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skin torn apart, has irregular edges
Blow from a sharp object
In tact skin with damage underneath
Small wound produced by a stab with a sharp pointed object
A crater like wound formed from erosion of the skin/and or mucous membrane and underlying structures
Cut with a sharp object...knife, scalpel.
Propelled object enters skin and leaves a well defined hole
Death of one or more cells or a portion of tissue or organ
painful, pale, crater like lesion.
Found on Big toe, between toes or on upper aspect of a foot.
Is usally cold with a weak or absent pulse
Necrotic, superficial, crater like lesion with minimal pain on ankles or lower legs.
Usually caused by chronic venous congestion.
Produces Copious Exudate
Any lesion caused by unrelieved pressure resulting in damage of underlying tissue.
Ulcers that develope on the plantar surface of the foot, heel or anywhere pressure is exerted or an area where a person can have vascular or neurological complications from Diabetes
scraping or wearing away of skin
What delays wound healing?
- Advanced age
- Decreased blood supply
Ways you have decreased blood supply...
- Venous Stasis
What does smoking cause?
Nicotine causes vasoconstriction of the vessels, increasing platelet adhesiveness, RBC proliferation is reduced (diminishing oxygen transport). Carbon monoxide diminishes oxygen transport and metabolism...less oxygen to tissues
How do you assess a wound?
- Redness (color)
How do you measure the size of a wound?
For length and width use the face of a clock.
- Length use 12 and 6
- Width measure from 3 to 9...is there tunneling?
Depth-insert a sterile cotton tipped swab in to deepest part of wound.
Record all measurements in cm
How do you describe slough of a wound?
Tell what % of the wound has yellow slough
What does approximation mean?
Do the edges of the wound come together? Or is it partially separated?
What is important about edema and swelling of a wound?
Is it present in or around it?
How can you tell if a wound is healing well?
If it is black...necrotic and dead
If it is dark pink to beefy red and moist...it is revascularized and is HEALTHY
What's the significance of yellow slough in a wound?
it is necrotic tissue which is ideal for bacterial growth.
Purulent or green and sticky, smelly= INFECTION
Must remove slough for wound to heel
What do you do when you have red, yellow and black in your wound?
Most severe must be removed first...
Black, yellow...want red
Primary intention and wound healing
When the skin heals with a thin scar tissue formed at the closure site. Wound edges approximate closely.
Achieved by sutures or staples
What happens if the doctor anticipates a large amount of drainage from a wound?
Large amount= Jackson Pratt or Hemovac.
The device is kept compressed and negative pressure will withdraw fluid from the wound.
Why is it important for fluid to be removed from the wound?
To get infectious debris away from the wound
Secondary intention and wound healing
The wound is left open to heal, permitting drainage of infectious material and debris from non sterile body cavity.
Example: pressure ulcer, infected abscess, dehisced surgical wound
How do wounds heal?
from the edges inward and from the base upward until it is all filled in.
Tiertiary Intention and wound healing
Surgically debrided by doctor who then leaves the wound open for 3-5 days allowing for drainage and a decreased chance of infection.
Wound is closed by 1st intention, leaving a smaller scar.
Hydrophillic wound care product
- Will absorb moisture and collect exudate
Purpose is to collect newly grown tissue, absorb excessive drainage away from the wound and keep the wound free of contamination
Hydrophobic wound care product
- Non absorbent
- Clear, transparent...acts like a second skin, but retains moisture too.
- It is left on until they begin to leak or the protective seal is broken
3 dressings that provide moist healing....describe.
What's used to close wound?
Sutures, staples, steri strips and fibrin sealers
Name 6 irrigating, cleansing, packing solutions
- Normal Saline and Kara Klenz
- Acetic Acid
- Dakins and Betadine
How often do you change dressings?
Per physicians orders
Why do we want to use a wet moist dressing?
