Wound Care
The nurse is instructing a patient on how to change a transparent dressing. Which statement, if made by the nurse, requires correction?
"You will want to remove your gloves to prevent the transparent dressing from sticking to them. Remove the paper backing of the transparent dressing and firmly stretch it over the wound to prevent wrinkling."
Intrinsic Factors that affect wound healing.
-Age plays a role, epithelial thins as you age. -Chronic illnesses.-Circulation, resp, oxygenation, and diabetes -Reduced skin sensation. Intrinsic factors are difficult to change. -Immobility -impaired mental status -diminished sensation -excessive body heat
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.
Braden Scale
A tool for predicting pressure ulcer risk. The six sub scales are; sensory perception, moisture, activity, mobility, nutrition, friction/shear. Score of 6-23. Cutoff score is 18 for most adults. The lower the number the higher the risk.
Colonized wound
A wound in which one or more organisms are present on the surface of the wound when a swab culture is obtained but there is no overt sign of an infection in the tissue below the surface.
Infected wound
A wound showing clinical signs of infection, including redness, warmth, and increased drainage that may or may not be purulent (contain pus)
Chronic wound
A wound that fails to progress to healing in a timely manner, often remaining open for an extended period
Acute wound
A wound that progresses through the phases of wound healing in a rapid, uncomplicated manner
The nurse is performing a dressing change on a patient who is postoperative from a laparotomy. The patient coughs and the nurse sees a few loops of intestine uncoiling from the wound. What is the nurse's best action at this time?
Apply sterile saline-soaked towels to the area.
Foam Dressings
Are dressings that are absorbent and provide a moist healing environment while protecting wounds. -Can be beneficial to bony prominences because of the padding. -Self adherent or nonadherant.
Eschar
Black scab-like material
Dressing change procedure
Assess pain and medicate as needed, gather supplies Wash hands, don clean gloves, remove and discard old dressing and dirty gloves Wash hands, set up sterile field, don sterile gloves, apply dressing, tape Discard gloves, wash hands Chart-wound assessment, pt tolerance of procedure
Dehiscence
Bursting open of a wound, especially a surgical abdominal wound.
How is the vacuum re-established after emptying a drain such as a Jackson-Pratt drain or Hemovac?
By compressing the drain reservoir.
Which information would the nurse provide for a pt being discharged with a surgical wound?
Care of the surgical wound safe and effective use of meds list of appropriate community resources
Pseudomonas aeruginosa
Common bacteria that can lead to a bacterial infection that appears as a green, yellow, or black discoloration on the nail bed.
Effects of cold therapy
Constricts peripheral blood vessels-Controls bleeding Reduces muscle spasm Decreases capillary permeability decreases cellular metabolism Slows bacterial growth
Surgical Debridement
Removal of devitalized tissue by using a scalpel, scissors, or other sharp instrument.
Contaminated wound
Results from a break in sterile technique during surgery
Wound dehiscence
Separation of the layers of a surgical wound; may be partial, or superficial only, or complete, with disruption of all layers.
Clean-contaminated wound
Similar to a clean wound, but because the surgery involves organ systems that are likely to contain bacteria, the risk for infection is greater.
Hydrogel Dressings
Similar to alginate dressings because of the absorbent properties. -Do not affect hemostasis. -Composed of polymer gel, which absorbs exudate vertically. -Maintain a moist wound environment. -Used for wounds with necrosis, infection, and a need for a moist environment. -Not to use for dry gangrene or dry ischemic wounds. -Costly
Pressurized Cleansing
Some wounds require pressurized solutions for adequate cleansing coverage. Most wound solutions delivered at a minimum of 8 psi via a syringe or a catheter can achieve this.
A patient with lung cancer received radiation therapy to reduce the size of the tumor before a lobectomy (surgical removal of part of the lung). The patient is now being seen on home health services for packing of an abnormal passage between the patient's chest cavity and an opening on the patient's back. The nurse is aware the patient is at increased risk for:
Fluid and electrolyte imbalance.
Exudate
Fluid or semisolid material that is slowly released by blood vessels or tissues as a result of inflammation or injury.
Which component of hand washing would the nurse include that is most effective for removing microorganisms?
Friction
Stage 3 of Pressure Ulcer
Full-thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater. May see subcutaneous fat but not muscle, bone, or tendon.
