Complex Wounds and Wound Care Management

Flashcards covering complex wound management, surgical drains, dressing selection, wound assessment (BWAT), sterile technique, irrigation, debridement, culturing, and packing.

What underlying cardiovascular condition leads to the formation of venous ulcers?

Chronic venous insufficiency (poor blood return) and edema.

Where on the body are venous ulcers typically located?

Lower extremities.

What condition gives the skin of the lower legs a wooden-like appearance in patients with venous ulcers?

Lipodermatosclerosis.

Which type of leg ulcer is illustrated in Figure 47-14 A?

Venous leg ulcer.

What primary circulatory problem causes arterial ulcers?

Inadequate blood flow to the lower extremities (ischemia).

On what specific anatomical areas of the lower extremities do arterial ulcers typically develop?

Feet, toes, and toe joints.

What is the typical visual appearance of an arterial ulcer?

Deeper and smaller wound with a "punched out" appearance and necrotic characteristics.

Which type of wound is pictured in Figure 47-14 B?

Arterial lower limb wound.

Why can any break in skin integrity lead to a chronic, nonhealing wound in diabetic clients?

Because diabetic clients have a compromised healing potential.

How does sensory neuropathy contribute to skin integrity breaks in diabetic clients?

It leads to a loss of protective sensation, such as pain or temperature perception.

How does autonomic neuropathy contribute to skin breakdown in diabetic clients?

The absence of sweating leads to dry, cracked skin.

How does motor neuropathy affect foot structure in diabetic clients?

It causes changes in muscle contractions, leading to foot deformities like high arches or hammer toes.

What condition develops when increased pressure points occur on a diabetic foot?

Pressure ulcers.

What clinical condition and intervention is depicted in Figure 47-16?

Diabetic foot with callus and packing in the wound.

By what process of healing do ulcers normally repair?

Secondary intention.

How are chronic ulcers that are resistant to healing categorized in clinical practice?

As "maintenance" wounds or nonhealing wounds.

What are two essential general management strategies for maintenance wounds?

Keep the wound clean and dry, and ensure adequate client nutrition to promote healing.

What is the primary goal of complex wound management for nonhealing maintenance wounds?

To provide comfort and protection from infection.

What device may be inserted in or near a surgical wound following surgery to assist with fluid removal?

A surgical drain.

What type of device is a Jackson-Pratt drain?

A self-suction drain that collects accumulation of fluid within tissues to promote healing.

How does a Jackson-Pratt drain create suction to remove fluid?

It exerts a constant low pressure from its bulb.

What are the nursing responsibilities when managing a Jackson-Pratt drain?

Measure and document output, and notify the physician if there are large amounts of drainage or if the drain is blocked.

What drainage device is illustrated in Figure 47-20?

Jackson-Pratt drainage device.

Where is a Penrose drain positioned within a surgical wound?

It lies directly under a dressing.

What feature prevents a Penrose drain from slipping farther into a wound cavity?

A pin or clip placed through the drain.

What is the nurse's specific responsibility regarding a Penrose drain as drainage decreases?

Pull or advance the drain as drainage decreases to permit healing deep within the wound site.

What type of drain is shown in Figure 47-19?

Penrose drain.

What is a drainage evacuator?

A portable vacuum unit inserted into a large wound bed that exerts constant low-pressure to remove and collect drainage.

What must a nurse verify and document when caring for a client with a drainage evacuator?

Ensure that suction is present, and measure and document fluid output.

Which surgical device is shown in Figure 47-29?

Drainage evacuator.

What do the RNAO guidelines recommend regarding dressing changes?

Sterile dressings, good hand hygiene, and clean gloves changed between each of the patient's wounds or when soiled.

For which specific wound type is sterile technique most commonly indicated?

Surgical wound care.

What is the most important aspect of maintaining sterile technique during surgical wound care?

Ensuring as clean a field as possible with the use of sterile dressing packs, sterile scissors and forceps, and sterile dressings and gloves.

What are the 5 primary purposes of applying a wound dressing?

Protects wound from micro-organisms, aids in hemostasis, promotes moist wound healing, manages excess exudate (absorbs/supports autolytic debridement), and acts as a physical barrier to prevent trauma.

