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Advanced Clinical Nursing Theory > Wound Management > Flashcards

Wound Management Flashcards

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1
Q

describe an incised wound

A

clean edges, usually surgical

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2
Q

describe a laceration

A

jagged edge (e.g. barbed wire)

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3
Q

describe an abrasion

A

graze, epithelial damage seen

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4
Q

describe a contusion

A

bruising, develops over time

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5
Q

describe a puncture wound

A

deep, entry wound often not indicative of extent of injury beneath

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6
Q

where are bites commonly seen?

A

hindlimbs

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7
Q

what is commonly associated with bites?

A

large wound, lots of tissue necrosis and infection

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8
Q

what are other wound types seen commonly in practice?

A

burns
bites

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9
Q

what is the main way to classify wounds?

A

time of presentation after injury

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10
Q

what are the classifications of traumatic wounds?

A

class 1-3

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11
Q

what is the time lapse since occurrence of a class 1 wound?

A

0-6 hours

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12
Q

what is the level of contamination and tissue trauma of a class one wound?

A

minimal (fresh)

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13
Q

what is the time lapse since occurrence of a class 2 wound?

A

6-12 hours

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14
Q

what is the level of contamination and tissue trauma of a class 2 wound?

A

increasing levels of bacteria, more contamination present
microbial burden has not reached critical level

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15
Q

what is the time lapse since occurrence of a class 3 wound?

A

more than 12 hours

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16
Q

what is the level of contamination and tissue trauma of a class 3 wound?

A

wound infection present regardless of how wound was created

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17
Q

does wound class affect the approach to treatment?

A

yes

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18
Q

how may wound class affect treatment?

A

class 3 wound not suitable for wound closure

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19
Q

what are some key considerations for a patient who has presented with a wound?

A

clinical exam for other injuries
assess wound location
concurrent disease
medication
temperament
nutrition status
pain level
owner intention
client compliance
costs
resources in practice

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20
Q

what are the key considerations about wound location?

A

patient interference
infection risk (near butt)
any crucial structures near / affected by wound

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21
Q

how does anatomy differ between dogs and cats with regards to wound healing?

A

dogs have higher density of collateral subcutaneous trunk vessels than cats

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22
Q

how do primary closure incisions differ between dogs and cats with regards to wound healing?

A

strength 50% less at 7 days in cats than i dogs
equal at 14 days

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23
Q

how does second intention healing differ between dogs and cats with regards to wound healing?

A

decreased skin perfusion during the first week of healing in cats

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24
Q

how dos granulation differ between dogs and cats with regards to wound healing?

A

cats have less granulation tissue than dogs
tissue seen peripherally in cats and centrally in dogs
granulation tissue takes longer to appear and cover the wound in cats

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25
Q

how does epithelialisation differ between dogs and cats with regards to wound healing?

A

much slower in cats (13% in 14 days as opposed to 44% in dogs)

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26
Q

what is involved in the initial assessment of a patient with a wound?

A

general assessment and history
checking for trauma
analgesia
vital signs
give necessary first aid
regular monitoring to stabilise patient if necessary

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27
Q

what are the phases of wound healing?

A

inflammatory phase
debridement phase
repair / proliferative phase
remodelling phase

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28
Q

what phases of wound healing occur concurrently?

A

inflammatory
debridement

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29
Q

when does the inflammatory phase of wound healing occur?

A

0-5 days

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30
Q

when does the debridement phase of wound healing occur?

A

0 onwards

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31
Q

when does the repair/proliferative phase of wound healing occur?

A

day 3 - 4 weeks

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32
Q

when does the remodelling phase of wound healing occur?

A

day 20 - ongoing

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33
Q

what happens during the inflammatory phase of wound healing?

A

haemorrhage
vasodilation
increase in vascular permeability

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34
Q

what happens during the debridement phase of wound healing?

A

phagocytosis
migration of WBC
removal of cellular debris

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35
Q

what happens during the repair/proliferative phase of wound healing?

