Wound Care Chapter 28

evisceration

- "give way" feeling occurs - separation of wound with protrusion of oxygen - caused by: - insufficient diet - removal of sutures to early - straining (give laxative) - coughing (teach deep breathing, splinting) - sneezing - vomiting. dry heaves - hiccups - weak tissue - abdomen distention - accumulated gas - compromised tissue integrity (previous Sx in same area) - DO NO LEAVE PT - cover with NS soaked dressing - call for MD stat - prep Pt for Sx

When to medicate Pt for a painful dressing change

- 30 minutes prior to change

Incision

- a clean separation of skin and tissue with smooth, even edges.

Proliferation

- a period during which new cells fill and seal a wound - last from 2 days to 3 weeks - characterized by the appearance of granulation tissue - presence of collagen (tough and inelastic protein)

Remodeling

- a period during which the wound undergoes may changes and maturation - follows proliferation stage, may last 6 months to 2 years - scar shrinks

A nurse caring for a female client notes a number of laceration wounds around the cervix of the uterus due to birth. How could the nurse describe the laceration wound in the client's medical record?

- a separation of skin and tissue in which the edges are torn and irregular

Laceration

- a separation of skin and tissue in which the edges are torn and irregular.

dehiscence

- a separation of wound edges

Ulceration

- a shallow crater in which the skin or the mucous membrane is missing

Irrigation

- a technique for flushing debris (i.e. eyes, ears and vagina)

Abrasion

- a wound in which the surface layers of skin are scraped away.

A client's risk for the development of a pressure ulcer is most likely due to which lab result?

- albumin An albumin level of less than 3.2 mg/dL indicates the client is nutritionally at risk for the development of a pressure ulcer.

A nurse is caring for a client who had an appendectomy and has been readmitted for wound care. The incision has been opened for drainage. The wound is draining copious amounts of yellow exudate. Which type of dressing should the nurse understand is appropriate fro this wound?

- alginates - antimicrobials - composites These all work with heavy drainage and infected wounds.

First-Intention healing

- also called primary intention - is a reparative process in which the wound edges are directly next to each other. (i.e incision)

Steri-Strips

- also known as butterflies - use to close superficial lacerations - remove every other one - remove 1/2 one day 1/2 another (if need to)

Pressure Ulcers

- also known as, "decubitus" - if compression reduces pressure in the capillary to 32 mm for 1 to 3 hours without relief the cells die

Puncture

- an opening of skin, underlying tissue, or mucous membrane caused by a narrow, sharp, pointed object.

A nurse is caring for a client who is 2 days postop after abdominal surgery. What nursing intervention would be important to promote wound healing at this time?

- assist in moving to prevent strain on the surface line.

A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered? - autolytic - biosurgical - enzymatic - mechanical

- biosurgical debridgement (ref to page 617)

What is the two major processes involved in the inflammatory phase of wound healing?

- blood clotting is initiated, WBCs move into the wound

Soaks

- body part submerged in fluid to provide warmth for 15 to 20 minutes

Six basic techniques

- circular turn (secures bandage) - spiral turn (overlapping cylindrical parts) - spiral-reverse turn (reversed or turned downward) - figure-of-eight turn (bandaging a joint; elbow/knee) - spica turn (portion of the trunk) - recurrent turn (wrapping the stump of an amputated limb or the head)

serous

- clear, watery plasma

Contusion

- closed wound - injury to soft tissue underlying the skin, bruise.

Algiderm

- consist of absorbent, non-adherent, biodedradable, non-woven fibers... "seaweed" - forms a gel with contact of wound drainage - calcium alginate (comes in sheets, pads, ribbons) - moderate to heavy exudation - placed in sterile wound and the body absorbs it -maintain moist wound environment - best for wounds with heavy exudate

slough

- dead tissue (fat) on wound surface (i.e. moist stringy, yellow, tan, gray and/or green)

necrotic

- dead tissue on wound surface (i.e. dry, brown, black devitalized tissue)

A client suffering from infectious diarrhea, dehydration, and right-sided paralysis is confined to bed. What is the client MOST prone to? - bowel obstruction - decubitus ulcer - depression - urinary incontinence

