different to primary intention healing
secondary intention takes longer to heal, has more scarring, and at higher risk for infection
tertiary intention healing (delayed/ secondary closure)
-why? when? how long? examples?
- 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
wound care assessment
- 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
wound care assessment
- 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
eschar
dead tissue that appears black and leathery: impairs healing
slough
white, yellow, tan, gray, green tissue that is a consequence fo inflammatory phase of wound healing.
granulation
contain significant amounts of highly vascularized granulation tissue: red or deep pink color
exudate
- serous: clean watery
- sanguineous: bright red
- serasanguienous: pale, red, watery mixture of serious and sanguineous
- purulent: thick, yellow, green, tan, or brown
epithelialization
healing wound tissue
-pink in color
approaches to wound managements: RED
- protect
- granulation tissue
- gentle cleansing, use of moist dressings change only when necessary
approaches to wound management: Yellow
- clean
- slough tissue
- cleanse tissue, irrigate to remove
approaches to wound management: debride
- eschar tissue
debridement by APRN
healing principles: what is the best healing environment
- moist wound bed:a low for epidermal migration
- surrounding skin dry: prevent skin breakdown
healing principles: removal of nonviable tissue
2 things that are done to remove tissues
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
healing principles: prevent further injury
-apply dressing to wound itself to protect
-friction and shear (tissues move past each other ): capillary damage
-
healing principles: ensure adequate blood supply
-needed for healing: blood increases WBC, RBCs, and platelet to site of injury to remove toxin and debris
- external pressure reduce blood supple (ishemia)
-
healing principles: adequate nutrition
- 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
Primary dressings
- 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
saline moistened dressings
purpose? cleansing process? packing?
- 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
irritating wounds:
pressure?solutions? how long?
- gentle pressure
- solutions: salin vs. antiseptic or antibiotic solutions
- irrigate until solution flows clear
what things are not used to irrigate wounds?
iodine and hydrogen peroxide because they cause cell death
wound culture
- 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
when is the best time to obtain a wound culture?
- eradicate biofilm first
- roll to maximize contact
wound drains
purpose?placement? passive or negative pressure? assessment
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
Penrose drain
- passive drainage
- not sutured in place
- pulled out little by little as drainage lessens
- drainage will passively drain onto the dressing
Jackson pratt drain
- 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
hemovac drain
- negative pressure
- holds 400-800mL
- sutured in place
- emptied when 1/2 full
- protect from pulling
- drainage will drain into collection device
wound drainage: instruments: Vacuum-assisted closure
negative pressure wound therapy
- applies uniform negative pressure: pull of vacuum increases blood flow to the area
- fenestrated tube embedded in foam
- occlusive dressing
Negative pressure wound therapy: uses: what type of wounds
wide open wounds
- pressure ulcers
- diabetic ulcers
- dehisced wounds
- graft sites
Negative pressure wound therapy: benefits
- promotes wound bed circulation
- reduces risk of infection
- promotes wound contraction
Negative pressure wound therapy: who should you be careful with?
- anticoagulants
- immunosuppression
- bleeding problems
Negative pressure wound therapy: contraindications
- active bleeding
- malignancy
- exposure nerves
- tendons or ligaments
- fistulas.