A

fibroblasts proliferate
collagen synthesis
epithelialisation
contraction
wound bed rises - scar tissue formed

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36
Q

what happens during the remodelling phase of wound healing?

A

wound contraction (SA becomes smaller)
remodelling of collagen fibres

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37
Q

during the inflammatory phase of wound healing what is the purpose of vasodilation and increased vascular permeability?

A

cells and enzymes needed for debridement can access wound site more easily

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38
Q

what tissue is seen on the wound bed?

A

granulation

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39
Q

what does granulation tissue look like?

A

dark red

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40
Q

what does epithelialisation tissue look like?

A

pink

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41
Q

what will be performed on all wounds no matter the chosen closure technique?

A

lavage

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42
Q

what is the purpose of wound lavage?

A

reduction of bacterial load
reduce and remove debris
visualisation and assessment of wound

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43
Q

how effective is wound lavage at reducing bacterial load?

A

up to 50% lower for every hour earlier wound is lavaged

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44
Q

what must be considered about wound lavage?

A

fluid used
pressure
volume of fluid

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45
Q

what volume of fluid is recommended for wound lavage?

A

50-100ml per cm

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46
Q

what equipment will ensure correct pressure for wound flushing?

A

50ml syringe
green needle (18G)

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47
Q

what is the average suggested wound lavage pressure?

A

8-12 lbs/square inch

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48
Q

what is the risk of applying too much pressure during wound lavage?

A

push infection / debris further in

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49
Q

what solution should be used for wound lavage?

A

isotonic saline
owners could use cooled boiled water if needed

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50
Q

what should not be used for wound lavage?

A

chlorhexidine
povidine iodine
-potential for cell damage

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51
Q

what temperature should fluids for wound lavage be?

A

body temp

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52
Q

what are the main options for wound closure?

A

primary / first intention
delayed primary closure
secondary closure
second intention

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53
Q

what are the main considerations for second intention healing?

A

topical agents
dressings
types of bandage material
client complience
cost
expertise

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54
Q

what are the 5 main principles of wound management suggested by Esmarch?

A

non-introduction of anything harmful
tissue rest
wound drainage
avoidance of venous stasis
cleanliness

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55
Q

what is involved in tissue rest?

A

allow area to rest
minimal dressing changes
reduced patient movement

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56
Q

what is a crucial part of wound healing?

A

drainage

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57
Q

what is the benefit of negative pressure wound therapy (NPWT)?

A

reduced oedema
reduced exudate accumulation in wound
bandage strikethrough reduced as wound fluid is evacuated into collection canister
increased central wound perfusion and vascularisation
rapid contraction and wound healing
reduction in dressing changes

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58
Q

what is the benefit of reduced strikethrough in NPWT?

A

fewer bandage changes so tissue can rest

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59
Q

in what phase of wound healing is increased central wound perfusion and vascularisation vital?

A

inflammatory

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60
Q

how does NPWT reduce bacterial burden?

A

removal of infectious material

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61
Q

how does NPWT protect against infection?

A

provides protected wound healing environment

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62
Q

how does NPWT reduce excess exudate?

A

removal

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63
Q

how does NPWT reduce oedema?

A

removal

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64
Q

how does NPWT manage absence of moisture?

A

provides moist environment

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65
Q

how does NPWT manage lack of adequate blood flow?

A

promotes perfusion

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66
Q

how does NPWT manage lack of granulation tissue formation?

A

promotes formation and draws wound edges together

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67
Q

what can be used topically in wounds?

A

honey
silver

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68
Q

what types of honey can be used in wounds?

A

table honey
medical grade

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69
Q

why is honey being used more commonly?

A

broad spectrum antimicrobial activity
anti-inflammatory
effective against MRSA and pseudomonas

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70
Q

what type of wounds is honey especially effective for?

A

chronic non-healing

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71
Q

is medical grade or table honey better for wound management?

