Advanced Wounds Lab

Acute wounds in a healthy patient will heal fairly quickly because of a cascade of growth factors and cellular stimulants that tend to keep the acute wound on the "healing track".

ok!

These types of wounds often fail to heal within *3 months* and are generally caused by an underlying pathological process.

*Chronic* wounds

(Absorption Dressings) These are *nonlinting* and *absorbent*. they can vary in thickness and have *non-adherent layer* which allows for easy and painless removal. Some come with *adhesive borders* and/or a *film coating* which provides *bacterial barrier*. Can be changed up to 3 times a week. Provide a *moist* environment and *thermal insulation* Used to absorb of all amounts of exudate, and to pack. (Mr. Clean Does it allllll)

*FOAMS!*

*INFECTION* Edges of skin discoloration may be *D__________* and indistinct Systemic *F________* may or may not be present Usually moderate to large amounts of *E____________* Character of exudate is serous and seropurulent to purulent Specific *O__________* are related to some bacterial organisms Localized edema and induration accompanied by warmth usually indicative of infection

*INFECTION* Edges of skin discoloration may be *Diffuse* and indistinct Systemic *Fever* may or may not be present Usually moderate to large amounts of *Exudate* Character of exudate is serous and seropurulent to purulent Specific *Odors* are related to some bacterial organisms Localized edema and induration accompanied by warmth usually indicative of infection

*INFLAMMATION* Localized to the Wound Area Usually well defined _____________; approximately *1 cm or less* *O________* may or may not be present *Exudate usually minimal* and is serosanguineous to serous May be slight swelling or firmness at wound edge

*Inflammation* Localized to the Wound Area Usually well defined *borders*; approximately *1 cm or less* *Odor* may or may not be present *Exudate usually minimal* and is serosanguineous to serous May be slight swelling or firmness at wound edge

(Topical Wound Therapy) Absorb Excess Exudate: Large amounts of *exudate* can *_______________ peri-wound skin* and *increase the size* of the wound, as well as *delay wound healing*

*Macerate* peri-wound skin

A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care? A- The new nurse cleans the ulcer with a sterile dressing soaked in half-strength peroxide. B- The new nurse uses a hydrocolloid dressing (DuoDerm) to cover the ulcer. C- The new nurse irrigates the pressure ulcer with sterile saline using a 30-mL syringe. D- The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer.

A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care? *A- The new nurse cleans the ulcer with a sterile dressing soaked in half-strength peroxide.* (no peroxide! it kills the healing tissue!) B- The new nurse uses a hydrocolloid dressing (DuoDerm) to cover the ulcer. C- The new nurse irrigates the pressure ulcer with sterile saline using a 30-mL syringe. D- The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer.

A patient states that she is unable to get her transparent dressing to stay in place. What instruction should the nurse provide the patient? A- "If you are having difficulty with your dressing changes, we can see if the doctor will give you a referral to a home care agency." B- "This type of dressing requires frequent changing because they do not stay in place." C- "There are many options on the market. Why don't you use a nonadhesive-backed transparent dressing instead?" D- "Make sure that you have a margin of 1 to 1.5 inches around the wound, and that the skin is thoroughly dry before applying the dressing."

A patient states that she is unable to get her transparent dressing to stay in place. What instruction should the nurse provide the patient? A- "If you are having difficulty with your dressing changes, we can see if the doctor will give you a referral to a home care agency." B- "This type of dressing requires frequent changing because they do not stay in place." C- "There are many options on the market. Why don't you use a nonadhesive-backed transparent dressing instead?" *D- "Make sure that you have a margin of 1 to 1.5 inches around the wound, and that the skin is thoroughly dry before applying the dressing."* *(If the transparent dressing does not stay in place, the size of the dressing should be evaluated for adequate (1 to 1.5 inches) margin, and the skin should be dried thoroughly before reapplication. The patient requires further instruction, not necessarily a referral, regarding interventions to aid in dressing adherence. The dressing coming off is an unexpected outcome. Blaming the patient is non-therapeutic)

