NURS 308: UNIT 1 - TOPIC 6: WOUNDS, DRESSINGS, AND DRAINS

What is important to identify when classifying a wound?

The cause (surgical or nonsurgical) and whether it is acute or chronic.

How is wound depth classified?

Superficial (epidermis), partial thickness (extends to dermis), full thickness (deep layers of tissue destruction).

What is a skin tear?

A wound caused by shear, friction, or blunt force that results in separation of skin layers.

Who is most at risk for skin tears?

Older adults and critically or chronically ill adults.

What causes pressure injuries?

Pressure, pressure plus shear, and excessive moisture.

Where are pressure injuries most commonly found?

On the sacrum or heels, but they can occur on any area exposed to prolonged or repeated pressure and/or shear.

What are risk factors for developing pressure injuries?

Advanced age, immobility, impaired circulation, obesity, diabetes, and incontinence.

What is the final phase of the inflammatory response?

Healing.

What are the two major components of wound healing?

Regeneration and repair.

What happens during regeneration?

Cells and tissues are replaced with the same type.

What happens during repair?

Connective tissue replaces lost cells.

What are the types of repair?

Primary, secondary, or tertiary intention.

What is primary intention wound healing?

Healing where margins are closely approximated, such as a sutured wound or minor laceration.

What is secondary intention wound healing?

Healing where margins are gaping and cannot be approximated, occurring from the margins inward and from the bottom upward.

What is tertiary intention wound healing?

Delayed wound closure, often used for contaminated wounds, such as a stump following a traumatic amputation.

What are adhesions in wound healing?

Bands of scar tissue.

What are contractions in wound healing?

Tightening of the wound that may cause deformity.

What is dehiscence?

Separation of wound edges.

What is evisceration?

Protrusion of intestines from a wound.

What is excess granulation tissue?

Tissue that extends above the wound surface.

What is a fistula?

An abnormal passage between organs or between an organ and the skin.

What is a common complication of wound healing related to microbes?

Infection.

What is hemorrhage in wound healing?

Bleeding from the wound.

What are hypertrophic scars?

Large, raised scars.

What are keloid scars?

A mass of scar tissue that appears tumor-like.

What should you do if the depth of a pressure injury cannot be determined?

Do not stage it; describe what you see.

What characterizes a Stage 1 pressure injury?

Nonblanchable erythema.

What characterizes a Stage 2 pressure injury?

Partial thickness loss of skin.

What characterizes a Stage 3 pressure injury?

Full thickness loss of dermis.

What characterizes a Stage 4 pressure injury?

Full thickness tissue loss, with bone possibly visible.

What is an unstageable pressure injury?

Eschar or slough blocks the wound, so the depth cannot be determined.

What is a deep tissue pressure injury (DTPI)?

A persistent non-blanchable deep red, maroon, or purple area of tissue.

What are signs of a DTPI?

Epidermal separation with a dark wound bed or a blood-filled blister.

What causes a DTPI?

Intense and/or prolonged pressure.

How quickly can a DTPI develop?

It may evolve rapidly.

When should wound assessment be performed?

On admission and throughout the hospital stay.

What aspects of wound location should be assessed?

The specific site of the wound on the body.

How is wound size assessed?

By measuring length (proximal to distal), width (medial to lateral), and depth, including any undermining or tunneling.

What should be evaluated about wound margins?

Whether they are approximated, macerated, or erythematous.

What should be assessed about the wound base?

Presence of eschar, slough, exudate, or granulation tissue.

What should be assessed about wound exudate?

Consistency, color, odor, and quantity.

What health factors may delay wound healing? (DIDNT HEAL)

Diabetes, infection, drugs, nutritional problems, tissue necrosis, hypoxia, extensive tension, another wound, and low temperatures.

How are wound measurements recorded?

In centimeters, with the first measurement head to toe, the second side to side, and the third for depth.

What clinical problems are associated with wounds?

Impaired skin or tissue integrity, risk for infection, pain, and impaired mobility, including scars, adhesions, and contractures.

What are the goals when planning care for a wound?

Healing with no complications and prevention of pressure injuries.

What should be done for wound care implementation?

Provide appropriate wound care, choosing dressings and therapies in conjunction with the HCP or WOCN.

How can wound healing be promoted and further injury prevented?

Use positioning devices to reduce shear and pressure and provide nutrition care.

What infection control measures should be implemented?

Necessary infection control measures to prevent wound infection.

How should the nurse support the patient emotionally?

