Wound Care, Abx & Immunisations Flashcards
Wounds types & healing: 6 & 4
Traumatic:
- abrasion; epithelialisation & healing under scab
- cut; primary intention
- stab; primary intention
- impalement; primary intention followed by surg intervention
- laceration; secondary intention OR primary after debribement
Iatrogenic:
- incision; epithelialisation
- puncture; primary intention
- acid/alkali burns; primary intention
- split skin removal; primary after surg intervention
Healing types & closures
Epithelialisation; epithelium growths over a denuded surface
Primary: edges can be approximated & wound actively closed using techniques
Secondary: edges cannot be approximated & wound needs to heal from bottom thru granulation; left open & wound closes naturally
Tertiary: delayed primary closure due to infection risk, wound closed w techniques after time
HEIDI
H- Hx; wound, Pt, environment
E- Examination; Pt’s localised skin, circulation, etc
I- investigation; consider pathology, radiology, haematology or sonography
D- Dx; aetiology/pathophysiology
I- Implement; immed & long term
TIME
T- Tissue; non-viable tissue (slough/necrosis), foreign bodies
I- Inflammation; & infection
M- Moisture; imbalances, oedema, temp, pH
E- Edges; rolled, raised, undermined, calloused
Wound Exam general
- location
- type
- dimensions
- tissue types/wound bed
- exudate type & amount
- odour
- wound edges
- condition of surrounding skin
- pain
Tissue types & wound bed
Epithelialisation: pink, often irregular, at wound edges
Granulation: Red, bumpy, associated w healing wound (reducing size)
Agranular: Red/pink/pale; smooth; not healing (not reducing)
Slough: white-yellow; smooth; soft, sloppy & stringy to tenacious & adherent
Gelatinous slough: firm, gelatinous yellowish coating over the wound
Necrosis: black/tan; hard & dry OR moist & leathery
Hypergranulation: friable; spongy; exceeds over the wound edges
Fat: white-yellow globular
Tendon: white-yellow striated
Bone: white-yellow hard
Others; sutures, mesh, tumour
Clinical Pathway Wounds
1- Irrigation & wound cleaning
2- x-ray for foreign bodies PRN
3- primary or delayed primary closure
4- dressing PRN
5- analgesia PRN
6- ADT PRN
7- referral & Pt info
Suture/Staple location & days
Face - 3-5
Neck - 3-4
Upper extremity - 7-10
Hand - 10-14
Chest - 7-10
Back - 10-14
Buttocks - 10-14
Legs - 8-10
Foot - 10-14
Pressure injury classifications
Stage I- intact skin w unblanchable redness, usually over bony prominence; pigmented skin may be of diff colour than surrounding
Stage II- partial thickness loss of dermis; shallow ulcer w a red-pink bed but no slough; can present as intact/ruptured serum filled blister
Stage III- full thickness tissue loss; subcut fat may be visible, but no bone, muscle or tendon; slough, if present, does not obscure the depth of tissue loss; ulcer edge may be undermined
Stage IV- full-thickness tissue loss w exposed bone/muscle/tendon; may have slough, eschar, undermining, or tunnelling
Unstageable - full-thickness tissue loss & base of ulcer is covered by slough or eschar
Venous Ulcers
- often painful: elevation may help, often worsened by dependency of limb
- poss Hx of varicose veins, oedema that is worse at the end of the day, haemosiderin staining
- typically in the gaiter area (lower 1/3 of medial/lateral leg above the malleoli); edge is usually sloping & may be irregular; base maybe be granulating & sloughy; may be heavy exudate
- surrounding skin: pale scarring, venous dermatitis, or eczema
- unless comorbid arterial comprise, pulses should be normal
Rx:
Compression therapy: graduated comp therapy improves healing rate; reduces recurrence; must assess ankle brachial pressure index (ABPI) prior to use!
Ulcer dressing: local wound conditions should be optimised for healing; lock away fluid dressing, intact/active for 1 wk, low profile & addresses local wound cond to promote moist healing
Pain management: mod to sever pain can impact ability to tolerate compression; manage pain!