What 3 key questions should a nurse consider when selecting a wound dressing?

1. What is the action of the dressing? 2. What is the method of application and removal? 3. Is a secondary dressing required?

Provide an example of a primary and secondary dressing combination given in the notes.

Ribbon gauze (primary) combined with a foam dressing (secondary).

What is the indication and function of Gauze Dressings?

Used for general wounds; protects and covers while allowing airflow.

What is the indication and function of Hydrocolloid Dressings?

Maintains a moist healing environment for mild burns, ulcers, and low-drain wounds.

What is the indication and function of Foam Dressings?

Absorbs moderate drainage, cushions, and protects the wound.

What is the indication and function of Alginate Dressings?

Absorbs heavy exudate; used for wet or heavily draining wounds.

What is the indication and function of Silicone Dressings?

Gentle on fragile skin; reduces pain and trauma during dressing changes.

What is the indication and function of Hydrogel Dressings?

Provides moisture to dry wounds, soothes pain, and supports tissue repair.

What is the indication and function of Antimicrobial Dressings?

Controls bacterial growth; prevents or manages infection in high-risk wounds.

What category of wound dressing is Tegaderm?

Transparent dressing.

What category of wound dressing is Telfa?

Non-adherent dressing.

What is the definition of wound undermining?

An opening of the wound underneath the lip of the border, caused by edge detachment due to erosion, creating a pocket of space underneath the skin's surface.

What anatomical feature of wound erosion is illustrated in Figure 10?

Undermining of the wound.

What is wound tunnelling?

Development of channels or tunnels extending from the wound that can connect to other organs, similar to fistulas.

What 3 wound depth/space parameters are shown in Figure 11?

Undermining, volume, and sinus tracts/tunneling.

What are the 7 sequential steps for performing wound care?

1. Preparing for Dressing Change, 2. Assessment of wound, 3. Determining right equipment/dressings, 4. Setting up Sterile Dressing Tray, 5. Cleaning Wound (closed/open), 6. Applying dressing (wet/moist), 7. Documentation.

Name at least 8 items required for setting up a sterile wound care supply tray.

Clean gloves, sterile gloves, sterile dressing set (scissors, forceps), sterile drape, sterile dressings, sterile basin, sterile normal saline, tape/ties, protective waterproof underpad, biohazard bag.

What measurement tools are included in the equipment setup for wound assessment?

Cotton-tipped applicator and a measuring guide.

What personal protective equipment (PPE) may be needed when performing wound care?

Gown, goggles, and mask as needed.

Why is it important to evaluate whether a client is cooperative prior to performing wound care?

To determine if assistance is needed for the procedure.

Why should a nurse assess a client's pain level prior to performing wound care?

To check for PRN pain medications that can be administered before starting.

Why should the nurse check if the client needs to use the washroom prior to starting a sterile dressing change?

Because an interruption mid-procedure creates a risk for breaking the sterile field.

What type of client education should be provided prior to wound care?

Education related to the procedure and what to expect.

Give an example of a client-specific infection status instruction that impacts wound care precautions.

Specific precautions required if the client is MRSA positive.

What does the abbreviation BWAT stand for?

Bates-Jensen Wound Assessment Tool.

What is the clinical purpose of the Bates-Jensen Wound Assessment Tool (BWAT)?

It provides a standardized method for evaluating wound severity and progress.

What parameters are evaluated under 'Wound Measurement' on the BWAT?

Size (length, width, depth) and evidence of undermining.

What parameters are evaluated under 'Tissue and Exudate Evaluation' on the BWAT?

Necrotic tissue type & amount, exudate type, exudate amount, and peri-wound area.

What parameters are evaluated under 'Wound bed and healing indicators' on the BWAT?

Granulation tissue (within wound) and epithelialization (surface of wound).

What score on the BWAT Wound Status Continuum represents intact 'Tissue Health'?

1

What score range on the BWAT Wound Status Continuum represents 'Wound Regeneration'?

Scores from 10 to 15 (with 13 explicitly marked).

What score on the BWAT Wound Status Continuum represents maximum 'Wound Degeneration'?

60

How are BWAT assessment scores recorded on the continuum line to track wound progress over time?

By putting an "X" on the line and the date beneath the line to see regeneration or degeneration at a glance.

