Wounds

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Author:
Danette
ID:
145829
Filename:
Wounds
Updated:
2012-04-05 03:12:22
Tags:
Exam One
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Description:
Wound care
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  1. What is a wound?
    A break or disruption in the normal integrity of the skin & tissues.
  2. Wound Classifications
    • Intentional vs Unintentional
    • Open vs Closed
    • Acute vs Chronic
  3. Wound healing occurs:
    • Inflammatory phase - begins at time of injury - 3 days
    • Proliferation phase - 3 days - 24 days
    • Maturation phase - end, can last months
  4. Inflammatory phase
    1-3 days
    • Vasoconstriction
    • Vasodilation
    • Cells drawn to area
    • Mitosis
    • Clot dissolves
  5. Proliferation Phase - 3-24 days
    • Granulation tissue forms
    • Fibroblasts
    • Epithelialization
  6. Maturation Phase - 21 - ???
    • Withstand stress
    • Fibroblasts leave
    • Collagen organized & tighter
    • Strength approx 35%-59%
    • Scars - avascular collagen
  7. Wound Healing - 3 Intentions
    First Intention - Dry dressing

    • Second Intention -
    • 1. Largest scar
    • 2. Risk for infection
    • 3. Longest healing time

    • Third Intention - Wet to Dry Dressings
    • Debridement
    • Dressing - absorb
  8. The length of each wound healing phase depends on:
    • Primary, secondary, tertiary intentions
    • Type of injury
    • Patient health
  9. First Intention
    • No tissue loss
    • Sutured closed
    • Edges approximated
    • Epithelialization
    • Minimal scarring
  10. Second Intention
    • Tissue loss
    • Edges separated
    • Heal by granulation & contraction
    • Wound pink/red
    • Large scar
    • Chance of infection
  11. Third Intention
    • Open wound then approximated
    • Closure delayed until risk for infection is gone
    • Minimal scar
  12. Wound healing & type of injury
    • Partial thickness - damage to epidermis & dermis
    • Full thickness - damage beyond subcutaneous tissue/fascia/muscle/bone
  13. Wound Infection
    • #2 health care associated
    • 100,000 bacteria count
    • Appear 2-7 days post
    • Purulent drainage, pain, redness, edema, fever, chills, increased WBC count
    • Danger: sepsis & osteomyelitis
  14. Hemorrhage - External & Internal
    • External:
    • -Saturated dressing
    • -Blood pools under patient
    • -Check frequently

    • Internal:
    • -Hematoma
    • -Swelling
    • -Vital sign changes
    • -Hypovolemic shock
  15. Dehiscence & Evisceration
    Dehiscence - partial or total separation of wound

    Evisceration - protrustion of visceral organs incision
  16. Dehiscence & Evisceration
    Risk Factors & warning signs
    • Risk Factors:
    • Obesity, malnourished, smokers, infected wounds

    • Warning Signs:
    • 3-11 days post op
    • Increase in drainage from wound
  17. Dehiscence & Evisceration - what to do if it happens
    • Cover wound with sterile towels soaked in NS (normal saline)
    • Supine wiht knees bent
    • Notify MD immediately
    • Stay calm & remain with pt
  18. Assessment of wounds
    Appearance
    • Location
    • Size
    • Depth, W & L
    • Approximation of edges
    • Drainage
    • Color of wound
    • Surrounding skin
    • Odor
    • Drains, tubes
    • Sutures, staples
    • Pain
  19. S/S of inflammation
    • Pain
    • Redness
    • Swelling
    • Heat

    (Priscilla rides several horses)
  20. REEDA
    • Redness
    • Ecchymosis
    • Edema
    • Drainage
    • Approximation
  21. Drainage Types
    • Serous: clear, slightly yellow, thin
    • Sanguineous: RBC's, bright red vs dark red
    • Serosanguineous: mix of RBC & serum, pink to red
    • Purulent: WBC, dead tissue debris, bacteria, green, yellow, odorous
  22. Drains - reason & types
    • Remove blood & drainage from a wound
    • Open drain - Penrose & T-tube
    • Closed drain - Hemovac & Jackson-Pratt
    • Assess amount & color of drainage
  23. Wound Management
    • Prevent infection
    • Cleanse wound
    • Remove nonviable tissue
    • Manage exudate
    • Maintain a moist wound bed
    • Protect the wound
  24. CLEANSING - reason & types
    Reduces infection & removes nonviable tissue

