Wound care Flashcards Preview

Interventions > Wound care > Flashcards

Flashcards in Wound care Deck (35)
Loading flashcards...
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

hemovac drain

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