Allows for autolysis....mechanical debridement while allowing the bodies own natural process to debride the wound
What's the cardinal rule for wounds?
keep it moist and surrounding INTACT skin DRY
Desribe nursing interventions when wound problems are identified
- Immobilize and rest injured tissue-control bleeding
- Protect from futher injury/infection
- Convert to a clean wound by irrigation, packing and debridement
- Preserve blood supply to injured tissue
- Administer steroids with CAUTION
- Reduce swelling by elevating injured part
- GOOD NUTRITION
- Relieve pain
- Monitor for infection
- Document wound care given!!!
What's autolytic debridement
- First treatment of choice
- Cover or pack wound with dressing to keep it moist and surrounding skin dry and in tact.
- Allows the bodies natural defenses to clean the necrotic wound of debris.
INFLAMMATORY process in action
What's Enzymatic or chemical debridement?
using medications or topical enzymes to break down necrotic tissue and liquefy slough
What's mechanical debridement?
Using "wet to moist" gauze allowing for moisture to help the epithelization across the wound. Will debride necrotic tissue, but with less trauma to the wound.
NEVER "wet to dry" any more!! tears away newly generating tissue
How do you preserve blood supply to injured tissue to promote healing?
- CSM checks
- Warm packs
- Compression dressings or wraps to promote circulation in extremeties with poor venous return
What do steroids do to wound healing?
What's the foundation of wound healing?
What do you need to make sure you document with each assessment and dressing change of a wound?
How do tissues repair themselves and heal?
- Initial phase of inflammation
- Proliferative phase of granulation
- Remodeling phase of maturation
Discuss important nutritional assessments related to wound healing
- HIGH PROTEIN & Calorie diet
- With adequate carbs, fats, vitamins, minerals and rest.
POSITIVE nitrogen balance
vitamins important for wound healing...
- B-blood cell formation
- A-epithelization & collagen synthesis
- C-collagen formation & tissue synthesis
What minerals are important in wound healing?
- Copper & iron-RBC's Hgb and collagen synthesis
- Zinc- protein synthesis and cell proliferation
Describe 5 dietary interventions to promote wound healing in an elderly adult
- Nutrition supp. like Boost or Ensure
- Provide small meals & nutrient dense snacks
- Find something they like that is good for them and let them eat it all of the time if they want
- Give them ample eating time
- Encourage breakfast
- Monitor protein and serum albumin levels
- Monitor caloric intake....keep at 95% or must adjust
Discuss nursing diagnosis related to wound care:
- Partial thickness (dermal and epidermal damage)
- Full thickness (tissue damage)
- Dont want to leave it open...will get infected
- Dont want to put an antacid on it, it has sugar in it and will promote bacterial growth
- Dont put heat on it...will dry it out
- Spend $$ on good treatments...worth it
- Topical lotions and creams need to be administered with double gloves or you will get the affects of the ointment yourself.
Describe teaching a patient how to perform self dressing change:
- amount and type of dressings
- how to obtain supplies
- how often to change dressings
- how to change the dressing
Differentiate between the two types of wound separation:
Dehiscence-partial or complete separation of upper layers of a wound
Evisceration-total separation of layers and extrusion of internal organs or viscera thru the open wound
Interventions for wound separation:
- Dont panic
- If dehisced-cover with non adherent dressing.
- If eviscerated-cover wound with STERILE dressing moistened or saturated with normal saline
- Call MD STAT and stay with pt
- If eviscerated DONT re insert organs`
If the Dr. is anticipating a minimal amount of drainage what kind of device will be used to facilitate this?
What type of dressing provides a moist environment, but has limited absorption?
What kind of dressing is good for packing and absorbing?
What kind of dressing holds large armounts of exudate and is a non adhesive, which makes for easy removal.
What type of wound is Normal Saline and Kara Klenz used on?
All types of wounds
What type of wound do you put Neosporin on?
One that you suspect is infected....need a doctors order
What kind of wound do you put Acetic Acid on?
One that is positive for pseudomonas
What kind of wound to you put Dakins and Betadine on?
One that needs a broad spectrum antimicrobial