A

table honey had range of microbial species
and lower antimicrobial activity than medical grade
medical grade also sterile

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72
Q

is regular honey or manuka honey better for wound management?

A

manuka better as no hydrogen peroxide better antimicrobial

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73
Q

how does manuka honey promote wound healing?

A

pH of wound is lowered by honey (more acidic)
proteases which break down proteins involved in fibrin matrix of granulation tissue are denatured/less effective
granulation is more efficient and epithelialisation can occur

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74
Q

what are the main considerations when using honey?

A

higher level of exudate so may need more dressing changes / different dressings
may be cellular damage in healthy granulating wounds
need to stop using honey after a certain time to prevent proud flesh due to excessive granulation

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75
Q

why does use of honey on wounds lead to higher level of exudate?

A

honey has high sugar content so osmolarity is higher than fluid in wound - increased exudate

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76
Q

why should use of honey be stopped once granulation tissue has developed?

A

over production of granulation tissue may prevent epithelialisation

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77
Q

what is the role of granulation tissue?

A

creation of new tissue bed to enable epithelialisation

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78
Q

what forms can silver be applied to wounds in?

A

cream
dressing

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79
Q

what is the primary benefit of silver in wound healing?

A

antimicrobial properties

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80
Q

what phase of wound healing is silver best used in?

A

inflammatory

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81
Q

what wounds is silver not indicated for use in?

A

chronic non-healing

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82
Q

what is the purpose of wet to dry bandages?

A

macerate (overhydrate) wound and then desiccate wound bed

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83
Q

what happens when wet to dry dressings are removed?

A

non-selective mechanical debridement so that some of the cells and tissue essential for wound healing are removed along with necrotic tissue

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84
Q

what are the downsides of wet-to-dry dressings?

A

environmental bacteria can penetrate gauze
pain when removed
remnants of gauze fibre remain in wound resulting in inflammation
increase wound care total costs

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85
Q

what is a wet to dry dressing?

A

saline soaked swabs are packed into the wound
dry placed on top
removed after a number of days once swabs are dry
debridement

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86
Q

what is an example of a moisture retentive dressing?

A

allyven

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87
Q

what is the benefit of moisture retentive dressings?

A

removal of exudate while keeping wound moist to provide optimal healing environment
wound does not dry out as in a wet to dry
less frequent bandage changes

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88
Q

what are the main dressing types available?

A

hydrogel
hydrocolliod
vapour-permeable films and membranes
foam

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89
Q

what are examples of hydrogel dressings?

A

intrasite

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90
Q

what are hydrogel dressings made of?

A

water-based, amorphous, cohesive application that is applied to the wound bed

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91
Q

what are hydrogel dressings covered with?

A

secondary, non-absorbent dressing

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92
Q

what is the role of hydrogel dressings?

A

moist and warm environment created for wound healing

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93
Q

what is an example of a hydrocolloid dressing?

A

aquacel

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94
Q

what are hydrocolloid dressings made of?

A

carboxymethylated cellulose, pectin and geletine

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95
Q

how are hydrocolloid dressings applied to the wound?

A

non-adherent gel formed on contact with the wound

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96
Q

when are hydrocolloid dressings used commonly?

A

closed wounds
uncommon in open wound managment

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97
Q

what is an example of a vapour permeable membrane dressing?

A

primapore or melolin

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98
Q

what are vapour-permeable dressings made of?

A

a sheet of absorbent material between two thin layers of film that contains small pores for the movement of gas and fluid

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99
Q

when are vapour permeable dressings commonly used?

A

end stage wound healing as not as absorbent
surgical wounds

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100
Q

what is an example of a foam dressing?

A

allevyn

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101
Q

what are foam dressings made of?

A

polyurethane foam

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102
Q

what forms can foam dressings come in?

A

adhesive
non-adhesive
with or without breathable film backing

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103
Q

what is the role of allevyn?

A

absorb exudate as hydrophillic

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104
Q

what are the considerations when choosing a bandage for a patient?

