Wound Care Flashcards
Wound
disruption in the integrity and function of tissues in the body
Acute wound
Follows an orderly and timely healing process (e.g. surgical incision)
Generally closes within 24-48 hrs at skin level and then leave a scar, generally clean and intact
Chronic wound
- Does not heal easily, does not return to normal appearance and function quickly or at all (e.g., pressure injury/bed sore)
- Tend to be more open, lack anatomical integrity, chronically inflamed, vascular compromise
Primary intention
- Property of acute wounds
- Wound healing with little tissue loss
- Edges pulled together and secured with closure devices
- Gradual formation of scar tissue, wound closes slowly
- E.g, surgical incision
Secondary Intention
- Property of chronic wounds
- Wound involves lots of tissue loss
E.g., pressure injuries, infected surgical wound, traumatic wounds
Tertiary intention
- Delayed primary closure
- Would left open intentionally or unintentionally
- Would can re-open
Partial Thickness Wounds
- Shallow, involve damage or tissue loss limited to top layer (epidermis) with possible partial tissue loss to the dermis
- Heal through regeneration
e.g., surgical wound or abrasion
Phases of partial-thickness wound healing (2)
- Inflammatory response - first 24 hours
- Epithelial proliferation (reproduction) & migration
Re-establishment of the epidermal layers
Full-thickness wounds
Tissue damage through to the dermis and extending to deeper tissues below.
Heal by scar formation because the deeper structures don’t regenerate.
Phases of full-thickness wound healing (3)
- Inflammatory Phase (Reaction)
- Proliferative Phase (Regeneration)
- Remodelling (Maturation)
Inflammatory Phase (4)
First phase of full-thickness healing
- Begins minutes after injury up to 3 days
- Controls bleeding
- Delivers blood and cells to injured area
- Epithelial cells form at injured site
Proliferative Phase (4)
Second phase of full-thickness healing
- Lasts 3-24 days
- Filling in the wound with granulation tissue
- Contraction of the wound
- Resurfacing of the wound by epithelialization
Remodelling
Final stage of full-thickness healing (may take up to 2 years)
-Collagen fibers (scar tissue) continue to gain strength
Types of drainage fluid (4)
- Serous (light pale, thin)
- Serosanguinisous (serous + blood)
- Sanguinous (blood)
- Purulent (puss, etc.) = infection
Types of drains (3)
- Jackson-Pratt (J-P) drain (little bulb)
- Hemovac (sandwich looking thingy)
- Penrose (little latex nipple you pull out a bit every day)
* Drainage system must be kept below the drain site
Purpose of drains
We don’t want accumulation of fluid in wound bed
Fluid inhibits body’s ability to heal in the area, takes up space (has no where to go in a wound), which doesn’t allow for migration of new cells across wound bed and therefore compromises healing.
Wounds can re-open and become infected.
Blanching hyperemia
if a red area turns white and then red when you palpate = no tissue damage
Non-blanching hyperemia
if a red area does NOT blanch = deep tissue damage is likely
*Reddened skin will cool as tissue damage increases
Types of wound closures (3)
- Sutures
- Steri-strips
- Staples
Eschar
thick, black, hard necrotic tissue
Slough
yellow, necrotic tissue that is in the process of detatching from viable tissue
Maceration
occurs when skin is consistently wet. Skin soften, turn white, and can get infected
Types of chronic wounds (6)
- Arterial ulcers
- Venous ulcers
- Neuropathic ulcers
- Skin tears
- Perineal dermatitis
- Malignant of fungating wounds
Arterial ulcers (6)
- Caused by impaired arterial blood flow
- Located primarily on toes, foot or malleolus
- Cool, shiny, thin skin
- Decreased pulse strength in affected area
- Wound bed is pale, well-defined margins
- Quite painful
Venous ulcers (3)
- Caused by decrease in blood flow return from lower extremities to the har
- Most often located in the lower calf and ankle
- Often include brown discolouration of the lower calf and ankle skin, edema and dry scaly skin, irregular wound margins
Neuropathic (diabetic) ulcers (4)
- Caused by sensory, motor and autonomic neuropathy or decreased sensation
- Normally located on the metatarsal heads, tops of the toes and foot
- Often dry and cracked, warm and has decreased sensation
- Would margins are regular, often calloused
*Diabetic Ulcers are a type of neuropathic ulcer
Skin Tears
- Separation of the epidermis from dermis
- Normally affect skin of arms, hands and legs
People at risk:
- older patients
- People with dependent ADLs
- Ppl with decreased estrogen or taking steroid meds
- Skin is thin and less elastic
Wound appearance (5)
- Location
- Edges - are they well approximated? Are they lined up? Together? Is there gaping?
