MO Wound Care

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MO Wound Care
2010-02-23 17:56:23
wound care

wounds & dressing changes
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  1. What kind of wound describes ones that are shallow, superficial, e.g., a surgical wound. Loss of epidermis, possibly part of dermis
    Partial Thickness
  2. Describe three stages of partial thickness wounds
    • a) inflammatory response (first 24 hrs)
    • b) epithelial proliferation and migration- (resurfacing begins at wound edges; dry wound takes 6-7 days but moist only 4 days)
    • c) reestablishment of epidermal layers (dry pink tissue forms). No true scar formation; normal function returns
  3. Describe acute wounds
    Acute wounds (caused by trauma or surgery) follow the normal healing process in an orderly and timely way.
  4. Define fistula
    communication between 2 organs or an organ and the outside of the body
  5. Define tunnel
    in the wound itself; not r/t organs; 2 or 3 wounds are connected
  6. What are you checking when you palpate around a wound?
    temperature, edema, & tenderness
  7. Describe two types of infectious odors & give examples of types of infections
    • aerobic = musty, grapes at harvest. example = pseudomonas
    • anaerobic = putrid. example = gangrene.
  8. Why do wounds in fatty tissue take longer to heal?
    Fat has less blood supply to deliver nutrients
  9. What is dehiscence?
    Dehiscence is the partial or total separation of wound layers. A client who is at risk for poor wound healing (e.g., poor nutritional status, infection, obesity) is at risk for dehiscence.
  10. Evisceration
    Protrusion of visceral organs through a wound opening. emergency! Pour saline soaked gauze over wound and call MD stat. The client should be allowed nothing by mouth (NPO), observed for signs and symptoms of shock, and prepared for emergency surgery.
  11. When is risk highest for a hemorrhage following surgery or injury?
    first 24-48 hours
  12. Define and describe Braden Scale
    • Braden scale predicts risk for developing a pressure ulcer.
    • Braden scale assesses moisture, sensory perception, activity, friction/shear, mobility, and nutrition on a scale of 1=highest-4=lowest.
  13. Possible nursing diagnoses for patients with wound, pressure ulcers etc
    anxiety, self esteem, coping, impaired skin or tissue integrity, infection, other
  14. What should be included in documentation for wound care
    size, color, amount, odor, interventions, pt response.
  15. When to use wet to dry dsgs?
    Wet to dry for debriding contaminated, necrotic wounds
  16. When to use wet to moist dsg?
    wet to moist for a healthy, healing wound
  17. Why is a moist dsg conducive to a healing wound?
    Moist is good because epithelial cells only migrate across moist surfaces = healing
  18. What are cytotoxic solutions and when should they be used?
    Cytotoxic solutions to be used cautiously if at all: Acetic acid, hydrogen peroxide, betadine, Dakins (bleach soln.) may be used by some specialists to clean an especially contaminated wound. Others avoid.
  19. Describe a wound vac
    Wound Vac- purpose is to pull sides of an open wound together from inside out by applying negative pressure in a moist environment.
  20. Best way to measure a wound
    When measuring a wound, always measure in cm. A consistent observer is ideal.
  21. Undermining
    The edges of the wound curl under.
  22. Goals of wound healing
    • remove debris
    • reduce bacteria
    • promote optimal environment
    • promote inflammation
  23. Ideal dressing characteristics
    • provides a moist environment
    • provides thermal insulation
    • allows removal
    • without causing trauma to wound
    • removes drainage and debris
    • maintains an environment free of particulates and toxic products
  24. Describe chronic wounds
    Chronic wounds (peripheral vascular venous ulcers, lower extremity arterial ulcers, neuropathic ulcers, and pressure ulcers) heal slowly, repair does not occur, and return to normal function is slowed.
  25. Describe primary intention
    • The skin edges are approximated or closed, and the risk of infection is low because the wound is uncontaminated by microorganisms. Healing
    • occurs quickly. Inflammation typically subsides in less than 24 hours, the wound fills with epidermal cells, and resurfacing occurs between 4 and 7 days.
  26. Describe secondary intention
