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Clinical Nursing May Exam > Wound management > Flashcards

Wound management Flashcards

(69 cards)

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1
Q

why do wounds need to be classified?

A

allow correct management of wound and patient

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2
Q

state the 3 initial wound classifications

A

when did it occur
how contaminated is the wound and how did it occur
what is the type of wound

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3
Q

why is it important to find out when wounds occurred?

A

allows estimation of amount of bacterial multiplication that will be taking place in the wound

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4
Q

how do you classify the time since a wound has happened?

A 
class 1- 0-6 hours old, clean laceration, minimal contamination
class 2- 6-12 hours old, significant contamination
class 3- over 12 hours or assumed if dont know when it happened, gross contamination
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5
Q

list the different ways to describe how contaminated a wound is

A

clean
clean contaminated
contaminated
dirty or infected

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6
Q

define a clean wound

A

surgical wounds created under sterile conditions

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7
Q

what is a clean contaminated wound and when are they closed?

A

minimal contamination which is easily removed
surgical tract penetrated with minimal spillage
are able to close after treatment

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8
Q

what is a contaminated wound and when are they closed?

A

gross contamination with foreign objects

close after appropriate treatment

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9
Q

what is meant by a dirty or infected wound and when are they closed?

A

infection already present in the wound

not closed primarily

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10
Q

list the classifications of types of wounds

A 
incision
abrasion
avulsion
laceration
puncture
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11
Q

define incision

A

smooth edges cut by sharp object, minimal trauma around

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12
Q

define abrasion

A

blunt trauma, damage to skin and epidermis

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13
Q

define avulsion

A

tearing tissue from attachment, degloving

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14
Q

define laceration

A

irregular wound by tearing, variable damage

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15
Q

define puncture wound

A

penetration by sharp object causing deep damage

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16
Q

list the overall goals of wound healing

A

full epithelialisation with minimal scarring in as short time as possible, without risking recurrence or breakdown, and as cost effective as possible

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17
Q

what are the aims in wound healing?

A 
prevent further contamination
remove foreign debris and contamination
debride dead and dying tissue
promote viable vascular bed
provide drainage
close with appropriate method
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18
Q

state the 3 phases of wound healing and when they take place

A

inflammatory phase- first 72 hours
proliferative phase- 3-5 days
maturation phase- 2-4 weeks

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19
Q

what happens in the inflammatory phase of wound healing?

A

haemorrhage within minutes of injury
vasoconstriction to allow clots to form then vasodilation to reduce clotting elements into wound to trigger healing
white blood cells leak from vessels into wound to initiate debridement

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20
Q

what is the main aim of the inflammatory phase of wound healing?

A

debridement

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21
Q

what treatment can be provided in inflammatory phase of wound healing?

A

wet to dry or dry to dry swabs
hydrogels
topical agents
wound vac

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22
Q

what is meant by the proliferative phase of wound healing?

A

reconstruction phase

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23
Q

what happens during the proliferative phase of wound healing?

A

granulation tissue fills the wound
fibroblasts lay network of collagen in wound bed to give strength to tissues
epithelial cells from wound margins migrate to cover wound

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24
Q

what is the aims of the proliferative phase of wound healing?

