Wound Management

Phase of Wound Healing that happens in the 3rd week up to 2 years post initial injury

Maturation

sutures covered with rubber tubing

Retention Sutures Provides greater strength Often used in obese patients Do not have good cosmetic effect

drainage that contains blood.

Sanguineous

this dressing permits OXYGEN but not air impurities to reach wound

Semi-occlusive Dressing

drainage that contains serum and blood.

Serosanguineous

If an _________ dressing is used, tape is placed on *all sides of the dressing* "sealed" Otherwise tape is placed inches apart to *allow oxygen/air to enter.*

occlusive

Abrasion, open or closed wound?

open

Avulsion, open or closed wound?

open

amputations, open or closed wound?

open

this dressing does not allow air or oxygen

Occlusive Dressing

contusion, open or closed wound?

closed

crush injury, open or closed wound?

closed

What's more effective open/closed drains?

closed drains because they pull fluid by creating a vacuum or negative pressure.

Assess condition of wound & dressing every

every shift

Tertiary Intention results in what kind of scar?

larger and deeper scar than primary/secondary intention -delayed closure with suture

During Primary Intention, there is ____ tissue loss.

little

rubber sutures are left for how long?

longer 14 days or more

What can happen if exudate is not drained?

may lead to infection

Semi and Occlusive dressings are thought to promote healing by keeping the wound ____ yet sterile

moist

If a dry dressing adheres to the wound, it should be

moistened with sterile normal saline or sterile water before removal. NSS/SW

If the sutures/staples are left in over 10 days, removal would be

more difficult and may have increased risk for infection b/c it's a foreign body that made a hole into the skin w/c makes it easier for bacteria to go in

Secondary Intention Healing: some wounds develop a ______ exudate which the surgeon has to pack with gauze. slowly the necrotized tissue decomposes and escapes, and the cavity begins to fill with granulation tissue.

purulent (contains pus)

When there's Internal Bleeding in the abdomen, how will it look like?

rigid and distended

Care must be used to insure the dressing does not remain ____ continuously.

wet A too-wet dressing can cause maceration and bacterial growth.

When are Dry Dressings used?

when little exudate is present

Dressings over closed wounds are usually removed by the ____ day.

third

a cut produced surgically by a sharp instrument that creates an opening into an organ or space in the body

Incisions

smoothly divided wounds made by a sharp instrument.

Incisions

Tertiary Intention is also called

"Delayed Primary Intention"

How would a pt subjectively report dehiscence?

"something has given way"

Foods high in vitamins _ & _ are encouraged to facilitate wound healing.

vitamins A and C

3 TYPES of Wound Healing process

1. Primary Intention - just to put it together 2. Secondary Intention - keloid 3. Tertiary Intention - can be used for an abscess

Types of Wound Drainage (Exudate)

1. Serous 2. Sanguineous 3. Serosanguineous 4. Purulent

cavity containing pus and surrounded by inflamed tissue, formed as a result of PUS from a LOCALIZED infection.

Abscess

How to manage an Evisceration?

1) Patient is to remain in bed. 2) COVER Wound and contents with *warm, sterile saline* dressings. 3) Surgeon is notified IMMEDIATELY - this is a MEDICAL EMERGENCY - STRAIGHT TO SURGERY

What type of wounds may require a Wet to Dry Dressing?

1. Abdominal evisceration 2. Dehiscence 3. Infected open wounds 4. Pressure ulcers 5. Diabetic foot ulcers

Examples of Open Wounds (6)

1. Abrasions 2. Avulsion 3. Lacerations 4. Amputations* 5. Punctures 6. Bite*

Examples of Wound Complications:

1. Abscess 2. Adhesion 3. Cellulitis 4. Dehiscence 5. Evisceration 6. Extravasations 7. Hematoma *impaired wound healing

Pointer for dressing removal

1. Consult physician and agency policy 2. Medicate 30 minutes prior if pain is expected 3. Assemble equipment needed - give meds then go get your stuff 4. Use Sterile technique or standard precautions 5. Be careful not to disturb drains 6. Redress wound 7. Document the procedure

Closed Wounds (2)

1. Contusion 2. Crush Injury

Wound Complications r/t Internal Bleeding

1. Dressing may remain dry 2. Increased thirst 3. Restlessness 4. Rapid, thready pulse 5. Decreased blood pressure 6. Decreased urinary output 7. Cool clammy skin 8. Abdomen rigid and distended 9. Hypovolemic shock

Factors that Impair Wound Healing

1. Extent of the Injury 2. Type of Injury 3. Age 4. Nutritional Status - healthy people heal better than unhealthy 5. Obesity 6. Impaired Oxygenation 7. Smoking 8. Drugs 9. Diabetes Mellitus - b/c they have peripheral neuropathy** 10. Radiation 11. Wound Stress

What happens during the Reconstruction phase?

