wound care week 1 Flashcards
1
Q
what influneces skin fx and integrity
A
• Influenced by factors intrinsic to individual eg genetics age, general health. Also extrinsic factors eg hygiene, mechanical forces, living conditions
2
Q
what type of wound is the result of therapy eg Sx, venipuncture
A
intentional wound
3
Q
what is an unintentionl wound the result of
A
unplanned and not part of therapeutic intervention. Eg MVA
4
Q
how are closed and open wounds different
A
If tissues traumatized without a break in skin=CLOSED
Wound is OPEN when the skin or mucous membrane surface is broken
5
Q
char of clean wound
A
Clean wounds= o Uninfected o Minimal inflm o Resp, GI, urinary tracts not entered o Primariy closed wounds
6
Q
char of dirty or infected wound
A
Dirty or infected wounds
o Old traumatic wounds w retained dead tissue
o Wounds that involve existing clinical infection or perforated viscera
7
Q
char of clean contaminated wound
A
Clean contaminated wounds=
o Surgical wounds in which GI, resp, genital or urinary tract has been entered under controlled conditions
o No evidence of infection
8
Q
how are wounds classified
A
Wounds can be classified by intentional/unintentional, how theyre acquired, likelihood and degree of contamination, or depth (not including pressure ulcers and burns). Depth is classed by the tissue layers involved in the wound
9
Q
how are acute and chronic wounds different
A
Acute wound=heals within an expected timeframe
Chronic wound=any break or alteration in the skin thats of long duration (often 3 months or longer or recurs frequently
10
Q
how would you classify a wound by depth
what tissues are included
how does it heal
A
Partial thickness wound o Confined to dermis and epidermis o Heals by regeneration Full thickness wound o Dermis, epidermis and subcut tissue and possibly muscle and bone o Requires connective tissue repair
11
Q
is there a sequence to wound healing
A
yes, it occurs in phases. all wounds heal int he same phases
12
Q
+what does wound healing depend on
A
Wound healing depends on type of healing, location and size of wound, health of client
13
Q
what are the 3 types of wound healing
A
primary secondary tertiary
14
Q
describe tertiary healing
A
Tertiary intention healing aka delayed primary intention healing
o Wounds left open for 3-5 days to allow edema or infection to resolve or exudates to drain
o And are then closed w sutures, staples, adhesive skin
P&P scarring is usually minimal
During the healing process some type of dressing covers a wound
15
Q
which time of healing has a shorter repair time
A
primary intention
16
Q
which type of healing has more scarring
A
secondary intention
17
Q
which type of healing has a dec susceptibility to infection
A
primary
18
Q
examples of healing by secondary intention
A
o Eg pressure ulcer, severe laceration, massive surgical intervention
19
Q
primary intention healing
A
Primary intention healing aka primary union or first intention healing
o -occurs when the tissue surfaces have been approximated (closed)
o Minimal to no tissue loss has occurred
o Char by formation of minimal granulation tissue and scarring
P&P The wound heals quickly
20
Q
examples of wounds that heal by primary intention
A
o Eg closed surgical incision, tissue adhesive use (makes less noticeable scar)
21
Q
seconary intention healing
A
Secondary intention healing
o Extensive and involves considerable tissue loss
o Edges cant or shouldn’t be approximated
o Eg pressure ulcer, severe laceration, massive surgical intervention
P&P allowed to heal by scar formation
There is a gap between edges
CT develops
Slow healing (inc risk of infection)
Wound edges are open
Granulation tissue gradually fills in the area of the defect
22
Q
phases of wound healing
A
3 overlapping but distinct phases
o Inflammatory
o Proliferative
o Maturation
23
Q
2 major proc occurring during inflammatory phase of healing
A
2 major proc occurring:
Hemostasis
phagocytosis
24
Q
which phase of wound healing begins right after injury
how long does it last
A
inflammatory
3-6 days
25
end result of inflm phase
a clean wound bed in a pt w an uncomplicated wound
26
other than the clean wound bed what is the benefit of the inflm phase
it controls infection
27
2 major processes occuring during inflm phase
2 major proc occurring:
Hemostasis
phagocytosis
28
major summary of hemostasis
HEMOSTASIS cessation of bleeding dt vasoconstriction of larger blood vessels in affected area, retraction of injured blood vessels, deposition of fibrin and formation of blood clots in area.
