Acute and Chronic Wound Management
What is a drain tube?
A drainage tube is a device used to create and opening into a body cavity, wound or subcutaneous tissue in order to remove body fluids.
What is a chronic wound?
Occurs when the repair process does not proceed through an orderly and timely process as anticipated and healing is complicated and delayed by intrinsic and extrinsic factors that impact on the person, their wound or their environment.
Management of a pressure injury for a stage 3 or 4 pressure injury
Promote granulation and contraction (epithelialization)
Management of a pressure injury for a stage 2 pressure injury
Stage II or PTW (partial thickness wounds) Encourage regeneration of tissue and protect wound surface.
Types of pain associated with arterial ulcer
» Claudication or rest pain, may be worse at night when legs are elevated
What are the characteristics of an Arterial leg ulcer
» Oedema may be observed if infection is present » Thin shiny skin often with minimal hair growth » Leg shape may be straight » Limb cool to touch » Elevated legs become pale » Weak or absent pedal pulses » Ulcer margins well defined appear "punched out" » Poorly perfused wound bed » Difficult to remove necrotic tissue » Minimal wound exudate » Prone to infection
What are drain tubes used for?
• A drain promotes healing by providing an exit for blood, serum and debris • A drain can be free standing or attached to a drainage bag, intermittent suction, or to a self contained disposable drainage system that supplies its own suction
What type of autoimmune disorders cause chronic leg ulcers
Rhuematoid arthritis
What is an Ulcer?
is a loss of skin or mucosa integrity.
What type of haematological disorders cause chronic leg ulcers
- sickle cell anemia
What type of allergic response can cause chronic leg ulcers
- animal and insect bite - chemical - vegetation
Venous ulcer locations
- anterior to medial malleolus - pretibial area (lower third of leg) - shallow ulcer with ragged, irregular areas - ruddy granulation tissue on wound bed - wound exudate medium to high - may be odorous
What are the 4 types of Leg Ulcers?
- arterial - involving arteries and arterioles - venous - involving veins and venules - mixed arterial / venous - neuropathic - due to a loss of protective sensation
What type of tumors cause chronic leg ulcers
- basal cell carcinoma - squamous cell carcinoma - malignant melanoma
Invasive diagnostic tests include?
- blood profiles - wound tissue biopsy - MRI
Preparing the leg and wound
- cleanse the leg - maintain skin integrity - control eczema - daily inspection of the legs and feet - debridement
Preventative recurrence management of a venous ulcer consists of?
- compression therapy - education
Patient management of venous ulcer
- education - psychological - elevation and exercise - nutrition
Changes in the leg associated with Venous Ulcers
- firm "brawny" oedema - haemosiderin deposit - hard and woody skin (liposclerosis) - evidence of healed ulcers - hair is evident - white areas of intact skin - venous eczema - altered shape "inverted champagne bottle") - leaking oedema - limb may be warm
What type of infections cause chronic leg ulcers
- fungal infections - herpes - TB - HIV/AIDS - bacterial infections
What type of metabolic disorders cause chronic leg ulcers
- gout - diabetes
Compression management of a venous ulcer consists of?
- graduated compression therapy 30-40 mmHg at the ankle
Treatment for Leg Ulcers?
- identify and treat precipitating cause - promote circulation and improve venous return - promote healing - promote preventative care
What type of trauma can cause chronic leg ulcers
- lacerations - pressure injuries - burns - frostbite
What type of lymphatic disorders cause chronic leg ulcers
- lymphoma - lymphedema
Comprehensive patient history assessment includes?
- medications - psychosocial - co-morbidities - pain - nutrition - quality of life
Non-invasive diagnostic tests include?
- pedal and leg pulses - ABPI (indicates venous or arterial ulcer) - X-ray - wound swab - arterial and venous duplex scanning - pulse oximetry
Patient leg ulcer history assessment includes?
- the duration of the current leg ulcer - previous ulcer and the time they have taken to heal - time spent free of ulcers - strategies used to manage previous ulcers
Review management of a venous ulcer consists of?