A

location of wound (is bandaging possible)
client compliance
finance
prognosis
is surgery a likely outcome

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105
Q

when are tie-over dressings used?

A

hard to bandage areas

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106
Q

how is a tie over dressing performed?

A

sutures placed into healthy tissue around wound edge
swabs packed into wound
once sufficiently padded, sutures used to thread ties through and secure bandage to patient

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107
Q

what are the downsides of tie-over dressings?

A

strike through
risk of bacterial contamination
GA for dressing changes needed

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108
Q

how often do tie over dressings need to be changed?

A

every 5 days

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109
Q

how can wound healing be monitored?

A

photos
measure
record subjective assessment

110
Q

what should be assessed if a wound is not healing?

A

swab taken for culture
patient considerations: interfering, nutrition
client factors: complience

111
Q

when should swabs of wounds be taken?

A

at initial presentation
every dressing change?
if any concerns

112
Q

what is the benefit of swabbing wounds?

A

targeted antibiotics

113
Q

what is involved in a good bandage?

A

toes padded if included
dressing secured but comfortable
even tension
not too tight
neat
2/3 to 1/2 overlap for each throw
(check bandage lectures)
keep it dry!

114
Q

is laser therapy beneficial for wound healing?

A

evidence base unclear

115
Q

what are some of the claimed benefits of laser therapy?

A

pain relief
increased vascular activity
anti-inflammatory
faster wound healing
nerve regeneration
rapid cell growth

116
Q

define avulsion

A

injury where tissue is separated from underlying tissues

117
Q

define debridement

A

removal of necrotic or damaged tissue

118
Q

define degloving

A

tissue is removed from a limb like a glove

119
Q

define desiccation

A

dried out

120
Q

define eschar

A

scab

121
Q

define excoriated

A

where the skin has been abraded / is raw /irritated

122
Q

define hygroma

A

soft fluidy mass found on bony prominances

123
Q

define laceration

A

deep cut/tear to the skin

124
Q

define maceration

A

breakdown of skin due to prolonged exposure to moisture

125
Q

define peracute

A

extremely sudden onset

126
Q

define plexus

A

network or web

127
Q

define seroma

A

a fluid filled swelling often associated with dead space after surgery

128
Q

define shearing injury

A

when tissue is damaged as layers move over the top of each other

129
Q

define tissue viability

A

a measure of whether tissue is healthy

130
Q

what are the main wound closure options?

A

primary
delayed primary
secondary
second intention healing

131
Q

what are the downsides of second intention healing?

A

can be painful
expensive
can lead to contracture
may need revision

132
Q

what is primary closure?

A

wound is sutured closed immediately

133
Q

what is delayed primary closure?

A

wound is closed but may need to wait for space on the list or patient to be stable so will be managed for a short period beforehand

134
Q

what is secondary closure?

A

wound and patient managed long term before surgical closure
e.g. skin graft

135
Q

what is second intention healing?

A

wound is not sutured closed and heals on its own

136
Q

what are the surgical wound closure techniques available?

A

‘simple’ closure
subdermal plexus / pedicle flap
axial pattern flap
free skin graft

137
Q

what is often included in simple closure of wounds?

A

light surgical debridement

138
Q

what skin closure technique should be used first?

A

the simplest possible

139
Q

what are the benefits of simple suturing for wound closure?

A

simple
quick
easy

140
Q

what are the disadvantages of simple suturing for wound closure?

A

relies on accurate wound assessment
failure to assess correctly leads to wound breakdown
may be non-viable tissue left behind
excess tension on wound
inappropriate suturing can cause issues

141
Q

what types of closure is simple suturing most suitable for?

A

primary
delayed primary

142
Q

what wound aetiology is simple suture most suitable for?

A

full thickness skin defect (shallow)
sharp incisional injury (e.g. shard of glass)

143
Q

what wound is most suitable for closure by simple suture?

