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Applied Clinical Veterinary Nursing > Wound Management and Reconstruction > Flashcards

Wound Management and Reconstruction Flashcards

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1
Q

what is a class 1 wound?

A

0-6 hours since occurrence?

minimal contamination and tissue trauma

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2
Q

what is a class 2 wound?

A

6-12 hours since occurrence

microbial burden has not reached critical level

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3
Q

what is a class 3 wound?

A

occurred more than 12 hours ago

wound infection

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4
Q

which wound class is not suitable for surgical closure?

A

class 3

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5
Q

what considerations would we have for a patient presenting with an open wound?

A

when it happened
exactly how it happened
overall stability of the patient
consider effects of shock

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6
Q

what should we consider in out initial assessment of a patient presenting with a wound?

A

general assessment and history

possibility of trauma

vital signs

analgesia required?

first aid required?

regular monitoring to stabilise patient if necessary

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7
Q

what are the main phases of wound healing?

A

inflammatory phase
debridement phase
repair/proliferative phase
remodelling

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8
Q

when is the inflammatory phase?

A

0-5 days

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9
Q

what occurs during the inflammatory phase?

A

haemorrhage

vasodilation

increased vascular permeability

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10
Q

when is the debridement phase?

A

day 0 onwards

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11
Q

what occurs in the debridement phase?

A

phagocytosis

migration of WBC

removal of cellular debris

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12
Q

when is the repair/proliferative phase?

A

day 3 to 4 weeks

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13
Q

what occurs in the proliferative phase?

A

fibroblasts proliferate

collagen synthesis

epithelialisation and contraction

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14
Q

when is the remodelling phase?

A

day 20-ongoing

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15
Q

what occurs in the remodelling phase?

A

wound contraction and remodelling of collagen fibres

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16
Q

what is the purpose of wound lavage?

A

reduction of bacterial load (50% for every hour earlier)

allows for visualisation of underlying tissues

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17
Q

what equipment should be used for wound lavage?

A

35/40ml syringe and 19G needle - pressures still widely unclear

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18
Q

approx how much fluid should be used for wound lavage?

A

50-100ml per square cm of wound

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19
Q

why is it important not to use too much pressure during wound lavage?

A

can encourage bacteria further into the wound

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20
Q

what solution should be used for wound lavage?

A

isotonic saline

can start with tap water if finishing with saline

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21
Q

why must we consider warmth of the lavage solution?

A

patient often sedated/under GA - warm fluid to avoid getting any colder

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22
Q

what are the different overall options for wound management?

A

primary wound closure (first intention healing)

delayed primary closure/secondary closure (third intention healing)

second intention healing (contraction and epithelialisation)

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23
Q

what considerations do we have when choosing second intention healing?

A

use of topical agents, dressings, types of bandage material

client compliance

cost

expertise

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24
Q

what are the 5 general principles of wound management?

A

non-introduction of anything harmful

tissue rest

wound drainage

avoidance of venous stasis

cleanliness

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25
Q

what are the advantages of negative pressure wound therapy?

A

reduced oedema and exudate accumulation

elimination of strikethrough - wound fluid collected into canister = reduction in dressing changes

increased central wound perfusion and vascularisation

rapid contraction and wound healing

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26
Q

why is honey used for wounds?

A

broad spectrum antimicrobial activity

anti-inflammatory properties

shown to be effective against MRSA and pseudomonas

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27
Q

which honey product has been found to be more beneficial for wounds?

A

table honeys generally possess lower antibacterial activity than medical grade honey, contain wide range of microbial species

medical grade honey is sterile

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28
Q

which types of wound is honey more beneficial for?

A

chronic, non-healing wounds

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29
Q

how does manuka honey promote wound
healing?

A

related to decreases in pH levels leading to a rise in oxygen release from haemoglobin in the capillaries

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30
Q

how can use of honey lead to a prolonged inflammatory phase?

