Fundamentals ATI > Wound Care > Flashcards

Wound Care Flashcards

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1
Q

3 categories of chronic wounds

A

Venous disease wounds
Arterial disease wounds
Neuropathic disease wounds

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2
Q

Days 1-4 of acute wound healing

A
  • redness
  • Edema
  • Exudate
  • Epithelial closure by day 4
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3
Q

Days 5-14 of acute wound healing

A
  • Bright pink
  • Edema and exudate resolve by day 5
  • Staples/sutures removed between days 9 and 14
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4
Q

Days 15-1 year

A
  • Pale pink
  • Scar tissue forms
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5
Q

What is primary intention?

A

Wound edges are approximated, which prevents granulated tissue formation

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6
Q

What is secondary intention?

A

Wound edges are not approximated, such as in a pressure injury

Heals by granulation tissue formation and re-epitheliazation

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7
Q

What is tertiary intention?

A

Wound is left open and closed at a later time

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8
Q

Negative Pressure Wound Therapy/Vacuum Assisted Closure

A
  • Applies continuous or intermittent suction to wound
  • removes bacteria and exudate
  • Promotes granulation
  • Not for areas of poor perfusion
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9
Q

Open drainage system

A
  • Penrose drains (absorbent dressing with collapsable tube)
  • Pros: protects surrounding skin, provides drainage
  • Cons: difficult to assess the amount of drainage and to control microbes
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10
Q

Closed drainage system

A
  • Use compression/suction to remove drainage in reservoir
  • Pros: accurate measurement of drainage and prevents infection
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11
Q

Types of closed drains

A
  • Self-contained drainage system (bulb)
  • Portable wound suction device
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12
Q

Describe components of wound assessment

A
  1. Location, shape, size (width by length by depth in mm), color
  2. Erythema (blanchable or nonblanchable (structural damage))
  3. Temperature (cold indicates low perfusion vs expected warmth)
  4. Odor (helps identify certain microorganisms)
    presence of exudate, slough, or eschar
  5. Signs of impaired healing (necrosis, tunneling, undermining, edema)
  6. Signs of good healing (clean edges or granulating tissue)
  7. Condition of the area around the wound
  8. Psychosocial: body image, esteem, sex, socialization
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13
Q

What are dry dressings used for?

A

Wounds with little or no exudate
(use sterile or clean technique, self-adhered or held by gauze and tape)

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14
Q

Wet-to-dry dressings

A
  • Saline soaked gauze that is squeezed
  • Pulls healthy and necrotic tissue out of wound when it dries
  • Do not use on clean wound with granulation
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15
Q

Chemically impregnated dressings

A
  • Silver, povodine iodine, petrolatum, collagen, or antibiotics
  • Speed healing process
  • Make sure using appropriate dressing for wound/microbe type
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16
Q

Foam dressings

A
  • Absorbent and provide more support for boney prominences
  • Mild to moderate exudate
  • Self-adherent or nonadherent
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17
Q

Alginate dressings

A
  • Made from seaweed
  • Provides moist healing environment, absorbs exudate, and promotes hemostasis
  • Doesn’t adhere to wound and needs second dressing
  • Good for lots of exudate or packing deep wounds
    * Do not use on dry wounds
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18
Q

Hydrogel dressings

A
  • Promotes moist environment and absorbs exudate
  • No effect on hemostasis
  • Swells with exudate and requires secondary dressing on top
  • Good for necrosis and infection and dry wounds
    * Do not use on excessive exudate
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19
Q

Wound fillers

A
  • Gels, powders, beads
  • Soften tissue to facilitate debridement
  • Do not use on dry wounds
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20
Q

Transparent dressing

A
  • No absorption, but provides barrier, moist environment, oxygen, and visualization of wound
  • Good for necrotic tissue and superficial tears
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21
Q

Hydrofiber dressings

A
  • Moderate to high exudate wounds
  • Hemostasis and very absorptive, less maceration than alginate
  • Can stay in place for several days
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22
Q

Hydrocolloid dressings

A
  • Autolytic debridement, make moist wound bed, bacteriostatic, and stimulate cell growth
  • Can’t see through and can look like purulent drainage
  • Good for small abrasions, superficial burns, pressure injuries, postoperative wounds
    * Do not use on dry wounds, and some infected wounds
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23
Q

Types of antiseptic agents

A

Provodine iodine
Silver
Hydrogen peroxide

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24
Q

Chemical debridement gels

A

For pressure injuries with eschar or slough, or uneven edges
Use only on necrotic tissue