    Examples of tissue-loss wounds include burns, pressure ulcers, or severe lacerations. A wound involving loss of tissue heals by secondary intention. The wound remains open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention, and thus the chance of infection is greater. These wounds require ongoing wound care (a moist environment) to support wound healing.
  27. Which wounds extend into the dermis and heal by scar formation. An example is a pressure ulcer.
  28. Hemorrhage occurring after hemostasis indicates:
    • A slipped surgical suture
    • A dislodged clot, infection
    • Erosion of a blood vessel by a foreign object (e.g., a drain)
  29. Hemorrhage may occur externally or internally. The nurse can detect internal bleeding by:
    • Looking for distention or swelling of the affected body part
    • A change in the type and amount of drainage from a surgical drain
    • Signs of hypovolemic shock (e.g., increased pulse, decreased blood pressure, cool, clammy skin)
  30. Describe hematoma
    a localized collection of blood underneath the tissues that often takes on a bluish discoloration. The area is swollen and involves a change in color, sensation, or warmth.
  31. The chances of wound infection are greater when:
    • The wound contains dead or necrotic tissue.
    • There are foreign bodies in or near the wound.
    • The blood supply and local tissue defenses are reduced.
  32. A contaminated or traumatic wound may show signs of infection within _______ . A surgical wound infection usually develops postoperatively within ________.
    • 2-3 days
    • 4-5 days
  33. Signs of infection include:
    • Fever
    • Tenderness and pain at the wound site
    • An elevated white blood cell count
    • The edges of the wound may appear inflamed.
    • If drainage is present, it is odorous and purulent, which causes a yellow, green, or brown color, depending on the causative organism.
  34. When does dehiscence typically occur?
    Dehiscence often occurs with abdominal surgical wounds after a sudden strain, such as coughing, vomiting, or sitting up in bed. Clients often report feeling as though something has popped. When there is an increase in serosanguineous drainage from a wound, the nurse should be alert for the potential for dehiscence.
  35. How do blood counts influence wound healing?
    A hematocrit value below 33% and a hemoglobin value below 10 g per 100 mL negatively influence tissue repair because of decreased oxygen delivery.
  36. How does smoking affect wound healing?
    • Smoking reduces the amount of functional hemoglobin in the blood, thus decreasing tissue oxygenation.
    • Smoking may increase platelet aggregation and cause hypercoagulability.
    • Smoking interferes with normal cellular mechanisms that promote the release of oxygen into tissues.
  37. How does drug therapy affect wound healing?
    • Long-term steroid therapy may diminish the inflammatory response and reduce the healing potential.
    • Steroids slow collagen synthesis.
    • Cortisone depresses fibroblast activity and capillary growth.
    • Chemotherapy depresses bone marrow production of white blood cells and impairs immune function.
  38. When is a Jackson-Pratt drain used?
    when small amounts (100 to 200 mL) of drainage are anticipated
  39. What type of drainage system is appropriate for up to 500 mL?
    Hemovac drainage system
  40. What is a Penrose drain and when is it used?
    When drainage is expected within the wound, a Penrose drain may be used to help prevent complications. This soft rubber drain is a soft tube that can be "advanced" or pulled out in stages as the wound heals from the inside out.
  41. What about drainage system is important for RN to assess post-surgery?
    Identify the placement of closed wound drain or type of drainage system when a client returns from surgery. Awareness of drain placement is needed to plan skin care and identify the quantity of dressing supplies required.

    Inspect for tube patency by observing drainage movement through the tubing in the direction of the reservoir, and look for intact connection sites.A properly functioning system maintains suction until the reservoir is filled or drainage has ceased. Tension on the drainage tubing increases injury to the skin and underlying muscle.
  42. When is dry guaze used on a wound?
    These are most often used for abrasions and postoperative incisions when minimal drainage is anticipated.
  43. When are moist dressings used?
    Moist dressings are often used to help heal full-thickness deep wounds. Granulation tissue and new capillary networks must form to fill in the defect.