Wounds Flashcards
What are the risk factors for pressure ulcer development
- impaired sensory perception
- moisture
- alterations in consciousness
- impaired mobility
- shear
- friction
Pressure Ulcer Stages 1-4
1= intact skin with non blanchable redness, usually over bony prominence. May have warmth, edema, hardness, pain. 2= partial skin-thickening loss, involving epidermis, dermis, or both. Red/pink wound, no slough. Blister may be present. 3= full thickness tissue loss, with visible fat. May include tunneling or undermining. Some slough may be present. 4= full tissue thickness is lost, exposed bone, muscle or tendon. Eschar or slough may be present.
What is granulation tissue?
- red, moist tissue composed of new blood vessels. Indicates progression towards healing.
What is Slough?
- soft, yellow, white tissue. Appears stringy and attached to wound bed.
- must be removed by skilled clinician before the wound can heal
What is eschar
- black or brown necrotic tissue. Needs to be removed before healing can begin.
What is primary intention wound healing
- example is surgical incision. Little tissue is lost.
- Edges approximate, or are closed. Low risk of infection.
- quick healing. Minimal scarring.
What is secondary intention wound healing?
- Wound is open until it fills with scar tissue. Edges don’t approximate
- greater chance of infection
What is hemorrhage and hematoma?
Hemorrhage= bleeding from wound site that is normal during and immediately after trauma. Can be internal or external
- locate internal by looking for distention and swelling of the affected body part, or signs of hypovolemic shock.
- Hematoma is localized collection of blood under tissues. Swelling, change in color, sensation, and warmth occur.
Infection in wounds
- infected wounds have purulent draining (yellow, green, or brown), even if its culture is negative it is still considered infection.
- A positive culture does not always mean its infected.
- all dermal wounds are considered contaminated with bacteria. The amount of bacteria present is what differentiated contaminated from infected
Signs of infected wound
- a surgical wound infection doesn’t appear till 3-5 days after surgery
- fever, tenderness, pain at site.
- edges of wound are inflamed
- drainage is odorous and purulent
What is dehiscence
- Wound fails to heal properly, so tissues separate.
- Partial or total separation of wound layers
- patients at risk for poor wound healing is at risk for dehiscence
- Occurs from strain too (coughing, vomiting)
- when there is an increase in serosanguinous drainage, be alert for potential dehiscence
- prevent by placing folded blanket or pillow over abdominal wound when patient is coughing.
what is evisceration?
Total separation of wound layers
- Protrusion of visceral organs through a wound opening
- emergency
- nurse needs to place sterile towels soaked in saline over tissues to reduce chances of bacteria and drying of the tisue
- patient is NPO
- notify surgical team immediately, emergency.
How does a nurse asses pressure ulcer risks
- Braden Scale
- ranges from 6-23. lower score=higher risk
- assesses sensory perception, nutrition, moisture, activity, mobility, and friction/shear
What is the nursing intervention for a patient with risk factor of decreased sensory perception
- Asses pressure points for signs of non-blanching reacting hyperemia
- provide pressure-redistribution surface
What is the nursing intervention for a patient with moisture as a risk factor?
- Assess need for incontinence management
- following each incontinent episode, clean area with no-rinse perineal cleaner or nonionic and protect skin with moisture barrier ointment
- frequently assess at a minimum of once a day, or once per shift for a high risk patient
nursing intervention for a patient at risk for friction and shearing?
- reposition patient using drawsheet and lifting off surface
- provode trapeze to facilitate movement
- position patient at 30 degree lateral turn and limit head elevation to 30 degrees
nursing intervention or a patient at risk for decreased activity?
- Establish a post individualized turning schedule at least every 2 hours
- pad bony prominences
- dont let them sit in a chair for longer than 2 hours. if sitting in chair, have them shift weight every 15 min
nursing intervention for a patient at risk for poor nutrition?
- Provide adequate nutritional and fluid intake, assist as necessary
- consult dietician
What is mechanical debridement
- wet-to-dry saline gauze dressings. Place moistened gauze into wound and allow dressings to dry thoroughly before removing gauze that adheres to tissue.
- removed both viable and dead tissues so its is not used often
- never use this method in a clean granulating wound.
- other type is Wound Irrigation (high pressure irrigation, or pulsitile, and whirlpool)
What is Autolytic debridement
- synthetic dressings oer a wound that allow eschar to be self digested by the action on enzymes that are present in wound fluids
- examples are transparent film and hydocolloid dresings
What is chemical debridement?
- use of topical enzyme preparation
- Dakins solution or sterile maggots (EWWWWWW)
- ## enzymes help break down necrotic tissue
What is surgical debridement
- removal of vitalized tissue by a scalpel, scissors, or other sharp instrument.
- some states require an advanced practicing nurse of HCP to do the procedure- check hospital policy
- usually done for cellulitis or sepsis
What are some essential factors for managing wounds
- educating patient and family
- support nutritional status
- patients with pressure ulcers need increased caloric intake and protein intake. Increase protein to 1.8 g/kg/day to help build epidermal tissue. Increase calories to build subcut tissue
- increase vitamin C for collagen synthesis, capillary wall integrity, fibroblast fx
- Maintain hemoglobin level to 12 g/100ml
What should you do immediately for a puncture wound?
