wound assessment, healing & nursing care – Flashcards
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What is an example of a chronic wound?
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Pressure ulcer
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Surgical asepsis is also known as?
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Sterile technique
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When do you need tp perform sterile technique?
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Anytime a procedure pierces or penetrates the skin. (Catheter, wound change, surgery)
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What are the principals of sterility?
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...
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What are pressure ulcers?
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Chronic, open wounds caused by localized ischemia due to pressure, friction and/or shearing.
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Excessive moisture on or around a wound can cause what?
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Maserations
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Inadequate nutrition causes a decrease in protein which can lead to?
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Edema which makesnthe skin morenprone to injury
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Why are diabetics prone to pressure ulcers?
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Neuropathy- dimished sensation
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People with diabetes and PVD are at risk for what?
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Pressure ulcers
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What are the four classifications of pressure ulcer formation?
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Satge I,II,III,IV
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What does a stage I pressure ulcer look like?
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Nonblanchable erythemia (potential for an ulceratoin)
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What does a stage II pressure ulcer look like?
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Superficial ulcer. Abrasian. Skin tear. Involves epidermisnand loss of firstnlayer of skin. Requires dressings.
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What does a stage III pressure ulcer look like?
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Damage or necrosis to subcutaneous tissue. Subcutaneous fat is visible.
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What does a stage IV pressure ulcer look like?
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Full thickness skin loss with tissue necrosis and damage to underlying structures. (Muscles or bones, supporting structures such as tendons)- no pain
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What are the different types of wound healing?
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Primary intention. Secondary intention. Tertiary intention.
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What is primary intention?
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Minimal tissue loss; skin edges approximated (closed surgical incision)
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What is secondary intention?
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Considerable tissue loss. Skin edges are open. Greater chance of scaring. Heals from bottom up. Greater chance of infection.
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what is tertiary intention?
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would becomes infected, has to be reopened and allowed to reheal. may be irrigated and packed.
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Name the phases of wound healing.
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Inflammatory phase. Proliferative phase. Maturation phase.
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what is the bodies initial response to an injury?
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blood vessels contsrict
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How long does the inflammatory phase last?
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3-6 days
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what occurs during the inflammatory phase?
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Hemostasis and phagocytosis. Injured cells release histamine which dilates the capillaries. This leads to a rapid influx of WBCs, RBCs, platelets, and antibodies. Antibodies and leukocytes begin to destroy micro organisms by phagocytosis
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How long does the proliferative phase last?
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day 3-about day 21
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what occurs during the proliferative phase?
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A seal is formed over the injured area to localize inflammation, prevent further fluid loss,protect exposed nerve endings, and decrease pain.
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How is a scab formed?
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Formed from dry exudate (drainage) of RBCs, platelets, and plasma.
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How long does the maturation phase last?
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Day 21 lasting up to 2 years.
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what occurs during the maturation phase?
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Healing of the tissue by clearing away useless or dead tissue by the lymphatic system.
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What two types of tissue can be formed during the maturation phase?
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Granulation and Fibreous tissue.
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What is granulation tissue?
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It is the replacement tissue of useless or dead cells created by identical cells
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What is fibrious tissue?
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Fibrant enters the area and nits the wound together forming a scar.
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What does scar tissue inhibit?
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Range of motion and tenderness.
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What is scar tissue within an organ called?
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Adhesion
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What is a lysis of adhesion?
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Removal of the adhesion
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Who performs a lysis adhesion?
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Doctor
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What are the complications of wound healing?
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Hemorrhage. Infection. Dehiscence and possible evisceration.
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What is a hemorrhage?
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Massive bleeding
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What is a hemorrhage caused by?
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dislodged clot, slipped stitch. erosion of a blood vessel.
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What is a hematoma?
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localized collection of blood beneath the skin. Can cause pressure on blood vessels obstructing flow.
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When are you at risk for a hematoma?
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first 48 hours after surgery. surgical infection can occur 2-10 days after surgery.
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What is a sign of infection?
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purulent drainage.
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Where do you swipe a culture swab to obtain a culture sample of purulent drainage?
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Middle of the wound
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What is dehiscence of a wound?
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Partial rupture of a sutured wound.
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what is evisceration of a wound?
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Total rupturing of a sutured wound. usually abdominal with a protrusion of the internal viscera through an incision
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What factors put you at risk for a dehiscence or evisceration?
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Obesity. poor nutrition. excessive coughing. vomiting. dehydration. multiple trauma.
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What are the different types of wound drainage (exudate)?
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Serous. Sanguinous. Sero-sanguinous. Purulent.
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What is serous drainage?
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Consists of serum; appears watery & clear. (light pink in color)
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What type of wound drainage would be from a burn?
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serous
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What is sanguinous exudate?
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Large amounts of RBCs; indicates damage to capillaries; bloody
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What type of drainage might be present 24 hours after surgery?
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Sanguinous
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What type of exudate consists of clear and blood-tinged fluid, that appears pink?
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Sero-sanguinous
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What is purulent exudate?