A

class 1 injury (no infection present) - clean or clean/contaminated
fresh wound
not a big wound, not much skin lost during injury
minimal debridement needed if any

144
Q

what is involved in the treatment plan of a patient undergoing simple suture wound closure?

A

GA or sedation and local
basic surgical kit only
staples if only skin involved
may or may not bandage

145
Q

what is a subdermal plexus flap?

A

skin is undermined (elevated and dissected away from underlying musculature) and plexus of small arteries and veins sitting in the subdermal tissue are preserved
this skin is then moved to cover a large defect

146
Q

where can a subdermal plexus flap be placed?

A

using skins elasticity either advanced in a straight line or rotated into place depending on would location and skin tension

147
Q

what must be understood when forming a subdermal plexus flap?

A

skin tension lines

148
Q

why is a subdermal plexus flap called that?

A

subdermal plexus of small arteries and veins under the skin which are used to keep flap viable

149
Q

what are the named subdermal plexus flaps?

A

flank fold flap (inguinal wounds)
elbow fold flap (axillary wounds)

150
Q

what wound closure type is a subdermal plexus flap most useful for?

A

primary
delayed primary
secondary

151
Q

what are the benefits of subdermal plexus flap?

A

simple yet versatile
good for medium sized wounds
reduces tension

152
Q

what are the downsides of subdermal plexus flap?

A

relies on accurate wound assessment
has size limitations as only small blood vessels
damage to plexus possible
infected tissue may be left behind

153
Q

what is the issue if too large a subdermal plexus flap is raised?

A

blood supply is inadequate and can lead to vascular necrosis

154
Q

what is the issue if the person forming the subdermal plexus flap has poor technique?

A

plexus damage leading to vascular necrosis

155
Q

what wound aetiologies can subdermal plexus flap be used for?

A

wide variety

156
Q

what age of wound can subdermal plexus flap be used for?

A

fresh
delayed primary and so bandaged for a while

157
Q

what class of wound can subdermal plexus flap be used for?

A

clean if primary closure
may have been contaminated / dirty if surgery is delayed primary or secondary but should be ‘clean’ at time of surgery

158
Q

what site or size of wound is appropriate for subdermal plexus flap?

A

anywhere on the body
medium sized defects
reduce tension

159
Q

what level of surgical debridement may be needed for a wound closed with subdermal plexus flap?

A

may have been significant thus increasing the final skin deficit that requires closing

160
Q

what is involved in the treatment plan of a subdermal plexus flap?

A

basic surgical kit only
may bandage post op (more likely than for simple)

161
Q

how does an axial pattern / pedicle flap differ from a subdermal plexus flap?

A

axial pattern / pedicle flap incorporates a direct cutaneous artery and vein capable of providing blood to large area rather than just the plexus of small vessels

162
Q

what is the main advantage of a axial pattern / pedicle flap over a subdermal plexus flap?

A

can cover large defects with less chance of breakdown due to vascular necrosis

163
Q

what is required prior to axial pattern / pedicle flap surgery?

A

planning
assessment of skin tension
measurement
mapping

164
Q

what are the benefits of axial pattern / pedicle flap?

A

good blood supply
longer and wider flaps possible than subdermal
can offer rapid healing of chronic wound

165
Q

what are the disadvantages of axial pattern / pedicle flap?

A

steep learning curve
flap necrosis would be catastrophic
good post op care vital
owner must be warned about cosmetic result

166
Q

what wound healing method is axial pattern / pedicle flap most appropriate for?

A

secondary

167
Q

what wound aetiology should axial pattern / pedicle flap be used for?

A

pretty much any!

168
Q

what class of wound can an axial pattern flap be used for?

A

secondary closure
usually bandaged for a while
must be clean at time of surgery

169
Q

what site size of wound is an axial pattern flap good for?

A

only specific areas
large skin deficits

170
Q

what is involved in the treatment plan of a wound being closed with an axial pattern flap?