A patient's 4 × 3-cm leg wound has a 0.4 cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound? A- Transparent film dressing (Tegaderm) B- Dry gauze dressing (Kerlix) C- Nonadherent dressing (Xeroform) D- Hydrocolloid dressing (DuoDerm)

A patient's 4 × 3-cm leg wound has a 0.4 cm black area (*eschar!*)in the center of the wound surrounded by yellow-green semiliquid material (*exudate*). Which dressing should the nurse apply to the wound? A- Transparent film dressing (Tegaderm) (no good for exudate) B- Dry gauze dressing (Kerlix) (no good for exudate) C- Nonadherent dressing (Xeroform) *D- Hydrocolloid dressing (DuoDerm)*

Reduce *pressure* Reduce *friction* Reduce *shear* Reduce *moisture* Increase *blood supply* and *oxygenation* (COPD, or PVD) *Affect healing* at the *cellular level* Reduce increasing *neuropathy* by controlling glucose These are all ways to reduce ________________ factors of wounds

Causative Factors

(Methods of Debridement) Chemical Enzymatic debridement can be augmented further by using ________________ retentive dressings.

Chemical Enzymatic debridement can be augmented further by using *moisture* retentive dressings.

(Absoprtion Dressings) These are *Occlusive or semi-occlusive* dressings composed of such materials as *gelatin*, *pectin*, *carboxymethylcellulose*. They come in various shapes, sizes, adhesiveness and foams (including wafers, powders and pastes) They provide a moist healing environment that allows clean wounds to granulate and necrotic wounds to debride autolytically.

Hydrocolloid Dressings (Duoderm, Restore, Tegasorb)

(Absorption Dressings) These are sheets without adhesive borders, changed up to once per day, while sheets with adhesive borders can be changed up to 3 times per week They *Donate fluid to the wound* *Water or glycerin based gel*, *impregnated gauzes*, or *sheet dressings*. Because of their high water content, some *can't absorb large amounts of exudates.*

Hydrogels

Surface swab: Fluid Culturing: Wound biopsy: These are the three methods of __________________ a wound

Culturing

(Wound Culturing Methods) When collecting, *don't use purulent drainage matter* to culture and don't do *over hard eschar*. Use a *sterile calcium alginate* or *rayon swab*, not a cotton tipped swab. Thoroughly *rinse the wound with sterile saline* solution before culturing. Swab edges using *10 point coverage*. Another technique consists of *rotating the swab over a 1cm area, with sufficient pressure to express fluid from the wound base.* This technique is believed to be more reflective of "tissue" bioburden than swabs of exudate or swabs taken with a Z stroke. Theoretically, this technique is the best technique for wound swabbing provided the wound is clean first and the area sampled is over viable tissue, not necrotic tissue or eschar.

Surface swabs

(Methods of Debridement) This is considered the *gold standard* for debridement. It requires *local*, *regional* or *general anesthesia* for *pain*. It is *fast* and *selective*

Surgical Debridement

Maintain *nutrition* and *hydration* Control *blood glucose* levels Avoid *steriods* Establish protocols for morbidly obese patients for special equipment (such as beds, side rails, walkers, toilet facilities) These are ways to provide ______________________ support for wounds

Systemic Support

Friction is the mechanical force of something being dragged. Shear is...

Two surfaces being dragged in parallel but opposite directions

(Adjuncive Wound Care Therapies) Vibrations from the sound waves pass into the tissue, causing it to *vibrate and heat up*. Thermal effects increase local circulation that disperses the heat and increasing cell metabolism. There are increases in *macrophage activity*, *protein synthesis by fibroblasts* and *angiogenesis*. As a result, wounds may *progress through the inflammatory phase faster* or acute *inflammation may be reinitiated if healing has stalled*. Nonthermal effects stimulate movement of fluid within and between cells which is thought to encourage debridement. Benefits are inconclusive. DONT use over *eyes*, *heart*, *active bleeding*, *infection*, over *malignancies*, *thrombophlebitis*, *pacemakers*, and *reproductive organs*.