- allow it to bleed (ex-dog bite, letting it bleed lets the dogs saliva, bacteria, etc. drain out)
- if puncture is sharp object like knife, leave the object in place, do not remove it until patient is at emergency facility.
How should you clean a minor laceration, or abrasion, small wound? how should you care for a laceration that is bleeding profusely?
Small wounds- use NS and lighting cover with dressing
Large, bleeding wounds- brush away surface contaminants and concentrate on hemostasis until patient can be cared for in a hospital setting.
What are the purposes of wound dressings
- protects from M.O.
- aids in hemostasis
- promotes healing by absorbing drainage and debriding wound
- supports or splints the wound site
- protects patient from seeing wound
- thermal insulation of wound surface
- moist environment
What are pressure dressings used for?
they promote hemostasis byt exerting pressure on the bleeding site
dressings for pressure ulcers
- continously provides moist environment
- clean wouns and periwound area at each dressing change
- keep surrounding skin dry, but wound moist
- may need to change the type of dressing over time as the ulcer heals. Assess it regularly to determine if modifications are necessary
- consider caregiver time, ease of use, availability, and cost of dressing when selecting it.
For “clean” wounds, what dressing should be used?
- non-adherent gauze (Tefla) is used on wounds with little or no drainage
- wont stick to wound
When should you use a self-adhesive transparent film dressing?
- they trap moisture over wound and provide moist environment
- idea for small, superficial wounds, partial thickness wounds, or used to protect high risk skin* (dont use if a lot of moisture)
- allows surface to breath, but provides barrier to bacteria
- moist environment speeds epithelial growth
- can view wound
- does not require secondary dressing
When should you use hydrocolloid dressings?
- use on shallow to moderately deep dermal ulcers
- contain complex formulations of colloids, elastomeric and adhesive components
- adhesive and non occlusive
- max wear time is 7 days
- support healing in clean granulating wounds
- debride necrotic wounds autolytically
- absorbs drainage through use of exudate absorbers in the dressing
- maintains wound moisture
- impermeable to bacteria
- preventative for high risk infections
- can be left in place for 3-5 days
When/why to use hydrogel dressings?
- hydrates and absorbs smaller amounts of exudate/moisture
- used for partial thickness and full thickness wounds, deep wounds with some exudate, necrotic wounds, burns, radiation damaged skin.
- Useful in painful wounds, very soothing
- disadvantage- require secondary dressing
When to use calcium alginate dressings
- NEVER use on dry wound.
- good for significant exudate. Requires secondary dressing
Wounds covered with eschar are…
unstagable
Steps in packing a wound
- assess size, depth, shape (to determine dressing needed)
- entire wound surface must be in contact with dressing/gauze
- ## dont pack too tightly, and it should not extend over wound surface
What is a VAC
- vacuum-assisted closure (or negative pressure wound therapy)
- facilitated healing and collects wound fluid
negative pressure draws edges of wound together. - reduces edema, removes fluid, helps granulation tissue form, etc.
Describe wound irrigation
- require sterile tech.
- use 35 mL syringe with 19 G needle
- doesnt damage healed tissue
- never occlude wound opening with syringe and make sure fluid flows directly into wound, and not over surrounding site before it gets to wound.
When is the application of heat contraindicated?
- area of bleeding
- acute localized inflammation (appedicitis)
- CV problems
When is cold application contraindicated?
- if site is edematous
- impaired circulation
- neuropathy
- if patient is shivering
Conditions that increase risk of injury from hot/cold applications
- very young or old patients= thin skin, reduced sensitivity
- open sounds, broken skin, stomas= subcut and visceral tissues are more sensitive to pressure and temp. fewer pain receptors
- areas of edema and scar formation= reduced sensation
- peripheral vascular disease= diabetes, arteriosclerosis. Extremities are less sensitive to temp due to circulatory impairments. Cold application further constricts blood flow
- Confusion/unconsciousness= perception of sensory or painful stim is reduced
- spinal cord injury= alterations in nerve pathways prevent reception of sensory or painful stim
- Abcessed tooth or appendix= infection is highly localized, heat can cause rupture
What is the physiological response to heat and its therapeutic benefits?
- Vasodilation–> improves blood flow, delivery of nutrients, removal of wastes, lessens venous congestion
- Reduced viscosity–> improves delivery of leukocytes and antibiotics
- Increases tissue metabolism–> increases blood flow, provides local warmth
- increase capillary perm–> promotes movement of waste products and nutrients
What conditions would be improved by heat application
- open wounds, rectal surgery, episiotomy, painful hemorrhoids, muscle tension, vag inflammation, wound debridement
What is the physiological response to cold and its theraputic benefits?
- Vasoconstriction–> reduced blood flow, prevents edema, reduces inflammation
- Local anesthesia–> reduced pain
- Increased viscosity–> promotes coagulation
- Decrease muscle tension–> relieves pain
What conditions are improved by applying cold?
- direct trauma (sprain, strain, fracture, muscle spasm), superficial laceration, puncture wound, minor burn, injection, joint trauma
What are some safety suggestions for applying heat/cold therapy?
- explain to patient what will be felt
- instruct patient to report changes or discomfort
- timer or clock to time the application
- call light within reach
- refer to hospital policy for safe temps
- do not allow patient to adjust temp
- do not allow patient to move an application
- do not place patient in position that prevents them from moving away from the temp. source
- do not leave a patient who is unable to sense temp changes or move away from the temp source