A

advanced surgical kit
good post op care vital to avoid major complications

171
Q

what is a significant risk of axial pattern flaps?

A

seroma

172
Q

what is required within a wound before a free skin graft can be placed?

A

healthy bed of granulation tissue

173
Q

what are the techniques used for free skin grafting?

A

sheet
punch

174
Q

what is involved in punch free skin grafting?

A

skin grafted using biopsy punch
sutured into place on the wound

175
Q

what is involved in sheet free skin grafting?

A

skin taken in a sheet from another area and sutured to cover wound
releasing incisions made which reduce risk of seroma formation and mean smaller tissue needed from donor site

176
Q

how should the donor site of a free skin graft be closed?

A

primary wound, may need a subdermal plexus flap

177
Q

what wounds is a free skin graft useful for?

A

distal limb defect where subdermal flap or APF is not an option

178
Q

what are the downsides of free skin grafts?

A

lower success rate
sheet graft is complex surgery
good post op care vital
partial or complete failure not uncommon
needs talented surgeon, committed nursing and committed owner

179
Q

what is required before a free skin graft can be performed?

A

healthy granulation bed

180
Q

what type of wound closure is free skin graft appropriate for?

A

secondary only

181
Q

what are the advantages of free skin grafts?

A

punch grafts simple
sheet grafts good for large extremity defects
offer rapid healing of chronic wound

182
Q

what wound aetiology can free skin grafts be used for?

A

pretty much any
secondary surgical repair
if axial pattern flap has failed

183
Q

describe an abrasion

A

superficial wound caused when skin moves parallel to a rough surface at speed
does not extend deep into demis

184
Q

what happens during an avulsion injury?

A

tissue (ligaments, muscles, skin) is torn from attachment

185
Q

what are the main types of burn?

A

thermal (dry/wet)
chemical
radiation
electrical

186
Q

how does degloving differ from avulsion?

A

degloving is severe avulsion that affects extremities e.g. legs/tails

187
Q

what are the types of degloving injury?

A

mechanical
physiological

188
Q

what is a mechanical degloving injury?

A

skin is pulled from subdermal attachments

189
Q

what is a physiological degloving injury?

A

skin necroses and sloughs due to damage to blood supply

190
Q

how may an incision injury be caused?

A

surgical or traumatic

191
Q

describe an incision

A

caused by sharp object
typically skin deep and a clean cut

192
Q

describe a laceration

A

tearing injury which damages skin and deeper tissues
irregular edges

193
Q

what are the main types of open wounds?

A

incision
laceration
puncture
abrasion
avulsion
degloving
burn
pressure sore
shearing

194
Q

describe a puncture wound

A

object creates a relatively small hole (e.g. bite, gunshot, penetrating foreign bodies)

195
Q

how does a shearing injury differ from degloving?

A

similar aetiology
usually involves the loss of deeper tissues
may expose joints/bone

196
Q

what are the main types of closed wound?

A

contusion
crush injury
haematoma
hygroma

197
Q

describe a contusion

A

area of injury where capillaries have been damaged

198
Q

how are crush injuries caused?

A

prolonged period of compression
leads to direct tissue injury and secondary injury from damage to blood supply

199
Q

what issues with casts/bandages can cause wounds?

A

over tight
inadequate padding
excess exercise
wet/dirty

200
Q

what should be assessed about a wound itself when initially deciding on treatment?

A

size of defect
is there missing skin
is the defect likely to get bigger (tissue death)
are there multiple wounds

201
Q

what about wound aetiology may stop it from healing simply?

A

level of contamination
infection likely?
infection already present
depth of wound and so depth of potential infection

202
Q

what may a wound be contaminated with?

A

micro-organisms
debris

203
Q

what should be assessed about a patient as a whole when they present with a wound?

A

signalment
comorbidities

204
Q

what should be considered about patient signalment when deciding on wound management?

A

very young or very old - immunity
species (cats are not small dogs)
breed - amount of excess skin, skin strength
temperament

205
Q

what should be considered about patient comorbidities when deciding on wound management?

