wounds

Question 1

factors that affect wound healing

Answer 1

1. age
2. loss of skin turgor
3. skin fragility
4. decreased circulation and oxygenation
5. slower tissue regeneration
6. decreased absorption of nutrients
7. decrease in collagen
8. impaired immune function
9. dehydration
10. overall wellness
11. decreased WBC
12. infection
13. meds (chemo, anti-inflammatory, steroids)
14. low Hgb
15. obesity
16. smoking
17. chronic disease
18. malnutrition

Question 2

3 key components of wound management

Answer 2

1. assessment
2. cleansing
3. protection

Question 3

inflammation is

Answer 3

a localized protective response to injury or destruction of tissues

Question 4

wound assessment

Answer 4

1. appearance: red (healthy), yellow (infected), black (eschar)
2. length, width, depth (sinus tracts, tunnels, redness/swelling around wound
3. closed wounds: skin edges well approximated (staples, sutures, tissue adhesives)
4. note drains/tubes present
5. pain around incision?

Question 5

wound drainage

Answer 5

result of the healing process - normal or abnormal

accumulates during inflammatory and proliferative phases of healing

Question 6

wound drainage documentation

Answer 6

*document amount, odor, consistency, color
*note integrity of surrounding skin

Question 7

when cleaning wound drainage

Answer 7

observe skin around a drain for irritation or breakdown

Question 8

how do you accurately measure wound drainage?

Answer 8

weight the dressing

1g = 1mL of drainage
*scant, moderate, large, copious

Question 9

serous

Answer 9

portion of blood (serum) that is watery and clear or slightly yellow in appearance

(what is in blisters, clean wounds)

Question 10

sanguineous

Answer 10

serum and RBCs
thick, appears reddish
*darker: older bleeding
*brighter: active bleeding

(deep or highly vascular wound)

Question 11

serosanguinous

Answer 11

serum and blood, watery, looks pale/pink
(new wound)

Question 12

purulent

Answer 12

result of INFECTION
thick, contains WBCs, tissue debris and bacteria
*yellow, tan, green, brown

Question 13

diet for patient’s with wounds

Answer 13

-adequate hydration
-high PRO/CHO/vitamins and moderate fat
-monitor albumin and pre-albumin levels

Question 14

nursing interventions for patients with wounds

Answer 14

-wound cleansing
-remove sutures/staples as ordered
-administer analgesics and monitor for pain management
-administer antimicrobials as ordered and monitor effectiveness
-document descriptively and thoroughly

Question 15

wet-to-dry wound dressing

Answer 15

used to mechanically debride a wound until granulation tissue starts to form

Question 16

self-adhesive would dressings

Answer 16

transparent
ex: tegaderm

Question 17

mechanical debridement

Question 18

hydrocolloid wound dressing

Answer 18

occlusive dressing that swells in presence of exudate
ex: duoderm

Question 19

hydrogel

Answer 19

mostly water, gels after contact with exudate
promotes autolytic debridement
rehydrates and fills dead space
-may need secondary occlusive dressing
-for: infected, deep wounds or necrotic tissue –> NOT draining a lot
-provides moist wound bed and can reduce pain
-prevents skin breakdown in high-pressure areas

Question 20

autolytic debridement

Question 21

alginates

Answer 21

non adherent dressing that conform to wound shapes and absorb exudate

Question 22

collagen

Answer 22

powders, pastes, granules, gels

Question 23

wound vacs

Answer 23

use of foam strips into the wound bed with occlusive dressing — creates NEGATIVE PRESSURE once tubing connected
helps with tissue generation, decrease swelling, and enhance healing in moist protective environment

Question 24

complications of wound healing

Answer 24

adhesions
contractions
hemorrhage
dehiscence
evisceration
fistula formation
infection
excessive granulation tissue
keloid formation

Question 25

when are you at greatest risk for a hemorrhage?

Answer 25

24-48 hours after surgery

Question 26

how can hemorrhage be caused?

Answer 26

clot dislodgment, slipped suture, or blood vessel damage

Question 27

how may internal bleeding present?

Answer 27

swelling distention in area sanguineous drainage initially, subtle change in V.S. --> increase HR d/t compensation for decrease in stroke volume

Question 28

what is a hematoma?

Answer 28

local area of blood collection that appears as red or blue bruise

Question 29

what to do if a wound hemorrhages?

Answer 29

could be an emergency apply pressure dressing, notify HCP, monitor VS

Question 30

dehiscence

Answer 30

partial or total rupture/separation of a sutured wound, usually with a separation of underlying skin layers

Question 31

evisceration

Answer 31

organs out of wound IMMEDIATE NEED FOR SURGERY

Question 32

manifestations of evisceration

Answer 32

significant increase in flow of serosanguinous fluid on wound dressing immediate hx of sudden straining patient reports of a sudden change or "popping"/"giving way" in wound area visualization of the organs

Question 33

risk factors for dehiscence and evisceration

Answer 33

-chronic disease -older -obesity -invasive abdominal cancer -vomiting -excessive straining, coughing, sneezing -dehydration, malnutrition -ineffective suturing -abd surgery -infection

Question 34

management fo dehiscence/evisceration

Answer 34

-notify provider immediate d/t need for surgery -stay with pt -cover wound and any protroducing organs with sterile -towels or sterile dressings soaked in NS -DO NOT REINSERT ORGANS -position pt supine with hips and knees bent -maintain calm environment -keep pt NPO in prep for surgery

Question 35

risk factors for infection of surgical wounds

Answer 35

-old -immune suppression -impaired circulation/oxygenation -wound condition & nature -malnutrition -chronic disease -poor wound care

Question 36

manifestation of an infected surgical wound

Answer 36

2-11 days after injury/surgery (NOT in 24-48hr) -pain -redness, edema, purulent drainage -(low-grade) fever & chills -odor -increased HR, RR, WBC