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Wound Care & Dressin
Canadian Clinical Nursing Skills + Techniques - Ch 39 &40
| Question | Answer |
|---|---|
| What are risk factors for pressure injuries? | Immobility, loss of sensory perception, decrease in activity, and malnutrition |
| Debridement | removes nonviable tissue, which can delay wound healing and contribute to wound infection; methods include enzymatic, mechanical, autolytic, or sharp |
| Phases of wound healing | hemostasis, inflammation, proliferation (repair), and maturation (remodelling). |
| The T.I.M.E. framework stand for? | tissue management, inflammation/infection, moisture, and edge of wound’s perimeter. |
| The key principles of a physiological wound environment include | adequate moisture, temperature control, pH, and control of bacterial burden. |
| Primary wound healing occurs when | tissue is cut cleanly and margins are reapproximated (i.e., surgical incisions). |
| Secondary wound healing occurs | skin is left open and allowed to heal from granulation tissue forming at the base of the wound combined with epithelialization from the sides. |
| Dry gauze dressings | used for abrasions and nondraining postoperative incisions; disadvantages of use include rapid moisture evaporation |
| Pressure bandages | control excessive, sudden, and unanticipated bleeding; they stop blood flow and promote clotting |
| Transparent film dressings | clear, adherent, nonabsorptive, and are impermeable to fluids and bacteria; they are appropriate for prophylaxis on high-risk intact skin, superficial wounds with minimal exudate, and eschar-covered wounds. |
| Hydrocolloid dressings | formed of elastomeric, adhesive, and gelling agents; they absorb drainage and hydrate and debride wounds. Indicated for wounds with low levels of exudate and contraindicated for infected wounds. Observe periwound skin for maceration. |
| Hydrogel dressings | Indicated for wounds with minimal or no exudate to add moisture and/or to facilitate autolytic debridement. Contraindicated for moderately and highly exudating wounds. Periwound skin may need protection from maceration. |
| Foams | Indicated for low- to moderately exudating wounds and to facilitate autolytic debridement but are contraindicated for highly exudating wounds where dressing changes are required daily or more frequently |
| Antimicrobial agents | Indicated to reduce bacterial burden and/or to disrupt biofilms in locally infected wounds and in wounds with spreading or systemic infection. They |
| Calcium alginates | Indicated for moderately to highly exudating wounds and autolytic debridement facilitation. Contraindicated for dry wounds. |
| Transparent film dressings | Contraindicated for moderately and highly exudating and infected wounds. |
| Tertiary intention | occurs when surgical wounds are not closed immediately but left open for 3 to 5 days to allow edema or infection to diminish. Then the wound edges are sutured or stapled closed |
| Eschar | black or brown tissue, represents full-thickness tissue destruction. |
| Slough | can be yellow, cream coloured or grey slough. Can represent nonviable tissues as well as byproduct from part of the inflammatory process (fibrin, white blood cells, bacteria, debris and dead tissue). |
| Granulation | red tissue, the result of an increasing amount of new blood vessels in the wound. |
| Scab | rusty brown, dry crust that forms over any injured surface on skin, within 24 hours of injury |
| Not advancing wound healing | can be indicated by wound edges that are raised, rolled, red or dusky. |
| Advancing wound healing | Wound edges are pink and in line with the wound bed |
| High pressure irrigation is used for? | Wounds with necrotic tissue (eschar, fibrin & slough), bacterial burden (infection) or a large amount of exudate |
| Low pressure irrigation is used for? | Wounds with granulation tissue (red/pink) with little exudate |
| Stage 1 | Intact skin with nonblanchable redness of a localized area usually over a bony prominence. |
| Stage 2 | Partial-thickness loss presenting as a shallow, open injury with a red-pink wound bed without slough. |
| Stage 3 | Full-thickness skin loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present |
| Stage 4 | Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. |
| Unstageable | Full-thickness tissue loss in which the base of the injury is completely obscured by slough (yellow, tan, gray, green, or brown) or eschar (tan, brown, black) in the wound bed. |
| Deep Tissue Injury | Purple or maroon, localized area of discoloration, intact skin or blood-filled blister due to damage of underlying soft tissue from pressure, shear, or both |
Created by:
KadduonoLU
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