Integumentary System: Wounds and Debridement

Question 1

Examination of the Integumentary System

Answer 1

Edema Measurements
Vital Signs
Circulation
Skin Integrity
Skin Observation
Risk Assessment (Braden Scale, Norton)
Pain
Sensory Integrity, ROM, Strength
Posture, Gait, Function, Cognition
Wound Characteristics

Question 2

Wound Documentation of the Integumentary System

Answer 2

Location
Size
Shape/Borders
Edges
Tunneling, Undermining
Wound Base (Necrosis, Exudate, Granulation tissue)
Peri-wound area
Pain

Question 3

Wound Drainage: Serous

Answer 3

Clear, light color
Thin, watery

Inflammatory & Proliferative Phase

Question 4

Wound Drainage: Sanguineous

Answer 4

Red Color
Thin, Watery

Inflammatory & Proliferative Phase

Question 5

Wound Drainage: Serosanguineous

Answer 5

Clear or tinge of red/pink
Thin, Watery

Inflammatory and Proliferative Phase

Question 6

Wound Drainage: Seropurulent

Answer 6

Cloudy, Opaque, Yellor or Tan
Thin, Watery

Early warning sign of infection (Abnormal)

Question 7

Wound Drainage: Purulent

Answer 7

Yellow, green
Thick, viscous

Wound infection (Abnormal)

Question 8

Integumentary System: CODES

Answer 8

C = Color
O = Odor
D = Drainage
E = Extent
S = Surrounding Skin

Question 9

Wound Bed Preparation

Answer 9

Identify the Cause
Assessment the Wound
Debridement
Bacterial Control
Moisture Balance
Monitor Rate of Healing

Question 10

Wound Bed Preparation: Cause

Answer 10

Assessment should include
- Blood supply to the area
- Other factors influencing healing

Involve patient in the process
Compliance through Active Participation
Education and support

Question 11

Wound Bed Preparation: Assess the Wound

Answer 11

Location, Size, Tissue Composition, Undermining, Exudate, Peri-wound, Thickness, Pain

Question 12

Wound Bed Preparation: Debridement

Answer 12

Surgical Sharp
Mechanical Autolytic
Enzymatic or Maggot Debridement
- Goal is to remove necrotic tissue or infected tissue from wounds

Question 13

Wound Bed Preparation: Bacterial Control

Answer 13

Treat s/s of infection
Anti-inflammatory, Antibacterial or Antibiotic interventions

Question 14

Wound Bed Preparation: Moisture Balance

Answer 14

Choice of cleansers that are non-cytotoxic to healthy tissue
Dressing that help create moisture balance with wound
Stimulate new tissue growth

Question 15

Monitor Rate of healing

Answer 15

Monitor and Modify

Question 16

Goals for Wounds

Answer 16

Reduce
-Skin Breakdown, Edema, Necrotic Tissue

Improve
-Skin Care habits, ROM, Strength, Function, Circulation, Wound Healing

Question 17

3 Key Wound Management Principles

Answer 17

Debridement Necrotic Tissue
Control Infection
Balance Moisture

Question 18

What Impedes Wound Healing?

Answer 18

Aging

Malnutrition
- Vitamin Deficiencies (Vit. A, B, C)
- All patients with chronic wounds should be considered for vitamin supplementations

Poor Tissue Oxygenation
- Arterial Doppler study, ABI
- Vascular status should be considered BEFORE Debridement
- Arterial Insufficiency: Pain, Pallor, Paresthesia, Pulseless Paralysis

Infection
- Osteomyelitis
- Most accurate diagnostic imaging is an MRI
- Gold Standard is bone Biopsy

Question 19

Surgical Debridement of Wound

Answer 19

Fast, most effective way to remove necrotic tissue
Converts chronic wounds to an acute wound
Required when areas of undermining cannot be visualized
Could be required to remove necrotic bone, muscle, tendon

Question 20

Surgical Debridement Cautions

Answer 20

Extreme caution with Debridement for those taking anticoagulants

Contraindicated for a medically unstable patient OR lack of vascular supply to support healing process

ONLY performed by Physician, Podiatrist, Certified PA

NOT US

Question 21

Sharp Debridement of a Wound

Answer 21

Exclusive Debridement of NON-VIABLE tissue only
- Can use scalpel, forceps, scissors, tweezers
- More conservative than surgical
- Removal of non-viable tissue beneficial for healing
- Removes Escher and loose slough
- Sterile gloves and soiled Debridement field should be removed and replaced with clean filled BEFORE wound re-dressing

Question 22

Cautions to Sharp Debridement

Answer 22

CAUTIONS
- Tunneling
- Undermining with no visual on the viable tissue edge
- Low platelet count
- On anticoagulation therapy

