Wounds (treating P ulcers, types of drsgs, dressing wounds) Flashcards
what is most serious complication of P ulcer
infection
The RYB Colour Code of p ulcers Universal classification of wounds by colours = red, yellow, black (RYB) Red = what kind of tissue Yellow =? Black = ?
which colour do you Want to:
cleanse
protect
debride
what if there is a mixd wound with all 3 colours, what do you treat first?
red=granulation
yellow=slough
black=necrosis
protect (cover) red, cleanse yellow, and debrideblack
tx aimed at black first, then yellow, then red
what do you want to do to red P ulcer?
how can you do this?
what stage of healing is it likely in?
Need to cover + keep moist
o Gentle cleansing
o Protect periwound skin w alcohol-free barrier cream
o Filling dead space w hydrogel or alginate
o Cover w approp dressing
o ∆ drsg as infrequently as possible
Pale pink to beefy red – indicates depth of granulation tissue
Can be in inflammatory or proliferative stage of healing
you have a yellow p ulcer and the slough isnt being removed by cleansing. do you leave it or do you debride?
debride
what colours indiate slough
what is slough
Pale ivory to shaes of yellow, green, and brown – indicate presence of slough (dead but moist tissue)
how do you treat yellow P ulcer
Need to be debrided to remove slough + reduce bacteria
Methods of cleansing: wet-to-damp drsg, irrigation, absorbent drsgs
Consult dr about need for topical antimicrobial
Slough not removed by cleansing needs debridement
you have black wound with eschar is this viable tissue?
what should be done and what is the exception to this rule?
Black/brown or tan – indicates dead tissue that is dehydrated to some degree
Covered with eschar (thick, hard, leathery necrotic tissue) – when present, cannot assess depth of wound
Eschar = breeding ground for bacteria, devitalized tissue that impairs wound healing
If DM with inadequate blood supply, dry eschar kept intact until thorough vascular exam done
when is sharp debridement used and who can do this
only specially trained can perform sharp debridement. It can be used when there is urgent need of debridement (advancing cellulitis and sepsis)
what are the risks of sharp debridement
what tools are used
serious risk of bleeding + damage to underlying nerves and tissue
scalpel or scissors
what is mechanical debridement
what is it used for
and what are its disadvantages
Mechanical debridement: uses physical forces to remove foreign material and contaminated tissue
Use whirlpool baths, dextranomers, and wound irrigations; may be used as prep for sharp debride;
is slow + painful. pain mgmt is key!!
what is chemical debridement?
aka
who is it used for
Chemical or enzymatic debridement: topical application of proteolytic substances (enzymes); collagenase enzymes such as papain-urea often used;
relatively slow;
is good for those not able to use sharp, in long term facilities, and when infection not present
what is the most selective method of debridement
autolytic (it causes the least damage to surrounding and healing tissues
what is the slowest method of debridement
autolytic
what is autolytic debridement
synthetic drsg used to cover wound + allow eschar to self digest by enzymes in wound fluids; slowest but most selective so doesn’t harm surrounding tissues
should an occlusive drsg be used in pt with infection
Occlusive drsg not be used with infection (b/c create anaerobic enviro)
why are maggot larvae used for wounds
Maggots received inc attention lately as option as they sevrete Es that break down necrotic tissue hile leaving the remaining tissue untouched, ingest bacteria and dec bact growth d/t them causing inc in pH
which colour wounds need to be kept moist
black and yellow
what is the drawback of the RYB system
it doesnt address the underlying pathology and tx of certain wounds like venous or art ulcers (compression for V and revascularization for art)
what is the preferred wound cleanser
NS
transparent drsg is... what kind of wounds is it used for? not used for? how long can it stay on? benefits?
it is nonporous and self adhesive
what kind of wounds is it used for?–Applied to superficial wounds and skin breaks to maintain healing environment
not used for? Not to be used if evidence of yeast infection (will make it worse)
how long can it stay on? Left in place up to 7 days
benefits? Elastic so do not disrupt mobility
Do not adhere to wound itself, only skin around it (because wound kept moist)
Can shower
can assess through
Semiocclusive
because a transparent drsg is semiocclusive what benefit does this have
Semiocclusive so wound remains moist + retains serous exudate, which supports epithelial growth, autolytic debridement, reduces risk of infection
not putting much on applying removing transparent type of drsg..
why houldnt you stretch it as you put it on
why and how clean the skin first
stretching it as applied dec pt mobiity
if drsg adherence is concern then clean area adjacent to wound with alcohol or acteon to defat the kin
what kind of drsg is good for wounds with moderate-minimal drainage and those requiring debridement
what are the benefits of this drsg type
hydrocolloid
Provide wound hydration
Can cut to size of wound (ensure 1-2inch beyond wound margins)
Do not need cover dressing and H2O resistant so pt can bathe
3-7 days (depends on drainage)
Act as temporary skin + effective bacterial barrier
Dec pain, thus dec need for analgesics
hydrocolloid is it good for infection?