Ultrasound

(Adjunctive Wound Care Therapies) These are *controlled negative pressure* systems which assist and accelerate wound healing by *removing fluids*, *stimulating granulation* formation, reducing *bacterial burden* of the wound and maintaining a *moist wound environment* This is done by placing open-cell reticulated foam into the wound, sealing with semi occlusive drape, and creating a subatmospheric pressure via tube and computerized pump. Used in *chronic*, *acute*, *traumatic*, *subacute* and *dehisced wounds* (remember that one dude at marquis sam?..woof), *partial thickness burns*, *pressure/diabetic ulcers*, *flaps* & *grafts*

Wound Vac Systems (negative pressure wound therapy).

(Wound Culturing Methods) *Removal of a piece of tissue* with a scalpel or punch. The wound may be anesthetized topically rather than by injection as the topical anesthetic does not affect the fluid balance in the tissue and so will not affect the culture results.

Wound biopsy

(Methods of Debridement) These are a specific type of chemical debridement. Also called biologic debridement. They are sterilized before being introduced into the wound. It is theorized that the process involves *proteolytic enzymes*, including *collagenase*, that *break down the necrotic tissue*. It is also believed other microorganisms such as colonized bacteria, are consumed and destroyed in the process. This is *fast* acting, *psychologically uncomfortable* for some, and *short term use* only.

*Maggots*

(Methods of Debridement) This method includes *Wet-To-Damp* (or wet-to-dry), *Irrigation* & *Whirlpool* methods

*Mechanical*

(The Red Yellow Black Classification System) *Fibrin* left over from the healing process usually appears as yellow colored *S____________* or *Dead tissue* in the wound base. This provides a medium for *Bacterial Growth*.

*Slough*

Provides an accurate description of the wound to colleagues as well as clues about the etiology and plan of care. For example, a coccyx wound should prompt caregivers to explore the patient's sitting or lying positions. When documenting and describing a wound, we use the clock time table with 12/noon pointing towards the patient's head.

*Anatomic Location*

(Methods of Debridement) This method of debridement includes *enzymes*, *sodium hypochlorite*, *Dakin's Solution*, *maggots*, *Silver Nitrate*

*Chemical* debridement

(Methods of Debridement) Appropriate technique and dressing material is critical for effective wet-to-dry debridement. Gauze should be ___________________ (not dripping wet) when applied to the wound, and although the gauze should contact the entire wound surface, it should not be packed ________________ into the wound. Wet-to-dry dressings must be allowed to ________________ before removal, thus the need to avoid oversaturation of the gauze.

(Methods of Debridement) Appropriate technique and dressing material is critical for effect wet-to-dry debridement. Gauze should be *moistened*(not dripping wet) when applied to the wound, and although the gauze should contact the entire wound surface, it should not be packed *tightly* into the wound. Wet-to-dry dressings must be allowed to *dry out* before removal, thus the need to avoid oversaturation of the gauze.

(Methods of Debridement) The *most effective* type of dressing material for *wet-to-dry* dressings is an *OPEN-WEAVE cotton fabric* because it has both *mildly a____________ qualities* (scruffy) and *ad____________ properties* (sticky). Non-woven gauze is ineffective because fibers don't allow for adherence

(Methods of Debridement) The most effective type of dressing material for wet-to-dry dressings is an open-weave cotton fabric because it has both *mildly abrasive qualities* and *adherent properties*. Non-woven gauze is ineffective because smoother fibers don't allow for adherence

(Absorption Dressings) These are used for *full thickness wounds*, *undermining* or *tunneling* Can handle moderate to *heavy* exudates. Work in *contaminated/infected wounds* They can absorb *20x their weight*, form a *gel* to create ideal healing environment, facilitate *autolytic debridement* can be applied and removed easily. *NOT* good for *light exudate* wounds, or *dry eschar* because they can *dehydrate the wound bed*

*Alginates*

(Absorption Dressings) A PRIMARY DRESSING: Spun fibers of brown *seaweed that absorbs* serous fluid or exudate, to *form a gel* that fits the wound shape. *non-adhesive*, *non-occlusive* so they require a *secondary cover* and should be changed up to once a day. Available in *ropes* or *sheets* and cut to loosely fit/pack wound. Used to absorb and pack.

