Flashcards in Wound care Deck (35)
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1
primary intention healing (primary union/ first intention healing)
-what it is? Materials? when is it used? examples?
-tissue surfaces are close together
-stitches, stables, skin glue, tape
-are used where there is little tissue lose
-surgical incisions, Iv therapy, lumbar puncture
2
open wounds vs closed wounds
closed: skin integrity remains intact
open: skin integrity is compromised
3
secondary intention healing
what? when? examples?
-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
4
how is secondary intention healing different to primary intention healing
secondary intention takes longer to heal, has more scarring, and at higher risk for infection
5
tertiary intention healing (delayed/ secondary closure)
-why? when? how long? examples?
- 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
6
wound care assessment
-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
7
wound care assessment
-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
8
eschar
dead tissue that appears black and leathery: impairs healing
9
slough
white, yellow, tan, gray, green tissue that is a consequence fo inflammatory phase of wound healing.
10
granulation
contain significant amounts of highly vascularized granulation tissue: red or deep pink color
11
exudate
-serous: clean watery
-sanguineous: bright red
-serasanguienous: pale, red, watery mixture of serious and sanguineous
-purulent: thick, yellow, green, tan, or brown
12
epithelialization
healing wound tissue
-pink in color
13
approaches to wound managements: RED
-protect
-granulation tissue
-gentle cleansing, use of moist dressings change only when necessary
14
approaches to wound management: Yellow
-clean
-slough tissue
-cleanse tissue, irrigate to remove
15
approaches to wound management: debride
- eschar tissue
debridement by APRN
16
healing principles: what is the best healing environment
-moist wound bed:a low for epidermal migration
-surrounding skin dry: prevent skin breakdown
17
healing principles: removal of nonviable tissue
2 things that are done to remove tissues
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
18
healing principles: prevent further injury
-apply dressing to wound itself to protect
-friction and shear (tissues move past each other ): capillary damage
-
19
healing principles: ensure adequate blood supply
-needed for healing: blood increases WBC, RBCs, and platelet to site of injury to remove toxin and debris
- external pressure reduce blood supple (ishemia)
-
20
healing principles: adequate nutrition
-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
21
Primary dressings
-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
22
saline moistened dressings
purpose? cleansing process? packing?
-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
23
irritating wounds:
pressure?solutions? how long?
-gentle pressure
-solutions: salin vs. antiseptic or antibiotic solutions
-irrigate until solution flows clear
24
what things are not used to irrigate wounds?
iodine and hydrogen peroxide because they cause cell death
25
wound culture
- 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
26
when is the best time to obtain a wound culture?
-eradicate biofilm first
-roll to maximize contact
27
wound drains
purpose?placement? passive or negative pressure? assessment
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
28
Penrose drain
-passive drainage
-not sutured in place
-pulled out little by little as drainage lessens
-drainage will passively drain onto the dressing
29
Jackson pratt drain
-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
30