- Size (length, width, depth)
- Shape
- Colour
Character of Wound Drainage
Amount and type
Palpation of wounds (4)
- Observe swelling or separation of wound edges
(Sometimes they curl in on themselves and look like scar tissue = NOT A NORMAL FINDING) - Lightly press wound edges to detect areas of tenderness and /or areas of warmth and hyperemia
- May cause fluid to be expressed if there is a pocket of drainage
- Extreme tenderness may be a sign of infection
Obtaining wound cultures (5)
- Cleanse wound with normal saline
- Swab the healthiest looking tissue (we don’t want to collect pus or exudate in the swab)
- DO NOT swab over a scab or dying tissue (eschar)
- Apply pressure with the swab to elicit fluid
- Insert the tip of the swab into the appropriate sterile container
Preparing client for dressing change (4)
- Administer required analgesics
- Describe steps to lessen anxiety
- Gather all supplies required for the dressing change
- Answer questions, explain what you see
*remember all wounds have a real person attached to them
Packing a wound (5)
- To eliminate dead space as the wound is open and stop fluid from accumulating
- Packing should be loose and should be flat (not mounded) at the surface of the skin
- Assess for undermining and tunneling
- Measure and record wound depth
- Protect integrity of skin around wound to prevent maceration (when tissue underneath dressing becomes white and moist)
Undermining
Tissue destruction at the edge of the wound (a lip)
Tunneling
Channels or “sinus tracts” extend from wound into subcutaneous tissue or muscle
Usually result of infection, previous abscess formation, trauma to wound and surrounding tissue, or impact of pressure and shear forces on tissue layers causing a “sink hole”
Principles of cleansing wounds (3)
- Cleanse wound with normal saline (NS)
2 Cleanse from least contaminated (wound site) to most contaminated (surrounding skin) - Use 1 gauze for every cleansing pass that you do
Risk Factors for Pressure Injuries (12)
Patients are predisposed to PIs or impaired healing of PIs in the presence of:
- Impaired sensory perception
- Impaired mobility
- LOC
- Shear
- Friction
- Moisture
- Nutrition
- Tissue perfusion (low perfusion slows healing)
- Infection
- Pain (impacting ability to move)
- Age
- Psychosocial Impact of wounds
Stage I pressure injury
Intact skin, non-blanchable, usually over a bony prominence
Suspected Deep Tissue Injury (DTI)
Purple or maroon discoloration of intact skin OR a blood-filled blister
Stage II pressure injury
- Partial-thickness loss of dermis
- Shallow, open ulcer with a red-pink wound bed
- No slough
Stage III pressure injury
- Full-thickness tissue loss
- Subcutaneous fat maybe visible
- Bone/tendon/muscle not exposed
- Slough may be present
Stage IV pressure injury
- Full thickness tissue loss
- Exposed bone, tendon, muscle
Unstageable pressure injury
- Full-thickness tissue loss
- Base of ulcer covered in slough or eschar
Complications of Wound Healing (5)
- Hemorrhage
- Infection
- Dehiscence
- Evisceration
- Fistula
Hemorrhage (4)
Some bleeding is expected with a surgical wound, but too much bleeding is a hemorrhage
- External: visible on inspection (look on all sides of client)
- Internal: look for swelling/distention, more drainage in drain reservoir
- Can progress to hypovolemic shock
Signs of Infection (9)
- Pain/tenderness
- Erythema (redness)
- Edema
- Inflammation of wound edges
- Purulent discharge
- Warmth at site, fever, chills
- Foul odour
- Increased white blood cells (WBCs)
- Delayed healing
Dehiscence
- Partial or total separation of the wound layers
- Can be caused by coughing, vomiting, sitting up in a chair
• Multiple risk factors: ○ Obesity ○ Smoking ○ Poor nutrition ○ Multiple traumas ○ Failure of suturing ○ Excessive coughing ○ Vomiting ○ Dehydration
Nursing intervention: splint the area with blanket/pillow
Evisceration
- Protrusion of visceral organs through a wound opening
- This is a medical emergency
- Nursing intervention: cover area in sterile-soaked gauze or towel, notify surgeon
- Patient is then NPO (nothing in the mouth)
- Observe for signs/symptoms of shock
- Emergency surgery
Fistula
- Poor healing
- Abnormal finding
- A passage/space develops between two spaces or organs or organ and outside the body) where there shouldn’t be a space
E.g., tearing in birth
Pathogenesis of a Pressure Injury (3)
- Pressure intensity
- Pressure duration
- Tissue tolerance
Pressure Intensity
If pressure over capillaries in the tissue exceeds normal pressure for a prolonged period of time, tissue ischemia (reduction in bood flow to tissues) can occur, possibly resulting in eventual tissue death.
Pressure Duration
Low-pressure over long period of time
High-pressure over short period of time
Tissue Tolerance
The ability for the tissue to endure the pressure
Depends on tissue integrity and integrity of supporting structures
Affected (negatively) by:
Shear
Friction
Moisture
Poor nutrition, age, low BP all affect tissue tolerance
Preventing pressure injuries (5)
- Assess pressure points, hyperemia, use good positioning/supports
- Assess incontinence to address moisture; keep area clean and dry
- Reposition patient with appropriate tools and angles (30-degree lateral)
- Schedule mobility/activity appropriate to pt capabilities (ie. move the pt!)
- Ensure good nutrition, fluid intake, oral hygiene
Debridement (4)
- Removal of necrotic, nonviable tissue
- Removal of infection source
- Enables visualization of wound bed
- Makes clean base for healing
Purpose of Bandages, Splits, and Binders
- Used to create pressure
- Immobilize a body part
- Support a wound
- Reduce or prevent edema
- Secure a splint
- Secure dressings