29
what is the framework for cell repair
o The bood clots & fibrin are framework for cell repair
30
what makes up a scab and whats its use
```
o Scab (clots and dead and dying tissue)
o Scab helps hemostasis and inhibits contamination of wound by microorgs
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31
fx of vascular and cellular responses
Vascular and cellular responses-intended to remove foreign substances and dead or dying tissues. (inc blood supply->red, edematous, exudates of fluid and cell debris is normal and cleanses wound
32
how do steroids affect healing
they dec healing
33
when do neutrophils appear for healing
what inc circulation?
```
o Neutrophils (during cell migration) move into IS first 24hrs. Replaced by macrophages after->phagocytosis
o Macrophages rel angiogenesis factor which stim formation of epithelial bud->new vessels->inc circ->inc healing
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34
when does the proliferative phase occur
days 3 or 4 to 21
35
wht creates the raised healing ridge along a suture
```
o Fibroblasts (in wound from 24hrs post injury) synthesize collagen and proteoglycan abt day 5
o Collagen adds tensile strength-inc collagen=inc wound strength. If wound is sutured a raised healing ridge appears under the intact suture line. In newly sutured wound collagen is often visible
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36
what is granulation tissue and hen does it occur
during proliferative phase
cpillaries have grown over the wound. fibrin and collagen are present
granulation tissue is fragile new tissue made of the above that is translucent red color. It occurs when skin edges arent sutured
37
what is epithelialization
if a wound doesnt close by epithelialization it gets covere w dried plasma proteins and dead cells called.
construction of new epidermis
eschar.
38
what color is drainage from secondary intention healing
blood tinged
39
is contraction good. when does it occur
it reduces the size of the wound
| the books disagree. either proliferative or maturation
40
a wound doesnt have a healing ridge. what do? when does the ridge normally ppear
this is cause for concern and you should begin interventions to reduce mechanical strain
day 5-9
41
KELOID=
o In some an abn amount of scar tissue is laid down resuting in hypertrophic scar or keloid
42
when is the maturation phase and what happens during it
o Day 21-1 to 2 years after injury
o Fibroblasts continue to make collagen
o Collagen orders itself
o Wound contracts (P&P says this occurs in proliferative phase)
43
how strong is scar tissue
o Scar is stronger but never as strong as original tissue (only 80% of tensile strength)
o Scar is at inc risk of reulceration
44
PUSH=not sure if important
PUSH
Can document pressure ulcers w PUSH tool (pressure ulcer scale for healing
Change in total score over time can be used as indication of healing
Categorize ulcer w respect to SA, exudates, type of wound tissue.
Record sub scores for ea of above char
Meas length and width in cm. Multiply to obtain SA in square cm. Max score 10
Exudates amount (none, light moderate or heavy. Heavy=3)
Tissue type. 4 if necrotic (eschar), 3 if slough present and necrotic tissue absent, 2 if wound is clean and has granulation tissue, 1 if superficial and reepithelialising, 0 if wound is closed
Max score 17
45
reasons dressings are applied (at least 11)
Dressings applied for
o Protecting from mechanical injury
o Protecting from microbe contamination
o Provide/maint moist wound healing
o Provide thermal insulation
o Absorb drainage or debride a wound or both
o Prevent hemmorhage (w P dressing or elastic bandages)
o Provide thermal insulation
o Absorb drainage or debride a wound or both
o Prevent hemmorhage (when applied as a pressure dressing or with elastic bandages)
o To splint or immobilize the wound site and thereby facilitate healing and prevent injury
o Aesthetic or psych comfort
46
how should tape be placed on a drsg
o place tape so drsg cant be folded back to expose the wound. Place strips at ends and space evenly in middle
o ensure that tapes long and wide enough to adhere to several sm fo skin on each side of the drsg but not so long or wide that the tape loosens w activity
o place tape in Opposite direction from body action
o select tape, the ends of which should be folded over slightly in advance of securing to aid ease of removal
47
what type of tape can apply some pressure
elastic tape
48
you need to do frequent drsg changes
o Montgomery straps (tie tapes) commonly used for wounds requiring freq drsg changes (prevent skin irritation and the discomfort caused by removing the adhesive ech time the drsg is changed
49
are antimicrobials used to cleanse wounds
no theyre cytotoxic
50
what do you inspect a surgical wound for
```
(inspect surgical wounds for the following)
1. Appearance
security
2. Size
of drainage on the gauze
4. (edema) Swelling
ng
5. Pain
6. Status of drains or tubes
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51
when you inspect wound appearance what are you assessing
