wound management

what is a wound?

injury or disruption in skin integrity caused by an external force and it can involve any tissue or organ

what is healing?

cell response to an injury in an attempt to restore normal structure and function

examples of mechanical wounds?

abrasions, bruises, cuts, incisions, stabs, gunshots, bites

examples of chemical wounds?

acidic or alkali

examples of thermal wounds?

burn, freeze

examples of radiation wound?

sun, medical radiation

example of a special wound?

snake bite

describe a closed wound?

-no break in skin, soft tissue damage

-bruise, internal fracture

describe an open wound?

-break present in skin, tissue damage is present

-incision, abrasion, laceration

describe acute wound healing time and example?

relatively short, less than 12 weeks. post op wound

describe chronic wound healing time and example?

exceed expected healing time due to disease process. post op wound that got infected

cause of intentional wounds?

surgical or injection

cause of unintentional wounds?

abrasions, lacerations, puncture wounds

depth of superficial wounds?

epidermis only

depth of partial thickness?

epidermis and dermis

depth of full thickness?

epidermis, dermis, subcutaneous tissue, may include muscle and bone

level of contamination - class 1: clean?

-uninfected, no inflammation

-resp, GI GU tracts not entered

-closed primarily

-eye or vascular surgery

level of contamination - class II: clean-contaminated?

-resp, GI, GU tract entered, controlled

-no unusual contamination

-gynecological or chest procedures

level of contamination - class III: contaminated?

-open, fresh, accidental wounds

-major break in sterile technique

-gross spillage from GI tract

-acute nonpurulent inflammation

-penetrating injury, rectal surgery

level of contamination - class IV: dirty/infected?

-old traumatic wounds, devitalized tissue

-existing infection or perforation

-organisms present BEFORE procedure

-abscess, wound debridement

abrasions?

superficial layer of skin, scrape

contusions?

bruise

laceration?

tearing of tissue

puncture?

sharp object, forceful

incision?

clean edges, heals well

inflammatory phase?

3-6 days

proliferative phase?

3-24 days

maturation or remodeling phase?

20 days-2 years

wound healing: physiology - inflammatory phase length?

3-6 days

wound healing: physiology - inflammatory phase hemostasis?

vasoconstriction, platelet aggregation, clot formation

wound healing: physiology - inflammatory phase inflammation?

-edema, erythema, pain, elevated temperature, WBCs

-phagocytosis

-exudate

-scabs

wound healing: physiology - proliferative phase time?

3-24 days

wound healing: physiology - proliferative phase characteristics?

-fibroblasts to collagen

-angiogenesis

-granulated tissue

-connective tissue

-epithelization

wound healing: physiology - remodeling phase days?

20 days to 2 years

wound healing: physiology - remodeling phase?

-collagen fibers are remodeled

-scar forms

-80% original strength

why should you take notes of scars?

because the skin is weaker in that area

in the process of wound closure what is primary intention?

approximated edges. clean surgical incisions, paper cut

in the process of wound closure what is secondary intention?

burns, deep lacerations or pressure ulcers

in the process of wound closure what is tertiary intention?

delay between injury and wound closure. dog bite. because part of it is deep, other part is not so it will take time to get all stitched up

what are wound healing risk factors?

age, chronic illness, immunosuppression, stress: physiological and psychosocial, impaired mobility, nutrition, oxygenation, smoking, altered sensation, medications, obesity

what is keloid?

abnormal scar, excessive collagen

what is hypertrophic scar?

raised, thickened scar

what is eschar?

dead tissue, part of healing

what are complications of infection?

swollen and erythema. pain, febrile, chills, warm to touch, drainage color, foul odor, dehiscence (separation), delayed healing

what is the diagnostics of infection treatment?

wound culture and white blood cell count

what is the treatment for infection?

cleansing, antibiotics, debridement

what are other complications of wound healing?

hemorrhage, dehiscence, evisceration (organ or fat is hanging out), and fistulas (2 areas of body connected that should not be connected)

what are the complications in dehiscence and eviscerations in wound healing?

both are emergencies, cover wound area with sterile towels soaked in sterile normal saline, position patient with hips and knees bent (so you dont put a strain on abdominal muscles), notify MD immediately

what are some nursing diagnoses for wounds?

impaired skin integrity, impaired tissue integrity, risk for impaired skin integrity, risk for infection, and acute pain

delegation for initial assessment?