1. Fibroblasts produce a glue-like protein called collagen, which adds *tensile strength* to the wound. 2. Collagen formation increases rapidly between 5-25 days post-op. 3. Wound has an irregular raised purplish immature scar.

Types of Dressings (3)

1. Gauze 2. Semi-occlusive dressing 3. Occlusive dressing Tape ties, bandages or cloth binders may be used to secure dressing

What supplies do you need to do a dry sterile dressing change?

1. Gloves, 2. gauze, 3. tape, 4. basin, 5. NSS or SW normal saline solution / sterile water, 6. 30-60 ml syringe, 7. pad

4 PHASES of Wound Healing

1. HEMOstasis -not homeostasis 2. Inflammatory 3. Reconstruction 4. Maturation

Cellulitis is characterized by: (4)

1. Heat 2. Pain 3. Redness 4. Edema

5 Cardinal Signs and Symptoms of Inflammation

1. Heat 2. Redness 3. Swelling 4. Pain 5. Tissue dysfunction (loss/decreased function)

Two types of drainage devices that are portable and provide constant low-pressure suction to remove and collect drainage without wall suction.

1. Jackson-Pratt (JP) Drain 2. Hemovac

What happens during the Inflammatory Phase?

1. Leukocytes engulf bacteria, fungi, viruses, and toxic proteins. 2. New cells form. 3. As the blood clot dissolves, the wound fills. 4. The sides usually meet in 24-48 hrs. 5. This process seals the wound and protects it from contamination.

What happens during Hemostasis?

1. PLATELETS adhere to the walls of the injured vessel. 2. FIBRIN in the CLOT will HOLD the wound together and stop the bleeding.

When dehiscence occurred on a pt's wound, what are some pointers to keep to manage it?

1. Patient should remain in bed 2. Kept NPO 3. Told not to cough*** 4. Reassure patient 5. Place sterile dressing over area - to keep it clean until physician evaluates the site.

How to monitor drainage

1. Weigh soiled dressings 2. Circle and date drainage area 3. Report number and type of dressings used

How does a pt with an infected wound present?

1. with fever 2. tenderness and pain at the wound site, 3, edema, 4. and an elevated WBC. 5. Positive Wound Culture

when something becomes infected it takes _ to _ times longer for it to heal

2 to 3 don't let your pt have a set back, always assess for infections!

Exudate/drainage greater than ___ ml in the first 24 hours is ABNORMAL

300 ml

Exudate/drainage greater than ___ ml in the first 24 hours is abnormal

300 ml

how long are sutures usually left on?

7-10 days

a scraping or rubbing away of a surface, such as skin or teeth, by a substance or surface with a hardness greater than that of the tissue being scraped or rubbed away. may be the result of trauma, such as a skinned knee; of therapy, as in dermabrasion for the removal of scar tissue; or of normal function, such as the wearing down of a tooth by mastication

Abrasions

a wound in which the surface layers of the skin are scraped away causing tissue loss in the epidermis and possibly the dermis.

Abrasions

band of scar tissue that binds together two anatomical surfaces normally separated; most commonly found in the abdomen.

Adhesion

the separation, by tearing, of any part of the body from the whole

Avulsion

wounds in which a portion of tissue is completely separated from its base and is either lost or left with a narrow base of attachment (a flap).

Avulsion

infection of the skin characterized by heat, pain, redness, and edema.

Cellulitis

Physical injury involving the underlying tissue of the body with the top layer of the remaining intact or not broken.

Closed Wounds

- Self-contained suction units that connects to drainage tubes within the wound. - Creating a vacuum or negative pressure - Prevents environmental contaminants from entering the wound or cavity.

Closed/Suction Drains

COCA

Color Odor Consistency Amount

injuries that do not break the skin. Injury to soft tissue underlying the skins from the force of contact with a hard object; called a bruise.

Contusion

An injury that does not disrupt the integrity of the skin, caused by a blow to the body and characterized by swelling, discoloration, and pain. The immediate application of cold may limit the development of this.

Contusion "bruise"

separation of a surgical incision or rupture of a wound closure.

Dehiscence

bluish discoloration of an area of skin or mucous membrane caused by the extravasation of blood into the subcutaneous tissues as a result of trauma to the underlying blood vessels or fragility of the vessel walls

Ecchymosis

discoloration of the skin, called a bruise.

