wounds & drains

what are the ways wounds can be classified?

duration, condition, and depth

what are closed wounds?

no breaks in the skin → contusions, hematomas

what are open wounds?

breaks in the skin or MM → lacerations, puncture, surgical incision

what are acute wounds?

expected to be of short duration and in a healthy person progress through the stages of healing uninterrupted

what are chronic wounds?

take longer than expected to heal, may have complications that interrupt the stages of healing (underlying conditions, trauma, infections)

what are superficial wounds?

only in epidermis → friction, shearing, or burning

what are partial thickness wounds?

extend through epidermis but not the dermis

what are full thickness wounds?

extend into subcutaneous tissue

what are the stages of wound healing?

hemostasis (immediate), inflammatory (24 hours to 2 weeks), proliferative (depends on severity of wound), maturation (up to 2 years)

what are some general wound care concepts?

important to know that no two wounds are the same, need more POC representation in textbooks, important to mark borders of lesions so changes can be measured/monitored, accurate wound assessment and team collaboration dictates wound care processes

what are some “location” wound assessments?

measurement of the wound, injury type (often dictates type of care to implement), peri-wound skin

what are some “tissue type” wound assessments?

exudate (how much and what type of exudate), presence of infection, type of dressing

what are some nursing interventions for wound care?

prevention!! → positioning, nutrition, hydration, surveillance, education, hygiene → want to assess vitals, pain, function, risks, labs, meds, hx then administer any orders

what is the most important thing to remember when changing dressings?

don’t cross-contaminate → remove gloves/wash hands when going from dirty to clean dressings

how to document wound care?

size, location, type, appearance, dressing, exudate, surrounding skin, progression → provides the status of the effectiveness of therapies and can guide further tx decisions

what are the function of surgical drains?

inserted into wounds to allow for fluid and exudate to exit the body → drains prevent excessive pressure from building in the tissues and are usually placed during a surgical procedure; some are sutured in place and others are just in a cavity

what does a provider order mean that states “drain placed to suction”?

nurse needs to compress device to create suction and facilitate removal of drainage → if specific pressure is ordered some drains can be connected to suction and then placed at specific amount (ex: place hemovac to 20 mmHg suction at all times)

what are some passive drainage mechanisms?

pen rose drain, billi bags, colostomies, chest tubes to water seal, foley catheters

what are some active drainage mechanisms?

JP drains, hemovacs, NG tubes or chest tubes with suction order

what to assess when looking at insertion sites?

securement (staples, sutures, tape?), skin integrity (redness, exudate, swelling?), dressing (covered or open to air?), does it look the same as previous assessment?

why is it important to trace your lines?

want to ensure tubing from patient to device is intact, patent, and free of kinks → kinks can cause the tubing to become occluded or cause pressure injuries to patients

what to assess when looking at exudate?

characteristics of it and the amount (measure amount in drain or time dressing has been on wound)

when are drains often discontinued?

when there is little to no amount of drainage

what to assess when looking at dressings?

is there drainage, does it need to be changed, when was it last changed, what type of dressing?

when is the best time to educate patients on their drains?

as soon as it’s placed → prevent overwhelming them at discharge