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NURS 205 > Lecture 7: Wound Assessment and Management > Flashcards

Lecture 7: Wound Assessment and Management Flashcards

1
Q

5 main functions of the skin

A

-protection
-storage
-absorption
-heat regulation
-sensation/perception

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2
Q

3 part structure of skin…

A

skin
1. epidermis
2. Dermis
3.Subcutaneous tissue
muscle

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3
Q

wound classifications (5)

A
  1. Cause (surgical vs non surgical)
  2. Duration (acute vs chronic)
  3. Level contamination
  4. Depth of tissue affected
  5. Colour of wound

L CD CD

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4
Q

Acute wound

A

Any surgical wound that heals by primary intentions or secondary intention (normal healing phases)

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5
Q

Chronic wound

A

Wound that fails to progress through normal healing phases. Stuck in inflammatory phase.

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6
Q

Level of contamination of wounds (4):

A

clean wound: no inflammation, operative incision

Clean/contaminated no inflammation but has resp, GI, urinary tract as been entered.

contaminated wound: open traumatic wounds or surgical wound, beak in sterile field, shows signs of inflammation.

Infected wound: Old, traumatic, dead tissue and wound evidence of infection

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7
Q

Types of tissue colour
-Red
-yellow
-black

A

Red: Granulation tissue (clean, superficial or deep)
Yellow: Slough tissue (ideal for bacterial growth)
Black: Eschar or necrotic tissue
(gangrenous ulcers)

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8
Q

what are 3 types of wound debridement

A
  1. Conservative sharp wound debridement: Use an instrument to remove wound tissue
  2. Surgical debridement
  3. Non-surgical debridement:
    -autolytic
    -enzymatic
    -Mechanical
    -Maggot therapy
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9
Q

Serous drainage

A

Clear or straw coloured
-Protein and fluid

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10
Q

Sanguineous

A

Red,thin,watery
-blood drainage

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11
Q

Serosanguinous

A

-Pink,thin,watery
-blood cells mixed with serous drainage
-expected drainage few hours post surgery

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12
Q

Purulent

A

yellow, grey,green

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13
Q

Hemorrhage

A

Thick!!!
-leaking blood vessel

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14
Q

most wounds heal by_____

A

tissue repair

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15
Q

wounds usually result in what

A

Scar tissue

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16
Q

What’s the wound healing process…

A
  1. Initial hemostasis/inflammatory
    3-5 days

2.Granulation proliferative) phase
5 days-3 weeks

3.Maturation
remodeling
several months or years

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17
Q

Homeostasis inflammation

A

-lasts several days
-occurs immediately after injury
-platelet aggregation
-edema
-macrophage engulf and remove debris
-release of cytokines

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18
Q

clinical manifestations of inflammation:
-local response
-systemic response
-exudate formation

A

local: redness, heat,swelling, loss function

systemic response: leukocytosis,nausea,anorexia,fever

exudate formation: fluid and leukocytes move from the circulation to the site of injury

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19
Q

major events of granulation phase of wound healing

A

1.Epithelization
2.Collagen formation
3. Granulation tissue formation
4. Contraction

20
Q

maturation phase

A
  • can last up to 2 yrs
  • collagen reorganization
  • increased tensile strength of the scar
  • colour of scar changes from red to white
21
Q

methods of wound closure

A

primary - 1st intention
secondary - 2nd intention
tertiary - 3rd intention

22
Q

1st intention

A
  • closing the wound by mechanical means i.e: sutures staples, tape, skin glue

indicated:
- minimal tissue loss
- skin edges are well approx
- clean lacerations

most surgical incisions closed using primary intention: 3 phases of healing occur quickly w minimal scarring

23
Q

2nd intention

A

the wounds usually are large w either:
- significant tissue loss/damage
- bacterial concentration

take more time to heal - uses same phases of healing

24
Q

3rd intention - delayed primary intention

A
  • is a method of wound closure that uses a combo of primary and secondary intention
  • the wound is left open for short period (usually a few days) to allow edema and infected exudate (pus) to resolve, then closed by primary intention or secondary intention
25
Q

complications of wound healing

A
  • infection
  • hypertrophic scars/keloid formation
  • contracture
  • dehiscence
  • adhesions
26
Q

infection

A
  • ranges from superficial cases of cellulitis to deep-seated abscesses
  • staphylococcus and pseudomonas species are common organisms causing wound infections
27
Q

hypertrophic scars and keloids

A

hypertrophic scar: inappropriately large, red, raised and hard. it remains confined to the wound edges and may regress in time.

keloid: is an even greater production of scare tissue that extends beyond the wound edges and may form tumor-like masses

  • overproduction of collagen
28
Q

contractures

A

excessive wound contraction may result in deformity or contracture, especially if wound is near a joint.