- decubitus ulcer

Packs

- differ from soaks in 2 ways - duration is longer - initial application of heat is generally more intense - POTENTIAL for causing burns, a pack is never used on unresponsive or paralyzed and cannot perceive temp

Hydrocolloid dressing

- duoderm self adhesive opaque, skin toned - air and water occlusive (repels urine, stool) - covers wound 2 inch margin around it - keeps wounds moist (cells grow rapidly in this environment) - left in place for up to 1 week (or odor) - ??? something # means protein ??? idk, it was written on the note card, stated in class maybe?idk

Second-Intention Healing

- edges are widely separated, margins of the wounds are not in direct contact which leads to a more time-consuming and complex process of healing

Third-Intention Healing

- edges intentionally left wide/separated and later brought together with some type of material - results in a broad, deep scar - contain extensive drainage and tissue debris

Principles of applying roller bandages

- elevate and support the limb - wrap from a distal to proximal direction - avoid gaps between each turn of the bandage - exert equal, but not excessive tension with each turn - keep bandage free of wrinkles - secure the end of the roller bandage with metal clips - check the color and sensation of exposed fingers or toes often. - remove the bandage for hygiene and replace at least twice a day.

The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action?

- elevate and support the stump

undermining

- erosion of tissue from underneath intact skin at wound edges

The nurse is assessing a client's surgical wound after abdominial surgery and sees that the viscera is protruding through the abdominal wound opening. Which term best describes this complication?

- evisceration

Open Drains

- flat, flexible tubes that provide a pathway for drainage toward the dressing - occurs passively by gravity and capillary action - use of safety pin or long clip attached

Guidelines for cleansing wounds

- general prinicples; - aseptic - clean to dirty - Surgical: - follow MD order *double check it* - cleaning agent - normal saline that is sterile - irrigation - warm solution - clean to dirty

Heat

- heat produces vasodilation in 20-30 minutes, continue past this time tissue congestive and blood vessel constriction occurs - provides warmth - promotes circulation - speeds healing - relieves muscle spasm - reduces pain - apply as tolerated (warm/hot) - never on a Pt who is unresponsive, paralyzed, or cannot perceive temp tech - soaks - moist packs - therapeutic bath - sodium bicarbonate (baking soda) - cornstarch - oatmeal - sitz bath - aquathermia pad (an electrical heating device)

What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing?

- hydrocolloid dressing are occlusion or semi-occlusiove dressing that limit exchange of oxygen between wound and environment; provide minimal to moderate absorption of drainage, maintain a moist wound environment; may be left in place for 3 to 7 days

Gerontologic Consideration

- ice/heat caution with 2y, older adults, DM, comatose or neuro impairment - thinning of dermal - positional changes q2h or prn - absorbent garments an contribute to break down diminished mobility - healing delayed in older adults, (2x for 80y v/s 30 - diminished immune response from the low T-lymphogues

gauze dressing

- ideal for bleeding/exude drainage - secured with tape - with frequent changes or allergy to tape use "montgomery straps" prevent skin break down - lube with petroleum ointment *granulation tissue may adhere to fibers - cannot see wound

Preventing pressure ulcers

- if bed ridden change positions freq (at least 2h or prn) - sitting or standing shift q1h, shift legs q15 minutes - lift than drag Pt, keep * head at 30 angle to avoid shearing - avoid plastic covers - use pillow in between bony - lateral oblique - massage body areas - keep skin clean and dry - use moisturizing cleanser than soap - rinse and dry well - pressure relieving devices - use cushing or gel filled mattress

Mechanical Debridement

- includes physical removal of debris from deep wound - wet to dry - algiderm - hydrotherapy - irrigation

3 phases of wounds

- inflammation - proliferated - remodeling

Stage I

- intact but red and fails to resume it's normal color when pressure is relieved.

