Wounds and Wound Care
Stage II pressure ulcer
partial thickness skin loss with exposed dermis
deep tissue pressure injury
persistent non-blanchable deep red, maroon, or purple discoloration
Types of healing
primary intention secondary intention tertiary intention
describe the status of the wound using the___
red, yellow and black classification system
erythema
redness of the skin due to capillary dilation
sharp debridement
requires the use of scalpel, scissors, and/or forceps to selectively remove devitalized tissues, foreign materials or debris from a wound. -most often used for wounds with large amounts of thick, adherent, necrotic tissue, also for cellulitis or sepsis. most expedient form of removing necrotic tissue.
transparent dressing
see-through, film life, thin sheet that is semipermeable, allowing for an interchange of oxygen between the wound and the environment
Montgomery straps
special adhesive strips that are applied when dressings must be changed frequently at the surgical site
Evisceration
The displacement of organs outside of the body.
Epiboly
closed or rolled wound edges
infected wound
colonized with bacteria causing erythema, swelling and warmth around the wound; foul odor, drainage, and discomfort or pain.
contaminated wound
colonized with microorganisms but has not progressed to an infection
Vacuum assisted closure
device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together
binders
devices applied to hold dressings in place, provide support, apply pressure, or limit motion
Jackson-Pratt drain
drainage system that uses a compressed bulb, applies slight suction within the wound
alginate dressings are contraindicated in
dry wounds and full thickness wounds with exposed tendons or bone
undermining
erosion of tissue from underneath intact skin at wound edge
causes of pressure ulcers
-Immobility -Inadequate nutrition -Fecal and Urinary Incontinence -Decreased mental status -Diminished sensation -Excessive body heat -Advanced age -Chronic Medical condition
Foam dressing
-a highly absorbent dressing that wicks exudate off the wound, decreasing maceration of surrounding tissue -maintains wound moisture
Classification of wounds
-duration of healing -depth of wound -presence and extent of microorganisms in the wound
Hydrogel dressing
-forms a gelatinous mass when in contact with exudate to maintain a moist wound environment -pads the wound, increasing comfort and reducing shearing -softens eschar via autolytic debridement
growth factor-impregnating dressing
-growth factors are small protein hormones that enhance wound healing at various places along the healing cascade
assess the characteristics of the wound by:
-identify the location of the wound -measure length, width, and depth, amount of tunneling and undermining -approximation or non-approximation (dehiscence) -assess the condition of the surrounding skin for infection -identify type of exudate -document the number of saturated gauze or abdominal pads -document output from wound drains in mL -Identify the stage of the wound (pressure ulcer stage) -identify pain or discomfort associated with the wound
Alginate dressings
-made of soft, nonwoven fibers developed from seaweed in the form of pads, ropes, or ribbons for application to various shaped wounds -becomes a gel on contact with exudate and absorbs 20 times its weight
what are foam dressings used for?
-used for heavily exudating wounds, such as deep cavity wounds, weeping ulcers, and chronic wounds -used in wound vacuum-assisted closure systems
what is the use of a hydrogel dressing?
-used for partial-thickness and full-thickness wounds, necrotic wounds, and superficial burns
what is a hydrocolloid dressing used for?
-used for wounds with light to moderate drainage -contraindicated with heavy drainage because this type of dressing absorbs slowly -used for shallow to medium depth skin ulcers and donor sites and packing for small cavity wounds *does not permit visualization of the wound
what are alginate dressings used for?
-used for wounds with moderate to high amounts of drainage -used for partial-thickness and full-thickness wounds, venous status ulcers, pressure ulcers, diabetic ulcers, graft sites, traumatic and surgical wounds, and infected wounds
what is a transparent dressing used for?
-used over intact skin to reduce shearing or to protect a small superficial wound such as a blister, stage I or II pressure ulcer, abrasion, skin tear, IV site or minor burn *used for wound with minimal drainage
growth factor-impregnating dressings are used to:
-used to attract immune cells to fight infection, promote production of connective tissue, facilitate new blood vessel growth to nourish the area and promote remodeling
slough
A layer or mass of dead tissue separated from surrounding living tissue, as in a wound, sore, or inflammation.
tunneling wound
A passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound. Open wound.
clean wound
A wound that is not infected
Dehiscence
Bursting open of a wound, especially a surgical abdominal wound
Hemovac drain
CLOSED DRAIN SYSTEM, a surgical drain to prevent blood and lymphatic fluid buildup under your skin and encourage healing. drains fluid by passive suction
unstageable pressure ulcer
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
Stage IV pressure ulcer
Full-thickness tissue loss with exposed bone, tendon, or muscle
Stage III pressure ulcer
Full-thickness tissue loss with no bone, tendon, or muscle visible
stage I pressure ulcer
Nonblanchable redness of a localized, area of intact skin
mechanical debridement
Physical removal of debris by irrigation, hydrotherapy or wet-to-dry dressing application
Tertiary intention
The wound is purposely left open due to heavy infection or contamination initially cleaned, debrided and observed (Tissue Graft, Stage 4 Pressure ulcer with necrotic tissue and infection)
Maceration
To soften tissues after death by soaking and by enzymatic digestion
Penrose drain
a flat, thin, rubber tube inserted into a wound to allow for fluid to flow from the wound; it has an open end that drains onto a dressing
fistulas
abnormal passage from one organ or cavity to another
secondary intention
extensive tissue loss seen in messy large wounds with jagged edges; granulation tissue sometimes forms and remains under/within wound after healing *should not be closed, heals from the inside out
Factors that delay wound healing
increased age, chronic illnesses and impaired health, edema, fever, infection, lifestyle, medications, multiple wounds, nutrition, tissue perfusion, radiation, wound tension
hydrocolloid dressings are contraindicated in
infected wounds, wounds with exposed tendon or bone, and foot ulcers associated with diabetes mellitus
Superficial wound
involves only the epidermis ex: superficial excoriation caused by friction may take several days to a week to heal
full thickness wound
loss of epidermis and dermis; may extend into deeper structures, such as subcutaneous tissue, muscle, joint, and bone, which are nonregenerative ex: stage III, IV pressure ulcer may take months or years to heal; some may never heal because of underlying pathology, such as inadequate circulation secondary to a peripheral occlusive disorder or diabetes.
partial thickness wound
loss of epidermis and possibly partial loss of the dermis ex: partial thickness burn may take 2-3 weeks to heal
primary intention
minimal/no tissue loss edges well approximated little scarring/surgical incisions
Black
necrotic tissue (eschar) care involves: debridement
eschar
necrotic tissue that would need to be surgically removed
Red
newly granulating tissue care involves: gentle cleaning and a moist dressing (transparent or hydrocolloid)
Hydrocolloid dressing
occlusive adhesive dressing that adheres to wet and dry sites -protects the wound from contamination, serving as an excellent microbial barrier
clean-contaminated wound
occurs from the surgical entry of the reproductive, urinary, respiratory, or gastrointestinal system
Yellow
oozing exudate which may be purulent care involves: cleansing or irrigating the wound; using a wet to moist dressing, foam absorptive dressing, hydrogel, or alginate to debride the wound
T-binders
used to secure a dressing like the anus or perineum or within the groin.
Enzymatic debridement
using topical substances that break down dead tissue
hydrogel dressings are contraindicated in
wounds that infected, have excessive exudate or are bleeding
foam dressings are contraindicated in
wounds with little drainage because of its drying effect