What are the visual characteristics of serous wound drainage?

Clear, thin, watery fluid with a slightly yellow tint.

What are the visual characteristics of serosanguineous wound drainage?

Pink to light red, thin, watery fluid composed of a mixture of clear serous fluid and red blood cells.

What are the visual characteristics of sanguineous wound drainage?

Bright red, thick drainage indicating active bleeding.

What are the visual characteristics and clinical significance of purulent wound drainage?

Thick, opaque fluid that can be yellow, green, or brown, indicating wound infection.

What initial step begins the wound cleaning process?

Setting up your sterile dressing tray while adhering to Principles of Sterile Technique.

What are the 6 key procedures included under wound cleansing and care?

1. Cleansing, 2. Irrigation, 3. Debridement, 4. Dressings, 5. Drains, 6. Surgery.

What is Principle 1 of Surgical Asepsis (Sterile Technique)?

A sterile object remains sterile only when touched by another sterile object.

What is Principle 2 of Surgical Asepsis (Sterile Technique)?

Only sterile objects may be placed in a sterile field.

What is Principle 3 of Surgical Asepsis (Sterile Technique)?

A sterile object or field out of the range of vision or an object held below a person’s waist is contaminated.

What is Principle 4 of Surgical Asepsis (Sterile Technique)?

A sterile object or field becomes contaminated by prolonged exposure to air.

What is Principle 5 of Surgical Asepsis (Sterile Technique)?

When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action.

What is Principle 6 of Surgical Asepsis (Sterile Technique)?

Fluid flows in the direction of gravity.

What is Principle 7 of Surgical Asepsis (Sterile Technique)?

The edges of a sterile field or container are considered to be contaminated (2.5 cm border).

What is the primary purpose of performing wound irrigation?

To remove debris and cleanse the wound of exudate to facilitate healing by secondary intention.

What technique must be used when performing wound irrigation?

Sterile technique.

In what direction should irrigation solution flow relative to the wound?

Fluid needs to flow directly into the wound, avoiding contaminated areas before entering the wound.

How should a client be positioned for wound irrigation?

Positioned comfortably to permit gravitational flow of irrigating solution through the wound and into a collection receptacle.

What solutions are appropriate for use during wound irrigation?

Sterile saline solution, saline solution, or tap water.

What syringe size is recommended for performing wound irrigation?

A 30 - 60ml syringe.

What device can be attached to the syringe when performing wound irrigation?

A 19 gauge needle or angiocatheter.

Why is a 19 gauge needle or angiocatheter attached to the syringe during wound irrigation?

It allows the solution to flow at a safe pressure that will not damage healing wound tissue.

At what distance above the wound should the syringe tip be held during irrigation?

2cm - 2.5cm above the upper part of the wound.

What is the endpoint indicator that all debris has been removed during wound irrigation?

Flushing with continuous pressure until the solution running into the drainage basin is clear.

What steps should be performed immediately following wound irrigation?

Dry the wound edges with gauze, pack the wound and/or apply appropriate dressing, and document findings.

What is the purpose of tissue debridement?

Removal of necrotic (dead) or infected tissue from a wound to promote healthy tissue growth.

How is surgical (selective) debridement performed?

Using a scalpel or scissors to excise nonviable tissue.

What are two examples of mechanical (non-selective) debridement?

Wound irrigation and wet-to-dry dressings.

How does chemical or enzymatic (selective) debridement work?

Topical enzymes are applied to break down devitalized tissue, which is then removed when the dressing is changed.

How does autolytic (selective) debridement work, and what dressings facilitate it?

Uses synthetic dressings (e.g., hydrogel, alginate) that do not stick to the wound bed to cover the wound and allow eschar to self-digest by natural wound enzymes.

What organism is used to perform biological (selective) debridement?

Maggots targeting necrotic tissue.

What rule must be followed regarding old drains when obtaining a wound culture?

Never collect a wound culture from an old drain.

What step must be performed before swabbing a wound for a culture?

Clean the wound first with normal saline.

Where on the wound bed should a culture swab be collected, and why?

Swab from the healthiest looking granulation tissue (or areas with undermining) to obtain results consistent with the infectious condition of the wound itself rather than surface bacteria.