Wound Care

Cellulitis

A diffuse, acute infection of the skin and subcutaneous tissue around the initial injury.

Sterilization Techniques

Boiling for 15 mins Dry heat Chemicals Autoclave Gases Ultraviolet Rays

Phagocytosis

Engulfing microorganisms or foreign particles

Use of Heat

Provides general comfort and speeds the healing process. Can be used for joint strains or low back pain.

Stage 3 Wound Healing

Reconstruction. May take up to several years. Lysis of old collagen - synthesis of new collagen tissue to produce a stronger scar.

Signs and symptoms of infection

Redness, erythema, exudate, edema, fever, chills, pain, decreased healing, unapproximated edges.

Wound Evisceration

Spontaneous opening and protrusion of internal organs through the incision.

Wound Dehiscence

Spontaneous opening of a surgical wound. Usually 4-5 days post-op.

Primary Intention

The extent to which cells and tissue have regenerated following intentional closure. Minimal loss of tissue. Surgical incisions. Edges well approximated. Slight chance of infection.

Secondary Intention

The extent to which cells and tissue in an open wound have regenerated. Large, jagged, gaping, infected wounds. Wound left open to drain and heal from the inside out. Necrotic tissue must be removed. Higher incidence of infection.

Inflammatory Phase Order

1. Inflammatory phase 2. Vascular constriction, platelet aggression, and fibrin formation. 3. Hemostasis and clot formation 4. Chemical release, small vessels dilate. 5. Fluid accumulates causing edema 6. Redness, tenderness, swelling. 7. Phagocytes enter and cause phagocytosis.

Proliferation Phase Order

1. Proliferation phase 2. Phagocytosis continues 3. Fibroblasts synthesize collagen 4. New capillary networks form 5. Granulation tissue forms 6. Contraction, possible contractures 7. Epithelialization

Wound Culture and Sensitivity

A microscopic examination of presence of pathogens in a wound

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.

Wound Healing Definition

A process to restore a state of soundness to any injury resulting in the interruption in the continuity of the external surface of the body.

Fistula

Abnormal passage formed between two internal organs or leading from internal to outside the surface of the body.

Enzymatic Debridement

Acuzyme - Takes away bad tissue when dressing changes. Breaks down and liquefies dead tissue. Normally used on uninfected wounds.

Montgomery Straps

Adhesive tape with eyelets and ties. Holds bulky dressings in place and prevents skin breakdown from frequent dressing changes.

Factors that Affect Wound Healing

Age, malnutrition, obesity, impaired oxygenation, smoking, drugs, diabetes, radiation, wound stress.

Wet to Moist Dressings

Aids in debridement of wounds, providing moisture and protection of granular tissue. Gauze is moistened and placed in wound. Gauze is not allowed to completely dry or is moistened slightly before removal. Generally changed 4-6 times a day.

ABCs

Airway, Breathing, Circulation

Shadowing

Always check opposite side of wound to check for internal bleeding

Assessing a Drain

Always observe the surrounding skin for breakdown After cleansing area, apply a drain sponge Standard Precautions/Infection control when emptying drains Record drainage as output. Assess drainage. Compress drain after emptying

Wound

Any physical injury involving a break in the skin, caused by an act or accident. Includes surgical incisions.

Cleaning a Drain

Area of the drain is considered more contaminated than the surrounding area. Dry incision near the moist drain. Clean from incision to drain. If the drain is isolated, start at the drain and swab around it moving in a circular motion away from drain.

Inflammatory Response Duration

Begins immediately and ends approximately 4 days.

Body injury

Biological, physical, chemical, trauma, heat, cold, pressure

VAC Dressings - Granu Foam

Black - Water repelling, good for drainage or exudate removal, better distribution of pressure across wound bed, better fit for irregular shaped wounds.

Sanguineous

Bloody discharge

Arterial Stasis Ulcer

Caused by a disruption of the arterial blood supply. Usually in lower legs, tips of toes, between toes, or malleolous. Open wound.

Venous Stasis Ulcer

Caused by a disruption of venous blood flow. Usually in the lower legs, feet, and ankles. Open wound.

Inflammatory Response

Cellular Reaction. Epithelial cells migrate towards the base of the scab. Histamine, serotonin, prostaglandin are released. Chemicals cause small vessels to dilate, which causes redness. Plasma and electrolytes leak into the site, causing edema.

Indications of VAC Dressing

Chronic Diabetic, pressure ulcers, acute/traumatic or dehisced wounds, skin flaps, skin grafts, partial thickness burns.

Red Wounds

Clean and ready to heal

Bandage/Wrap Guidelines

Elevate and support limb while applying Face patient and wrap distal to proximal Apply even pressure exerting equal tension Smooth wrinkles Always assess neurovascular status before and after Assess underlying skin frequently

Serous

Clear yellowish discharge, composed of serum

Contusion

Closed wound. Damage occurring to the blood vessels resulting in the leaking of blood into the tissue. Intact skin.