Assist with managing body image concerns and fears.

What should be done for pain management?

Provide effective pain management.

How should the effectiveness of wound care be evaluated?

Assess whether wound care is promoting wound healing.

What teaching should be provided to patients and caregivers?

Teach about wound care and pressure injury prevention.

How should clean wounds be managed?

Use closure devices and dressings, keep the wound surface clean and slightly moist to promote epithelialization, use topical antimicrobials cautiously, and remove fluid with drains.

Why must contaminated wounds be cleaned?

Healing cannot occur until the wound is clean.

What may be necessary for contaminated wounds?

Debridement, depending on wound type, amount of debris, and condition of wound tissue.

What methods can be used for debridement?

Surgical, mechanical, autolytic, or enzymatic methods.

What types of dressings may be used for contaminated wounds?

Absorptive or hydrocolloid dressings.

What factors determine the choice of dressing?

Wound base, healing rate, and amount of exudate.

What are the purposes of wound dressings?

Enhance and promote wound healing, retain moisture, act as a barrier, absorb exudate, control pain, and support autolytic debridement.

What is autolytic debridement?

Using the body’s own enzymes and fluids to heal the wound.

What is an example of a dressing that supports autolytic debridement?

Hydrogel.

Who is involved in interprofessional wound management?

Wound care RN/team, dietician, and other specialists as needed.

What dietary recommendations are made for wound healing?

High fluid intake; diet high in protein, carbohydrates, and moderate fat; vitamins A, B complex, and C; enteral (EN) or parenteral (PN) feedings if needed.

What is hyperbaric oxygen therapy?

Delivery of oxygen topically or systemically at increased atmospheric pressure.

What is negative-pressure wound therapy?

Also called a wound vac, it applies suction to promote wound healing.

Why are drains used in wound management?

To remove excess fluid and prevent accumulation in or around the wound.

What is negative-pressure wound therapy (NPWT) used for?

Both acute and chronic wounds.

How does NPWT work?

Suction removes fluid, exudate, and bacteria and enhances blood flow to the wound base.

What should be monitored during NPWT?

Serum protein levels, fluid and electrolyte balance, and coagulation studies.

What are common types of surgical drains?

Jackson Pratt drain and Penrose drain.

What nursing care is required at the drain insertion site?

Maintain cleanliness.

How often should drains be emptied?

As prescribed or indicated.

What should be recorded when managing a drain?

The amount and color of the drainage.

When should patients be assessed for pressure injuries on admission?

On admission, using the Braden Scale.

How often should patients be reassessed for pressure injuries in acute care?

Every 24 hours.

How often should residents be reassessed in long-term care?

Weekly for the first 4 weeks after admission, then at least monthly or quarterly.

How often should patients be reassessed in home care?

At every nurse visit.

What are the priorities in managing pressure injuries?

Keep the wound clean and free from infection, and debride nonviable tissue if present.

What is included in planning care for pressure injuries?

Reduce pressure and use dressings for stage 2 or higher to protect the wound and keep it moist.

What are the goals for wound outcomes in pressure injury management?

No deterioration of the wound, no infection, healing occurs, and no recurrence.

What is the focus of nursing management for pressure injuries?

Implementation of prevention strategies and health promotion.

What should patients and caregivers be taught regarding pressure injuries?

Prevention techniques.

What are the primary nursing responsibilities for pressure injury prevention?

Identification of patients at risk, implementation of prevention strategies, and use of evidence-based practices.

What devices can reduce pressure and shear to prevent pressure injuries?

Low-air loss mattresses, foam mattresses, wheelchair cushions, padded commode seats, foam or air boots, and lift sheets.

How often should patients be repositioned to prevent pressure injuries?

At least every 2 hours.

What psychological factors can affect wound care?

Fear of scarring, disfigurement, or loss of function, fear of pain, and distress over exudate or odors.

What is a recommended approach to managing odor in wound care?

A dab of mentholated ointment (like Vick’s) under the nose can help mask odors.

What does “poker face” mean in wound care?

Maintaining no inappropriate facial expressions to avoid causing distress.

How should care be approached for patients with wounds?

Treat the whole patient, not just the wound.

What vital sign is especially important to monitor during evaluation?

Temperature.

What should be assessed about the wound?

Whether it is healing as expected.

Which laboratory tests are important for evaluation?

Culture and sensitivity (C&S) and WBC count.

What should be evaluated regarding self-care?

Whether the patient can manage wound care after discharge.