Question 23

Contraindication to Sharp Debridement

Answer 23

CONTRAINDICATED
- Dry gangrene
- Severely impaired arterial blood flow
- Impaired clotting mechanism
- Non-infected pressure ulcer on the heel (covered in dry-Escher)

Question 24

Pain Cautions in Sharp Debridement

Answer 24

PAIN CAUTIONS
- No pain should be experienced with non-viable tissue
- Unless necrotic tissue adherence at borders is tight
- Oral meds may be ordered
- Topical analgesic may be placed, covered for 15-20 min

Question 25

Bleeding Cautions in Sharp Debridement

Answer 25

BLEEDING CAUTIONS - Minor Bleeding = Firm pressure over site for minimum of 10 minutes continuously to stop bleeding without lifting pressure - If it persists over 10 minutes, use silver nitrate stick to aid in coagulation

Question 26

Application of Topical Medications what Section of the Rules? (May not be needed idk man)

Answer 26

Can apply according to Section 2620

Question 27

Mechanical Debridement of a Wound

Answer 27

Removal of non-viable tissue with mechanical source

Question 28

Methods of Mechanical Debridement

Answer 28

Soft Abrasion Wet-to-Dry dressing Hydrotherapy

Question 29

Advantages/Disadvantages of Mechanical Debridement

Answer 29

ADVANTAGES - Helps soften or remove tissue DISADVANTAGES - Non-Selective Method - Can be performed incorrectly and result in trauma/pain

Question 30

Soft Abrasion Debridement

Answer 30

Gauze Sponge or Swab Good for moist necrotic tissue May be painful if applied over healthy, granulation tissue Can be performed daily or PRN Discontinue if loose, moist necrotic tissue no longer visible CAUTION Anticoagulant Therapy

Question 31

Wet-to-Dry Dressings

Answer 31

Moist gauze dressing placed over wound and removed with slough Pre-medication may be needed

Question 32

Advantages and Disadvantages of Mechanical Debridement

Answer 32

ADVANTAGES - Risk of harm to healthy tissue minimal - Most effective with loose slough DISADVANTAGES - Could remove granulation / viable tissue - Bleeding or pain could occur - May be too drying for the wound bed - Time intensive, costly

Question 33

Whirlpool

Answer 33

Submerging wound, immersing in tank filled with water Decline in its use… Lack of evidence to support Disadvantage - Intensity of agitation may impede healthy tissue - Unable to control water pressure forces - Gravity Dependent position - Macerates surrounding skin - Potential for cross contamination

Question 34

Whirlpool Precautions

Answer 34

PRECAUTIONS Clean, granulated wound bed New skin graft Venous insufficient wounds Distal extremity edema Sensory impairment Diabetic ulcers

Question 35

Whirlpool Contraindications

Answer 35

CONTRAINDICATIONS Compromised CV or pulmonary function Acute infection Renal failure Impaired cognition Dry gangrene Neuropathic foot Severe Arterial Insufficiency Already macerated tissue Bow and Bladder

Question 36

Pulsation Lavage with Suction

Answer 36

Pressure cleaning and Debridement of wound bed, with vacuum to remove exudate/debris Pressure of 15 psi is MAX level, removing 84% of bacteria in the wound

Question 37

Pulsation Lavage with Suction Advantages

Answer 37

Positive pressure aids in Debridement Negative pressure helps stimulate granulation tissue

Question 38

Pulsation Lavage with Suction Indications

Answer 38

For Venous, Neuropathic, Pressure, Post-Surgical, Infected, Fasciotomies

Question 39

Pulsation Lavage with Suction Details

Answer 39

Single use only Used in private room (NO CURTAIN ROOM) Limb can be elevated Lavage is SITE SPECIFIC Can reach hard areas NO KNOWN ABSOLUTE CONTRAINDICATIONS

Question 40

Pulsation Lavage with Suction Precautions

Answer 40

PRECAUTIONS Insensate areas Anticoagulant therapy Wounds without full visual

Question 41

Negative Pressure Wound Therapy

Answer 41

Negative pressure directly over wound bed through foam or gauze dressings and vacuum pump Aids in drainage removal and necrotic tissues Debridement while keeping moist wound environment Dressing is sealed, has a protective layer to improve perfusion, enhance granulation tissue, and reduce bacteria

Question 42

Autolytic Debridement

Answer 42

Moisture-retaining dressings to help the body breakdown necrotic tissue on its own Very Selective, requires minimal skill, and PAINLESS Slowest of all the Debridement methods and monitoring for infection is important

Question 43

When is Autolytic Debridement used?

