Wounds (treating P ulcers, types of drsgs, dressing wounds) Flashcards
(47 cards)
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