A

pre existing conditions
conditions associated with injury
anything that may affect healing

206
Q

what factors can affect wound healing?

A

immunosuppressive conditions
endocrine issues: cushings, hypothyroid, DM
poor nutrition
drug therapy
stress

207
Q

what should be considered about infection when deciding on wound management?

A

likely?
is it present already
can wound just be flushed to clean
do you need topical or systemic antibiotics
swab for culture

208
Q

what should be considered about surgery timing when deciding on wound management?

A

when will the patient be stable for GA
does the wound need to stabilise before surgery
what closure option is being used
infection

209
Q

what should be considered about wound location when deciding on wound management?

A

what is it near
are there structures in the way
how much spare skin is available
how mobile is the area

210
Q

what is important to consider about cost with wound management?

A

bandaging not necessarily cheaper

211
Q

what are the main phases of wound healing?

A

inflammation (debridement)
proliferation
maturation

212
Q

what occurs during the inflammation phase of wound healing?

A

haemorrhage
vasoconstriction to cause haemostasis
vasodilation to allow inflammatory cells and enzymes to area for debridement

213
Q

what occurs during the proliferation phase of wound healing?

A

fibroblasts arrive
granulation tissue formed
wound contracts
epithelialisation leading to skin healing

214
Q

what occurs during the maturation phase of wound healing?

A

collagen maturation
scar forms and area is stronger

215
Q

what are the objectives for patient management for patients admitted with a wound?

A

assess - other injuries? comorbidities?
stabilise

216
Q

how should a wound be managed if the patient is unstable?

A

protect wound from further damage while stabilising patient

217
Q

how should a wound be managed if the patient is stable?

A

full assessment
decide best course of action

218
Q

what are the main client factors which may affect patient wound management?

A

cost - bandaging vs surgery
complience - revisits, bandage management, medication
is it practical - regular trips for bandage change vs POC for surgery

219
Q

what are the areas of a wound that should be monitored at each bandage change?

A

tissue
infection/inflammation
moisture
epithelialisation

220
Q

what does TIME stand for in wound management?

A

tissue
infection/inflammation
moisture
epithelialisation

221
Q

what is the aim of TIME wound monitoring?

A

remove non-viable tissue
treat infection or factors predisposing to infection
ensure optimal moisture balance
identify delayed healing

222
Q

what tissue types are viable?

A

epithelial
granulation

223
Q

how does epithelial tissue appear?

A

healthy pale pink

224
Q

how does granulation tissue appear?

A

red and moist
bleeds easily

225
Q

what tissue types are non-viable?

A

sloughing
necrotic

226
Q

how does sloughing tissue appear?

A

yellow
grey
brown

227
Q

how does necrotic tissue appear?

A

hard
dry
balck

228
Q

how can tissue viability be assessed?

A

can take a number of days to be sure if tissue viable or not

229
Q

why should necrotic tissue be removed?

A

promotes infection

230
Q

when may debridement be performed?

A

at presentation (primary repair)
delayed - patient unstable, wound managed with bandaging (delayed primary or secondary repair)

231
Q

what amount of debridement may be performed?

A

all at once (primary closure)
gradual over bandage changes and then surgery

232
Q

what is promoted by removal of necrotic tissue?

A

healthy granulation tissue formation

233
Q

what can debridement be used for as well as removal of necrotic tissue?

A

removal of gross contamination

234
Q

what method of debridement may be used?

A

surgical
bandaging
combination of both

235
Q

what must you be cautious of during debridement?

A

not taking too much tissue so that wound healing or closure is affected
need as much tissue as possible

236
Q

if a wound is thought to be clean and free of infection what measures should be taken?

A

monitor
swab to be sure
may need antibiotics

237
Q

if a wound is thought to have a level of bacterial colonisation what measures should be taken?

A

debridement (e.g. bite/high risk wound)

238
Q

if a wound seems to have local infection what measures should be taken?