Enzymatic debridement

- involves the use of topically applied chemical substances that break down and liquefy wound debris - uninfected wounds or for clients who cannot tolerate sharp debridement - appropriated for uninfected wounds and those who cannot tolerate sharp debridement

Sutures

- knotted ties that hold an incision together, generally are constructed from silk or synthetic materials such as nylon. - few days to 2 weeks

Stage IV

- life threatening, deeply ulcerated exposing muscle and bone - evident of slough and necrotic tissue - foul odor - infection present and can spread "sepsis"

Factors that effect pressure ulcers

- localized edema - sedation - inactivity - incontinence - immobility - dehydration - diaphoresis - malnutrition - emaciated - vascular disease

Bandages and binders are made of and various purposes are

- made from gauze, muslin, elastic rolls, and stockinette - holding dressing in place, especially when tape cannot be used or if the dressing is extremely large - supporting the area around a wound or injury to reduce pain - limiting movement in the wound area to promote healing

Hydogels

- maintain a moist wound environment and are best for partial or full-thickness wounds

Wet to dry

- mechanical debridement - removed approximately 4 to 6 hours later when gauze is dry - disadvantages - impedes healing from local tissue - disruption of angiogenesis (formation of new blood cells - increased risk for infection from frequent dressing changes

The nurse is caring for a client for who maggot therapy has been ordered for non-healing leg wound. The client states, "You're not putting those nasty bugs on me!" What is the appropriate nursing response?

- medical maggots are sterilized before they are introduced to the wound - I understand your concern' let's talk further about you thoughts about this treatment - the choice regarding whether to have or decline this treatment is yours

The nurse is providing care for a client whose recent health deterioration has led to a nursing diagnosis of Risk for Impaired Tissue Integrity. What assessments should the nurse consequently perform?

- monitor the client's fluid intake - monitor the client's nutritional status - assess the client's level of mobility - assess the client's bowel and bladder

Binder

- not commonly as bandages - t-binder after rectal or vaginal Sx

Transparent dressing

- op-site, clear adhesive single sheet of tape that covers wound - used with minimal exudate, IV sites, stage 1 ulcers - less bulky - not absorbent - allows exchanged of o2 BT air and wound bed - change when you need to unless ordered, can stay on for days

2 Types of wounds

- open wound (one in which the surface of the skin or mucous membrane is no longer intact.) - close wound (there is no opening in the skin or mucous membrane. they occur more often from blunt trauma or pressure.)

Autolytic debridement

- painless, natural self dissolution - body's enzymes soften and liquidity and release devitalized tissue - used when wound is small and free of infection - takes longer to heal -> monitor s/s of infection - occlusive or semi-occlusive dressing - keep wound moist

Inflammation

- physiologic process immediately after tissue injury - last 2 to 5 days purposes - limits the local damage - removes injured cells and debris - blood vessels constrict to control blood loss and confine the damage s/s - swelling, redness, warmth, pain, and decreased function, increased WBC

Cold

- produces max vasoconstriction when temp reaches >60F - reduces swelling on any small injury - reduces fever - helps control bleeding - relieves pain - numb sensation -ice bag - ice collar (tonsil removal) - chemical pack (packs struck/crushed to activate) - compress (moist, warm, cool cloths) - aquathermia pad ( an electrical cooling device)

A nurse is caring for a client in a wound care clinic. The client has a wound on the left forearm from a roofing accident. During would care the nurse notes the wound base is beefy red and bleeds easily during wound cleansing. Which stage of wound healing should the nurse recognize with this client's wound?

- proliferation phase

Drains

- promotes wound healing by removing fluid and cellular debris through open or closed drains

Nutritional

- protein - vitamin C - zinc

Stage II

- red accompanied by blistering or a skin tear without slough - may lead to colonization and infection

The nurse is caring for a client who has a deep wound and whose saline-moistened would dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate?

- reduce the time interval between dressing changes.

Sharp debridement

- removal of neurotic non-living tissue from healthy area of a wound with - sterile scissors, forceps, or other instruments - helps wound to heal quickly - painful and the wound may bleed afterward - medication q30 mins preTx

Which processes are responsible for restoring integrity of the skin and damaged tissues when caring for a client with an open wound?

- resolution - regeneration - scar formation

Most common place for pressure ulcers

- sacrum - hips - heals - elbows - shoulders - back of head

A nurse is caring for a client at a wound care clinic. The client has a 5cmX6cm abdominal wound dehiscence. Which type of wound repair would the nurse expect with the wound?

- secondary intention the wound edges are not well approximated

Which is part of the graded criteria for predicting pressure ulcers using the Braden scale? Select all - sensory perception - nutrition - age - ability - friction

- sensory perception - nutrition - ability - friction All part of the criteria used in the Braden Scale

The nurse is caring for a woman with labile carbuncle. Which intervention will most likely be included in the plan of care?