*Alginates* (Probably similar substance as "agar agar" for cooking (alganose), or "agar" mediums for petri dishes... NEAT! off topic..but NEAT!)

Infection *prolongs* the *inflammatory phase*, *delays collagen synthesis*, and *prevents epithelizalization*. _________________________ are used for infections involving the *soft tissue or bone* (They are *not* for bacterial control at the *wound surface*) Antiseptic solutions generally are not recommended.

*Systemic antibiotics*

(Methods of Debridement) *Autolysis* can be used alone or combined with other debridement techniques. Autolysis is *automatically employed* whenever a ______________ retentive dressing is employed. The only time we would use autolysis for the *sole method* of debridement would be for *non-______________ wounds* with a *limited volume* of *________________ tissue*

. Autolysis is automatically employed whenever a *Moisture* retentive dressing is employed. The only time we would use autolysis for the sole method of debridement would be for *non-infected wounds* with a limited volume of *necrotic tissue*

Alganates ABSORB a lot... Hydrocolloids provide a moist environment AND absorb some Hydrogels...

...Don't absorb at all Good for keeping things moist

(Topical Wound Therapy) Identify and eliminate infection: All wounds are __________________ with bacteria. This may be minimized through *wound cleansing* and *debridement* *Normal Saline* is preferred cleansing agent because *it will not harm healing tissue* and is adequate enough to clean most wounds.If the irrigation pressure is too high, it can damage healing tissue. If its too low, it will not clean. *Safe* & *effective* irrigation pressures of *4* to *15* PSI can be obtained using a _____ gauge needle (angiocath) with a ____mL syringe

All wounds are *colonized* with bacteria. Safe & effective irrigation pressures of 4 to 15 PSI can be obtained using a *19* gauge needle (angiocath) with a *35* mL syringe

All wounds are classified based on the depth of tissue destruction. Depth of tissue destruction is either ___________________ or __________________

All wounds are classified based on the depth of tissue destruction. Depth of tissue destruction is either *Partial Thickness* or *Full Thickness*

Although chronic wounds can be categorized as failing to heal after 3 months, and are often due to underlying pathological processes, the *time frame is only part of the data to determine if the wound is chronic*. Chronic wounds, such as *P______________ U____________*, *V_______________ U_____________* and *Neur______________* Wounds behave much differently and may be extremely slow to heal

Although chronic wounds can be categorized as failing to heal after 3 months, and are often due to underlying pathological processes, the *time frame is only part of the data to determine if the wound is chronic*. Chronic wounds, such as *Pressure Ulcers*, *Vascular Ulcers* and *Neuropathic Wounds* behave much differently and may be extremely slow to heal

(Topical Wound Therapy) Treat Systemic Infection: Evaluate for *Bacteremia*, *Sepsis*, *advancing cellulitis* or *osteomyelitis* and treat with appropriate _______________

Antibiotic

Tissue perfusion/oxygenation Nutrition Infection Inflammation Diabetes Obesity Medications Age Stress Immunosuppresion Any systemic condition (disease, malignancy, sepsis) Blood abnormalities Wound "factors" (temp., edema, bacteria, pH) These can all hinder

Healing

(Methods of Debridement) This is the *slower process* of disintegration or liquefaction of tissue or cells by the body's own mechanisms (leukocytes or enzymes). Naturally occurring process in *moist* & *vascular* environments. Requires moisture, adequate *leukocyte function* and *neutrophil count* Enhanced by applying *moisture-retentive dressing* to necrotic tissue and not disturbing it for a period of time. If wound is dry, we want to make it moist (*hydrogels*), if its *too wet* we want absorb excess exudate without drying it (alginate or hydrocolloid dressings)

Autolysis

(Topical Wound Therapy) Maintain Moist Wound Surface: A moist wound surface facilitates wound healing. Choose a _________________ that keeps the surrounding *intact skin dry* while keeping the *wound bed moist*

Choose a *dressing* that keeps the surrounding intact skin dry while keeping the wound bed moist

(Methods of Debridement) When performing a Whirpool mechanical debridement, vasodilation occurs, increasing circulation to the wound. But it could also increase overall circulation to the extremities of a patient with *venous insufficiency* which would contribute to Venous _________________... So be careful, yo

Congestion! Warm whirpool can make the blood flow to the feet, but then it can't get back up!