Answer 43

Conservative method for those who cannot tolerate more aggressive forms and need rehydration of a wound If infection suspected this type must be stopped immediately Often used in conjunction with other Debridement If change isn’t seen in 3 days DO SOMETHING ELSE

Question 44

Contraindications to Autolytic Debridement

Answer 44

CONTRAINDICATION Dry Gangrene (Needs to be kept DRY)

Question 45

Enzymatic Chemical Debridement

Answer 45

Selective, apply topical agents to promote wound softening Type of enzyme dependent on the wound’s presentation Most effective to loosen a large necrotic area Close monitoring if using on an infected wound CROSS HATCHING dry Eschar enhances the the enzyme by creating a larger surface area

Question 46

Enzymatic Chemical Debridement Precautions

Answer 46

PRECAUTION - Maceration - Irritation - Pain to periwound region

Question 47

Enzymatic Chemical Debridement Contraindications

Answer 47

CONTRAINDICATION Heavily draining wounds

Question 48

Maggot Debridement Therapy Indications

Answer 48

Indicated for non-healing wounds or those with increased bleeding risk, other methods are contraindicated Steril larvae from the Green Bottle Fly NO MORE THAN 10 LARVAE PER SQUARE Left in place 1-3 days

Question 49

What is Maggot Debridement

Answer 49

Eats the dead tissue and excrete an enzyme that further aids in breaking down necrotic tissue Very little pain associated with this type No reported toxicity or allergic reactions Slower than sharp or surgical Debridement methods

Question 50

Autolytic Debridement (Method, Indication, Contraindication)

Answer 50

M = Natural Debridement promoted by moisture I = Anticoagulant therapy, Medically stable C = Infection, Immunosuppressed, Dry, Gangrene or dry ischemic

Question 51

Enzymatic Debridement (M, I, C)

Answer 51

M= Chemical Debridement, selective, liquifies necrotic tissue I = Moist necrotic wounds, Eschar after Cross-hatching C = Ischemic wound, Dry gangrene, Clean, granulated wounds

Question 52

Mechanical Debridement (M, I, C)

Answer 52

M = Non-selective, removes tissue that is non-viable I = Moist necrotic wounds bed w/ foreign material C = Clean, granulated wound

Question 53

Sharp Debridement (M, I, C)

Answer 53

M = Selective, Scalpel to remove necrotic tissue without anesthesia I = Excise leathery Eschar, Excise moist necrotic tissue C = Clean wound, advanced cellulitis, anticoagulant therapy

Question 54

Surgical Debridmement (M, I, C)

Answer 54

M = Selective, Deep Ulcer, Sterile instruments I = Advanced Cellulitis, immunocompromised, Infection C = Cardiac, Pulm disease, DM, Deathly ill

Question 55

Biological Maggots (M, I, C)

Answer 55

M = Maggots Debridement nonviable tissue I = Cannot tolerate other forms, non-healing wounds C = Increased stress, Pain increases, Poor perfusion

Question 56

Transparent Films (M, I, T)

Answer 56

M = Clear, adhesive, semipermeable to O2 (not bacteria) I = Pressure, Autolytic Debridement, Cover for hydrogel T = Visualize wound, Dressing times vary, NO INFECTION

Question 57

Hydrocolloid (M, I, T)

Answer 57

M = Adhesive water, has absorptive quality I = Autolytic Debridement, Mild exudate, Non-adhesive T = Odor, and yellow exudate, DON’T USE w/ infection

Question 58

Hydrogel (M, I, T)

Answer 58

M = Solid sheets or in gauze bandage I = Wounds with necrosis & Slough, burns T = Requires 2nd dressing, NOT for heavy drainage, NO inf.

Question 59

Foams (M, I, T)

Answer 59

M = Absorptive foam and adhesive to protect the wound I = Packing in a wound to absorb exudate, partial/full thickness C = Non-adherent and conforms to wound, NOT for dry wounds

Question 60

Alginates (M, I, T)

Answer 60

M = Absorbent dressing derived from seaweed I = Packing into a wound to absorb exudate, Mod-large exudate C = Change when exudate is leaking or at least 3 days

Question 61

Gauze (M, I, T)

Answer 61

M = Absorptive and permeable to water, air I = All wounds (Exudate/necrotic/tunnels/infected) C = Available used as a form of mechanical Debridement

Question 62

Wound Dressing Considerations: Calcium Alginates

Answer 62

Calcium alginates have absorptive property for weepy wounds and turns into a gel so keeps a moist environment but absorbs excess fluid

Question 63

Wound Dressing Considerations: Foams

Answer 63

Have the same absorptive property but do not conform to cavities (Tunnels)

Question 64

Wound Dressing Considerations: Hydrogel

Answer 64

Can come in gels, sheets, or in a gauze bandage Caution it does not contribute to maceration of wounds or peri-wound areas

Question 65

Wound Dressing Considerations: Keep in Mind

Answer 65

Time needed for wound healing Pain during dressing change Frequency of dressing change Costs of wound care Required length of hospital admission Silver is the most common antimicrobial agent