    • Cleansing a closed incision site
    • Irrigation of a wound
    • Debridement - removal of nonviable necrotic tissue
  25. Cleansing incisions
    • Apply noncytoxic solution
    • Normal saline
  26. Irrigation
    • Removes exudates, use sterile technique with 35 mL syringe & 19 gauge needle
    • Normal saline
  27. Suture Care
    Consult health care facility policy
  28. Drainage Evacuation
    Portable units that exert a safe, constant, low pressure vacuum to remove & collect drainage
  29. Wound cultures
    • Clean wound first with NS
    • Use a sterile swab from a culturette tube
    • Rotate swab in clean tissue, put pressure to obtain fluid
  30. Prevent wound infections
    • Use sterile technique
    • Aseptic technique
    • Protection of wound
    • Monitoring of patient's glucose, nutrition, albumin levels & hemoglobin
  31. Debridement Types
    • Mechanical:
    • -Wet to dry saline gause dressing
    • -Whirlpool treatments
    • -Never use in clean granulated wound

    • Autolytic:
    • -Synthetic dressings over a wound to allow the eschar to be self digested by body's own enzymes

    Chemical:

    • Surgical:
    • -Removal of thick, adherent wound crust using a scapel or scissors
    • -Surgical procedure
  32. Why do we apply dressings?
    • Protects wound
    • Hemostasis
    • Promotes healing
    • Supports wound site
    • Provides moist environment
  33. Gauze
    • Advantages:
    • -Readily available
    • -Packing wounds
    • -Can be combined with other products

    • Disadvantages:
    • -Fiber shreds
    • -Change frequently
    • -May stick to wound bed
    • -May delay healing
  34. Transparent Film
    • Advantages:
    • -Waterproof
    • -Promotes autolytic
    • -Change q 5-7 days or when it starts to leak
    • -Transparent

    • Disadvantages:
    • -Doesn't absorb moisture
    • -May stick to wounds
    • -Not for draining wounds
  35. Foam
    • Advantages:
    • -Many sizes
    • -Easy to apply
    • -Easy to remove

    • Disadvantages:
    • Needs a topper
    • Not for dry wounds
    • Not for infected wounds
  36. Composites
    • Advantages:
    • -Adhesive border
    • -Used for autolytic debridment

    • Disadvantages:
    • -May not keep wound moist
  37. Hydrocolloid
    • Advantages:
    • -On for 3-5 days
    • -Reduce pain
    • -Self adhesive
    • -Absorbent

    • Disadvantages:
    • -Have odor
    • -Loss of shape on wound
    • -Expensive
    • -Not for heavy drainage
  38. Hydrogel
    • Advantages:
    • -Rehydrate
    • -Reduce pain
    • -Changed daily
    • -Autolytic debridement

    • Disadvantages:
    • -Need a secondary dressing
    • -May cause maceration
  39. Alginate
    • Advantages:
    • -Absorbent
    • -Can be used as packing for deep wounds
    • -Can be used in infected wounds

    • Disadvantages:
    • -Needs topper
    • -Distinct odor & gelling may be confused with infection
  40. Silver
    • Advantages:
    • -Inhibits pathogen growth
    • -Cost effective antimicrobial action for 7 days

    • Disadvantages:
    • -Needs topper
    • -Needs to be removed prior to MRI
    • -May turn skin black
  41. Dressings
    • Changing:
    • -Know type of dressing, placement of drains, & equipment needed

    • Securing:
    • -Tape, ties, or binders

    • Comfort measures:
    • -Carefully remove tape - towards wound
    • -Gently cleanse wound
    • -Administer analgesics before dressing change
  42. Principles of Sterile Technique
    • Sterile to Sterile - don't cross over field
    • Only sterile objects on sterile field
    • A sterile object or field out of range of vision or an object below the waist is contaminated
    • A sterile field becomes contaminated by prolonged exposure to air
    • Sterile to wet = contaminated
    • The edges of field are considered contaminated
  43. Documentation
    • Drainage
    • Wound site
    • Granulation
    • Skin condition
    • Type of irrigation fluid used
    • Method of wound irrigation
    • Observations of wound
    • Type of dressing applied

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