RN

what is the delegation for ongoing evaluation?

RN and LPN but RN should always be documenting and also look at the change

delegation for invasive and sterile?

RN and LPN. wound culture, irrigation, sterile dressing change

delegation for skin inspection, simple dressing and taping?

NAP

what should you get for wound assessment?

location, size in cm (length, width, depth, sinus tracts and tunnels), bleeding, and infection

what is the assessment for closed wounds?

edges approximated, wound closure (staples, sutures or stitches, wound closure strips, tissue adhesive). nurse needs to document how many staples and stitches there are.

describe color RYB code?

red, yellow, and black. color of open wound and secondary intention healing

red?

granulation tissue

yellow?

fluid. some yellow is bad, but not all

black?

necrotic, eschar

what does a red wound mean?

late regeneration phase of tissue repair, clean and uniformly pink in appearance

red wound goal?

protect and use gentle cleansing

red wound avoid?

dry gauze, wet to dry

what to use for a red wound?

transparent, hydrocolloid

what does a yellow wound mean?

primarily liquid to semiliquid slough that is often accompanied by purulent drainage

what is the goal for a yellow wound?

cleanse

how to clean yellow wound?

irrigation, wet to damp dressings, and hydrogel

what is a black wound?

eschar, necrotic tissue. hard, black, and firm

what is the goal of black wound?

debridement (the removal of damaged tissue or foreign objects from a wound), then treated as yellow or red wound

what to assess in wound drainage?

color amount and odor

what is serous?

pale yellow, watery

what is serousanguinous?

mix of pale, pink-yellow, thin, and blood

what is sanguineous?

bloody

what is purulent?

thick, opaque, varies from yellow, green, or tan depending on microorganism

what are nursing interventions for wound care?

routine skin inspection, treat pain, proper dressing changes (medicate for pain, assess pain before and after), turning and positioning, hygiene, nutrition, client education

what is the purpose of wound dressings?

absorbs drainage, deride wound when removed, protect wound from microbes, support and splint wound, cover disfigurements, protect wound from mechanical injury, provide thermal insulation, prevent hemorrhage, maintain a moist enviornment

what are the types of wound dressings?

gauze, films, hydrogels, hydrocolloids, foams, alginates (made from seaweed, turns into gel when gets wet), composites (4 by 4 gauze with sticky quarter), interactive dressings

describe dry gauze?

most common. squares, sheets, rolls. adherent, non adherent. petroleum gauze

what is abdominal pads?

cover dressing

describe films?

transparent, transparent wafer

describe hydrogels?

water or glycerin based

what are primary dressing layers?

-contact dressing: single layer, non adherent. petroleum gauze

-absorbent dressing: alginate, hydrocolloid

what are secondary dressing layers?

-cover dressings, bandages

-abdominal pad, roll gauze

for gauze packing is wet to dry recommended?

no

for gauze packing is wet to moist recommended?

promotes healing of non infected wounds

what are the pros of gauze packing?

cost effective, easy to use

what are the cons of gauze packing?

must remoisten, better alternatives, painful

what are the types of taping?

cloth, plastic, paper. non allergic tape. Montgomery straps

in taping what should you assess?

skin. make sure it is not fragile. use gauze and skin protectant. for allergies

what is the purpose of wound cleansing?

removal of debris, slough, and microorganisms. promotes tissue healing

what is the cleansing procedure for wounds?

-doctor's order

-clean or sterile technique

-cleaning solution: normal saline, antiseptic solutions, wound cleaners

what is cleansing procedure for a wound?

clean initially and each dressing change. wipe with gauze once, dispose. direction: open wound, linear incision: horizontal and vertical

what is the purpose of irrigation?

removes exudates and debris, foreign materials, excess slough

what is Levine technique?

pressure to wound bed to express drainage

what is Z-stroke technique?

swab from margin to margin, zig zag pattern. do not touch edge wound

describe needle aspiration for obtaining a wound culture?

insertion of needle into wound, organisms in wound fluid tested for bacteria. invasive

describe tissue biopsy?

most accurate method for culturing a chronic wound. tissue is removed from the wounds edge and sent to pathology. painful, can risk sepsis and may delay wound healing

what are some wound drainage device types?

gravity system - Penrose, closed suction drainage system - hemovac (should always be compressed), Jackson-pratt (should always be closed, concave, uses negative pressure)