A

lower pH levels cause a suppression of proteases in the wound bed - leads to breakdown of protein fibres and the fibrin matrix

means fibroblasts and epithelial cells struggle to migrate across the wound bed

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31
Q

what is the result of a prolonged inflammatory phase?

A

over-granulation of the wound

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32
Q

what are our considerations for using honey on wounds?

A

higher level of exudate - consider dressing

consider the cellular damage in healthy granulating wounds and epithelialisation

consider initial honey use to aid granulation then switch to hydrogel

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33
Q

what is the primary benefit of using silver in wound healing?

A

antimicrobial effects - indicated for use in the inflammatory phase

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34
Q

what formulations is silver available in?

A

creams
dressings

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35
Q

why are wet-to-dry bandages used less often in practice now?

A

overhydrate then dessicate wound bed, compromising function of cells involved in wound healing

bacteria can penetrate gauze

cause discomfort when worn and removed

fibres remain when removed, causing inflammation

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36
Q

what type of debridement does wet-to-dry do?

A

nonselective mechanical debridement - much-needed cells and tissue (WBCs, granulation tissue, epithelium) and necrotic tissue are pulled off

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37
Q

how are hydrogel dressings (e.g. intrasite, granugel) used?

A

water-based, amorphous, cohesive application that is applied to the wound bed and covered with a secondary, non-absorbent dressing

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38
Q

how do hydrocolloid dressings work?

A

forms a non-adherent gel on contact with the wound (uncommonly used)

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39
Q

what are vapour-permeable films/membranes?

A

e.g. primapore, melolin

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

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40
Q

what are foam dressings?

A

e.g. allevyn, kendall foam, activheal foam

hydrophilic dressings made of polyurethane foam, which can be adhesive or non-adhesive and with or without a breathable film backing

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41
Q

how do foam dressings work?

A

absorb exudate but doesn’t adhere to the wound - commonly used in open wound management

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42
Q

when might a tie-over dressing be used?

A

tie-over bandages are often the ideal choice for placement over wounds in areas that are mobile, difficult to cover, or lack sufficient local skin for tension-free primary closure

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43
Q

what is an abrasion?

A

superficial skin damage caused by friction parallel to the skin surface

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44
Q

what is an avulsion?

A

injury where tissue is separated from underlying tissues

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45
Q

what is a contusion?

A

injury where the capillaries have been damaged e.g. bruise

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46
Q

what is a crush injury?

A

an injury where the tissue has been compressed (and therefore may have vascular damage)

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47
Q

what is eschar?

A

a scab

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48
Q

what is excoriation?

A

erosion or ulcer caused by scratching, biting, or rubbing

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49
Q

what is exudate?

A

fluid full of inflammatory cells

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50
Q

what is a haematoma?

A

blood-filled swelling caused by blood vessel rupture

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51
Q

what is a hygroma?

A

soft fluidy mass found on bony prominences

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52
Q

what is a laceration?

A

deep cut/tear in the skin

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53
Q

what is maceration?

A

a breakdown of skin due to prolonged exposure to moisture (wrinkly bath fingers)

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54
Q

what does peracute mean?

A

extremely sudden onset

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55
Q
A
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56
Q

what is a seroma?

A

a fluid-filled swelling often associated with dead space after surgery

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57
Q

what is a shearing injury?

A

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

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58
Q

what are the options for wound closure?

A

primary closure

delayed primary closure

secondary closure

second intention healing

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59
Q
A
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60
Q
A
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61
Q

what are the disadvantages of second intention healing?

A

can be painful and expensive

can lead to contractures which require revision

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61
Q

what are the options for surgical reconstruction techniques?

A

‘simple’ closure

subdermal (pedicle) plexus flap

axial pattern flap

free skin graft

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62
Q

what are the pros of ‘simple’ suturing of wounds?

A

simple, quick, easy

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63
Q

what are the cons of ‘simple’ suturing of wounds?