A

maintain moist wound environment

prevent damage to cells

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25
what happens in the late proliferative phase?
wound contracts epithelialisation exudate reduces and moist environment is maintained
26
what is meant by the maturation phase of wound healing?
remodelling phase
27
when does maturation phase begin?
when wound has filled in and resurfaced
28
what happens during the remodelling phase?
collagen fibres reorganise, remodel and mature to give wound tensile strength forming scar tissue
29
what factors are used to assess tissue viability?
colour warmth pain sensation bleeding
30
what factors make it okay for wounds to close?
sufficient tissue to allow reconstruction without dehiscence no devitalised tissue no foreign material functional structures affected by delayed closure or contraction no infection or contamination healthy adjacent skin
31
what are the 4 types of closure?
primary closure delayed primary closure secondary closure second intention healing
32
when is primary closure used?
minimal tissue contamination, loss or trauma | still within golden period/6-8 hours
33
what do you do before allowing primary closure or delayed primary closure?
explore wounds lavage to clean debride
34
define debridement
removal of dead or damaged tissues, foreign bodies, MOs to promote wound healing
35
describe the process of primary closure
fibrin seal forms in 4-6 hours to protect wound against MOs and prevent fluid leakage from wound epithelialisation of wound surface happens after 48 hours tensile strength of wound increases by days 7-10
36
why are sutures normally removed on day 10?
generally enough tensile strength of wound
37
when is delayed primary closure done?
wounds passed golden period | needing further debridement
38
when is secondary closure done?
heavily contaminated and dirty wounds
39
what is the process of secondary closure?
managed as open wounds until granulation bed established | wound debrided and closed
40
what wounds need second intention healing?
significant tissue loss, contamination or infection
41
what is the process of second intention healing?
managed as open wound and allowed to granulate and epithelialize
42
state some areas that are hard to dress?
ears bottom back some extremities
43
how can you help make easier hard areas to dress?
held by tie over dressings, bandages, vac pac
44
how is the type of dressing chosen?
correct for most appropriate stage of wound healing to promote healing
45
what are the properties of non-adherent/passive/absorbent dressings?
``` absorb fluid breathable deliver moist environment semi permeable membrane made of hydrophilic polyurethane foam dressings ```
46
what are non-adherent/passive/absorbent dressings used for?
exudative wounds
47
what are the properties of non-adherent/mildly absorbent/passive dressings?
perforated PET film cellulose backing allows epithelialisation absorbs exudate
48
when are non-adherent/mildly absorbent/passive dressings used?
exudating lesions sutures wounds superficial cuts and abrasions light burns
49
what affects when dressings get changed?
type of wound volume of exudate type of dressing stage of wound healing
50
when are wet to dry and dry to dry dressings typically changed?
1-2x daily
51
when are granulating wound dressings usually changed?
every 2-3 days
52
what is important when triaging patients with superficial wounds?
look at whole patient for other more serious injuries
53
what are the stages of triaging patients with wounds?
get brief history then gain full later when patient stable clinical exam- TPR, fractures, respiration, hydration, haemorrhage further investigations as needed manage wounds- restrained with GA or sedation, analgesia
54
describe the process of cleaning wounds
cover and protect wound with sterile lube or damp sterile swab clip hair around wound to keep clean and check for further injury thoroughly flush wound to remove debris investigate wound, potentially doing bacteriology swab for culture
55
list equipment needed for flushing wounds
``` large bag of warm 0.9% saline or hartmanns giving set 3 way tap 18/19g needles 20-30ml syringe incontinence pads ```
56
what is an important consideration when flushing patients wounds?
limit fluid on patient to prevent hypothermia
57
when are dressings placed on patients with wounds?
after cleaned and bacteriology swab taken
58
what are nursing considerations for patients with wounds?
analgesia antibiotics where needed prevent patient interference all elements of patient care
59
how are dressings and wounds managed?
type of dressing correct for wound and stage of healing | should be same staff but if not possible photos to allow consistent monitoring of progress and changes
60
what are some considerations specific to equine wounds?
usually lower limbs most dirty due to environment commonly have tension over wound due to location and inability to fully restrict movement need to aim for minimal scar tissue
61
why is it important to minimise scar tissue when healing wounds?
scar tissue is weaker than original tissue
62
state the 2 types of surgical drains and examples of each
passive- latex tubing | active- blake-wound explorations, jackson pratt (abdomen)
63
what determines what type of surgical drain is used?
location requirement of drain patient consideration
64
how can you ensure good communication between client and staff when managing patients with wounds?
photos to show development address any concerns make owner aware of responsibility if caring for at home
65
why is it vital to have good communication with client when managing patients with wounds?
may be in hospital for long time | may be hard to visit around dressing changes and recovery
66
what are other considerations when managing patients with wounds?
weight- hard to maintain when multiple dressing changes a day, need enough calories, monitor weight daily stimulation- hospitalised for long time, may have exercise restrictions, allow supervised play, grooming, walks, TLC
67
how should bandages be managed?
prevent interference keep dry check regularly for wetness, slipping, interference, tightening, temperature of toes
68
when should you discharge patients with wounds?
as soon as possible but when dressing changes are every 2-3 days and wound has made good progress
69
what needs to be done before discharging patients with wounds?
give client clear instructions on care and managing dressings, contact information if concerned, cover for walks

Clinical Nursing May Exam (22 decks)

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