wounds Flashcards
factors that affect wound healing
- age
- loss of skin turgor
- skin fragility
- decreased circulation and oxygenation
- slower tissue regeneration
- decreased absorption of nutrients
- decrease in collagen
- impaired immune function
- dehydration
- overall wellness
- decreased WBC
- infection
- meds (chemo, anti-inflammatory, steroids)
- low Hgb
- obesity
- smoking
- chronic disease
- malnutrition
3 key components of wound management
- assessment
- cleansing
- protection
inflammation is
a localized protective response to injury or destruction of tissues
wound assessment
- appearance: red (healthy), yellow (infected), black (eschar)
- length, width, depth (sinus tracts, tunnels, redness/swelling around wound
- closed wounds: skin edges well approximated (staples, sutures, tissue adhesives)
- note drains/tubes present
- pain around incision?
wound drainage
result of the healing process - normal or abnormal
accumulates during inflammatory and proliferative phases of healing
wound drainage documentation
*document amount, odor, consistency, color
*note integrity of surrounding skin
when cleaning wound drainage
observe skin around a drain for irritation or breakdown
how do you accurately measure wound drainage?
weight the dressing
1g = 1mL of drainage
*scant, moderate, large, copious
serous
portion of blood (serum) that is watery and clear or slightly yellow in appearance
(what is in blisters, clean wounds)
sanguineous
serum and RBCs
thick, appears reddish
*darker: older bleeding
*brighter: active bleeding
(deep or highly vascular wound)
serosanguinous
serum and blood, watery, looks pale/pink
(new wound)
purulent
result of INFECTION
thick, contains WBCs, tissue debris and bacteria
*yellow, tan, green, brown
diet for patient’s with wounds
-adequate hydration
-high PRO/CHO/vitamins and moderate fat
-monitor albumin and pre-albumin levels
nursing interventions for patients with wounds
-wound cleansing
-remove sutures/staples as ordered
-administer analgesics and monitor for pain management
-administer antimicrobials as ordered and monitor effectiveness
-document descriptively and thoroughly
wet-to-dry wound dressing
used to mechanically debride a wound until granulation tissue starts to form
self-adhesive would dressings
transparent
ex: tegaderm
mechanical debridement
hydrocolloid wound dressing
occlusive dressing that swells in presence of exudate
ex: duoderm
hydrogel
mostly water, gels after contact with exudate
promotes autolytic debridement
rehydrates and fills dead space
-may need secondary occlusive dressing
-for: infected, deep wounds or necrotic tissue –> NOT draining a lot
-provides moist wound bed and can reduce pain
-prevents skin breakdown in high-pressure areas
autolytic debridement
alginates
non adherent dressing that conform to wound shapes and absorb exudate
collagen
powders, pastes, granules, gels
wound vacs
use of foam strips into the wound bed with occlusive dressing — creates NEGATIVE PRESSURE once tubing connected
helps with tissue generation, decrease swelling, and enhance healing in moist protective environment
complications of wound healing
adhesions
contractions
hemorrhage
dehiscence
evisceration
fistula formation
infection
excessive granulation tissue
keloid formation
when are you at greatest risk for a hemorrhage?
24-48 hours after surgery
how can hemorrhage be caused?
clot dislodgment, slipped suture, or blood vessel damage
how may internal bleeding present?
swelling
distention in area
sanguineous drainage
initially, subtle change in V.S. –> increase HR d/t compensation for decrease in stroke volume
what is a hematoma?
local area of blood collection that appears as red or blue bruise
what to do if a wound hemorrhages?
could be an emergency
apply pressure dressing, notify HCP, monitor VS
dehiscence
partial or total rupture/separation of a sutured wound, usually with a separation of underlying skin layers
evisceration
organs out of wound
IMMEDIATE NEED FOR SURGERY
manifestations of evisceration
significant increase in flow of serosanguinous fluid on wound dressing
immediate hx of sudden straining
patient reports of a sudden change or “popping”/”giving way” in wound area
visualization of the organs
risk factors for dehiscence and evisceration
-chronic disease
-older
-obesity
-invasive abdominal cancer
-vomiting
-excessive straining, coughing, sneezing
-dehydration, malnutrition
-ineffective suturing
-abd surgery
-infection
management fo dehiscence/evisceration
-notify provider immediate d/t need for surgery
-stay with pt
-cover wound and any protroducing organs with sterile -towels or sterile dressings soaked in NS
-DO NOT REINSERT ORGANS
-position pt supine with hips and knees bent
-maintain calm environment
-keep pt NPO in prep for surgery
risk factors for infection of surgical wounds
-old
-immune suppression
-impaired circulation/oxygenation
-wound condition & nature
-malnutrition
-chronic disease
-poor wound care
manifestation of an infected surgical wound
2-11 days after injury/surgery (NOT in 24-48hr)
-pain
-redness, edema, purulent drainage
-(low-grade) fever & chills
-odor
-increased HR, RR, WBC
