Wound Management Flashcards
why is classification of a wound important?
enables you to ensure correct management of the wound and patient
how should a wound be classified?
when did the wound occur
how contaminated is the wound
how did the wound occur
what type of wound is it
why is it important to know when the wound occurred?
in order to classify level of bacterial multiplication (longer time = more bacteria)
what are the classes of wound based on bacterial multiplication?
class 1 class 2 class 3
how old is a class 1 laceration (bacterial classification)?
0-6 hours old
how old is a class 2 laceration (bacterial classification)?
6-12 hours old
how old is a class 3 laceration (bacterial classification)?
older than 12 hours (or unknown time of wound occurance)
describe the contamination level of a class 1 (bacterial multiplication) wound
minimal contamination
describe the contamination level of a class 2 (bacterial multiplication) wound
significant contamination
describe the contamination level of a class 3 (bacterial multiplication) wound
gross contamination
describe the type of wound of a class 1 (bacterial multiplication) wound
clean laceration
what are the levels of wound contamination?
clean
clean contaminated
contaminated
dirty / infected
when are clean wounds created?
under sterile conditions
describe the level of contamination of clean contaminated wounds
minimal contamination - easily removed
when are clean contaminated wounds produced?
during surgery if a tract is perforated with minimal spillage
when can clean contaminated wounds be closed?
after appropriate treatment
describe contaminated wounds
gross contamination with foreign debris
what could cause a contaminated wound?
dog fight
RTA
gunshot
when can a contaminated wound be closed?
after appropriate treatment
describe a dirty / infected wound
infection (>10^5 organisms per gram) already exists
at how many organisms per gram is there said to be an infection?
> 10^5 organisms per gram
should dirty / infected wounds be closed primarily?
no
how can a wound be tested for infection?
flushed and then swabbed for culture and sensitivity tests
what are the 5 types of wound?
incision abrasion avulsion laceration puncture
what creates and incision wound?
sharp objects
describe an incision wound
smooth edges
minimal surrounding trauma
surgical wound
what creates an abrasion wound?
blunt trauma or shearing force
describe an abrasion wound
damage to skin including epidermis
what happens during an avulsion wound?
tearing of tissue from attachment (e.g. degloving)
what is a laceration wound created by?
tearing
describe a laceration wound
variable damage to tissues
describe a puncture wound
penetrating wound
minimal superficial damage but substantial deeper damage
what can cause a puncture wound?
sharp object / missile
what must be considered about the anatomy near to / within a wound?
deterioration or progression of the wound and how this may affect the patient (long and short term)
side effects / results of tissue breakdown due to associated anatomy
how may a wound affect mobility in the long term?
if near to a joint scar tissue may form which alters range of movement
what are the 3 phases of wound healing?
inflammatory
proliferative
maturation
what is the aim in the inflammatory phase?
debridement
when does the inflammatory stage of wound healing occur?
within the first 72 hours post injury
when does haemorrhage occur post injury?
within minutes
what is the role of vasoconstriction during the inflammatory phase of wound healing?
reduces haemorrhage and allows clot to form
what is the role of vasodilation in the inflammatory stage of wound healing?
releases clotting elements into the wound and triggers the healing process
what process in the inflammatory stage of wound healing initiates the debridement phase?
white blood cells leak from the blood vessels into the wound - ‘clean up’
when does the early proliferative stage begin?
3-5 days post injury
what happens during the early proliferative stage of wound healing?
granulation tissue fills the wound
fibroblasts lay a network of collagen in the wound bed which gives strength to tissue
epithelial cells from the wound margins migrate to cover the wound
what is the aim during the early proliferative stage of wound healing?
maintain moist wound environment
prevent damage to cells
what happens during the late proliferative stage of wound healing?
wound contracts
epithelialisation
what are the aims during the late proliferative stage of wound healing?
exudate reduced
maintain moist environment
when does the maturation stage of wound healing begin?