1. Appearance
Colour of wound and surrounding area
Approximation of wound edges
If staples or sutures are present then note their security
52
what do you inspect for drainage
3. Drainage
Location, Colour, Degree of saturation of drsgs
Note number of gauzes saturated or the diameter of drainage on the gauze
53
is moderate swelling normal in a wound in the early stages of wound healing
yes
54
how long should you expect moderate to severe pain for
what could it indicate after this
5. Pain
Expect moderate to severe pain postop for 3-5 days
Persistent severe pain or sudden onset of severe pain may indicate internal hemmorhaging or infection
Note specific areas of incison that cause pain when cleansed or dressed
55
when assessing status of drains or tubes what do you look for
```
6. Status of drains or tubes
Drain security and placement
Amount and char of drainage
Fx of collecting apparatus if present
Note method of security eg sutures, safety pin
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56
what might a pt feel that indicates they may be exp dehiscence or evisceration of the wound)
a popping or giving
57
• For surgical incisions healing by primary intention the nurse can expect the following signs of sequential healing
1. Absence of bleeding and the appearance of a clot binding the wound edges. Wound edges are well approximated and bound by fibrin int he clot within the first few hours after surgical closure
2. Inflammation at wound edges for 3-5 days
3. Reduction in inflammation when the clot diminishes as granulation tissue starts to bridge the area. Wound is bridged and closed within 7-10 days. Inc inflm assoc w fever and drainage is indicative of wound infection The wound edges then appear brightly inflamed and swollen
4. Scar formation. Collagen synthesis starts 4 days after injury and continues for 6mo or longer
5. Diminished scar size from months-yrs.
58
is a surgical stab wound made for a drain (eg penrose drain) cleaner than the main surgical wound
no
59
factors that dec wound healing
* Hypovolemia, HoTN, vasoconstriction, edema, and **hypoxia**negatively affect wound healing because adequate perfusion and oxygenation are nec for new vessel dev, collagen synthesis and dev of tensile strength
* Nutritional status nec for collagen synthesis, tensile strength, immune fx
* Infection prolongs inflm response and uses nutrients and oxygen nec for wound repair
* Pt w DM may have impaired wound healing dt abnormal and prolonged inflm, reduced collagen synthesis, impaired epithelial migration
* Hyperglycemia is assoc w compromised neutrophil fx and impaired migration
* Corticosteroid therapy or use of other immunosuppressive agents such as chemo inc the pts susceptibility to infection
* Inc age dec healing dt dec cells nec
60
what does viable, healing tissue usually look like
o Viable tissue is usally red to pink in color and moist in appearance=granulation tissue
61
what should be done with eschar int he wound bed
o Black brown or tan tissue int he wound is slough or eschar and should be removed
62
NPWT
benefits
how is it covered
o It acceerates healing by edema, fluid removal, wound contraction, mechanical stretch perfusion (stim angiogenesis), optimizes blood flow, maintains moist env
o Drsg placed into a wound maint moist env
o Suction device is placed over drsg
o This is all covered w a transparent drsg to make airtight seal.
63
can you use NPWT for chronic wounds
o NPWT is approved for chronic wounds eg P ulcers, diabetic ulcers, traumatic wounds and venous stasis ulcers
64
when do you change NPWt
Its changed on schedule (usually no earlier than 48hrs
65
how would you debride a wound if there was black tissue in it vs low risk of infection
what would the back tissue indicate
what would be applied to infected wound
o Black=necrotic tissue or dessicated tissue eg tendon, gangrenous lesions 2’ to PVD if goal is debridement then sharp debridement is used to remove quick
o If infection risk is low then use of moisture-retentive drsg assists in debridement eg hydrocolloids, hydrogels, alginates
o If wound is infected then topical antimicrobials are used
66
what drsg would you select for a wound w granulation tissue
o Select drsg that maint clean, moist wound env and dec damage to healing tissue
67
what is dehiscence
o Dehiscence is the failure of wound healing in which the surgical wound separates and opens to the fascial level
68
when would a surgical infection generally present
if theres a device left in place during the procedure?
o Surgical site infection presents within 30 days if theres no implanted device or 1yr if a device is left in place during the procedure
69
when does dehiscence generally occur by
o Occurs early after Sx by postop day 5-8 in pts in whom normal healing responses lag. The wound edges open and serosanguinous drainage is present-then allowed to heal by secondary intention
70
what can contribute to dehiscence
| probably all apply to evisceration
o Anemia
o Malnutrition
o Obesity
o Use of steroids
71
care for dehiscence of a wound
how does it heal
drsg?
