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NRS 130 Test #8 > ATI Wound Care Content > Flashcards

Flashcards in ATI Wound Care Content Deck (56):
1

What are the basic phases of wound healing?

-the inflammatory phase
-the epithelialization phase
-the proliferative phase
-the remodeling phase

2

The inflammatory phase of wound healing:

-begins once the skin (and sometimes underlying tissues) is injured and continues for about 24 hours.
-The major characteristics of the inflammatory phase are skin color changes, heat, swelling, pain, and loss of function.

3

The epithelialization phase of wound healing:

-provides temporary protection at the site of injury to keep outside organisms from entering and causing infection.
-Epithelialization typically begins at the wound’s edges and gradually moves upward to form a fully covered surface.
-Moist environments help promote this process.

4

The proliferative phase of wound healing:

-restores skin integrity by filling in the wound with new tissue.
-a rough scar is formed during this phase, it is still very vulnerable to trauma.
-dehiscence and evisceration are risks during this phase of healing.
-contraction of the wound’s edges also begins through the work of myofibroblasts.

5

The remodeling phase of wound healing:

-completes the wound healing process and often takes several years.
-Beginning and overlapping with the proliferation phase, remodeling works to form and lyse collagen within a scar to help increase strength and skin integrity.

6

Intrinsic factors that affect wound healing:

-Age plays a major role in wound healing.
-The major cell functions essential for the various phases of wound healing diminish with age.
-The epidermis thins, making it more prone to injury.

7

Extrinsic factors that affect wound healing:

-Medications can affect wound healing, especially those that inhibit platelet action, such as aspirin, and those that suppress the immune system, such as corticosteroids.
-Cancer treatments are another factor, as they are meant to cause cell destruction and suppress the immune system.
-Inadequate nutrition is yet another factor; a lack of dietary protein, vitamins, and iron can slow healing time.
-Stress can also affect wound healing by altering the body’s ability to respond to injury.
-Infection can dramatically slow the process of healing by prolonging the phases of wound healing.

8

Chronic vs Acute Wounds

Chronic wounds are classified as wounds with prolonged healing time; wounds that heal faster are classified as acute wounds.

9

Healing of Chronic Wounds

Chronic wounds heal through secondary intention, a process during which the wound edges do not come together; instead the wound heals by the formation of granulation tissue, wound contraction, and epithelialization.

10

The epithelialization phase of chronic wounds:

-Characterized by inefficiency in the migration of keratinocytes for the formation of matrix and scar tissue.
-Chronic wounds also tend to have irregular wound edges, which inhibits cells from forming a matrix for healing.

11

The proliferative phase of chronic wound healing:

-Slowed by higher concentrations of fluid and pro inflammatory cytokines.

12

Chronic wound management:

-requires a long-term multidisciplinary plan to address all extrinsic factors and thus promote wound healing.

13

The basics of wound assessment:

Wound assessment includes both an accurate history and a physical examination.

14

Physical assessment of wounds:

-Visual assessment includes: shape, size, depth, colors, exudate, bleeding, any tissue that impairs healing (necrosis, erythematous or infected tissue, tunneling, edema), and any tissue that helps with healing (granulating tissue, clean wound edges).
-Temperature changes range from very warm (typical with infection) to very cold (vascular compromise).
-Textural changes include roughened or raised wounds or deep wounds that interrupt the natural contour of the skin.
-Odors, a very important component of wound assessment, can help you detect specific infectious organisms or suggest the cause of the wound.

15

Passive irrigation:

-Method that involves a solution and gravity.
-The solution is introduced in a top-to-bottom fashion to allow it to flow by gravity along the full length of the wound to the absorbent pad beneath the patient. This allows micro-organisms, tissues, and any unwanted materials to run down and away from the wound gradually for better overall wound cleansing.
-Top-to-bottom irrigation can sometimes eliminate the need for mechanical cleansing with a gauze pad.

16

Mechanical cleansing:

-Involves the use of gauze and a cleansing solution to clean contaminated wound areas.
-Excessive scrubbing of a wound can be painful, however, and can also remove healing tissue.

17

Drains are used in wound care to:

-collect exudate, measure it, protect the surrounding skin, contain micro-organisms, and reduce the frequency of care.