- soak in a warm bath for drainage heat promotes vasodilation, allowing for the consolidation of pus in infected areas.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and unblanchable. How will the nurse categorize this pressure ulcer?

- stage I

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound present as shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. what is the correct name of this wound?

- stage II

Bandage

- strip or roll of cloth wrapped around a body part

Avulsion

- stripping away of large areas of skin and underlying tissue, leaving cartilage and bone exposed.

Which activity should the nurse implement to decrease shearing force on the client with stage II pressure ulcer?

- support the client from sliding in bed

The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room?

- tegaderm

Teaching regarding ice bags

- test the ice bags for leaks - fill it 1/2 to 2/3 full of crushed or small cubed - eliminate as much air from the bag - pour water over the ice to provide slight melting (smooths sharp edges) - cover the bag with a layer of cloth before placing it on the body - leave no more that 20-30 minutes, wait 30 minutes before reapplying - remove promptly if the skin becomes mottled or numb (its too cold)

Phagocytosis

- the process by which cells consume pathogens, coagulated blood and cellular debris.

Debridement

- the removal of dead tissue - four methods - sharp (not as an LPN) - enzymatic - autolytic - mechanical

Hydrotherapy

- therapeutic use of water - contains antiseptic that softens dead tissue - loose debris left use sharp to remove

purulent

- thick, yellow, green, tan, brown

Closed Drains

- tubes that terminate in a receptacle - more efficient due to vacuum or negative pressure pulling fluid out - record output - clean insertion site in a circular manner, use a precut sponge or gauze (i.e. hemovac and jackson-pratt drain)

Binder

- type of cloth cover generally applied to a particular body part such as the abdomen or breast

Factors that affect wound healing

- type of injury - expanse or depth of wound - quality of circulation - amount of debris - presence of infection - health status of client (i.e. obesity, poor nutrition, impaired inflammatory or immune response, corticosteriods, excessive tension and pulling on wound delays or disrupts the process)

Wound Management Dressing purposes

- types and sizes depend on purpose - keeps wound clean - absorbing drainage - control bleeding - protect from future injury - holding Rx in place - maintaining moist enviroment

Stage III

- ulcer with shallow crater that extends to the subcutanous tissue - may accompany and/or caused by - serous drainage (clear/watery plasma) - purulent drainage (thick yellow, green, tan, brown) - relatively painless

A nurse is evaluating a client who was admitted with second-degree burns. Which describes a second-degree burn?

- usually moist with blisters, they maybe pink, red, pale ivory, or light yellow-brown

serosanguinous

- watery mixture of clear to red fluid

Dressing Changes

- when assessment is needed - becomes loose - becomes saturated with drainage - MD may choose to complete the initial dressing change and then allow the nurse

The nurse assesses the wound to determine

- whether it is intact or shows evidence of unusualness, the location, size - inflammation = swelling, redness, warmth - drainage (serous, purulent, serosangulinous, sanguinous) - increasing discomfort. (scale it, note char, check order for Rx) - undermining - slough - neurotic

The speed of wound repair and the extent of scar tissue that forms depends on...

- whether the wound heals by first, second, or third intention.

Staples

- wide metal clips - do not encircle a wound like sutures, they form a bridge that holds two wound margins together - do not compress the tissue if the wounds swells basic food items you always want to have on hand - few days to 2 weeks - remove every other one - remove 1/2 one day 1/2 another (if need to)

Generally, the integrity of skin and damaged tissue is restored by 3 things.

DURING PROLIFERATION STAGE (1) resolution = a process by which damaged cells recover and reestablish their normal function (2) regeneration = cell duplication (3) scar formation = replacement of damaged cells with fibrous scar tissue

Granulation tissue

DURING PROLIFERATION STAGE - a combination of new blood vessels, fibroblast, and epithelial cells - bright pink to red - grows from the wound margin toward the center

sanguinous

bright red, active bleeding

Define Wound

damaged skin or soft tissue

Most common wound coverings

gauze, transparent and hydrocolloid

Wound results from

trauma Definition: a general term referring to injury (i.e. cuts, blows, poor circulation, strong chemicals, and excessive heat or cold.)