*Full thickness* wounds extend through the *dermis* into *tissue beneath* and may expose *adipose tissue*, *muscle*, or *bone*. These wounds heal by *C___________________* and *S_____ T__________*

Contraction & Scar Tissue

Remove tissue and foreign matter *that supports bacterial growth* *Reduce the volume of pathogenic microbes* present in the wound thereby reducing infection and the risk for infection *Visualization of the wound wall* and base. These are the main objectives of...

Debridement

The primary purpose of _____________________ is to reduce or remove dead and necrotic tissue in a healable wound because this tissue is an *inflammatory stimulus* and *culture medium for bacteria growth*

Debridement

(Debridement) Classified as *Selective* or *Non-Selective* But then debridement is classified by __________________________ (autolysis, chemical, mechanical, or sharp (surgical))

Debridement is classified by *actual mechanism of action* Autolysis (cell suicide) Chemical Mechanical Sharp (surgical)

(Methods of Debridement) Wet-to-dry dressings are rarely done correctly, are *labor intensive*, provide several opportunities to *break sterile technique*, and they kinda suck for the patient... Debris removal is often less than ideal because the nurse did what to the dry dressing before removing it? On the other hand, if removed correctly, it causes acute pain and may require analgesics... This mechanical method is also nonselective, so it tends to remove what else along with the necrotic tissue? If the wound is *exudative*, this method provides insufficient absorption and can cause tissue damage around the wound.

Debris removal is often less than ideal, because the nurse tends to incorrectly *moisten the gauze* before removing it... thus limiting the amount of debris taken with it. Its nonselective, so it removes *granulation* tissue and *epithelial* tissue along with he necrotic tissue

A unique form of pressure ulcer. A pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise

Deep tissue injury

(Methods of Debridement) When using the *irrigation* method of mechanical debridement, why should you wear a mask, gown and gloves?

Delivering fluid under pressure to the wound bed can cause *dissemination of wound bacteria over a wide area*, exposing the *patient and care provider to potential contamination*. You should wear a mask, gown, and gloves. CAUSE THAT PUS AND GOOP GONNA SPRAY INTO YOUR MOUF!

(Topical Wound Therapy) Control Pain: Control pain so the body can focus on healing

Duh

(Adjunctive Wound Care Therapies) This uses a transfer of current to tissues to support wound healing. The current stimulates *fibroblasts*, a key cell in wound contraction and collagen synthesis. Also creates positive blood flow and local tissue oxygenation, it also has bacteriostatic/cidal effects. (not FDA approved)

Electrical Stimulation

(The Red Yellow Black Classification System) Black, the least healthy wound color, signals necrosis. *Dead avascular* tissue (known as *E_______________*) slows healing and provides a site for microorganisms to proliferate.

Eschar

(Absorption Dressings) These are used as *primary* dressing for *absorption and insulation*, or as a *secondary* dressing for *wounds with packing*. *Partial* to *full thickness wounds* Can handle a *little or a lot* of exudate. Work well in *infected wounds* May be used to provide *additional absorption* around *drainage tubes* and/or *offloading* Non-adherent forms protect surrounding skin. Conform to angular shapes and can be used *under compression* for *venous ulcers* They are *NOT* good for wounds with *dry eschar*

FOAMS!

(Wound Culturing Methods) Done by *needle aspiration*, which involves insertion of a needle in the tissue adjacent to the wound to aspirate tissue fluid. Negative pressure is applied, and the needle tip is inserted into the tissue in several directions in order to obtain wound exudate.

