Wound Care

Question 1

Types of Healing

Answer 1

1. Primary intention healing
2. Secondary intention healing
3. Tertiary intention healing

Question 2

Primary intention healing

Answer 2

• tissue surfaces approximated (brought together)
• minimal or no tissue loss
• minimal granulation tissue and scar
• surgical incision as an example

Question 3

Secondary intention healing

Answer 3

• Edges cannot or should not be approximated (brought together)
• repair time longer, more scarring and risk for infection

Question 4

Tertiary intention healing

Answer 4

“delated primary intention”

• left open for 3-5 days and then closed
• allows edema to resolve exudate to drain
• closed with sutures, staples, or adhesive skin closures

Question 5

Phases of Wound Healing

Answer 5

1. Hemostasis Phase
2. Inflammatory Phase
3. Proliferative Phase
4. Maturation Phase (Remodeling)

Question 6

Hemostasis Phase

Answer 6

• cessation of bleeding
• vasoconstriction and formation of clot
• scab inhibits infection
• epithelial cells migrate into wound to prevent entry of microorganisms

Question 7

Inflammatory Phase

Answer 7

Blood supply increases

• erythema and edema
• exudate cleanses wound
• neutrophils first 24 hrs
• replaced by macrophages
• phagocytosis
• crucial healing

Question 8

Proliferation Phase

Answer 8

Day 3-4 to 21 days

• Fibroblasts synthesize collagen that adds strength to wound
• Capillaries grow across wound, bring fibrin
• Granulation tissue forms
• Light red or pink

Question 9

Maturation Phase

Answer 9

• Remodeling*
• From day 21 to 1-2 yrs
• fibroblasts continue to synthesize collagen
• wound site is remodeled and contracted
• scar becomes stronger
• too much collagen?

Question 10

Complications

Answer 10

• Hemorrhage
• Infection
• Dehiscence
• Evisceration

Question 11

Hemorrhage

Answer 11

• May bleed uncontrollably
• apply pressure
• surgery may be needed
• Hematoma under wound, may obstruct blood flow to area

Question 12

Infection

Answer 12

• microbes compete for oxygen and nutrition (impairs wound healing)
• change in wound color, pain, drainage
• may occur druing injury, surgery, post-op
• confirmed by culture
• may have fever, increase WBCs
• immunosuppressed increase risk

Question 13

Dehiscence

Answer 13

• Partial or total rupture of sutured wound
• cover with sterile saline gauze
• patient to bed with knees bent
• notify doctor

Question 14

Evisceration

Answer 14

• protrusion of internal viscera through an incision
• usually occurs 4-5 days post-op
• cover with large sterile dressing
• patient in bed with knees bent
• notify surgeon immediately

Question 15

Risk factors for evisceration

Answer 15

• obesity
• poor nutrition
• trauma
• failure to suture
• coughing
• vomiting
• straining

Question 16

Prevention

Answer 16

• protein
• CHOs
• Lipids
• Vit A and C
• Iron
• Zinc
• Copper

Question 17

Lifestyle Preventative measures

Answer 17

• regular exercise leads to better circulation

- smokers at risk for delayed healing

Question 18

Medications not good for wound healing

Answer 18

• anti-inflammatory (need inflammatory response for wound healing)
• antineoplastic (cancer drugs, same thing)
• prolonged antibiotics (prone to infection from resistant bacteria)

Question 19

Exudate

Answer 19

• serous (clear, light yellow)
• serosanguineous (light pink)
• sanguineous (bloody red)
• purulent (yellow green, puss)

Question 20

Elderly patients Considerations

Answer 20

-at risk for imparied wound healing due to:

• impaired liver fx
• nutritional deficiencies
• chronic illness
• vascular changes
• delayed inflammatory response
• slowed collagen synthesis

Question 21

Diagnostic Tests

Answer 21

wound culture and sensitivity

Question 22

Surgery

Answer 22

• Emergency: life threatening/ repair tissue or vessels
• Non-emergency: ineffective healing/debridement for infected or necrotic tissue
• necrotic tissue removed
• wound flushed with saline
• abscess (incision and drain)
• Escharotomy to remove eschar

Question 23

What is the difference between necrotic tissue and eschar?

Answer 23

?

Question 24

Pharmacologic Therapy

Answer 24

• Antibiotics
• Topical gels or injectable meds with growth factors
• opioids and NSAIDs

Question 25

Non-Pharm Therapy

Answer 25

- nutrition - compression - vacuum-assisted closure - hyperbaric oxygen therapy - stem cells - maggots - alternative

Question 26

Nursing Care

Answer 26

- Assessment - Maintain moist wound healing - promote optimal nutrition and hydration - prevent infection - position to minimize pressure on the wound

Question 27

EBP

Answer 27

- Hydrocolloid dressings best for dry wounds * impermeable to oxygen, moisture, and bacteria * Maintain moist environment * Support autolytic debridement * dry wound with no drainage - transparent film * exudative wound - absorptive dressings

Question 28

Drain purpose

Answer 28

allow excessive fluid, purulent drainage to drain; assists with granulation tissue formation

Question 29

Drain labels

Answer 29

- type of drain - date - initials

Question 30

nursing care of drains

Answer 30

maintain suction as needed, assess and document drainage

Question 31

Wound V.A.C.

Answer 31

Vacuum Assisted Closure - continuous or intermittent negative pressure - removes fluid and exudate - prepares the wound for healing and closure

Question 32

Wound V.A.C. complications

Answer 32

- hemorrhage from suction with anticoagulant therapy | - wound infection from dressing pieces left in wound

Question 33

Wound V.A.C. Care

Answer 33

- eval pts for risk of bleeding - stop VAC if bright red blood seen - apply pressure and notify MD - Perform proper dressing change