A

relies on accurate wound assessment - failure to assess correctly leads to breakdown

possible infection

non-viable tissue left behind
excess tension or inappropriate suturing can lead to breakdown

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64
Q

which wounds are most appropriate for simple suturing?

A

fresh wound, clean or clean/contaminated

wound not large, not much skin lost during injury

65
Q

should wounds be debrided before simple suturing?

A

not usually required - increases skin loss

if done, should be minimal and unlikely to increase wound tension

66
Q

what is required for simple suturing?

A

GA or sedation + LA
basic surgical kit
staples if very superficial
+/- bandage for post-op

67
Q

what does a subdermal plexus flap utilise?

A

generous plex of small arteries and veins sitting in the subdermal tissue in a ‘plexus’ under the skin

68
Q

how is the subdermal plexus flap achieved?

A

the skin is undermined and the vessels are preserved, with the skin elasticity allowing the skin to be moved to cover a larger defect

69
Q

what does undermining mean?

A

where the skin is elevated and dissected away from the underlying musculature

70
Q

what are the 2 named subdermal skin flaps?

A

flank fold flap for inguinal wounds

elbow fold flap for axillary wounds

71
Q

what are the cons of a subdermal plexus flap?

A

relies on accurate wound assessment

has size limitations

damage to plexus possible

infected/non-viable tissue left behind

71
Q

what are the pros of a subdermal plexus flap?

A

simple yet versatile
good for medium-sized wounds
reduces tension

72
Q

which type of closure is a subdermal plexus flap most appropriate for?

A

primary
delayed primary
secondary

73
Q

appropriate wound selection for a subdermal plexus flap

A

wound may be fresh or may have been bandaged for a while

anywhere on body, used for medium-sized defects

74
Q

are wounds requiring a subdermal plexus flap likely to require debridement?

A

likely to require significant debridement - increases final skin deficit that requires closing

75
Q

what is required for a subdermal plexus flap?

A

basic surgical kit
+/- bandage post-op (likely required)

76
Q

what can make a subdermal plexus flap vulnerable to vascular necrosis?

A

too big a flap raised –> blood supply inadequate

poor technique leading to plexus damage

77
Q

what can occur if too big a flap is raised for a subdermal plexus flap?

A

vascular necrosis due to inadequate blood supply

78
Q

how can good blood flow be ensured to an axial pattern flap?

A

incorporation of a direct cutaneous artery - less chance of vascular necrosis

79
Q

what needs careful consideration when performing an axial pattern flap?

A

planning, assessment of skin tension, measurement and mapping

80
Q

what are the pros of an axial pattern flap?

A

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

81
Q

what are the cons of an axial pattern flap?

A

steep learning curve

flap necrosis can be catastrophic

good post-op care vital

+/- cosmetic result

82
Q

which type of closure is most appropriate for an axial pattern flap?

A

secondary closure

83
Q

what type of wounds might require an axial pattern flap?

A

usually a wound being bandaged for a while

wound must be ‘clean’ at time of surgery

only for specific sites on the body, used for large skin defects

84
Q

what is required for an axial skin flap?

A

advanced procedure - more advanced surgical kit required

good post-op care vital to avoid major complications

85
Q

what type of tissue is required for a skin graft?

A

a healthy bed of granulation tissue must already be present

86
Q

what are the 2 common techniques for a free skin graft?

A

sheet graft
punch biopsy graft

87
Q

where are free skin grafts useful?

A

distal limb defects where a subdermal flap/APF not an option

88
Q

what are the pros of a free skin graft?

A

punch grafts are simple

sheet grafts often good for large extremity defects

offer rapid healing of chronic wound

89
Q

what are the cons of a free skin graft?

A

sheet graft is an advanced technique

good post-op care vital

partial/complete failure not uncommon

90
Q

what type of closure is a free skin graft used for?

A

only really used as part of secondary surgical repair - can be used if APF has failed

91
Q
A
92
Q

what is required for a free skin graft?