18

Drainage systems:

-are either open or closed and are typically put in place during a surgical procedure, with subsequent nursing care until they are removed.

19

Documentation for drains includes:

-the amount of drainage
-its appearance and odor
-the assessment findings for the surrounding skin

20

Open drainage systems:

-Penrose drains are used commonly as open drainage systems for wound care.
-An absorbent dressing is applied to the area to collect drainage and to keep the area dry.
-Uses a small plastic tube that collapses easily and has a safety pin or clip attached to keep it in place.

21

Drawbacks of open systems are:

Difficulties in assessing the amount of drainage and in controlling the transmission of micro-organisms from both the outside environment and from the wound itself.

22

Closed drainage systems:

-Use compression and suction to remove drainage and collect it in a reservoir.
-Reduce the risk of infection and allow more accurate measurement of drainage.

23

Hemovac

-A portable wound suction device that applies negative pressure to the wound.
-Incorporates a larger, disc-shaped reservoir for collecting drainage.
-Has a pouring spout for emptying the collection reservoir.

24

Dry dressings:

Typically composed of some form of gauze pad that is secured to the wound by rolled gauze and tape or as a self-adherent bandage with a gauze center.
-Are simple, inexpensive, and widely available and are an appropriate dressing choice for numerous types of wounds.
-Work well for wounds with small amounts of exudate, but they can stick to the wound bed of heavily exudative wounds or expose the wound to the outside environment.
-May be applied both in sterile and in clean environments.

25

Wet-to-dry dressings:

-Historically, have been used extensively for wounds requiring debridement.
-To create this type of dressing, place a saline-soaked gauze or cotton sponge within a wound with exudate or drainage. As the dressing dries, it pulls exudate out of the wound.
-May appear inexpensive initially because of the materials used, but the labor and frequency of dressing changes makes them fairly costly.
-Are time-consuming to apply and are generally painful to remove.

26

What are the disadvantages of wet-to-dry dressings?

-They are nonselective with debridement; therefore, they take healthy as well as necrotic tissue with them.
-Surrounding wound edges can become macerated because of the moisture contained in the dressing, and that can lead to enlargement of the wound’s diameter.
-Cross-contamination is also an issue as the saturated gauze in wet-to-dry dressings does not provide any barrier to the environment, thus allowing organisms in and out of the wound easily.

27

Chemical-impregnated dressings:

-Many manufacturers provide dressings that are impregnated with chemicals or agents intended to speed up the healing process.
-Examples are povidone-iodine (Betadine), silver, petroleum, collagen, and antibiotics.
-Some chemical-impregnated dressings come in sheets that require secondary dressings.
-Remember to use specialty dressings only for wounds that are likely to respond to the agent within the dressing.
-Consider cost, availability, and the potential for allergic reactions before using these dressings.

28

Foam dressings:

-Some dressings have additional foam padding to protect wound fields.
-Are absorptive and provide a moist healing environment while protecting wounds that resulted from pressure, friction, or shear.
-Are used widely for early-stage pressure ulcers.
-Most foam dressings are self-adherent, so take care to avoid damaging the surrounding skin when applying and removing these dressings.

29

Alginate dressings:

-Composed of calcium, calcium or sodium salts, or seaweed within a gel dressing.
-Provide a moist environment for healing and good absorption of exudate, establish hemostasis, and do not adhere to the wound.
-Helpful in treating wounds with large amounts of exudate including ulcers, donor sites, tunneling wounds, and some bleeding wounds.
-Do not moisten alginates before applying them to a wound. Contact with the wound bed should help activate the gel. And, to protect the wound bed fully, apply a secondary dressing.

30

Hydrofiber dressings:

-Similar to alginate dressings in their absorptive properties.
-Do not affect hemostasis.
-Composed of the polymer carboxymethylcellulose, a substance that can absorb exudate vertically.
-Are manufactured in sheets to place in wounds that have considerable exudate. The sheet materials swell on contact with exudate, thus absorbing the unwanted material.
-Cut these dressings to a size just larger than the wound cavity and use a secondary dressing over them.

31

Transparent film dressings:

-Have a thin layer of plastic that covers the wound area.
-Provides no absorption but does create a barrier to the environment.
-Allows some oxygen exchange to reduce anaerobic bacteria growth and a wet environment to promote healing.
-Are commonly used for wounds with dry eschar or for superficial skin tears but are not recommended for infected wounds.
-Removal of transparent dressings can cause damage to underlying skin, and the uniform application can cause maceration of wound edges.

