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N126 Wounds
Wound Assessment and Care r/t Nursing
| Question | Answer |
|---|---|
| Regenerative/ epithelial healing | Wound effects only epidermis. New skin is formed and no scar is present. |
| Primary intention healing | Wound involves minimal tissue loss with well approximated edges. Minimal scarring. Ex: Clean surgical scar. |
| Secondary intention healing | Wound involves tissue loss. Edges not approximated / wound should not be closed due to infection. Heals slowly by filling with granulation tissue from the bottom up, prone to infection. More scar tissue. Ex: Pressure ulcer, infected wound. |
| tertiary intention healing | Wound is contaminated/ clean-contaminated. Follows secondary intention healing. When there is no edema, infection or debris, two surfaces of granulation tissue are sutured together. Strict aseptic technique - prone to infection. Less scar than secondary. |
| Inflammatory phase "cleansing" (days 1-5) | 1.Hemostasis: vessels constrict limiting hemo. Platelets aggregation & Clotting mechanism. 2.Inflammation:edema, erythema, pain, warmth, WBC migration. macrophages engulf debris & pathogens. Scab formed. |
| Proliferation Phase "granulation" (days 5-21) | New cells fill the wound. Fibroblasts form collagen for strenth. Blood & lymph vessels are re-formed, resulting in formation of granulation tissue. Epithelialization begins. |
| Maturation phase "epithelialization" (2nd or 3rd week until healed) | Collagen fibers are remodeled into an organized structure (scar), increasing tensile strength. Epithelialization continues. *Scar is only 80% as strong as original tissue* |
| Hemorrhage/Hematoma (major complication) | may indicate a clotting issue,infection,slipped suture,internal bleeding |
| Dehiscence (major complication) | separation of one or more layer. RN intervention: Apply a binder & modify activity to prevent evisceration. |
| Evisceration (major complication) | total separation w/ protrusion of viscera. surgical emergency. Cover opening w/ sterile saline soaked sterile towels, notify the surgeon, and prep pt for surgery. |
| Fistula (major complication) | abnormal passage between two body cavities or a body cavity + the skin that is created by an abscess. |
| Infection (major complication) | contaminated/traumatic wound s/sx: 2-3 days; clean surgical wound s/sx: 4-5 day post op. s/sx: edema, erythema, warmth, pain, fever above 100.4, odor, purulent drainage, color change in drainage. |
| serous exudate | consists of serum. Staw colored fluid w/ watery consistency that separates out of blood when a clot is formed. Uusally present in a clean wound. |
| sanguineous | bloody drainage. Indicates damage to capillaries. Usually present with deep wounds or highly vascular areas. |
| serosanguineous | combination of bloody and serous drainage. Common in new wounds. |
| Purulent exudate | yellow (or sometimes blue-green), thick drainage from infected wounds commonly caused by infection of a pyogenic (pus-forming) bacteria such as strep or staph. Possibly malodorous. Contains pus (WBCs, bacteria, and cellular debris) |
| Predisposing for evisceration/ dehiscence | Usually in inflammatory phase before collagen reinforced. Assoc w/ abd. wound, obesity (Fat does not heal quickly), malnutrition, inadq muscle closeure, or infection. Triggered by coughing, vomiting& change in position. |
| Stage I Pressure Ulcer | nonblanchable erythema on intact skin (Dark skin=red/blue/purple hue) that remains for more than 30 minutes after pressure is relieved. |
| Stage II Pressure Ulcer | Involves partial-thickness skin loss of the epidermis, dermis or both. Abrasion, blister, or shallow crater. |
| Stage III Pressure Ulcer | Full-thickness skin loss involving damage or necrosis of sub-q tissue. May extend down to fascia (but not through) Deep crater with poss undermining. |
| Stage IV Pressure Ulcer | Full thickness skin loss with extensive destruction, necrosis, or damage to muscle, bone or support structures. Presence of undermining and sinus tracts common. |
| Eschar | Black, leathery covering of necrotic tissue and plasma proteins that forms when a wound cannot close by epithelialization. |
| Preventing Pressure Ulcers | Daily skincare, warm water(not hot) for high risk pts. Use soap only as needed. Lotion if dry. Keep linen free of wrinkles. Adq calories & protein. Reposition q2h using the rule of 30 degrees. Therapeutic mattresses and cushions. Family teaching. |
| RYB color code system (wound mgmt) RED | Granulation. RN goal=Protect the wound Activites=Keep the wound moist and covered |
| RYB color code system (wound mgmt) YELLOW | Moist, devitalized tissue (slough) RN goal=cleanse the wound Activites=irrigation and dressings. Poss debridement |
| RYB color code system (wound mgmt) BLACK | Eschar Debride the wound Sharp, mechanical, ensymatic, or autolytic debridement. |
