my wound care exam

What type of individuals are at risk for skin breakdown and wounds

Older adults, Those with pathology, Immobility, Decreased sensation or circulation, Poor nutrition/hydration, History of wounds, Incontinence

What would you intervention include for prevention of wounds for

Pressure reliefs and positioning changes, Equipment, Daily skin checks and hygiene, Water temp checks for bathing, Moisturizer, Toe nail clipping, Shoe inspection, Proper nutrition

What is a Hubbard tank

large whirlpools only really seen in burn centers anymore

Low boy

smaller bath sized tub (for leg wounds)

High boy

bath size tub with high walls (hands,feet)

Purpose of whirlpools

clean, debride, and lower the bacterial load of a wound

Indication for whirlpool

wounds that require debridement, Tissue is loosely adherent necrotic tissue, debris, and exudate

Considerations of using whirlpool

Cost (Clean between treatments, Staffing it, Where to put it), Infection risk for other patients, Full body immersion, Dependent positioning

When would it be inappropriate to use whirlpool

If the wound doesn’t need debrided (If necrotic/eschar is not loose), If the wound is healing well (Irriation forces damage healthy tissue), use only on grade III/IV pressure ulcers

What is the appropriate temperature range for whirlpool treatments Hubbard tank

usually 92 to 99 degrees

do not exceed what temperature for whirlpool

102°

For venous insufficiency, sensation loss, CV conditions what is temperature of whirlpool

88 to 92°

What would be included in your documentation post

whirlpool treatment

Types of debridement

selective and non selective debridement

Selective debridement

only removes necrotic tissue, Sharp and enzymatic debridement (cross

Non selective debridement

can harm viable tissue, Wet dry dressing (don’t pick this option on NPTE), Surgical debridement, whirlpool

What is cross hatching and what tissue should it be done

It is an enzymatic debridement done for eschar tissue

What is autolytic debridement

Debridement where a moist, closed environment is created to naturally break down necrotic tissue, Typically, done with hydrogel or hydrocolloid dressings

Purpose of wound care dressing

Provide moist environment, Debride tissue, Absorb or provide moisture, Lower bacterial load, Promote growth, To protect or keep warm

What is the ideal wound environment that promotes healing

Not too wet, not too dry, Clean and warm

Purpose of Hydrogels

Provides moisture (A. Insufficiency)

What dressings Stimulates granulation and autolytic debridement

hydrogels and hydrocolloids, alginates

Purpose of Hydrocolloids

Provides moisture and protection (A. Insufficiency), Occlusive and sterile

Purpose of Foams and alginates

Mod max absorption (V. Insufficiency), Non occlusive

Purpose of Transparent film/Semipermeable film

Protects wound, occlusive, Cannot use with lots of drainage, won’t stick

Purpose of Antiseptics

Kills bacteria, Can prolong inflammation due to its cytotoxicity, Limit use

Purpose of Antibacterial/Antimicrobial

Destroys bacteria, Some made with silver (kills 99.5% of bacteria in 2 hours), Be careful with silver products and MRI

Purpose of Antifungals

Eliminates fungal infections

Purpose of Enzymatic debriders

Ointments used with cross hatching for eschar (Digests collagen and protein of necrotic tissue)

Purpose of Wet dry

Wet gauze with sterile water, saline, Pack into wound and put dry gauze on top and allow to fully dry, Typically painful for the patient, but works well

Purpose of Collagen dressing

Delivers collagen to assist in wound healing, Used for non healing chronic wounds, Cannot use if allergic to ~COW materials~

Purpose of Growth factor dressing

Platelet derived to promote cell proliferation and assist with granulation

Purpose of Gauze

Cotton or synthetic fabric used as a secondary dressing

Purpose of Wound fillers

Ointments, gauze, or foam used to fill cavity to keep wound warm

Purpose of Cellulose

Used for fluctuating wound drainage

What is composite dressing

combines 2 or more types of dressings

What is an occlusive vs non occlusive dressing

Occlusive dressings protect the wound from outside exposure, limiting bacterial infiltrate

What patient/family education should be done with an individual who is receiving wound care and dressing changes

Signs of infection or DVT, How to change dressings, Pressure reliefs or positioning changes, Proper footwear, Proper hygiene

Interventions for someone with pressure ulcer

Positioning changes, pressure reliefs, Patient education

Interventions for someone with PVD

Therapeutic exercise, Edema control (Venous), Wound risk education, Claudication (Arterial).

What is an Unna Boot

The best thing for venous insufficiency, Semi rigid wrap that manages edema, protects and offloads the wound

Contraindications for unna boot

Not used for heavily draining wounds, Not used for infected wounds, Not used for wounds that need debrided