32

Hydrogel dressings:

-Used for autolytic debridement, or promoting the body’s own natural functions of removing necrotic tissue.
-Works by maintaining a moist wound environment.
-Used for wounds with necrosis, infection, moderate amounts of exudate, and a need for a moist healing environment.
-Do not use hydrogel dressings to treat dry gangrene or dry ischemic wounds.
-A disadvantage is that hydrogel dressings are costly. You’ll change these dressings every day or every other day and more often if they become saturated. Be sure to change them whenever the amount of exudate compromises the intended use.

33

Hydrocolloid dressings:

-Used for autolytic debridement instead of the older wet-to-dry dressing technique.
-Have the benefit of some absorptive capabilities while still maintaining a moist wound healing environment.
-Do not allow oxygen to enter the wound, which can lead to anaerobic bacteria growth.
-Not recommended for infected wounds but they are helpful for wounds that are vulnerable to infection.
-Do not use these dressings to treat dry gangrene or dry ischemic wounds.
-Are not transparent, so it is difficult to assess the wound without removing them.

34

Binders:

-A form of bandaging that provides support to the body area they surround.
-Most often used on the abdomen following a surgical procedure with a large incision.
-Made from woven cotton, synthetic, or elastic materials.
-Most binders require either Velcro closure or safety pins.
-Keep the underlying skin in mind when applying a binder. Binders that are too tight or have wrinkles could cause pressure areas on the skin beneath them.
-Assess binders every 4 hours and re-wrap them every 8 hours or sooner if needed.
-If the binder slips or becomes saturated with any body fluids, replace it.

35

Negative pressure wound therapy (NPWT):

-Used to provide debridement and removal of exudate.
-Applies suction to a wound area.
-This technology cleanses the wound, reduces bacterial counts through debridement, promotes granulation and epithelialization, and stimulates cell growth.
-It is used for treatment of wounds in all healthcare settings including hospital, extended care and home.

36

Short-wave electric stimulation:

-Used widely to treat pain, edema, and soft-tissue injuries and to simulate cell growth.
-Should be used with caution when treating patients who are heat-sensitive or have an inflammatory process.

37

Short-wave electric stimulation should not be used at all:

-with metal or synthetic materials, as they can cause burn injuries or deflect some of the energy
-in moist environments (moist dressings, perspiration, adhesives)
-for patients who have a cardiac pacemaker, are pregnant, or are prone to bleeding
-over ischemic tissue or infected areas, especially with osteomyelitis (a bone infection)
-over immature bone
-transcerebrally

38

Ultrasound therapy:

-Used to deliver a mechanical vibration to skin tissues to stimulate cell growth.
-Ultrasound is thought to accelerate the inflammatory phase of healing but in some cases can induce inflammation.

39

High-frequency vs Low-frequency Ultrasound:

-High-frequency (short-wave) ultrasound causes thermal and nonthermal effects that stimulate cell growth and enhance transdermal drug delivery.
-Low-frequency (long-wave) ultrasound can penetrate deeper tissues while also stimulating cell growth.

40

Ultrasound therapy is indicated for:

-Edema, pain, skin tears, ulcers, bruising, poor circulation, deep tissue injury, and bacterial infection.
-Also useful for debridement.

41

Phototherapy

- involves the use of light or radiant energy to heal wounds.

42

Indications for phototherapy include:

-Acute or chronic wounds, slowly healing or nonhealing wounds, and infected or colonized wounds.

43

Ultrasound therapy should not be used:

-To treat previously untreated cellulitis with an ischemic response
-When there is uncontrolled pain
-When there are metal components in the wound area

44

Phototherapy should not be used:

-over cancerous growths
-over the thyroid gland
-during pregnancy
-without eye protection in place

45

Hydrotherapy for wound care involves:

-the use of heated, moving water.
-Hydrotherapy increases circulation, skin temperature, and cellular processes (including growth), and it reduces pain and inflammation.

46

Hydrotherapy is contraindicated:

-for clean, granulating, or epithelializing wounds because the agitation of moving water can disrupt healing.
-New skin grafts and tissue flaps should not be exposed to hydrotherapy.
-Macerated ulcers can become enlarged if exposed to the agitation of hydrotherapy.