- ulcers not reduced by 25% in 4 weeks or failing to heal in 12 weeks should consider specialist referral
Pain and pain management
- varying from nil, mild or extreme - may be relieved by elevation of the leg
What is the most common cause of Leg Ulcers?
- vascular disorders - neuropathic disorders
Patient clinical history assessment includes?
- venous disease - family history - decreased calf muscle pump function - surgery or trauma to effected leg - chest pain or PE - varicose veins - phlebitis - DVT - obesity
What type of vascular disorders cause chronic leg ulcers
- venous stasis - hypertension - vasculitis
what are some examples of active drains and closed wound drains?
Bellova Drains Redivac Drains Jackson-Pratt Drains
Management of a patient with an arterial ulcer
Complete T.I.M.E assessment • Stop smoking • Prevent mechanical trauma (tapes, shaving) • Skin hygiene and moisturizing • Nutrition, exercise and weight loss • Podiatry care • Elevate head of bed • Surgery
People with diabetes and foot ulcers have
Impaired inflammatory response • Association of atherosclerosis • Damaged nerves which diminishes pain sensation • Increased risk of infection • Peripheral vascular disease • Callus formation
What is an acute wound?
Is any wound that heals by primary intention, or any traumatic or surgical wound that heals by secondary intention, and which proceedes through an orderly and timely repair process.
What are some examples of passive drains or non suction drains?
Silastic Drains Corrugated Drains Penrose Drains
Abnormal events associated with drains
• A sudden change in colour, consistency, or amount may indicate a serious problem for your client. • Serous drainage that suddenly turns bloody and profuse may be a sign of haemorrhage • A change from thin and pink to thick and brown may indicate there is faecal material leaking into the wound from a failed bowel resection.
What is a skin tear
• Common injury amongst the frail elderly, occurring on the extremities • Considered a traumatic wound • Result of friction and shearing forces • Causes separation of the layers of the skin • Ageing processes effecting the skin, impaired mobility, impaired vision and use of medications such as anti coagulants and steroids
Management of patient with diabetic foot ulcers
• Complete T.I.M.E assessment • Elevation of the affected foot • Relief of pressure (Podiatry care) • Stop smoking • Prevent mechanical trauma (tapes, shaving) • Skin hygiene and moisturizing • Nutrition, exercise and weight loss • Control and maintenance of blood glucose levels
Treatment of skin tears
• Depends on the amount of tissue damage and/or loss • Moist wound management principles • Prevent infection: especially if wound is on lower extremity of client with diabetes or peripheral vascular disease.
Nursing management of a drain
• If more than one drain, label each with a number for easy identification & accurate documentation. • Monitor drainage for colour, consistency & quantity. • Assess for patency regularly • Document drainage on FBC • Systematic recordings 0600, 1200, 1800 and 2400 hrs
Normal events associated with drains
• Initially drainage may be sanguineous (dark red, thick from blood around the surgical site) • Gradually the output will decrease as the wound heals & will change to serosanguineous(pink) • The consistency will be thinner as there is less blood in the drainage. • Once the blood is gone it will turn thin and serous, (pale yellow and slow to a trickle) • Medical staff will then indicate when drain is to be removed
what are active drains and closed wound drains?
• Low pressure suction devices that continuously remove fluids against gravity via a closed drainage system • The drain is attached to a collapsible reservoir that exerts negative pressure to pull accumulated fluids from the wound bed
What are passive drains or non suction drains?
• Provide an exit for fluids, pus, or blood that interfere with wound healing or provide a source for bacterial proliferation • The passive drain is usually placed in the incision line
Management of a pressure injury for a stage 1 pressure injury
• Recently closed wound, Stage I pressure ulcer, denuded or excoriated skin: Encourage adequate perfusion and protect from further tissue damage.
What is a stage V pressure ulcer?
• Stage V is a pressure injury that is not able to be staged • This could be due to necrotic tissue.
When managing a drain
• Type and purpose of the drain • Location of the surgical drain • Proper management strategies • Potential problems • How to troubleshoot complications