2-4 weeks post injury when the wound has filled in and resurfaced
what happens during the maturation stage of wound healing?
remodelling phase
collagen fibres reorganise, remodel and mature to give wound tensile strength forming scar tissue
what are the 4 key goals of wound healing?
full epithelialisation with minimal / no scar formation
in as minimal time as possible
without recurrence or risk of breakdown
as cost effectively as possible
what are the 6 goals of wound management?
prevent further wound contamination remove foreign debris and contamination debride dead and dying tissue promote viable vascular bed provide drainage where possible select appropriate method of closure
how can the viability of tissue be assessed?
colour
warmth
pain sensation
bleeding
why must tissue viability continue to be assessed after repair / dressing?
skin circulation can continue to deteriorate because of oedema and other factors
what are the 4 types of wound closure?
primary
delayed primary
secondary
secondary intention
when is primary wound closure indicated?
minimal tissue contamination, loss or trauma
when is the golden period for primary closure?
6-8 hours - if time of injury unsure assume this has passed
what should happen to wounds prior to primary closure?
explored, cleaned by lavage and surgically debrided
when does the fibrin seal form on a wound that is closed by primary closure?
within 4-6 hours
what is the role of a fibrin seal on a wound?
protects the wound against invasion of microorganisms and prevents fluid leakage from the wound
when does epithelialisation of the wound surface occur?
48 hours after formation of fibrin seal
when does wound tensile strength increase?
once sealed in the next 7-14 days
when are sutures usually removed?
at day 10 following primary closure
when is delayed primary closure indicated?
wounds that have gone beyond the golden period or require further debridement
what should happen to the wound in delayed primary closure?
wound explored, cleaned by lavage and debrided
what does debridement involve?
removal of dead or damaged tissues, foreign bodies and micororganisms
what will be caused by inadequate debridement?
delay in wound healing
what wounds indicate the need for secondary closure?
heavily contaminated or dirty wounds
how are secondary closure wounds managed?
as open until granulation bed is established
when are wounds closed during secondary closure?
debrided and closed once granulation bed is established (if possible)
what type of wound indicates secondary intention wound healing?
wounds that have significant tissue loss, contamination or infection
how are secondary intention healing wounds managed?
as open wounds that are allowed to granulate and epithelialise
when should wounds only be allowed to close?
if there is sufficient tissue to allow reconstruction without dehiscence
if there is no devitalised tissue or foreign material
if functional structures will be affected by contraction or delayed closure
no signs of infection or contamination
if adjacent skin is healthy
what are difficult areas to dress?
ears
bottom / back
some extremities
how can dressings be encouraged to stay on?
tie over dressings
bandages
vac pac
what does a vac pac do?
suctions debris away from wound
applies constant negative pressure to help with closure
what can be caused by using the wrong dressing?
delay in healing
what dressing should be used?
the one most appropriate for the stage of wound healing - should be assessed at each dressing change
what are the 2 main types of dressing options available?
non adherent / passive / absorbent
non adherent / mildly absorbent / passive
describe non adherent / passive / absorbent dressings
foam dressings absorb fluid (exudate) semi permeable (allow air to get to wound) delivers moist environment
what are non adherent / passive / absorbent dressings made from?
hydrophilic polyurethane
what are non adherent / passive / mildly absorbent dressings made from?
perforated PET film on a backing of cellulose fabirc
what is allowed by non adherent / passive / mildly absorbent dressings?
epithelialisation and absorption of exudate
when are non adherent / passive / mildly absorbent dressings indicated?
lightly exuding lesions
sutured wounds
superficial cuts and abrasions
light burns
what does frequency of dressing change depend on?
type of wound
volume of exudate
type of dressing in place
stage of wound healing
when should wet to dry or dry to dry dressings be changed?
daily or twice daily
when should dressings on granulating wounds be changed?
every 2-3 days
what are the limitations of wound treatment?
cost
infection / MRSA risk
patient tolerance of nursing
owners patience
what must be made clear about dressing changes?
when they were done and how the wound appeared at this stage
what is important to consider when triaging a patient with a large wound?
that you must look at the whole patient. The wound may look alarming but other injuries or problems could be more immediately life threatening
hydration status is also key
what are the key issues to check for with polytrauma patients aside from obvious fractures and wounds?
pneumothorax
diaphragmatic hernias
ruptured bladder
head injuries
what is involved in patient triage?
brief history from client and then ensure that further full history is gained when patient is stable
clinical exam
note obvious wounds haemorrhage and detail severity
what is included in the triage clinical exam?