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Thicker and consists of WBCs and dead debris. Depending on causative organism, can be blue, green or yellow exudate. Could be smelly.
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What do you measure when assessing a wound?
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Height. Width. Depth.
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When assessing the edges of an open would, what do you look for?
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Undermining and Approximation
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What should you assess the skin surrounding the wound for?
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Redness. Warmth. Inflammation. Induration. Maceration.
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What is induration?
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Hard area around the skin
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What should you assess the wound base for?
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Granulation tissue. Slough. Eschar.
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What is granulation tissue?
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Good healthy out growth of new capillaries. Very Red
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What is epithelialization?
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Extra piece of skin over wound
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What is Slough?
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Dead tissue. usually grey in color. appears stringy. Needs to be removed so the skin can heal.
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What is eschar?
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Dead tissue; appears black. Need to remove tissue (debridement)
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Why are drains used in wounds?
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to remove accumulation of fluid in the wound. (Surgically placed)
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What drain works by gravity and requires one suture to keep it from falling out?
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Pinrose drain.
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Can drainage be measured on a pinrose drain?
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no, drainage is absorbed by a 4x4
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What drain is inserted into an incision and constantly applies low suction by decompression?
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Hemovac drain
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How do you measure the drainage from a hemovac drainage?
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Squeezing container into graduated cylinder
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Which drain applies low constant suction by decompression, but will consist of a smaller amount of drainage?
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Jackson-Pratt (JP)
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Name the different types of sutures?
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Interrupted. Continuous. Retention. Absorbable
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Name the different types of wound closures.
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Sutures. Staples. Steri-strips. Glue.
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What are retention sutures?
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Have along plastic tube alternating with the sutures to prevent the sutures from embedding into the skin or wound. Used on obese patients/large abdominal wounds-anchor and pull incision toward the mid line.
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How are staples removed?
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Remove alternation sutures to make sure suture is healed.
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Why are staples interrupted?
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Each staple is separate from another
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When should a wound be cultured?
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Foul odor. Purulent drainage. Inflammation surrounding the wound. Non draining would starts to drain. fever.
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When can you culture a wound?
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Dr.s order
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What is wound debridement?
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Removal of necrotic tissue so that healthy tissue can regenerate.
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What are the different types of debridement?
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Mechanical. Surgical. Chemical.
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How do you provide mechanical debridement?
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NS is applied to dressing and as the dressing dries it will remove dead tissue.
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How do you provide surgical debridement?
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Dr uses scalpule or scissors to cut away dead tissue.
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How do you provide chemical debridement?
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Chemicals are used directly on wound to remove dead tissue. (ointment or cream)
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What is an example of chemical debridement?
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Accuzyme
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What is the purpose for dressing wounds?
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Protection from mechanical injury and microbial contamination. Provide thermal insulation. Provide humidity. Absorb drainage or debride wound Prevent hemorrhage. Immobilize the wound.
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Who orders the dressing type?
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Dr.
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Name the different types of dressings?
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Transparent wound barrier. Impregnated nonadherent dressing. Hydrocolloids Hydrogels. Polyurethane foams Exudate absorbers (alginates)
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What is the purpose of the transparent wound barrier?
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Allows you to look directly at site with out removing bandage, allows for O2 exchange, impermeable to bacteria and water
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What is the purpose of the impregnated nonadherent?
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It does not adhere to wound. Petroleum based to prevent the bandage from adhering to the wound
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what type of dressing is an op-site dressing?
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Transparent
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What type of dressing is adaptic gauze or xeroform?
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Impregnated nonadherent
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What is the purpose of a hydrocolloid dressing?
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Used for stage 1 or stage 2 ulcers. Helps heal but does not stick to tissue. Prevents mascerations. change dressing every 3-4 days.
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What type of dressing is a duoderm?
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Hydrocolloids
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What is the purpose of a hydrogel dressing?
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Helps bring drainage to the surface of a wound. Requires second dressing over top to secure placement.
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What type of dressing is a vigilon?
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Hydrogel
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What is the purpose of a polyurethane dressing?
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Helps absorb exudate
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What type of dressing is a lyofoam?
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Polyurethane dressing
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When is a wound vac used?
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Wounds that are hard to heal. Acute or chronic wounds.
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What is the benefit to using a wound vac?
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Increases blood flow to the area.
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How often is a wound vac dressing changed?
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2-3 times per week
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When can a nurse pack a wound?
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Drs. order
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When is it okay to don clean gloves?
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on a chronic wound, otherwise sterile technique is a must!
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What are some precautions to take with wound packing?
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Pack loosely but firmly (could destroy good tissue). Moisten dry packing to help remove the package to prevent pain.
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When is a nurse allowed to irrigate a wound?
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Dr. Order
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When irrigating a wound, what type of gloves do you need?
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Clean gloves bc syringe is not sterile.
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What the different tapes used to secure a dressing.
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Tape. Montgomery straps. Abdominal binders. Kling or kerlix.
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How do montgomery strips work?
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Peels and sticks to outter skin around wound then ties together