A

advanced procedure - more advanced surgical kit required

post-op care vital to avoid major complications

93
Q

what types of burns are possible?

A

thermal (dry/wet)

chemical/radiation/electrical

94
Q

what is degloving?

A

a type of severe avulsion affecting the legs, tails (extremities)

95
Q

what types of degloving can occur?

A

mechanical - skin pulled from subdermal attachments

physiological - skin necroses and sloughs due to damage to blood supply

96
Q

what cast/bandage complications might occur?

A

over-tight

inadequate padding

excess exercise

wet/dirty

97
Q

what do we need to consider in terms of wound aetiology?

A

level of contamination - micro-organisms, debris

likelihood of infection, presenting signs of infection, depth of infection

determines whether flushing vs topical vs systemic abs

98
Q

what patient factors go into our wound assessment?

A

signalment - young/old, species and breed, temperament

comorbidities - pre-exisitng or associated with injury, factors which could affect healing

99
Q

which patient comorbidities might affect healing?

A

immunosuppressive conditions
poor nutrition
drugs therapy
stress

100
Q

why do we need to think about wound position when during assessment?

A

how much spare skin at the site - depends on body position, breeds

how mobile is the area

whats ‘in the way’

101
Q

what are the overall factors we should be investigating when assessing for methods of surgical reconstruction?

A

wound factors
aetiology factors
patient factors
when are we likely to take it to surgery
where is the wound

102
Q

what are the 3 stages of skin healing?

A

inflammation
proliferation
maturation

103
Q

what occurs in the inflammation phase of wound healing?

A

haemorrhage

vasocontriction –> haemostasis –? closes wound

vasodilation –> inflammatory cells (neutrophils and monocytes)

104
Q

what occurs in the proliferation phase of wound healing?

A

fibroblasts
granulation
wound contraction
re-epithelialisation –> skin healing

105
Q

what occurs in the maturation phase of skin healing?

A

collagen maturation
scar formation = increased strength

106
Q

what should we consider in terms of patient assessment?

A

pre-existing co-morbidities
current status
injuries
primary vs delayed wound management

107
Q

what action should be taken if the patient is unstable?

A

protect wound from further damage while stabilising patient

108
Q

what action should be taken if the patient is stable?

A

fully assess wound and decide best course of action

109
Q

what are the overall client factors influencing wound management?

A

cost

owner compliance

practicalities

110
Q
A
111
Q

why is cost a considerable client factor influencing wound management?

A

bandaging may not necessarily be cheaper than surgery

112
Q

why does owner compliance influence wound management?

A

compliance with revisits, bandage management between visits, medications

113
Q

how can we help consider client factors when making decisions about wound management?

A

make sure owners are aware from the beginning how costly and intensive the process could be

114
Q
A
115
Q

what does ‘TIME’ stand for?

A

Tissue
Infection/inflammation
Moisture
Epithelialisation

116
Q

what do the components of ‘TIME’ mean for wound management?

A

remove non-viable tissue

treat infection/factors pre-disposing to infection

ensure optimal moisture balance

identify delayed healing

117
Q

what colour is epithelial tissue?

A

healthy pale pink

118
Q

what colour is granulation tissue?

A

red and moist - bleeds easily

119
Q

what colour is sloughing tissue?

A

yellowy/grey/brown

120
Q
A
121
Q

what colour is necrotic tissue?

A

black, hard and dry

121
Q

how do we assess viability of tissue?

A

necrotic tissue promotes infection

difficult to know which tissue is viable and which isn’t

whether or not tissue has declared itself - can take several days

122
Q

why is it difficult to tell whether tissue has declared itself?

A

can take several days

123
Q

what should we consider in terms of timing of debridement of a wound?

A

patient stability often determines whether primary or delayed debridement

all at once vs gradually

removal of necrotic tissue promotes healthy granulation tissue

can also use debridement to remove grossly contaminated tissue

124
Q

what do we need to consider in terms of debridement method?