TPR MM check of limbs demenour resp effort / pulse quality hydration status
once patient is triaged what must be done to ensure the wound can be safely managed / treated?
patient must be suitably restrained via sedation or GA
ensure adequate analgesia
why must PPE be used when cleaning a wound?
to prevent further contamination of the wound
what equipment is required for wound flush?
large bag of warm fluids (Hartmanns or saline) giving set 3 way tap 18 or 19 gauge needle 20-30 ml syringe incontinence pads
what is the recommended pressure that a wound should be flushed at?
8-12 psi
what can be done once the wound has been cleaned?
bacteriology swab
what drugs should a wound patient be managed with?
correct pain relief
antibiotic treatment indicated by swab
what must all wound patients wear to protect the wound?
buster collar
what must be considered when caring for the wound patient outside of medical care?
enrichment
grooming
play
owner visits
who should carry out each dressing change?
where possible the same staff should carry out each dressing change
what can be useful if the same staff cannot carry out dressing changes?
photographs of the wound at each change
where do equine injuries often occur?
lower limbs
why are most equine wounds considered dirty / infected?
due to the environment
why is there more concern with tension on equine wounds?
location of wounds and inability to restrict movement in the same way as with cats / dogs
what are sometimes used to relieve pressure on wounds in horse?
quills - using horizontal mattress suture pattern
why is the aim for minimal scar tissue formation in equine wounds?
scar tissue is 15-20% weaker than original tissue
what is the problem with topical antiseptics?
will not reduce bacterial load in deeper / necrotic tissue
what topical treatment is often used in treatment of equine wounds?
manuka honey - reduces bacterial colonisation, increases healing rates and achieves superior debridement to hydrogels
what types of surgical drain are available?
passive and active
what does the choice of surgical drain depend on?
location, requirement and patient considerations
name 2 types of active drains
blake - wound explorations
jackson pratt - abdomens, post ex lap
how should drains be managed?
with aseptic technique (PPE)
what can be used to aid communication with client?
photographs can show development and help with owner patience as long as they are ok with seeing photos
what must owner visits be fitted in around?
starvation, dressing changes and recovery time - can be difficult but should be accommodated
when should the wound patient be sent home?
as soon as suitable and when owner is prepared to care for the patient
when is staff communication about a wound patient crucial?
ensure patient is starved when required
dressing changes are carried out when expected
ensure any issues / concerns with dressings are addressed immediately
what can be done to show when a dressing change is required?
write the date / time of application of dressing onto the bandage itself using permanent marker
ensure this is written clearly on the hospital sheet
what can be difficult to maintain when patients are having multiple dressing changes?
weight - due to starvation and sedation associated with dressing changes
how are calorie requirements calculated?
RER = (BWx30)+70
what additional care do wound patients need due to the often long length of hospitalisation?
time without buster collar grooming supervised play longer walks on lead hand feeding sitting with them mini training sessions
what must be done to protect the bandage?
ensure patient cannot interfere
stop dressing from getting wet
how can you prevent the bandage from getting wet?
cover with plastic cover to go outside for walks
remove water bowls from the kennel
what should the dressing be checked for every 4-6 hours?
damp or wet slipping patient interference tightening (swelling above or below) checking toes for moisture and temperature patients tolerance of dressing
when are wound patients normally discharged?
when dressings are being changed every 2-3 days
what should clients be given when the patient is sent home?
clear instructions on dressing management
point of contact
cover for dressing
buster collar
what parameter must be managed very carefully in long term wound patients?
weight loss
