Wound Dressing Flashcards
what to consider when choosing a particular wound dressing? (13)
1) . cause
2) . severity
3) . environment
4) . size
5) . depth
6) . anatomic location
7) . volume of exudate
8) . risk or presence of infection
9) . pt medical status
10) . patient preference
11) . pt level of comfort
12) . cost-benefit analysis
13) . availability/durability
when first evaluating a wound, what is important to remove prior to indicating wound depth?
eschar (don’t remove this after the 1st eval, EVER)
wound types (6)
closed open (full or partial thickness) necrotic infected granulating epithelializing
closed wound: skin integrity? does dressing decrease infection risk? what type of dressing is used and why?
- skin integrity intact
- no evidence dressing decreases infection risk
- non adherent gauze absorbs exudate and prevents irritation
open wound: encourage what in this wound? what type of environment is best?
- encourage clean granulation
- moist environment without slough
necrotic wound: what to do first? then go to this type of dressing?
- surgically debride if possible
- then add hydrocolloid (duoderm) or hydrogels to help with further debridement
how do hydrocolloid dressings work? use? what type of environment?
when they contact exudate, their hydrophilic particles swell and form an inpermeable gel. The gel absorbs into necrotic tissue, rehydrates it, and causes it to separate from normal tissue (sloughs off afterwards)
- granulate lesions or debride necrotic tissue
- MOIST healing environment
how does duoderm work?
absorbs exudate and produces a moist environment without maceration of surrounding tissue
infected wounds: how to tx minor infections? extensive infections?
minor- normal saline irrigation
major- alginates
what are alginates derived from? how do they work?
brown seaweed; they are important for maintaining moisture!
- calcium alginate converts to soluble sodium salt & produces a hydrophilic gel when in contact with exudate. -Then remove gel with saline irrigation or bathing
- absorbs HEAVY exudate from deep wounds
granulating wound: requires what environment? removal of dressing shouldn’t do what to the wound?
MOIST environment
-removal of dressing shouldn’t damage tissue
granulating wound: what dressing works well?
Xeroform- but don’t let it dry out bc then it debrides new granulation tissue
*hydrocollloids/hydrogels with transparent film covering are good alternatives to impregnated gauze
epithelializing wounds: also called what? how do we treat these?
“abrasions”
- tx same as granulating wounds
- use telfa or transparent film that won’t remove new epithelial layer
three main stages of healing:
1) . Inflammatory
2) . proliferative
3) . maturation
inflammatory stage: what symptoms? how long does it last? what happens generally?
- edema, erythema, heat, pain
- lasts 4-6 days since injury
- macrophages migrate into wound and produce chemoattractants & growth factors (which facilitate wound healing)
