Fundamentals Theory Exam 3 PART 2

wound care

Abrasion

Superficial scraping/friction injury to the skin

Laceration

Cut / tear in tissue

Puncture

Wound caused by an object penetrating the skin/tissue

Hematoma

Collection of blood within tissue

Other terms for pressure injuruy

• Decubiti

• Bed sores

• Pressure ulcers

What contributes to pressure injuries

• Pressure

• Friction

• Shear

• Medical devices

• Moisture/maceration

lower score on braden scale means higher or lower risk?

higher risk

Stage 1 pressure injury

Intact skin with non-blanchable erythema

How can stage 1 pressure injury appear in darker skin tones?

Color may be unchanged or appear violet; compare bilaterally

Stage 2 pressure injury

Partial thickness skin loss with exposed dermis

What does stage 2 pressure injury look like

• Open shallow crater

• Pink/red/moist wound bed

• Intact blister

What can stage 2 pressure injury be mistaken for?

Moisture-associated skin damage

Stage 3 pressure injury

Full-thickness skin loss with exposed subcutaneous / fat tissue

What may be present in stage 3 pressure injury

• Tunneling

• Necrotic tissue

• Granulation tissue

• Epibole (rolled wound edges)

• Undermining

Epibole

wound-healing complication where the edges of a chronic wound roll or curl inward under themselves

What happens if necrosis prevents you from seeing the depth?

It is classified as unstageable

Stage 4 pressure injury

Full-thickness skin and tissue loss with extensive tissue damage

Structures that may be exposed in stage 4 pressure injury

• Tendon

• Muscle

• Bone

• Cartilage

• Necrotic tissue

What is an unstageable pressure injury

Full thickness tissue loss is present, but the depth cannot be determined because it is obstructed by slough/eschar

Deep tissue injury

Damage to underlying tissue that may initially present with intact skin or a blood-filled blister

What colors are associated with deep tissue injury

• Deep red

• Maroon

• Purple

Is a deep tissue injury blanchable

No

What can a deep tissue injury be mistaken for?

Ecchymosis/bruising or stage 1 pressure injury

What is the priority treatment for a pressure-related injury?

Remove the pressure

Nutritional interventions for pressure injury

• Increase overall calories

• Increase protein

• Increase vitamin A and C

Things to assess for wound assessment

• Location

• Wound length/width/depth

• Tunneling

• Edges

• General appearance

What units should wound dimensions be recorded in?

Centimeters

How should wound edges be described?

Approximated & non-approximated

What tissue types should you recognize in a wound bed?

• Granulation tissue

• Slough

• Eschar

What determines whether debridement may be needed?

presence of nonviable/necrotic tissue

4 types of wound drainage

1. Serous

2. Serosanguinous

3. Sanguinous

4. Purulent

Serous drainage

Clear/yellowish, watery drainage

Serosanguinous drainage

Thin, pink/red drainage containing serum and blood

Sanguinous drainage

Bloody

Purulent drainage

Thick drainage suggesting infection

What should you assess about exudate?

COCA (color, odor, consistency, amount)

What is required before wound cleansing?

Medical order according to the presentation

Optimal irrigation pressure for wound irrigation

4-15 PSI

Why is irrigation pressure important

Enough pressure is needed to remove debris/bacteria without unnecessarily damaging tissue

What syringe size/technique is used for wound irrigation

• 60-mL piston syringe without angiocatheter

• 30–35 mL Luer-lock syringe with 18–19G angiocatheter

How far should the angiocatheter be held above the wound for irrigation?

2.5 cm (1 inch)

Maceration

Softening / breakdown of skin from excessive moisture

Why dry the wound?

• Reduce infection risk from retained irrigant

• Maintain optimal wound moisture

• Prevent maceration of healthy periwound tissue

When should a wound culture be obtained?

After cleansing/drying, but before antibiotics

What is the surgical method for wound cultures

Tissue biopsy

What is the bedside method for wound cultures

Culturette/swab

How should you swab for wound culture?

Push 1-2cm into tissue/wound bed to elicit fluid

What are examples of topical wound medications?

• Enzyme debriding ointment

• Antibacterial cream

How much topical medication should be applied?

Consistent 1-inch layer

Is an order required for wound culture

Yes, to generate the label

How quickly should a wound specimen be sent to lab after collection?

Within 1 hour

Where is topical medication applied

To the wound bed

What determines which dressing should be selected?

