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Clinical Nursing May Exam > Wound management > Flashcards

Wound management Flashcards

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
Q

what happens in the late proliferative phase?

A

wound contracts
epithelialisation
exudate reduces and moist environment is maintained

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26
Q

what is meant by the maturation phase of wound healing?

A

remodelling phase

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27
Q

when does maturation phase begin?

A

when wound has filled in and resurfaced

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28
Q

what happens during the remodelling phase?

A

collagen fibres reorganise, remodel and mature to give wound tensile strength forming scar tissue

29
Q

what factors are used to assess tissue viability?

A

colour
warmth
pain sensation
bleeding

30
Q

what factors make it okay for wounds to close?

A

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
Q

what are the 4 types of closure?

A

primary closure
delayed primary closure
secondary closure
second intention healing

32
Q

when is primary closure used?

A

minimal tissue contamination, loss or trauma

still within golden period/6-8 hours

33
Q

what do you do before allowing primary closure or delayed primary closure?

A

explore wounds
lavage to clean
debride

34
Q

define debridement

A

removal of dead or damaged tissues, foreign bodies, MOs to promote wound healing

35
Q

describe the process of primary closure

A

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
Q

why are sutures normally removed on day 10?

A

generally enough tensile strength of wound

37
Q

when is delayed primary closure done?

A

wounds passed golden period

needing further debridement

38
Q

when is secondary closure done?

A

heavily contaminated and dirty wounds

39
Q

what is the process of secondary closure?

A

managed as open wounds until granulation bed established

wound debrided and closed

40
Q

what wounds need second intention healing?

A

significant tissue loss, contamination or infection

41
Q

what is the process of second intention healing?

A

managed as open wound and allowed to granulate and epithelialize

42
Q

state some areas that are hard to dress?

A

ears
bottom
back
some extremities

43
Q

how can you help make easier hard areas to dress?

A

held by tie over dressings, bandages, vac pac

44
Q

how is the type of dressing chosen?

A

correct for most appropriate stage of wound healing to promote healing

45
Q

what are the properties of non-adherent/passive/absorbent dressings?

A 
absorb fluid
breathable
deliver moist environment
semi permeable membrane 
made of hydrophilic polyurethane
foam dressings
46
Q

what are non-adherent/passive/absorbent dressings used for?

A

exudative wounds

47
Q

what are the properties of non-adherent/mildly absorbent/passive dressings?

A

perforated PET film
cellulose backing
allows epithelialisation
absorbs exudate

48
Q

when are non-adherent/mildly absorbent/passive dressings used?

A

exudating lesions
sutures wounds
superficial cuts and abrasions
light burns

49
Q

what affects when dressings get changed?

A

type of wound
volume of exudate
type of dressing
stage of wound healing

50
Q

when are wet to dry and dry to dry dressings typically changed?

A

1-2x daily

51
Q

when are granulating wound dressings usually changed?

A

every 2-3 days

52
Q

what is important when triaging patients with superficial wounds?

A

look at whole patient for other more serious injuries

53
Q

what are the stages of triaging patients with wounds?

A

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
Q

describe the process of cleaning wounds

A

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
Q

list equipment needed for flushing wounds

A 
large bag of warm 0.9% saline or hartmanns
giving set
3 way tap
18/19g needles
20-30ml syringe
incontinence pads
56
Q

what is an important consideration when flushing patients wounds?

A

limit fluid on patient to prevent hypothermia

57
Q

when are dressings placed on patients with wounds?

A

after cleaned and bacteriology swab taken

58
Q

what are nursing considerations for patients with wounds?

A

analgesia
antibiotics where needed
prevent patient interference
all elements of patient care

59
Q

how are dressings and wounds managed?

A

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
Q

what are some considerations specific to equine wounds?

A

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
Q

why is it important to minimise scar tissue when healing wounds?

A

scar tissue is weaker than original tissue

62
Q

state the 2 types of surgical drains and examples of each

A

passive- latex tubing

active- blake-wound explorations, jackson pratt (abdomen)

63
Q

what determines what type of surgical drain is used?

A

location
requirement of drain
patient consideration

64
Q

how can you ensure good communication between client and staff when managing patients with wounds?

A

photos to show development
address any concerns
make owner aware of responsibility if caring for at home

65
Q

why is it vital to have good communication with client when managing patients with wounds?

A

may be in hospital for long time

may be hard to visit around dressing changes and recovery

66
Q

what are other considerations when managing patients with wounds?

A

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
Q

how should bandages be managed?

A

prevent interference
keep dry
check regularly for wetness, slipping, interference, tightening, temperature of toes

68
Q

when should you discharge patients with wounds?

A

as soon as possible but when dressing changes are every 2-3 days and wound has made good progress

69
Q

what needs to be done before discharging patients with wounds?

A

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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