Penrose Drain

Common type of drain. Wide tube that fits into wound and allows removal of blood and drainage from a wound or cavity of the body.

Vascular Response

Constriction of blood vessels; clumping of platelets; formation of fibrin clot; helps to maintain hemeostasis.

Use of Cold

Decreases swelling and decreases pain.

Wound Approximation

Degree of closure of a wound

Third Intention

Delayed healing. Occurs when wound closures fail and the wound is reopened. Healed inside out usually drain or retention sutures are in place.

Scarring factor

Dependent on degree of stress on the wound.

Contraindications of Heat

Do not apply over an area where bleeding is occurring. Will increase bleeding. Do not apply to abdomen if there is a chance of appendicitis. Can cause appendix to rupture. If cardiovascular issues are present, do not apply to large part of body. Can cause massive vasodilation that may divert blood supply from major organs.

Wound Irrigation Cleansing

Does not involve any direct pressure applied to wound bed. Just pouring water over wound.

Diabetic Ulcer

Due to diabetic neuropathy. A non-inflammatory disease associated with DM. Usually in lower legs, feet, and toes. Open wound.

VAC Contraindications

Expose organs/blood vessels Untreated infection/osteomyelitis Unexplored fistulas Undiagnosed cancer Wound with eschar or necrotic tissue

Adhesion

Fibrous bands that hold together tissues that are normally separated. Interfere with normal functioning.

Open Drain

Flat, flexible tubes that provide a pathway for drainage away from the wound

Wound Irrigation

Generally ordered for infected wounds, wounds with alot of necrotic tissue, drainage, or bleeding.

Measuring undermining wound

Gently palpate the wound bed with a sterile cotton tipped applicator and note the specific location of the undermining.

Non-adherent Telfa

Has a non-stick surface to prevent injury to healing wound. Holds moisture in plastic like covering over gauze.

Granulation Tissue

Healing tissue

Complications of wound healing

Hemorrhage - loss of significant amount of blood volume over a short period of time. Can be internal or external.

Black Wounds

In need of debridement and removal of eschar and necrotic tissues.

Stage 1 Wound Healing

Inflammation - lasts 3-4 days

Infection definition

Invasion of microorganisms into the wound. More likely in traumatic wounds. Obtain a culture and sensitivity as ordered.

Appearance of venous stasis ulcer

Irregular border, superficial red wound bed, large amount of drainage, hyper pigmentation

Wound Dressing Purpose

Keep the wound clear and dry; protect from injury; control bleeding; support underlying tissue and promote healing; absorb drainage; hold medications in place

Sutures/Stitches

Knotted ties place approximated edges to wound. Nylon silk. Usually kept in place 7-10 days. Do not soak wound. Rinse and pat dry. Can be removed by physician or LPN.

Rules of Sterile Technique

Know what is sterile/not sterile Separate sterile from non sterile Remove contaminated items immediately Sterile can touch other sterile Any partially opened sterile package is contaminated If sterility is questioned - no longer sterile Time is a factor in sterility Non-sterile if passed expiration date or wet The outer 1 inch margin of sterile area is contaminated Below the waist - Contaminated Coughing, sneezing, excessive talking over a sterile field causes contamination Reaching across sterile field contaminates

Yellow Wounds

Layers of exudate, slough needs cleaned, absorption drainage

Gauze Fluffs

Loosely folded gauze used to pack wounds or absorb drainage.

Sterile Technique Definition

Measure that prevents contamination of items that are sterile. Practiced in invasive procedures, operating room, insertion of urinary catheters, some dressing changes, equipment used to start IVs, or give injections.

Surgical Clips/Staples

Metal staples place to approximate wound edges. Usually kept in place 7-14 days. Do not soak wound. Rinse and pat dry. Can be removed by physician or RN.

Measuring tunneling wound

Moisten a sterile cotton applicator and gently palpate the wound bed and surrounding tissue. Measure the depth of the tunnel.

Inflammatory process benefits

Neutralizes and destroys; limits spread to other tissues; prepares the damaged tissue for repair.

General Wound Care

Never remove post-op dressing. Report signs and symptoms or complications asap. Must have MD order for wound care, dressing changes, and/or irrigation.

Preparing a Sterile Field

Open packages away from body Touch only outer 1 inch corner Drop sterile items onto field 6 inches above Pour sterile solution onto dressing or into container after pouring out a small amount - do not let it touch Put on sterile gloves after everything is opened

Appearance of arterial stasis ulcer

Pale/necrotic wound bed, minimal drainage

Interventions for Dehiscence/Evisceration

Patient may state "feels like something let loose". Return to bed stat. Supine, cover with sterile saline soaked dressing. Control bleeding. ABCs. Report to RN/MD stat.