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25
Types of wound cleansing
Pressurized irrigation Passive irrigation Mechanical cleansing
26
Pressurized irrigation
8 psi through syringe or catheter Start at top edge and hold syringe 1 inch away from wound Irrigation and packing
27
Mechanical cleansing
gauze and solution to clean wound
28
Passive irrigation
0.9 % sterile saline solution and gravity Solution runs top-to-bottom
29
Types of debridement
Mechanical Autolytic Chemical Surgical
30
What is mechanical debridement
Either wet-to-dry dressing or pressurized irrigation
31
What is autolytic debridement?
Dressings help wound fluids self-digest necrotic tissue
32
What is chemical debridement?
Topical enzymes
33
Examples of pressure relief devices
Only work in combo with turning and skin care Heal protectors, pillows, foam surfaces, specialized beds
34
What types of wounds can electrical stimulation be used for?
Stage 2, 3, or 4 pressure injuries Stimulates granulation and decreases pain
35
What types of wounds are negative pressure wound therapy used for?
Stage 3 or 4 pressure injury Drains removed when drainiage is 30–100 mL within 24 hr
36
Hyperbaric oxygen therapy
100% oxygen stimulates cell growth for burns and necrosis
37
Growth factors
Plasma rich in platelets stimulates fibroblasts to activate cell growth
38
How does ultrasound therapy work to heal wounds?
Stimulates granulation, decreases pain, and decreases infection rate
39
Describe eschar
Black/brown Firmly attached Can be soft
40
Describe slough
Tan, yellow, white Stringy and soft Firmly attached
41
Describe fibrin
Yellow, white Stringy and soft Loosly attached clumps
42
Describe hyperkeratosis
White, grey Hard or soft Firmly attached surrounding edges
43
Describe gangrene
Black, brown Hard Firmly attached
44
Braden scale components
Braden Scale (score 6–23 where lower is bad) Perception Moisture Activity Mobility Nutrition Friction/shearing
45
Why do chronic wounds heal slowly?
They have more cytokines, which slow new cell proliferation
46
How should shearing be prevented?
Raise HOB to 30 degrees maximum
47
4 stages of healing
Hemostasis (vasoconstriction) Inflammatory phase Proliferative phase Maturation/remodeling phase
48
Describe components of the inflammatory phase
* **Begins after the skin is injured and lasts 3--6 days * Heat, swelling, color changes, pain, loss of function, fever * Presence of neutrophils, lymphocytes, macrophages, mast cells, plasma proteins, complement system ** Neutrophils: first to arrive, phagocytosis Macrophages: phagocytosis, release of nitric oxide, autolytic debridement, and secretion of growth factors (attract collagen-synthesizing fibroblasts) Mast cells secrete histamine (vasodilation=edema, and collagen formation)
49
Describe components of the proliferative phase
* Begins 3 days after injury and lasts 24 hours * **Fills in the wound with new tissue * Angiogenesis=creation of new blood vessels * Bleeding and edema due granulation tissue (fragile capillaries and tissue)** Epitheliazation: temporary protection, keratinocytes move inward from edges Begins at the edges and moves upward Fibroblasts synthesize collagen to form scaffolding for scar formation Myofibroblasts cause contraction of wound edges Risk of evisceration because scar is immature
50
Components of maturation/remodeling phase
* Completion of wound healing can take more than 1 year * Collagen is replaced with stroger collagen * Myofibroblasts continue to secrete proteins to cause contraction and wound closure * Color of scar changes from pink/red to white, or be more pigmented in melanated skin * Thinner and reduced need for blood
51
Skin problems in children
maceration and dermatitis Skin tears, pressure injuries, diaper rash
52
Skin problems in elderly
thinning of skin, collagen loss, decreased blood supply and hydration Skin tears, pressure injuries, dryness, infections
53
Skin problems with chronic illness
(reduced immune system, decreased oxygenation) Skin tears, pressure injuries, infection, lesions caused by moisture
54
Skin problems with reduced sensation
Skin tears, pressure injury, infection, incontinence related dermatitis
55
Extrinsic factors related to wound formation
Medications Radiation and chemo Inflammation and decreased blood supply (Delayed wound healing, dermatitis, infections, pressure iinjuries) Nutrition Stress reduces immune response Damage, repeat trauma, illness can lengthen healing
56
Moisture associated skin damage
* dermatitis develops when skin is exposed to urine, feces, sweat, stoma effluent, wound drainage * sweating, skin folds, abnormal skin pH are risk factors
57
Types of Biological Debridement
Collegenase (targets necrotic tissue only) Bromelain and papain Fly larvae secrete enzymes that liquifies necrotic tissue, which larvae eat
58
When are sterile dressings applied to a wound?
After surgery and kept in place for 24-48 hrs
59
Open dressings
* gauze * Used to pack wounds with saline (wet to dry)
60
Semi-open dressings
* 3 layers: fine knit gauze with therapeutic ointment, middle absorptive layer, and adhesive layer * Do not control drainage well and can cause poor wound healing
61
Semi-occlusive dressings
Most diverse in options: Hydrocolloid Hydrogel Alginate Foam Hydrofiber Polymeric membranes Films
62
Signs of wound infection
cellulitis warm skin redness around the wound exudate foul odor
63
Define Surgical Site Infection (SSI)
infections that occur near a surgical site incision in the 30 days after surgery (superficial) or 30-90 days after surgery (deep)
64
How should a wound culture be taken?
Apply saline top to bottom of wound to prevent contamination of culture with skin microflora Use cotton tipped applicator to swab wound without touching edges
65
Dehiscence
The complete or partial separation of the suture line and underlying tissues that occurs when a wound fails to heal properly from poor surgical technique, foreign material in the wound, or infection.
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