• Wound size

• Dead space

• Tissue in wound bed

• Moisture level

• Sutures/staples

• Exudate amount

• Whether the wound needs moisture added or removed

What is telfa dressing

nonadherent dressing (useful over sutures, lightly draining wounds, first degree/minor burns)

Granulating wound

new, red, bumpy connective tissue and tiny blood vessels filling the wound base

What is a contraindication for a dry sterile dressing?

clean, open, or granulating wound

How often do you change dry sterile dressing?

2-3x daily

What are transparent films used for?

• Primary dressing for dry wounds

• Visualization

• Autolytic debridement

• Waterproofing

• Secondary dressing for securement

What is autolytic debridement

wound care method that uses the body's own natural fluids, white blood cells, and enzymes to soften / melt away dead tissue

When are transparent films contraindicated?

• Infected wounds

• Third-degree burns

• Patients at high risk for skin tears

When are transparent films changed?

Every 3-7 days, or when exudate extends beyond the wound

hydrocolloid dressing

waterproof, self-adhesive bandage with an inner gel-forming layer

When are hydrocolloid dressings used

• Wounds with dead space OR shallow

• Low/moderate exudate

When are hydrocolloid dressings contraindicated

• Infected wounds

• Heavily exudative wounds

How often are hydrocolloid dressings changed?

Every 3-7 days

hydrogel dressing

dressing composed of about 90% water suspended in a gel structure, provides a cooling sensation

When are hydrogel dressings used

• Minimally exudative wounds

• Minor burns

• Pressure ulcers

When are hydrogels contraindicated?

• Heavily exudative wounds

• Third-degree burns

How often are hydrogel dressings changed?

1-3 days, depending on the secondary dressing

What are alginate dressings used for?

• Moderate-heavy exudative wounds

• Wounds with dead space (shallow or deep)

Calcium vs silver alginate dressings

Calcium - absorbs exudate, manages moisture
Silver - provides antimicrobial function for infected wounds

Can alginate dressing be used for packing?

Yes

Contraindications for alginate dressings

• Dry, necrotic wounds

• Third degree burns

• Minimally-exudative wounds

How frequently are alginate dressings changed

1-3 days depending on the exudate and secondary dressing

What are foam dressings used for?

• Moderate/heavy exudate

• Dead space

• Prevention (pressure wounds)

Contraindications for foam dressings

• Necrotic, dry wounds

• Third-degree burns

How frequently are foam dressings changed?

every 24 hours or PRN

What does Wound VAC stand for?

Vacuum Assisted Closure

what does negative pressure wound therapy do?

• Removes excess fluid

• Increases circulation

• Decreases bacterial burden

• Decreases inflammatory response

• Increases angiogenesis

• Increases granulation tissue

What types of wounds may receive a wound VAC?

acute and chronic wounds without eschar

wound vac contraindications

• Malignancy

• Exposed vasculature

• Exposed nerves

Who applies/changes the Wound VAC dressing

Wound, Ostomy, and Continence Registered Nurse (WOC rn)

What are Montgomery straps used for?

Securing dressings while reducing repeated adhesive trauma to the skin

What is necrotic tissue?

Nonviable/dead tissue

slough

moist, necrotic tissue that forms in a wound bed; appears soft, stringy, or mucinous and is colored yellow, white, gray, or tan

eschar

dry, thick, and leathery crust (typically black, brown, tan) adheres to the bed / edges of a severe wound / burn

Why is necrotic tissue removed?

• Reduce infection

• Visualize wound

• Promote healing

What are the five types of debridement?

• Mechanical

• Autolytic

• Chemical

• Surgical

• Biotherapeutic

Mechanical debridement

wound care technique that uses physical force to remove dead, damaged, or infected tissue and debris from a wound bed

examples of mechanical debridement

• Hydrotherapy

• Irrigation

• Pulsed lavage

• Whirlpool

• Wet-to-dry/moist packing

What is autolytic debridement?

Uses the patient's own WBCs and enzymes to break down necrotic tissue

What dressings can facilitate autolytic debridement

• Transparent film → adds moisture to dry wound

• Hydrocolloid → manages excess exudate

What is chemical debridement?

Topical enzymes break down and loosen necrotic tissue.

What enzyme is often used in chemical debridement

Collagenase

How is collagenase applied for chemical debridement?

With gauze or Q-tip

What can you not mix with collagenase and why?

Iodine and dakin’s solution (they inactivate the enzyme)

Surgical debridement

medical procedure used to remove dead, damaged, infected, or contaminated tissue and foreign materials from a wound or burn

When is surgical debridement particularly indicated?

Cellulitis and sepsis

What is biotherapeutic debridement?

Sterile maggots / larvae ingest necrotic tissue

when is biotherapeutic debridement used

When surgical debridement is contraindicated