47

Antiseptic agents

-Work by inhibiting or killing micro-organisms.
-Examples of antiseptic agents are povidone-iodine (Betadine), silver agents, and hydrogen peroxide.
-Used both for wound care and for sterilizing instruments.
-Used to cleanse or irrigate wounds or within some wound dressings for additional coverage.
-Dressings saturated in antiseptics provide a sustained release of the agent over time, while also creating a moist environment for healing.

48

Antibiotic ointments

-Used widely to treat infected wounds.
-Most have a clear color and a thick consistency. -Work by inhibiting bacterial growth in wounds that are already infected.
-Common antibiotic ointments are neomycin and polymyxin B (Neosporin) and triple antibiotic ointment (a combination of bacitracin, neomycin, and polymyxin B).

49

Resistance to antibiotic ointments:

-Some patients may develop resistance over time, particularly now that antibiotic-resistant organisms are so prevalent.
-Many healthcare providers no longer recommend extended treatment with antibiotic ointments for wound care.

50

Antibacterial agents

-Antibacterial agents work to destroy bacteria and inhibit growth.
-Bacitracin is a common antibacterial ointment.
-Antibacterial gels and sprays have become increasingly popular for use in hand hygiene prior to wound-care procedures.

51

Antifungal agents

-Typically used for fungal infections such as athlete’s foot or yeast infections.
-Fungal skin problems cause a bright red, malodorous, painful rash and can appear nearly anywhere on the body.
-Antifungal agents can be delivered in powders or ointments.
-Powders should be applied to a clean dry surface to avoid clumping.
-Some patients can develop resistance over time, so be sure to monitor each patient’s response to treatment.
-Examples of antifungal agents are nystatin, ketoconazole, and miconazole.

52

Chemical debridement gels/ointments

-Chemical agents that debride necrotic (dead) areas are typically used for pressure ulcers that have slough or eschar or for infected wounds with poor wound edges.
-These ointments are applied only to necrotic skin.
-Never place a chemical debridement agent on healthy granulating tissue as it can cause damage and pain.
-Most debriding agents have a bright or distinct color to make them easy to identify on the patient and on the dressing.
-Always place a dry dressing over the chemical debridement agent as it usually takes some time to be effective.
-Two commonly used debridement ointments are papain-urea chlorophyllin copper complex sodium (Panafil) and papain-urea (Accuzyme).

53

Barrier creams

-Used for patients prone to skin breakdown from pressure, shear, or incontinence.
-Intended for prevention and for resolving new-onset problems.
-Apply barrier creams several times a day on the skin over bony prominences or on areas prone to breakdown, such as the elbows, back, and buttocks.
-Some commonly used generic names for barrier creams are zinc oxide and vitamin A & D ointment.

54

Skin cleansers

-Skin cleansing agents work to remove micro-organisms while protecting the integrity of the skin. -Some preparations require rinsing while others are meant to dry and remain on the skin.
-Some skin cleansers are intended for full body use while others are formulated for specific areas such as hair or perineal areas.
-Specific uses are specified in the product name (body wash, shampoo).
-Consider the appropriate product for environments where the patient may not be able to be moved easily for a full shower or bath or for patients who have vulnerable skin.

55

Wound fillers

-Wound fillers are manufactured as pastes, powders, gels, and beads for providing a moist healing environment beneath dressings.
-Some help soften underlying necrotic tissue to speed up debridement.
-Fillers are helpful for deep wounds with some exudate and are less useful with dry wounds.

56

Pressure Ulcer Stages (6)

*Suspected deep tissue injury-->pertains to tissue with discolored but intact skin caused by damage to underlying tissue.
*Stage I--> is defined as non-blanchable redness caused by pressure or shear typically over a bony prominence.
*Stage II--> involves partial-thickness skin loss with a visible ulcer.
Stage III--> involves full-thickness tissue loss without exposed muscle or bone.
*Stage IV--> involves full-thickness tissue loss with exposed bone, muscle, the possibility of tunneling, and sometimes eschar (black scab-like material) or slough (tan, yellow, or green scab-like material).
*“unstageable”-->stage cannot be determined because eschar or slough obscures the wound.