Removal of Skin, Closures, Drains & Chronic Wound Care

What are the three layers of the skin?

Epidermis, Dermis, and Subcutaneous tissue

What are the key functions of the epidermis?

Non-vascular outer layer, protective barrier, fluid/electrolyte retention, temperature regulation, first line of defense

What specialized structures does the dermis contain?

Connective tissues, blood vessels, hair follicles, nerve endings, sweat glands, sebaceous glands

What does the subcutaneous tissue contain and what is its function?

Vascular networks, fat, nerves, lymphatic vessels; heat insulator

What are the ways wounds can be classified?

Underlying cause, duration, level of contamination, depth of tissue affected

What layers of the skin does a superficial wound involve?

Involves only the epidermis

What layers of the skin does a partial thickness wound involve?

Extends into the dermis

What layers of the skin does a full thickness wound involve?

Subcutaneous tissue, fascia, muscle, bone, tendons

What is apoptosis?

Programmed cell death for homeostasis

What is necrosis?

Tissue death due to injury, infection, or toxins, causing inflammation

What are the risk factors for pressure sores?

Impaired sensory perception, impaired mobility, altered consciousness, shear, friction, moisture, nutrition, tissue perfusion, infection, pain, age

How should dark skin at risk of breakdown be assessed?

Assess skin in well-lit environment, assess color, temperature, appearance, tissue resilience

What are the risk factors for venous insufficiency?

Thrombosis, muscle weakness, post-phlebitis syndrome, pregnancy, obesity, immobility, family history, ulcers, advanced age

What are the signs and symptoms of venous insufficiency?

Varicose veins, pitting edema, skin changes, stasis dermatitis

What are the characteristics of venous ulcers?

Shallow, irregular shape, lower leg/ankle location, edema-related pain

What are the risk factors for venous ulcers?

Deep vein thrombosis, heart failure, varicose veins, valve incompetence, muscle weakness, malnutrition, obesity, immobility, pregnancy

What is the etiology of arterial ulcers?

Smoking, atherosclerosis, Buerger’s disease, arterial trauma, embolic syndromes

What are the characteristics of arterial ulcers?

Full thickness, punched out appearance, smooth edges, pain relieved by lowering leg

What are the risk factors for arterial ulcers?

Vascular insufficiency, uncontrolled diabetes, limited joint mobility, inadequate footwear, structural abnormality, retinopathy, renal disease, history of ulcers, increased age

Where are arterial ulcers commonly located?

Toes, foot, ankle

What is the appearance of arterial ulcer edges?

Punched out, well defined

What does the wound bed of an arterial ulcer look like?

Covered with slough and necrotic tissue

Where are venous ulcers commonly located?

Medial gaiter region

What is the appearance of venous ulcer edges?

Sloping and gradual

What does the wound bed of a venous ulcer look like?

Covered with slough

What are the characteristics of diabetic/neuropathic ulcers?

Plantar surface of the foot, dry/cracked skin, thickened nails, round margins with calluses

What are the causes of diabetic/neuropathic ulcers?

Pressure, neuropathy, arterial insufficiency, poor circulation, blood glucose control, lack of sensation

What are the signs of a suspected deep tissue pressure injury?

Discolored intact skin

What characterizes a stage 1 pressure injury?

Intact skin with non-blanchable redness

What characterizes a stage 2 pressure injury?

Partial thickness loss of dermis

What characterizes a stage 3 pressure injury?

Full-thickness tissue loss with visible fat

What characterizes a stage 4 pressure injury?

Full-thickness tissue loss with exposed bone, muscle, or tendon

What characterizes an unstageable pressure injury?

Full-thickness tissue loss with base covered by slough or eschar

How does negative pressure wound therapy work?

Localized negative pressure for rapid healing

How are wound cultures obtained?

Clean with normal saline, swab cleanest tissue, Gram stains/tissue biopsy

What are the key components of wound management?

Treat cause, moist wound healing, bacterial balance, debridement, pain management, education, anemia/malnutrition management

What does serous drainage look like?

Clear, watery plasma

What does purulent drainage look like?

Thick, yellow, green, tan, or brown

What does serosanguineous drainage look like?

Pale, red, watery mix of clear and red fluid

What does sanguineous drainage look like?

Bright red, indicates active bleeding

What supplies are needed for suture and staple removal?

Waterproof bag, suture removal set, antiseptic swabs, gauze pads, Steri-Strips, clean gloves

What are the initial steps for suture and staple removal?

Order verification, patient identification, allergy/pain assessment, assessing healing ridge and skin integrity

How is a staple removed?

Place extractor under staple, close handles to bend staple upward, move away from skin, release into bag

How is a suture removed intermittently?

Grasp knot with forceps, snip suture close to skin, pull suture through and place on gauze; repeat for every other suture

What should be documented after suture and staple removal?

Time, number removed, cleaning, appearance, healing level, dressing, patient tolerance

What are the initial steps for wound irrigation?

Solution order, gather supplies, hand hygiene, patient identification, explain procedure

What are the steps for preparing for wound irrigation?

Position patient, set up sterile field, add supplies

What are the steps when starting wound irrigation?

Remove dressing, assess wound, wear PPE, warm solution, protect bedding, sterile gloves

How should wounds with wide openings be irrigated?

Steady pressure, flush until solution is clear

How should deep wounds with small openings be irrigated?

Insert catheter tip gently, flush slowly, move syringe around, continue until solution is clear

How is a wound culture collected during irrigation?

Swab wound, label and transport specimen, use biohazard bag

What are the steps following wound irrigation?

Dry wound edges, apply dressing, label with time/date/initials, remove PPE, clean gloves, dispose of equipment, hand hygiene, patient comfort

What should be documented after wound irrigation?

Patient response, solution used, outcomes, characteristics, drainage, cultures

What is the purpose of wound packing?

To fill dead space and avoid abscess formation

What materials can be used for wound packing?

Impregnated gauze, strip gauze, absorbent gauze, hydrating packing material

What should be documented after wound packing?

Size, depth, shape, tunneling/undermining, wound bed, cleansing agent, packing

What general information should be documented about wounds?

Wound appearance, drainage, complications, interventions, patient variables

What are the key aspects of nursing care for patients with drains?

Ensure patency, monitor site, maintain dressing, avoid tube tension

What are the characteristics of a Penrose drain?

Soft, flat, flexible, passive drain (gravity and capillary action)

What are the characteristics of a Jackson Pratt drain?

Constant low pressure via compressed bladder/bag, closed suction system

What should be documented regarding drains?

Time, reestablishment of vacuum, drainage amount/color/odor/consistency, dressing change, specimen collection

What parameters should be recorded during the documentation of wound care?

Appearance, size, exudate, edema, pain, tunneling, dressings, cleansing agents, medications, drains, patient tolerance

What are some examples of relevant nursing diagnosis for wound management?

Risk of infection, imbalanced nutrition, pain, impaired skin integrity, impaired tissue integrity