A

surgical vs bandaging vs combo

care with debridement - only remove necessary tissue

125
Q

why do we need to have caution during debridement (esp surgical)?

A

removed tissue can’t be put back - sometimes there is enough to sacrifice some tissue but other times you need all the spare tissue you can get

being cautious is prudent

126
Q

what is how can we treat local infection of a wound?

A

topical antibiotics

127
Q
A
128
Q

how can we treat mild contamination of a wound?

A

clean wound

128
Q

how can we treat colonisation of a wound?

A

debridement

129
Q

how can we treat systemic infection due to a wound?

A

systemic antibiotics

130
Q

how can we tell if there is likely a pre-existing infection in a wound?

A

age of wound
presence of discharge
smell

131
Q

how can we determine risk of infection to a wound?

A

site of wound
wound aetiology
degree of contamination
wound lavage

132
Q

what does unhealthy inflammation of a wound indicate?

A

infection

133
Q

what does healthy inflammation of a wound indicate?

A

granulation and healing

134
Q

how can we tell if a wound is too wet?

A

will be macerated and/or excoriated

135
Q

how can we tell if a wound is too dry?

A

will be dessicated +/- eschar present

136
Q

why might there be discharge from a wound?

A

wound maceration
pus

137
Q

how can we assess epithelialisation progress of a wound?

A

assess wound edges and tissue surrounding wound

measurements - width, length, depth

photos

drawings

138
Q

what do healing wound edges look like vs not healing?

A

healing = pink and smooth

not healing = darker red, uneven

139
Q

what might we see in the tissue surrounding a non-healing wound?

A

cellulitis
oedema

140
Q

what are the advantages of wound lavage?

A

rehydrates necrotic tissue

removes foreign material

reduces bacterial contamination

removes toxins and cytokines

141
Q

which wounds are suitable for lavage?

A

any traumatic wound

142
Q

how can we trap fur during lavage?

A

use of aqueous gels

143
Q

how should wound lavage be carried out?

A

no sedation required
apply with even pressure, not too high

144
Q

what equipment is ideal for wound lavage?

A

fluid bag (hartmanns?) with giving set

20ml syringe, 18g needle, 3 way tap

145
Q

how can we identify if wound lavage is too high pressure?

A

areolar tissue will show it by having a bubble-wrap appearance

146
Q

what is involved in surgical debridement?

A

sharp dissection to remove all contaminated, necrotic tissue

avoid damage to normal tissue!

147
Q

what is involved in physical debridement (bandaging)?

A

using adherent dressings that remove tissue when the dressing is removed

148
Q

what is involved in chemical debridement?

A

using chemical substances to remove dead tissue

149
Q

how does bandaging protect wounds?

A

against self-trauma

against contamination/infection from environment

against dessication

150
Q

what should a bandage provide for the patient?

A

pain relief

immobilisation of soft and any concurrent ortho injuries

pressure to reduce swelling/haemorrhage

deliver topical medications

151
Q

how can bandaging help with debridement?

A

chemical - hydrogels, enzymatic agents

physical - wet-to-dry, dry-to-dry, larvae

152
Q

how can bandages help with moisture of wounds?

A

keep moisture in e.g. hydrogels

take excess moisture away e.g. absorbent dressings

153
Q

how do nurses help with continuity in wound management?

A

develop a team to care for a patient with long-term bandaging needs

ensures continuity of products, application technique and communications

154
Q

how do nurses help advocate for clients in wound management?

A

discussions of cost and practicalities

emotional support - often difficult long journey

155
Q

how do nurses advocate for patients during wound management?

A

physical and mental support, esp in relation to caging/reduced exercise/boredom

flagging if a change of direction might be worth considering

early recognition of complications

156
Q

how can nurses advocate for the greater community through wound management?

A

antimicrobial stewardship - appropriate and targeted usage, appropriate course lengths, topicals wherever possible

157
Q
A

Applied Clinical Veterinary Nursing (31 decks)

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