Leg elevation: can aid venous return, reduce pain, reduce oedema; encourage during inactive periods
Exercise: reg gentle exercise (walking, dorsiflexing foot) to maintain calf pump function
Skincare: maintain skin integrity of lower limbs, prevent dryness w bland & simple moisturisers
Pt Ed: about disease process & how manage it
Arterial ulcers
- all Pts must be assessed for PAD (peripheral arterial Dx)
- often painful, aggrav+ by elevation, but relieved by dependency
- other features: vasc+ Dx, signs of ischaemia, pallor on elevation, redness on dependency, abnormal ABPI
- usually on toes, bony prominences, sides of feet or heel; edge may appear punched out; base may be sloughy or covered by eschar; usually minimal exudate
Rx
Ulcer dressing: no specific perfect dressing, select to suit wound
Pain management: very common & may req pain relief prior to dressing changes
Pressure area management: ? Referral to podiatrist to assess feet & footwear; advise Pt to wear well-fitting, closed footwear
Sterile technique
Free from microorganisms
Meticulous hand washing, use of sterile field, sterile gloves & dressing & instruments
Sterile to sterile rule!
Clean technique
Free of dirt, marks or stains
Meticulous hand washing, maintain a clean environment, using clean gloves & sterile instruments, preventing direct contamination of materials/supplies
NO sterile to sterile rule applies
Appropriate for long-term care, home care, & some clinical settings; for Pt’s not high risk for infection; for Pt’s receiving routine dressings for chronic wounds
Eg; removing staples/sutures
Aseptic technique
Free from pathogenic microorganisms
Purposeful prevention of the transfer of organisms from one person to another by keeping the microbe count as low as poss
Egs; wound care, wound closure, insertion of catheters or PEG tubes
No touch technique
Method of changing dressings with directly touching the wound or an surface that might come in contact w the wound
Clean gloves w sterile solution/supplies/dressings
LACERATED
L-Look: consider time of injury, depth, potential for retained FB & note any functional loss
A-Anaesthetise: choice of drug, max safe vol, ability to explore wound thoroughly
C-Clean: consider best wound decontamination method
E-Explore: satisfy yrself that the wound is suitable for closure
R-Repair: consider best approach to closure & Pt positioning
A-Apply: apply an appropriate dressing
T-Tetanus: check Pt’s status & consider ADT in relation to wound
E-Educate: Pt about ongoing wound care, complications, & removal of sutures
D-Documentation: wound assessment, repair & advice
Everting sutures
Simple continuous running: to close multiple layers with one suture; not cut till the end
Continuous locking (blanket): single suture is passed in & out of tissue layers & looped thru free end before passing thru the next - holding the prev one in place
Simple interrupted: each individual stitch is placed, tied & cut in succession
Horizontal mattress: stitches are placed parallel to the wound edges
Vertical mattress: uses deep & superficial bites, each crossing the wound at right angles. Works effectively for the approximation of edges of deep wounds
Skin closure tapes: Adv, Ind & technique
Advantages:
- rapid application, little/No Pt discomfort, low cost, no needle injury risk, Allows skin to breathe without moisture collecting under strip, less risk of irritation, no injection req
Indications:
- Minor injuries; lacerations/incisions
- Provide additional tension for wounds closer with Intracutaneous sutures
- Where early replacement of staples/sutures is req to improve cosmetics results
- suitable for thin, fragile or sensitive skin
Technique:
- prepare skin w tincture if benzoic compound to aid adhesion
- place strips with sufficient space between each to allow drainage of fluid
- tell Pt to keep area dry for 72 hrs
Cyanoacrylate glue: Adv, Ind, Technique
Adv:
- easy, fast, no pain, no removal/injected anaesthesia req
Ind:
Clean, short <5cm lacs under low tension & w good approximation
Technique:
- hold wound edges in opposition w fingers of non-dominant hand/forceps
- apply thin layer of adhesive across the entire wound, including a margin of at least 5-10mm on either side of wound
- hold for at least 30 secs before removing pressure/tension
Staples: Adv, Ind & Technique
Adv:
- ease of use, rapidity, cost-effective, minimal damage to host, low infection risk, off strong closure
Ind:
- scalp lacs that do not req extensive haemostasis
- linear non-facial lacs caused by shear forces (sharp objects)
- can also be used high on trunk
Technique:
- before inserting, it is important to line up wound edges w the centreline indicator on stapler head
- typically use forceps to evert & precisely line up for each staple
Bites & Clenched fist Injs: high risk x5
- wounds w delayed presentation (>8hrs)
- puncture wounds that cannot be debribed properly
- wounds; hands, feet, face
- wounds involving; bones, joints, tendons
- immunocompromised Pts