Fluid Culturing

anatomic location extent of tissue involvement percentage and type of tissue in the wound bed wound size (length, width, depth, undermining, tunneling) wound exudate odor wound margins periwound area wound pain *These are all parts of the ________________________*

Focused Wound Assessment

(Topical Wound Therapy) Protect a Healing Wound: Healing tissue is very __________, and a dressing should protect it from trauma and invasion

Fragile

Stage 3 pressure ulcer...

Full thickness wound, down to *Fat* Often includes undermining or tunneling

Stage 4 pressure ulcer...

Full thickness wound, down to muscle or bone often includes undermining or tunneling

(Absorption Dressings) These are OG dressings. they can be impregnated with stuff too. Function: Minimal to heavy absorption. Can by used as a packing material. When impregnated can deliver antimicrobial, medications, nutrients, and moisture. downsides: may *lint* or may adhere to wound and cause nonselective debridement *No longer the standard* of care. Cause *pain* and *poor antimicrobial properties*

Gauze and impregnated gauze

(Methods of Debridement) The timeframe for autolysis to occur varies depending on the *size* of the wound and the *amount & type* of *necrotic tissue*. Generally, progress should start to be seen within ____ to ____ hours. Black *Eschar* will *loosen from the edges*, become *soft*, *brown*/*gray* and eventually turn to stringy yellow *slough*.

Generally, progress should start to be seen within *72* to *96* hours. Black Eschar will loosen from the edges, become soft, brown/gray and eventually turn to stringy yellow slough.

(Adjunctive Wound Care Therapies) This is when you put someone in a big honkin tube, slowly pump it full of pure oxygen, and increase the pressure many times beyond that of sea level. This helps forcefully oxygenate a patient with poorly healing wounds from poor perfusion

Hyperbaric Oxygenation

Infected wounds are toxic to fibroblasts and other repairing cells. Necrotic tissue and exudates harbor bacteria The "bioburden" contributes to poor healing by competing for *N_______________* and due to the harmful bacteria by-products Wounds must be cleaned and necrotic tissue debrided *All chronic wounds* are considered *C_____________________* or colonized, but not necessarily infected

Infected wounds are toxic to fibroblasts and other repairing cells. Necrotic tissue and exudates harbor bacteria The "bioburden" contributes to poor healing by competing for *Nutrients* and due to the harmful bacteria by-products Wounds must be cleaned and necrotic tissue debrided *All chronic wounds* are considered *Contaminated* or colonized, but not necessarily infected

(Methods of Debridement) This is a type of mechanical debridement. Provides adequate force to remove debris without damaging healthy tissue or inoculating the underlying tissue with bacteria. Should use a 35 mL syringe, using a 19 gauge needle or angiocath to provide high pressure

Irrigation

(Methods of Debridement) When using chemical debridement methods, why would we want to select a *dressing* that requires the *same application frequency* as the *enzyme*/chemical put on the wound?

Its cost effective. A dressing meant to be in place for longer periods would just be replaced too soon every time we reapply the enzyme/chemical

Necrotic tissue that is not removed can impede wound healing. It can also cause the spread of bacterial damage to *deeper tissue* and cause *surrounding cellulitis*, *osteomyelitis*, and possibly *septicemia*. THis can ultimately lead to *limb amputation* and *death*

NEAT

Can you determine if a wound is acute or chronic simply based on time?

NO! No set time frame specifies when an acute turns chronic

(Topical Wound Therapy) Pack Dead Space: Open cavities provide a collection for wound ____________, which can be a *medium for bacterial growth* and *abscess formation*. Open cavities should be _________________ to absorb *drainage* and *prevent superficial wound closure* over a *fluid filled defect*

Open cavities provide a collection for wound *Exudate*, which can be a medium for bacterial growth and abscess formation. Open cavities should be *loosely packed* to absorb drainage and prevent superficial wound closure over a fluid filled defect

Stage 2 pressure ulcer...

Open into dermis, no slough

The ______________ Dressing is the therapeutic or protective covering applied *directly to the wound bed* to *meet the needs of the wound*.