Ecchymosis

Which wound complication is a surgical emergency?

Evisceration

protrusion of an internal organ through a wound or surgical incision.

Evisceration

passage or escape into the tissues; usually of blood, serum, or lymph.

Extravasations

this dressing permits air (with impurities) to reach wound

Gauze

collection of extravasated blood trapped in the tissue or in an organ resulting from incomplete hemostasis after surgery.

Hematoma

Phase of Wound Healing where termination of bleeding happens, clot begins to form, usually within minutes to hours after initial injury.

Hemostasis

closed drainage system used for larger amounts (up to 500 ml) of drainage

Hemovac

The invasions and multiplication of infective agents in body.

Infection

the invasion of the body by pathogenic microorganisms that reproduce and multiply, causing disease by local cellular injury, secretion of a toxin,or antigen-antibody reaction in the host

Infection

Phase of Wound Healing where there's an initial increase in blood elements: antibodies, electrolytes, plasma proteins and water flows out of the blood vessel and into vascular space causing edema

Inflammatory

Primary Intention healing begins during the __________ phase of healing

Inflammatory

This process seals the wound and protects it from contamination.

Inflammatory Phase

This process causes the cardinal signs and symptoms of inflammation

Inflammatory Response

aids in detecting an increase in drainage and color changes.

Inspection of the wound and dressing

What can cause dehiscence?

May result after periods of moving, sneezing, coughing, or vomiting.

Why do you want to assess condition of the wound and dressing?

It lets us know where pt is in the healing process. Note whether wound edges are closed.

Jackson-Pratt (JP) Drain vs Hemovac

JP - 100 to 200 ml Hemovac - up to 500 ml

closed drainage system used when small amounts (100-200 ml) of drainage anticipated

Jackson-Pratt (JP) Drain

Give two examples of a closed drainage system?

Jackson-Pratt, Hemovac

a torn, jagged wound caused by shear forces

Lacerations

wounds caused by shear forces that produce a tear in tissues. The separation of skin and tissue can be irregular or sharp.

Lacerations

Wound gains strength, scar formation, and may develop a KELOID (over growth of collagenous tissue) or HYPERTROPHIC scarring during this phase.

Maturation Phase

Can you just change a dressing when you think it needs to be changed?

NO. Do not change the dressing until an ORDER is issued.

Do all surgical wounds drain?

No

Are Dry Dressings used to debride a wound?

No Wet to dry dressings are used to debride wounds (Mechanical debridement).

Drainage passes through an open-ended tube into a receptacle or out onto the dressing great for abscesses

Open Drains

physical injury to the body tissue with openings or breaks in the skin

Open Wound

Example of an Open Drain

Penrose drain - a soft tube that drains by gravity and may be advanced or pulled out in stages as the wound heals from the inside out.

Wounds in which the skin edges are close together and little tissue is lost, such as those made surgically, heal by this which results in minimal scarring

Primary Intention

PMS Assessment stands for

Pulse Motor Sensory can they wiggle? can they feel?

a traumatic injury caused by skin penetration by an object such as a knife,nail, or slender fragment of metal, wood, glass, or other material. In such an injury to the eye, a lung, or a visceral organ, the object or implement is not removed until the person has been transported to a medical facility.

Punctures

wounds with a small opening and whose depth cannot be entirely Visualized; caused by a narrow, sharp or pointed object. can force dirt and microorganisms deep into tissue. Patients will usually require a tetanus booster.

Punctures

drainage that contains pus.

Purulent

If dressing becomes saturated, what should you do and only do?

REINFORCE by placing sterile gauze on top of the original dressing, record and report any dressing that is reinforced. BUT DO NOT CHANGE IT.

Phase of Wound Healing where collagen formation from fibroblasts occurs, usually from the 3-4th day to 2-3 weeks after initial injury.

Reconstruction

Wound dehiscence most frequently occurs during this phase.

Reconstruction Phase

In which phase is collagen formed from fibroblasts to promote healing?

Reconstruction phase

If suture line opens while you're removing it

STOP - If it remains closed, continue

A wound that must GRANULATE during healing, occurs when skin edges are not close together (approximated) or when pus has formed

Secondary Intention

The wound is allowed to GRANULATE and fill in with eventual epithelialization.

Secondary Intention

With this type of intention healing process, the surgeon may pack a wound with gauze or use a drainage system to remove exudate.