| Sharp debridement | use of a sharp instrument to remove devitalized tissue. Provides immediate improvement of the wound bed & preserves granulation tissue. |
| Wound care with drains | Remove one layer at a time carefully to avoid dislodging drains. Monitor drainage. Record amount of drainage as output. Empty container at designated volume to maintain suction. |
| Mechanical debridement. | Lavage:irrigation with a mild amount of force 4-15 psi. Wet do dry dressings: moist dressing is allowed to dry in the wound, then removed providing nonselective debridement. Painful. Hydrotherapy: for wounds w/ lots of nonviable tissue. Avoid water je |
| Enzymatic Debridement | clean wound w/ NS, apply topical enzymatic agent, cover w/ moisture retaining dressing. Apply product only to devitalized tissue. |
| Autolysis | use of an occlusive moisture retaining dressing and the body's own mechanisms for ridding itself of necrotic tissue. Activites: Apply dressing & observe fluid. Change q72h; cleanse wound at dressing changes. |
| Woven Gauze | Fine to coarse mesh. Absorbent. For packing wounds, wicking exudate or debridement. |
| Nonwoven gauze | for cleaning and wiping the skin or providing a layer of protection |
| Nonadherent gauze (Telfa) | Protection |
| Transparent film | clear & semiperm. keep wound moist.For wounds with min/ no drainage. Used to dress IV sites. Good for visual assessment, flexibility (joints) |
| Hydrocolloids | Wafers, pastes, powders. hydrophilic. Adhesive. Keeps wound moist.Moldable for tight spots, absorbant, promote autolysis. Good for stasis ulcers or stge II pressure ulcers. Not for infected wounds. anaerobic bacterial growth. |
| hydrogels | sheets, granules or gels with high water content. Jelly consistency; Nonadhesive. Mimimal absorbtion.. Softens slough or eschar. Can be used in infected wounds. may maserate periwound skin. |
| Absorption dressings | mod-lg exudate.Beads, pwd, paste, ribbon, alg. 2nd dressing req. |
| Heat therapy Indications | stiffness and discomfort r/t mussculoskeletal probmlems, wounds. Increases blood flow and tissue perfusion & relaxation. |
| Heat therapy assessment | Observe for faintness due to drop in BP (vasodilation). |
| Close observation of heat/cold therapy | Very Young Very old Sensory impairment high risk for injury: fingers, hands, face, perineum, feet Application to small area of intact skin is better tolerated |
| Moist heat | amplifies the intensity of the tx. |
| Cold Therapy Indications | decreases blood flow. Produces local anesthesia, decreases muscle tension. slows bacterial growth. limits edema, inflammation, pain, o2 requirements and bleeding. tx of fevers, sports injury & post op swelling. |
| Cold Therapy Assessment | May increase blood pressure. May cause shivering. Prolonged exposure may cause tissue damage. |
| Temp therapy safety measures | Avoid direct contact with skin Apply hot/cold intermittently No more than 15 min at a time check skin for redness, blistering, cyanosis or blanching |
| abrasion | superficial scrape of top layers of the skin |
| abscess | localized collection of pus due to invasion from a pyogenic bacterium or other pathogen. I&D to treat |
| Contusion | Closed wound caused by blunt trauma. AKA bruise/ ecchymotic. |
| Crushing | caused by force leading to compression or disruption of tissues. Assoc w/ fx. Minimal/no break in skin. |
| incision | open, intentional wound caused by a sharp instrument |
| laceration | torn open. Wound w/ jagged margins |
| penetrating | open woudn in which the agent causing the wound lodges in body tissue |
| puncture | open wound caused by a sharp onject. Often a collapse of tissue around entry point. Prone to infection |
| Tunnel | wound with an entrance & exit site |
| Factors affecting healing | age (older=longer healing time) impaired mobility/sensation, nutrition, hydration, poor circulation, medications, moisture, fever (increased metabolism, unavail for wound healing), contamination/infection. |
| BP meds Healing | decreases amt of pressure required to occlude blood flow to an area. Risk for ischemia |
| Anti-inflammatories | inhibit wound healing |
| Steroids | inhibit wound healing |
| Anticoagulants | may cause extravasion of blood into sub q tissue. min pressure/injury can cause a hematoma |
| chemotherapy | delay healing. toxicity |
| antibiotics, psychotherapeutic drugs, chemotherapy | increase sun sens |
| herbal products (tea tree oil, lavender) | dry out the skin. |
| for aerobic wound culture | Use sterile technique and a culturette tube |
| Low BP & increased arterial pressure are indicative of _______- | Internal Bleeding |
| Preferred dressing for dry yellow slough | Tightly adhering hydrocolloid dressing |
| Tx for fx ankle | ice |
| Nutrient to promote collagen synthesis & capillary wall integrity | Vitamin C |
Created by:
lilredsmiles
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