PRIMARY

Percentage and Type of Tissue in Wound Base Viable tissue needs to be distinguished from nonviable tissue. Many wounds contain a combination of tissue types and should be described in percentages. For example, 50% of the wound bed contains eschar and 50% contains granulation tissue. Type and amount is important because it indicates to what extent the wound is progressing toward healing. Healing wounds are characterized by increasing amounts of _________________ tissue and decreasing amounts of ________________ tissue.

Percentage and Type of Tissue in Wound Base Viable tissue needs to be distinguished from nonviable tissue. Many wounds contain a combination of tissue types and should be described in percentages. For example, 50% of the wound bed contains eschar and 50% contains granulation tissue. Type and amount is important because it indicates to what extent the wound is progressing toward healing. Healing wounds are characterized by increasing amounts of *granulation* tissue and decreasing amounts of *necrotic* tissue.

This type of wound occurs where the *tissue surfaces have been approximated* (closed). This can be with stitches, staples, skin glue, or steri-strips. This kind of closure is used when there has been *very little tissue loss*. An example would be a surgical incision.

Primary Intention Healing

(The Red Yellow Black Classification System) Red indicates *Normal Healing* When a wound begins to heal, a layer of pale pink _____________________ tissue covers the wound bed. As this layer thickens, it becomes beefy red

Red indicates *Normal Healing* When a wound begins to heal, a layer of pale pink *Granulation* tissue covers the wound bed. As this layer thickens, it becomes beefy red

Stage one pressure ulcer...

Red, non-blanchable, but still intact skin

A *Partial Thickness* wound involves the *epidermis* and *extends into the dermis but not through it*. These wounds heal by *R_____________________*

Regeneration

The _______________ Dressing serves as a *therapeutic or protective function* and *secures the primary dressing*.

SECONDARY

A wound that is *extensive* and *involves considerable tissue loss*, and in which *the edges cannot be brought together*, heals in this manner. An example would be pressure ulcers. Because we want these types of wounds to heal from the inside out, or the bottom up, the repair time is longer, scarring is greater, and chances of infection are greater.

Second intention Healing

Several methods of debridement (removal of devitalized tissue) are available. Debridement methods are classified as either *Selective* & *Non-selective* describe...

Selective debridement: *Only* necrotic tissue is removed Non-Selective debridement: *Viable tissue* along with *necrotic tissue* is removed

Wound healing that indicates a reason to *delay suturing* or *closing a wound some other way*, for example when there is poor circulation to the injured areas. *These wounds are closed later*. These wounds require more connective tissue (scar tissue) than other healing processes. An example of this wound healing would be an abdominal wound that is intentionally left open to allow for drainage but closed later.

Tertiary Intention Healing (aka Delayed Primary Closure)

What system is commonly used to help determine how well a wound is healing?

The Red-Yellow-Black Classification System

The basics of wound management is to (1) reduce ________________ factors, and (2) provide _______________ support.

The basics of wound management is to (1) reduce *causative* factors, and (2) provide *systemic* support.

The first step in classifying a wound is to determine whether the wound is ____________ or ______________

The first step in classifying a wound is to determine whether the wound is *acute* or *chronic* Be careful not to determine solely on *time* because no set time frame specifies when an acute wound becomes chronic.

The goal of topical therapy is to create an environment that supports

The healing process.

The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in caring for this patient includes A- Irrigation of the wound. B- Debridement of the wound C- Management of drainage. D- Monitoring of the wound.

The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in caring for this patient includes A- Irrigation of the wound. *B- Debridement of the wound* (time to get that dead goop out, son) C- Management of drainage. D- Monitoring of the wound.

Why are hydrocolloids most appropriate for *non* infected wounds?

They are *semi-occlusive* (so you can't see if the infection begins to grow underneath) They are impermeable to bacteria, so if the wound site is clean, it'll stay clean, however if it is contaminated at all, its the perfect moist environment for bacteria to grow.