Keloid

Permanent enlarged scar resulting from an overgrowth of collagen.

Exudate

Phagocytic cells remove debris and protect against invasion.

Mechanical Debridement

Physical removal of dead tissue by irrigation, whirlpool, wet to dry dressings.

Wound Care

Prevention of wound complications - promoting healing

Wet to Dry Dressings

Primarily used to debride wounds. Gauze is moistened with sterile water, saline, betadine, or acetic acid. Gauze is allowed to dry over a period of time. When dry, gauze adheres to wound bed, removes dead tissue and eschar from wound bed when removed.

Stage 2 Wound Healing

Proliferation - begins at 3-4 days and lasts 2-6 weeks

Tissue injury

Releases chemicals to begin to repair itself.

VAC Therapy

Removes infectious materials and fluid. Helps draw wound edges together. Promotes perfusion, protection, and moist, healing environment.

Kling/Kerlix Rolls

Roll of thin gauze used to hold dressing in place or to pack large wounds.

Contraindications of Cold

Should not be applied to an injury area where edema is already present. Will slow circulation and prevent absorption of interstitial fluid. If neuropathy is present, do not apply since patient has loss of sensitivity. If shivering is present, do not apply. Shivering raises body temp.

General Wound Assessment

Size and location (length, width, depth) Type of wound (surgical, open, closed) Appearance - Can be described like a clock Odors Closures (staples, sutures, steri strips) Drainage (amount, color, consistency, odor)

Wound Dehiscence Care

Soak pad in saline, cover up, and immediately call MD.

Incision

Surgical separation of tissue with clean, smooth edges. Open Wound. Or closed with sutures.

Dermabond

Synthetic, noninvasive glue used to approximate edges of wounds. Provides a seal under and above the skin surface to decrease tissue damage. Slowly peels off in 7-10 days. Do not pick off.

Patient Teaching for Wound Care

Teach proper technique for cleaning and redressing Send home with sufficient dressings Teach signs and symptoms of infection Send written instructions to reinforce teachings

Avulsion

Tearing away of a structure or part such as a finger tip. Open wound.

Undermining Wound

The destruction of tissue or ulceration extending under the skin edges so that the wound is larger at the base than at the skin surface. Open wound.

ABDs/Combo Pads

Thick coarse gauze covered with fine gauze. Larger sized, moisture resistant side, usually placed over smaller dressing for absorption of drainage.

Purulent

Thick, green, tan, pus discharge

Hematoma

Tissue injury that disrupts a blood vessel pooling of blood under broken skin.

Tegaderm

Transparent dressing. Clear thin plastic dressing adhesive on one side only. Allows visualization of skin underneath. Air permeable - never cover with tape.

Abrasion

Traumatic scraping away of the layers of the skin. Open wound.

Laceration

Traumatic separation of tissue with irregular, torn edges. Open wound.

Closed Drain

Tubes that lie in the wound bed or cavity and terminate in a receptacle. The receptacle or bulb provides suction to remove drainage.

Causes of diabetic ulcer

Uncontrolled blood glucose levels impairs wound healing and damages the microvascular circulation.

Autolytic Debridement

Use of body's own enzymes to breakdown nonviable tissue in a wound bed. The dressing provides a warm, moist environment. Puts wound at risk for infection. Used on small, uninfected wounds.

Sharp/Surgical Debridement

Use of sterile instruments to cut away eschar and sloughing tissue to promote wound healing. Usually done in OR. Very painful - premedicate if done at bedside. Assess for bleeding.

Chemical Debridement

Uses a Dakin solution or sterile maggots. Occasionally used on a wound with necrotic tissue that isn't responding to other treatments.

Wound VAC

Vacuum Assisted Closure Therapy. Controlled sub atmospheric pressure is applied to the wound through a specialized foam dressing.

Penetrating

Variable sized open wound through the skin and underlying tissue made by objects such as a bullet or a piece of wood. Open wound.

Signs and symptoms of hemorrhage

Weak, thready pulse, diaphoresis, cool clammy skin, hypotension, restlessness.

Chemotaxis

When phagocytic neutrophils are triggered to respond.

VAC Dressings - VERS Foam

White - moisture retaining, non adherent, used for tunneling and undermining.

Puncture

Wound made with a sharp, pointed object through the skin or mucous membranes and underlying tissue. Open wound. Often requires tetanus shot afterwards if not up to date.

Gauze

Woven fibers, highly absorbent, may stick to granulation tissue.

Sprain

Wrenching or twisting of a joint with partial rupture of ligaments causing bruising and swelling.

Wound Evisceration Care

Yell for saline and dressing. Take vitals while someone calls MD.

Serosanguineous

Yellow, blood tinged discharge