The wound edges open and serosanguinous drainage is present-then allowed to heal by secondary intention
o Topical care options include light packing w moist drsg covered with a dry drsg thats changed on a schedule to prevent the wound bed from drying out ie often every 8hrs
72
what is more serious evisceration or dehiscence
evisceration
73
evisceration
o evisceration=failure of wound healing w total separation of the layers fo the wound and protrusion of the internal organs through the wound=surgical emergency-must cover the wound w a moist sterile saline drsg. Notify the surgeon immed and prep the pt for emerg sx
74
T or F if there is nonviable tissue in a wound you should remove it by debridement
why or why not
T
nonviable tissue in a wound delays wound healing and contributes to wound infection
debridement is imp part of topical therapy
75
methos of debridement
methods of debridement=enzymatic (collagenase), mech, autolytic, sharp (sterile instruments to remove dead tissue ONLY performed by health care provider trained, competent, qualified
76
wound assessment
1. past ass? tool?
2. pain
3. explain
4. hand hygiene, get biohazard bag
5. remove drsg and examine drsg for quality of drainage (color, consistency) odor, quantity of drainage) discard drsg DISCARD GLOVES
6. inspect wound det type of wound healing (1’ or?)
7. assess wound using tool and look for above items
Using vihas system
PSBEEOS
pain
size
bed
exudate
edge
odour
skin
a. loc
b. are wound margins approximated? Should be no gaps
c. drainage
d. infect?
e. Lightly palpate along incision to feel a healing ridge. It appears as an accumulation of new tissue presenting as firmness beneath the skin, extending to about 1cm on each side of the wound bet 5-9 days after wounding. This is an expected positive sign
9. Reapply drsgs, place date, time, initials on new drsg
10. Reassess pts pain and level of comfort including pain at wound site
77
what to assess for wound healing by secondary intention
8. Wound healing by 2ary intention (P ulcer, contaminated Sx or traumatic wound)
a. Loc
b. Wound dimensions in cm. Meas in longest places. Meas depth by placing cotton tipped applicator into lg depth and mark it w pen at skin level. Discard in biohazard
c. Assess for undermining: use cotton tipped applicator to gently probe wound edges. Meas depth and note location using the face of a clock as a guide. Document the amount in cm that it extends from wound edges
d. Assess extent of tissue loss: if P ulcer then det the deepest viable tissue layer in wound bed. If necrotic tissue doesn’t allow visualization of base of wound, the stage cant be det
e. Note tissue type including percentage of tissue intact and presence of granulation slough and necrotic tissue
f. Note exudates....
g. Note if wound edges are rounded toward wound bed, may be indication of delayed woud healing. Describe presence of epithelialisation at wound edges because this indicates movement toward healing
h. Inspect periwound skin: include colour texture, temp, and description of integrity
78
what is written on new drsg
date, time, initials
79
dry gauze drsg is good for
not good for
* Dry gauze are commonly used for abrasions and nondraining postop incisions
* Dry gauze drsg are for wound healing by 1’ intention w little drainage. It protects the wound from injury, dec discomfort, & speeds healing (when used correctly)
not good for debriding wounds or maint a moist environment unless the wound is highly exudative
80
how does gauze compare to semiocclusive drsg in terms of freq of changing the drsg
• Gauze-freq drsg changes are usually nec and have inc infection rates when compared w semiocclusive drsg
81
what do you do if dry gauze drsg is stuck to wound
. IF the gauze adheres to a drsg can use NS or sterile water before removing to minimize wound trauma
82
moist to dry drsg
• Moist to dry drsg are gauze moistened w appropriate soln mostly for debriding mechanically, specifically full thickness woumds healing by secondary intention and wounds w necrotic tissue
83
```
fx of:
wound packing
impregnated gauze
strip gauze
damp gauze
```
* Packing is to fill dead space and avoid potential abscess formation by a wound closing too soon
* Impregnated gauze is useful when theres undermining-the destruction of tissue under intact skin around the wound perimeter
* Strip gauze is good for tunnelling
* Damp gauze is good for packing exudative wounds
84
should you clean open wounds each time you change the drsg
yes. w NS
85
where should wound packing end? just below the wound surface, just above, or at the wound surface level?