Secondary Intention

______ wounds generally heal better because they are "aseptically created"

Surgical

is a tubular device in the shape of a T, inserted into a cavity or wound; frequently seen in patients following a *cholecystectomy.*

T-tube Drain

Healing process where the practitioner leaves a CONTAMINATED wound open, then just closes it later --- after the infection is controlled, by suturing two layers of granulation tissue together in the wound

Tertiary Intention

With this type of intention healing process, the wound is initially cleaned, debrided and observed for a period of time (typically 4 or 5 days) before closure.

Tertiary Intention

With this type of intention healing process, the wound is purposely left open by placing dressing material in the wound to keep the edges apart.

Tertiary Intention

Remove EVERY OTHER staple or suture and replace with steri-strip. T/F

True

When there's Internal Bleeding, the dressing may remain dry while the abdominal cavity collects blood. T/F

True

Deep sutures are usually absorbable. T/F

True. The surgeon wouldn't have to reopen a wound just to get the deep sutures out.

Dressing appropriate for ischemic or necrotic tissue, large amounts of drainage/exudate.

Wet to Dry Dressing

a clear, watery drainage that has been separated from its solid elements (e.g. exudate of a blister).

Why so Serous ?

What may a wound bleeding indicate?

a slipped suture, dislodged clot, coagulation problem, or trauma placed on blood vessels or tissue.

Wetting solutions used.

a) Isotonic solutions. b) Acetic acid. c) Sodium hypochlorite solution. d) One-quarter to one-half strength providone- iodine. e) Other antibiotic solutions.

Where does adhesion commonly happen?

abdomen

Moistened layer increases the dressing's

absorptive ability.

As the dressing dries it

adheres to wound.

Why does Impaired Oxygenation impair wound healing?

b/c decreased oxygen in the blood will cause decreased ATP(energy) for the cells to regenerate and heal

Why is Tertiary Intention is also called "Delayed Primary Intention?"

b/c it can also occur when a PRIMARY wound becomes INFECTED, is opened, allowed to granulate, and is THEN SUTURED. -"like primary intention but you're delaying it"

How does Obesity impair wound healing?

b/c people who have their adipose tissue more expanded, makes the nerves and vasculature further from the skin therefore nutrients take longer to reach the wound.

Why would a pt have increased thirst, hypotension, decrease urine output when there's Internal Bleeding?

b/c they are losing fluid internally

Why do you want to keep a pt NPO if dehiscence occurs?

b/c they might end up going back to surgery STAT

What can happen if hypovolemic shock is not detected?

can cause circulatory system to collapse --- causing death.

Drains are established to drain exudate away from the surgical incision. If exudate enters or remains at the site, chances of __________ and _______ increases.

contamination and infection

When dressing is removed, the wound is

debrided.

Dressings prevent deeper tissue from

drying out.

CDC labels a wound ______ when it contains *purulent (pus) drainage.* Topical and systemic treatment ordered per pathogen and clinical Symptoms.

infected

every when should you assess condition of wound and dressing?

every shift or Checked after: (a) Each dressing change. (b) Application of heat and cold therapies. - you want to see how your modality affected the wound site (c) Wound irrigation. (d) Stress to the wound site.

Internal wounds heal _____ than external wounds.

faster

Primary intention results in a ___ scar

fine

Purulent drainage has a ___ odor and is brown, yellow or green, depending on the pathogen.

foul

Sutures and Staples are removed when?

generally within 7 to 10 days

Drainage may ______ slighty with ambulation

increase

Secondary intention results in a ____ scar

large

hypertrophic scar formed by excess collagen tissue usually over a wound or surgical incision elevated round and firm, color ranges from red to pink to white.

keloid

Some surgeons remove dressings on the first post-op day if

no drains are present.

Do bariatric (obese) pts have more adipose tissue?

no, their adipose tissues are just more expanded.

bites, open or closed wound?

open

laceration, open or closed wound?

open

punctures, open or closed wound?

open

Most surgical wounds heal by _______ intentions.

primary

Primary purpose of Wet to Dry Dressings?

primary purpose is to mechanically debride - increases the absorption of exudate

When a dehiscence is present, evidence of new or increased _________ drainage on the dressing is an important sign to assess.

serosanguineous

Why do you want to report number and type of dressings you used?

so that if shift after you pulls out only 5 when you put in 6 then that's alarming always keep track of what you put in someone and how many

How does healthy wound granulation tissue look like?

soft, pink, fleshy "lots of blood vessels aiding in healing"

Used when the appearance of the incision is not critical suture vs staple?

staples (a) Skin closure. (b) Abdominal surgery. (c) Orthopedic surgery.

Staples vs Sutures, which one is stronger?

sutures

Why are pts told not to cough if there's dehiscence?

the pressure can make it a bigger wound

Wounds heal at ______ speeds.

varying