A

topical antibiotics

239
Q

if there appears to be systemic infection due to a wound what measures should be taken?

A

systemic, targeted antibiotics

240
Q

what may indicate pre-existing wound infection?

A

age of wound
discharge
smell

241
Q

what can increase wound infection risk?

A

site (e.g. near butt)
wound aetiology
degree of contamination
wound lavage

242
Q

what will be seen if a wound is unhealthy?

A

infection

243
Q

what will be seen if a wound is healthy?

A

granulation and healing

244
Q

what effect can too much moisture have on a wound?

A

macerated
excoriated
pus

245
Q

what effect can too little moisture have on a wound?

A

desiccated
eschar present

246
Q

if a wound is too wet what is required?

A

dressing which absorbs moisture

247
Q

if a wound is too dry what is required?

A

dressing to add moisture
hydrogels

248
Q

will a wound always require the same level of moisture while healing?

A

no - will change

249
Q

how can epithelialisation and so wound healing be assessed?

A

wound edges
measurements
photos
drawings
look at surrounding tissues

250
Q

how can wound edges be assessed for healing?

A

should be pink and smooth not dark red and uneven

251
Q

what about wound measurements can assess healing?

A

look at width, length and depth
will contract in a circle

252
Q

what should the tissues surrounding the wound be assessed for when looking at healing?

A

oedema
cellulitis
skin changes

253
Q

how can epithelialisation be monitored?

A

looking for progression and reasons if not
promote epithelialisation with TIME
protect new tissue with bandageing

254
Q

what is the purpose of wound lavage?

A

rehydrate necrotic tissue
remove foreign material
reduce bacterial contamination
remove toxins and cytokines

255
Q

what needle and syringe is best used for wound lavage?

A

20ml and green needle (18G)

256
Q

what fluid should be used for wound lavage?

A

isotonic fluid (probably Hartmanns)
tap water initially if massive contaminated wound

257
Q

when should wound lavage be performed?

A

any traumatic wound

258
Q

is wound lavage a sterile procedure?

A

aseptic as possible
perform clip and sterile prep
use gels to fill wound while clipping

259
Q

how should wound lavage be performed?

A

lavage wound with warmed isotonic fluids
care with pressure
large volume needed for dilution of contaminants

260
Q

what are the main types of debridement?

A

surgical
non-surgical - physical or chemical

261
Q

what is involved in surgical debridement?

A

sharp dissection to remove all contaminated, necrotic tissue
avoid damage to normal tissue

262
Q

what is involved in non-surgical physical debridement?

A

adherent dressings that remove tissue when dressing is removed

263
Q

what is involved in non-surgical chemical debridement?

A

using chemical substances to remove dead tissue e.g. intrasite

264
Q

when is non-surgical debridement seen?

A

during bandaging

265
Q

what does a bandage provide protection from?

A

self-trauma
contamination
desiccation

266
Q

what can be provided to the patient through placement of a bandage?

A

pian relief
immobilisation of sort tissue and any concurrent ortho injuries
pressure to reduce swelling / haemorrhage
deliver topical medications

267
Q

what can be used to perform chemical debridement?

A

hydrogels
enzymatic / other agents

268
Q

what can be used to provide physical debridement?

A

wet to dry
dry to dry
larvae

269
Q

what can be used to provide moisture to wounds?

A

hydrogels

270
Q

what should be allowed to access wounds whenever possible?

A

air

271
Q

what is the nurses role in wound managememt?

A

continuity of patient and client care
advocacy
nurse clinics
clinical audits to flag issues in clinic

272
Q

what is involved in the nurses role of advocacy during wound management?

A

client - costs and practicalities, emotional support
patient - physical and mental, enrichment, change in direction of care needed, recognition of complications
antimicrobial stewardship - swabs and cultures, targeted antibiotic use, topical use, course length appropriate and kept to by owner

Advanced Clinical Nursing Theory (36 decks)

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