never pack above wound seurface level
86
Procedure: applying a drsg dry and moist to dry
look in book. its long
87
Wound is inflm and tender, drainage is evident and or odor present. what do
monitor pt for infection (fever, WBC)
- notify
- Wound culture as ordered
- if yellow, tan, brown necrotic tissue refer to health care provider for need for debridement
88
Pt reports sensation that somethings given way under the drsg
Observe wound for inc drainage or dehiscence (partial or toal separation of wound layers) or evisceration (total separation of wound layers and protrusion of viscera through wound opening)
- protect wound. Cover w sterile moist drsg
- instruct pt to lie still
- stay w pt to monitor vitals
- notify
89
Recording and reporting applying a rsg
Recording and reporting
• Appearance and size of wound, char of drainage, presence of necrotic tissue, type of drsg applied, pts response to drsg change, level of comfort
• Report unexpected wound drainage, accidental removal of drain, bright red bleeding, evi of wound dehiscence or evisceration
90
what do if Solns used may be irritating to healthy skin around wound
Protects healthy skin w protective barrier eg stomahesive or apply topical ointments eg zinc oxide. If used it should be taken off w mineral oil. Avoid scrubbing the skin because scrubbing can cause harm to epithelial layer
91
what do if Wound gets excessively dry
A continually moist drsg ( w a HCP order) can be tried. Don’t use fine mesh gauze and lightly pack wound w fluffy gauze dampened w prescribed soln
92
what do if Wound is deep and retention of drsg in cavity is suspected
Irrigate copiously to loosen drsg to be remove. Use continuous ribbon or strip of gauze to dress deep wounds
93
what do if Wound drainage is damaging healthy tissue
Protect healthy skin w skin barrier eg hydrocolloid. If lg amount of drainage may need occlusive drainage collection device
94
what do if Pts skin is irritated by tape
Use hydrocolloid under tape, Montgomery ties, fabric tape w multidirectional stretch, secure drsg w binder, or wrap w roll gauze on extremity
95
what are wound specimens for
| where do u get them from
* Spec of wound drainage is used to det type and number of pathogenic microorganisms
* Always collect wound culture sample from fresh exudates from the center of a wound after removing old drainage (there may be resident colonies on skin which aren’t causative)
96
what do you assess for a wound spec
o Pt understanding
o Pt for: fever, chills, excess thirst. WBC elevated?
o Pain? If yes wait for analgesic. (pain at wound site often inc w infection)
o When is drsg scheduled
o HCP order. An/aerobic?
o Wsh, glove, remove drsg and fold w soiled sides tog and dispose, remove gloves, apply sterile gloves to P wound. Observe for swelling, sep of wound edges, inflm, drainage. P gently along wound edges and note tenderness or drainage. Remove and discard gloves
97
t or f you clean a wound once for a woun drainage spec
f. once before to remove excess microorgs which will confound the results and once after you get the culture so you can apply new drsg
98
procedure getting a wound culture (aerobic)
do assessments
privacy
id pt
hygiene and clean gloves
-clean area around wound edges w antiseptic swab to remove old exudte
remove gloves, wash hands
open sterile culture tube packaging and apply STERILE GLOVES
get culture aerobic culture: take swab from culture tube, insert tip into wound in drainage and rotate gently. Remove swab and return to cult tube (wrap outside of ampule w gauze to prevent injury to your fingers). Crush ampule of medium and push swab into fluid
remove gloves, hygiene
label, verify ID in front of pt. indicate if pt is on Abx
send spec to lab immed
help pt to comfortable position
99
anaerobic culture
anaerobic cult: swab deeply into draining body cavity, rotate gently. Or put tip of syringe Without Needle into wound and aspirate 5-10ml of exudates. Attach 19 gauge needle, expel all air and inject drainage into special cult tube.
100
what do if Wound cultures reveal heavy bact growth
Monitor pt for fever, chills, excess thirst (indicate systemic infect)
Inform HCP of findings
101
what do if Wound culture is contaminated w superficial skin cells
Monitor pt for fever and pain
Inform as above
Repeat collection as ordered
102
what to record from wound spec
types of specs obtained, source, date, time and date sent to lab, describe appearance of wound and char of drainage
report evi of infect to charge nurse and health care provider
pt tolerance