29
Q

dehiscence

A
  • separation and disruption of previously joined wound edges

3 contributing causes:
- infection causing inflammatory process
- granulation tissue not strong enough to withstand external forces
- obesity

30
Q

evisceration

A

occurs when wound edges separate to the extent that intestines protrude through the wound

31
Q

what to do when evisceration occurs

A
  • call for help but stay pt
  • notify surgeon immediately
  • lower bed so its flat no higher than 20 degrees
  • bend knees to reduce abdominal muscle tension
  • sterile towels and soak w sterile saline
  • remove soiled dressing, don w sterile glove, place moistened towels over loops of bowel
32
Q

adhesions

A
  • filmy bands of scar tissue that may form btwn or around organs
  • most adhesions cause no sympt at all
  • serious complication is intestinal obstruction
33
Q

principles of wound care

A

“measures”
- minimize trauma to wound bed
- eliminate dead space
- assess and manage the amount of drainage/exudate
- support the body’s tissue defense sys
- use nontoxic wound cleansers
- remove infection, debris, and necrotic tissue
- environment maintenance; moist wound bed
- surrounding tissue, protect from injury and bacterial invasion

34
Q

cleansing - normal saline

A

0.9% NaCl
most used solution - intentional wound

35
Q

gauze dressing

A
  • provides absorption of exudates supports debridement (mechanical) if applied and kept moist
  • used to maintain moist wound surface or as a filler dressing
36
Q

non-adherent gauze

A
  • minimally absorbent
  • mainly used on minor wounds or as 2ndary dressing
  • woven or non-woven: may be impregnated with saline, petrolatum or antimicrobials ex: adaptic w vaseline gauze
37
Q

transparent dressings

A
  • no drainage/exudate
  • indications: superficial wound
  • pros: wound inspections
  • disadvantages: not for draining wounds, not absorptive
38
Q

hydrocolloids

A

light to moderate drainage
- indication: partial and full thickness wound. Ex: pressure injury 2 and 3; 1st and 2nd degree burn
- pros: promote autolytic debridement
- cons: not recommended for heavy (++) drainage wounds

39
Q

hydrogels

A

light drainage and black tissue
- indication: partial and full thickness wounds; pressure injury 2 to 4; 1st and 2nd degree burn, necrotic wounds
- pros: promote autolytic debridement
- disadvantages: some requires secondary dressing to secure, may macerate periwound, not recommended for heavy draining

40
Q

aliginates

A
  • heavy drainage/exudate: highly absorbent dressing made from seaweed material
  • pros: can be used w tunneling and undermining
  • cons: requires a 2nd dressing

replaces gauze packing in a very wet wound

41
Q

foam dressing

A

heavy drainage/exudate
- highly absorbent
- indications: partial and full thickness wounds, PI stage 2 to 4
- pros: comfortable, easy to apply and remove
- cons: not recommended for non-drainage wounds, not easily able to pack into wounds, may macerate peri-wound area if not changed appropriately

42
Q

antimicrobials

A

broad spectrum against bacteria

43
Q

-‘ve pressure wound therapy or vacuum assisted wound closure (VAC)

A

moderate to heavy drainage/exudate
- indication: partial to full thickness wounds, dehisced wounds, surgical wounds, acute traumatic wounds
- pros: decrease edema and bacterial colonization. increase blood supply and granulation
- cons: need training to apply; can be long/difficult to apply correctly

44
Q

Betadine and hydrogen peroxide

A
  • must be used as antiseptic only
  • indicated for intact skin only
  • not best practice: do not apply on open skin
45
Q

surgical drains

A
  • penrose drains
  • jackson-pratt drain
  • hemovac drain

NURS 205 (18 decks)

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