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