is it good for assessment?
what body image consideration is there
o Occlusive + opaque (no visibility)
o Should NOT be used if infect suspected as facilitate anaerobic growth
o Characteristic odour often confused for infection
t or f hydrocolloids are difficult to remove
they are absorbnt
o Difficult to remove, leave residue on skin
o Limited absorption capacity
which type of drsg is kept airtight with plastic film like plastic wrap.
what is the underlying drsg made of?
how long can this wrap be on
occlusive drsg
- May be commercial or prepared from gauze squares or wrap
- Cover topical meds applied to skin lesion
- Plastic surgical tape impregnated with corticosteroid can be cut to size + applied to lesions
• Don’t use plastic wrap for more than 12 hrs/day
which type of drsg used for acute weeping inflm lesion isnt used much anymore
wet drsgs
moisture retentive drsg
used instead of….
what are they good for?
are they impregnated?
- Used in place of wet dressings now
- More efficient at removing exudate b/c higher moisture-vapour transmission rate
- Some have reservoirs to hold excessive exudate
- Impregnated with NS, petrolatum, zinc-saline soln, hydrogel, antimicrobial agents – eliminates need to coat skin + therefore avoids maceration
how long can you use moisture retentive drsg
probly not imp why theyre used more than wet drsg
- Most remain 12-24hrs, some up to 1 wk
- Better than wet dressings b/c: improved fibrinolysis, accelerated epidermal resurfacing, less pain, fewer infections, dec scar tissue, gentle autolytic debridement + dec freq of dressing ∆
egs of moisture retentive drsg
hydrogels
hydrocolloids
foam drsg
calcium alginates
which type of drsg is good for autolyti debridement semi transparent (good for assessing) needs another secondary drsg because its not adhesive comfy
hydro gel
o Polymers with 90-95% H2O content
o Impregnated sheets or gel in tube
o High moisture makes ideal for autolytic debridement
o Semi-transparent so can view w/o dressing removal
o Comfortable + soothing
o Not adhesive – need secondary dressing
which kinds of wounds is hydrogel good for
o Good for: superficial w high serous output (ex: abrasions, skin graft sites, draining ven ulcers)
hydrocolloid benefits
what is made of
fx
can you assess through it?
remove for bathing?
o Made of H20-impermeable, polyurethane outer covering separated from wound by hydrocolloid material
o Adherent, non-perm to water vapour + oxygen
o As H2O evaporates from wound, goes into dressing dressing softens + discolours w inc H2O
o Easy to use, comfortable, promote debridement + formation of granulation tissue
o Most opaque so require removal to inspect wound
o Do not have to removed for bathing; left in place for up to 7 days
hydrocolloid covred wound has foul smelling yellow stuff on it. significance
o Causes form of foul-smelling yellowish covering over wound – is normal, d/t chemical interaction between dressing + wound exudate (do NOT confuse with purulent exudate)
what kind of wound is hydrocolloid good for
o Good for: exudative + acute wounds
what is foam drsg made of?
adheres to skin?
assess through it?
o Microporouspolyrethene w absorptive hydrophilic surface that covers wound + hydrophobic backing to block leakage
o Non-adherent (req secondary drsg to keep in place)
o Opaque (must remove for inspection)
benefits of foam drsg?
what kind of wound is it for
o Moisture absorbed into foam – prevents maceration
o Moist enviro maintained, removal doesn’t damage wound
o Good for exudate wounds esp good over bony prominences b/c provide cushioning
which kind of drsg is good for iritated tissue or macrated tissue? what is it made of?
what other kind of wound is it good for?
o Derived from seaweed – tremendously absorbent Ca alginate fibres
also good packed into deep cvity, wound, sinus tract with heavy drainage
how does calcium alginate work
is it adherent
drawback
o Derived from seaweed – tremendously absorbent Ca alginate fibres
o As exudate absorbed, turns into fiscoushydrogel
o Forms moist pocket over wound while keeping surrounding tissue dry
o Reacts w wound to cause foul-smelling coating
which 2 drsgs cause foul odour
calcium alginate and hydrocolloid
which drsgs are nonaherent and need second drsg to hold in place
foam drsg
hydrogel
which drsgs are good for absorption
Alginates, composite dressings, foams, gauze, hydrogels
which drsgs can provide autolytic debridement
)Absorption beads, pastes, powders, alginates, composite dressings, goams, hydrate gauze hydrogels, hydrocolloids, transparent dressings, wound care systems
what is diathermy
Produces electrical current to promote warmth + new tissue growth
how can you add moisture to wound/hydrate
Gazue (sat with NS), hydrogels, wound care systems, fibrous fleece dressings
what to use to main mosit env
not putting anything on how to protect and covr wound/periwound skin becase it includes basically everything
Composites, contact layers, foams, gauze (impregnated or sat), hydrogels, hydrocolloids, transparent films, wound care systems
what can be used to provide therapeutic compression for those with venous stasis disease
compression bandages and wraps
