Wound care

Question 1

primary intention healing (primary union/ first intention healing)

-what it is? Materials? when is it used? examples?

Answer 1

• tissue surfaces are close together
• stitches, stables, skin glue, tape
• are used where there is little tissue lose
• surgical incisions, Iv therapy, lumbar puncture

Question 2

open wounds vs closed wounds

Answer 2

closed: skin integrity remains intact
open: skin integrity is compromised

Question 3

secondary intention healing

what? when? examples?

Answer 3

• edges of wound are not close together
• wounds are extensive and have a lot of tissue loss
• examples: large open wounds (burns, pressure ulcers, venous stasis ulcers

Question 4

how is secondary intention healing different to primary intention healing

Answer 4

secondary intention takes longer to heal, has more scarring, and at higher risk for infection

Question 5

tertiary intention healing (delayed/ secondary closure)

-why? when? how long? examples?

Answer 5

• indicated if there is a reason to delay suturing or closing a wound ( usually to allow for drainage, edema, or infection to resolve)
• used for heavy contamination of wound
• usually cleans and heal open for less the 48hrs. and then surgically closed
• examples: abdominal wound left open for drainage and closed later, dog bits

Question 6

wound care assessment

Answer 6

• size: length, width, depth
• location: nearest anatomic landmark
• undermining: erosion around wound bed
• tunneling/sinus tract: passage way to opening in skin in 1 direction
• tissue in the wound base: eschar, slough, granulation
• exudate/drainage: amount (scant, moderate, copious), color and type (serious, sanguineous, purulent) Odor
• peri-wound skin: surrounding skin (pink, excoriated, macerated, reddened)
• pain: tolerance for dressing change

Question 7

wound care assessment

Answer 7

• size: length, width, death
• location: nearest anatomic landmark
• undermining: erosion around wound bed
• tunneling/sinus tract: passage way to opening in skin in 1 direction
• tissue in the wound base: eschar, slough, granulation
• exudate/drainage: amount (scant, moderate, copious), color and type (serious, sanguineous, purulent) Odor
• peri-wound skin: surrounding skin (pink, excoriated, macerated, reddened)
• pain: tolerance for dressing change

Question 8

eschar

Answer 8

dead tissue that appears black and leathery: impairs healing

Question 9

slough

Answer 9

white, yellow, tan, gray, green tissue that is a consequence fo inflammatory phase of wound healing.

Question 10

granulation

Answer 10

contain significant amounts of highly vascularized granulation tissue: red or deep pink color

Question 11

exudate

Answer 11

• serous: clean watery
• sanguineous: bright red
• serasanguienous: pale, red, watery mixture of serious and sanguineous
• purulent: thick, yellow, green, tan, or brown

Question 12

epithelialization

Answer 12

healing wound tissue

-pink in color

Question 13

approaches to wound managements: RED

Answer 13

• protect
• granulation tissue
• gentle cleansing, use of moist dressings change only when necessary

Question 14

approaches to wound management: Yellow

Answer 14

• clean
• slough tissue
• cleanse tissue, irrigate to remove

Question 15

approaches to wound management: debride

Answer 15

• eschar tissue

debridement by APRN

Question 16

healing principles: what is the best healing environment

Answer 16

• moist wound bed:a low for epidermal migration

- surrounding skin dry: prevent skin breakdown

Question 17

healing principles: removal of nonviable tissue

2 things that are done to remove tissues

Answer 17

remove microorganism and debris

• cleansing: approximated: clean to dirty, top to bottom and unapproximated: half circles from center to periphery
• debridement: can be done through topical application of enzymes to breakdown tissue, dressing or mechinical

Question 18

healing principles: prevent further injury

Answer 18

-apply dressing to wound itself to protect
-friction and shear (tissues move past each other ): capillary damage
-

Question 19

healing principles: ensure adequate blood supply

Answer 19

-needed for healing: blood increases WBC, RBCs, and platelet to site of injury to remove toxin and debris
- external pressure reduce blood supple (ishemia)
-

Question 20

healing principles: adequate nutrition

Answer 20

• vitamin A,B, C(collagen synthesis, capillary formation, K minerals, trace elements)
• protein: cell mediated defense (WBC formation)
• insufficient caloric intake: glucose needed for healing
• encourage meals

Question 21

Primary dressings

Answer 21

• DPD: dry protective dressing: well approximated wounds, minimal drainainge
• Hydrocolloids (duoderm): absorb drainage
• hydrogels (Aquasorb): maintains moist environment
• transparent (tegaderm): allow oxygen but no bacterial penetration
• Saline moistened dressing: allows for debridement, moist to dry

Question 22

saline moistened dressings

purpose? cleansing process? packing?

Answer 22

• purpose: promote healing
• clean from center to periphery or if infected clean from clean to dirty
• pack lightly but completely unfold the dressing to get better contact with wound bed

Question 23

irritating wounds:

pressure?solutions? how long?

Answer 23

• gentle pressure
• solutions: salin vs. antiseptic or antibiotic solutions
• irrigate until solution flows clear

Question 24

what things are not used to irrigate wounds?

Answer 24

iodine and hydrogen peroxide because they cause cell death

Question 25

wound culture

Answer 25

- wound biofilms are result of bacteria growing ing clumps, imbedded in a thick, self made, protective, slimy, barrier fo sugars and proteins - impair wound healing and lead to increased inflammation - remove biofilm - yellow/greenish

Question 26

when is the best time to obtain a wound culture?

Answer 26

- eradicate biofilm first | - roll to maximize contact

Question 27

wound drains purpose?placement? passive or negative pressure? assessment

Answer 27

purpose: anticipation that fluid will collect - placement: decided by surgery, type of wound - passive/passive pressure drainage: will depends on where it is placed - assessment: many times during shift, note drainage, site, pain, patient tolerance

Question 28

Penrose drain

Answer 28

- passive drainage - not sutured in place - pulled out little by little as drainage lessens - drainage will passively drain onto the dressing

Question 29

Jackson pratt drain

Answer 29

- gentle negative pressure - holds 50-100mL - sutured in place - empty when 1/2 full - protect from pulling - located along side wound, coiled inside - drainage will drain into collection device - secured with safety pin

Question 30

hemovac drain

Answer 30

- negative pressure - holds 400-800mL - sutured in place - emptied when 1/2 full - protect from pulling - drainage will drain into collection device

Question 31

wound drainage: instruments: Vacuum-assisted closure

Answer 31

negative pressure wound therapy - applies uniform negative pressure: pull of vacuum increases blood flow to the area - fenestrated tube embedded in foam - occlusive dressing

Question 32

Negative pressure wound therapy: uses: what type of wounds

Answer 32

wide open wounds - pressure ulcers - diabetic ulcers - dehisced wounds - graft sites

Question 33

Negative pressure wound therapy: benefits

Answer 33

- promotes wound bed circulation - reduces risk of infection - promotes wound contraction

Question 34

Negative pressure wound therapy: who should you be careful with?

Answer 34

- anticoagulants - immunosuppression - bleeding problems

Question 35

Negative pressure wound therapy: contraindications

Answer 35

- active bleeding - malignancy - exposure nerves - tendons or ligaments - fistulas.