(Methods of Debridement) Chemicals for debridement are derived from various sources, such as *krill*, *crab*, *papaya*, *bovine extract* and *bacteria* They work in one of two ways: 1- By *directly* digesting the components of *__________* (fibrin, bacteria, leukocytes, cell debris, serous exudates, DNA) or 2- By dissolving _________________ "anchors" that secure a-vascular tissue to the underlying wound bed.

They work in one of two ways: 1- By directly digesting the components of *Slough* (fibrin, bacteria, leukocytes, cell debris, serous exudates, DNA) or 2- By dissolving *Collagen* "anchors" that secure a-vascular tissue to the underlying wound bed.

Remove Necrotic Tissue Identify & Eliminate Infection Treat Localized Infection Treat Systemic Infection Pack Dead Space Absorb Excess Exudate Maintain Moist Wound Surface Protect Against Heat & Cold Protect A Healing Wound Control Pain These are all the key principles of ________________ Therapy

Topical

(Topical Wound Therapy) Treat the Localized Infection: For signs of localized infection, or wounds that don't show progress after 2-4 weeks, a *2 week trial of __________ ________________* should be considered. Do *not* use topical *antiseptics*, such as *povidine*, *iodine*, *iodophor*, *dakin's*, *peroxide*, or *acetic acid* to decrease bacteria wound tissue. *These are toxic to healing tissue*

Topical Antibiotics

(Absorption Dressings) These vary in thickness and size. They are *waterproof and impermeable to bacteria and contaminants*. Have *no absorbent capacity*. Are *semipermeable to oxygen* Leave on for up to 7 days. Adhesive, semipermeable polyurethane membrane dressings. They allow for *visualization of the wound!*

Transparent Films (Opsite, Tegaderm). Great for surgical sites, laproscopic entry points, IV sites etc. Hemostasis needs to be established before putting these on though

(Adjunctive Wound Care Therapies) Assists in wound healing by *inducing an inflammatory reaction*, stimulating *growth of granulation tissue*, and *promoting breakdown and elimination of dead tissue* from the wound. Also helps to *reduce the "bioburden"*. and it gives you a beautiful glow

Ultraviolet light

(Methods of Debridement) This has been the conventional *non-selective* method for decades.It allows frequent visualization to the area. It works best in *heavily necrotic wounds* and *infected* wounds. *Saline damp gauze* put on wound bed, allowed to *dry*, thus *trapping the debris*. Once dry (4-6 hrs), the *dressing is pulled off* along with the *trapped debris*. The wound is cleansed, and another saline damp gauze is applied.

Wet-to-Damp (Wet-to-Dry) mechanical debridement

When irrigating a wound, the pressure of the lavage should be: A- Kept to between 4 and 15 psi. B- Determined by wound size. C- Cooled to discourage pathogen growth. D- Minimal enough to not cause pain.

When irrigating a wound, the pressure of the lavage should be: *A- Kept to between 4 and 15 psi.* (therapeutic pressures) B- Determined by wound size. (doesn't matter) C- Cooled to discourage pathogen growth. (we want normal temp) D- Minimal enough to not cause pain. (it might hurt)

(Methods of Debridement) This is a type of mechanical debridement. Commonly used to remove bacteria/debris from surface of *large wounds* (*BURNS!*). Also *softens* and *loosens* adherent *necrotic tissue* while also *cleansing* and *removing* most *wound exudates*. Also causes *vasodilation* which results in better *circulation* to wounded areas

Whirlpool

An acute wound occurs from injury or trauma... Any acute wound can progress to _______________ if it does not follow the expected stages of healing, or if it does not heal within the expected time frame for that wound type. This can occur as a result from *poor blood supply*, *oxygen*, *nutrients* or *hygiene*, among other shtuff.

a chronic wound

The removal of dead and necrotic tissue is necessary to reduce the ____________ burden of the wound in order to control and prevent wound infection

biological

(Topical Wound Therapy) Protect Against Heat & Cold: Healing is enhanced when a normal _____________ maintained

body temperature

Unstageble pressure ulcers are covered with stable layer of

eschar

The advantage of chemical enzyme debridement is that its *FAST* acting and has no affect on nearby viable ___________

tissue