Stage 4 of Pressure Ulcer
Full-thickness tissue loss with exposed bone, muscle, or tendon. Sometimes has eschar or slough.
Which of the following regarding removal of the old dressing on a surgical incision are accurate? (Select all that apply.)
If dressing is over a hairy area, remove tape in the direction of hair growth Use caution to avoid tension on any drains that are present
Impaired tissue integrity
Damage to mucous membrane, corneal, integumentary, or subcutaneous tissues.
Wet to Dry Dressing
Damp gauze dressing placed on a wound and removed after the dressing dries to the wound. -Never use in a clean wounds with granulation. -Pulls exudate out of the wounds as it dries.
Which of the following is a method of wound debridement?
Damp-to-dry dressing
Tertiary healing intention
Delayed primary (surgical) closure: Contaminated wound that is initially treated with repeated debridement and antibiotics before closing surgically. Wait for inflammatory response to decrease, secondary intention for a brief period of time
Effects of heat therapy
Dilates peripheral blood vessels Increases capillary permeability Increases inflammation Systemic (prolonged or large surface area)
Choosing dressing based on
Location, size, type of wound Amount of exudate Whether wound requires debridement or is infected Frequency of dressing change Ease, difficulty of application Cost
Identify the functions of dressings. (Select all that apply.)
Maintaining a moist environment Control of bleeding and drainage. Protection from outside contaminants and further tissue injury. Increased patient comfort.
Alginate Dressings
Manufactured from seaweed. -Provide a moist environment for healing and good absorption of exudate, establish hemostasis, and do not adhere to the wound when used appropriately. -Helpful for wounds with large amounts of exudate. -Can be used to pack deep wounds. -NOT used in dry wounds. -Secondary dressing required over.
A patient is to have frequent dressing changes. What should the nurse use to secure the dressing?
Montgomery ties
NPIAP
National Pressure Injury Advisory Panel. Provide a staging system used to describe the severity of pressure injuries.
Stage 1 of Pressure Injury
Nonblanchable redness caused by pressure typically over a bony prominence
Shear
Occurs when the skin itself stays in place and the subcutaneous tissue shifts under the skin.
Clean wound
One in which there is no infection and the risk for development of an infection is low
Stage 2 of Pressure Injury
Partial-thickness skin loss with visible injury or fluid-filled blister
Chemical Impregnated Dressings
Dressings that are impregnated with chemicals or agents intended to speed up the healing process. Examples are povidone-iodine, silver, petroleum, collagen, and antibiotics. -Use only for wounds that are likely to respond to the agent in the dressing.
When is a surgical wound at greatest risk for hemorrhage?
During the first 24 to 48 hours after surgery
Granulating Tissue
Pink, healthy, healing tissue. Clean edges of a wound.
During an assessment which finding prompts the nurse to don a protective gown?
Excessive wound drainage
Inflammatory Phase of wound healing
Starts when the skin is injured for about 24 hrs of partial-thickness wounds. Main characteristics are skin color changes, heat, swelling, pain, and loss of function. WBC's, neutrophils, macrophages, lymphocytes, plasma proteins and mast cells are present.
Hemostasis
Stoppage of bleeding
Edema
Swelling caused by excess fluid in the body tissues
Partial-thickness wound
The dermis and epidermis of the skin are broken. Heal by re-epithialization.
Full-thickness wound
The dermis, epidermis, and subcutaneous tissue are penetrated; muscle and bone may be involved. Heal by scar formation.
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.
Evisceration
The displacement of organs outside of the body.
A nurse is applying negative-pressure wound therapy (e.g., wound vacuum-assisted closure [V.A.C.]) independently for the first time. Assuming all other steps are performed correctly, which action, if made by the nurse, indicates that further instruction is needed in performing this procedure?
The nurse cuts the foam approximately one-half inch smaller than the size of the wound and gently places the foam in the wound, avoiding any tunneled and undermined areas.
The nurse is caring for a patient with a Jackson-Pratt drain. Which of the following indicates correct understanding? (Select all that apply.)
The nurse instructs the NAP to measure the drainage and record on the intake & output form every 8 to 12 hours and as needed for large drainage volume. The nurse ensures the drainage device appears deflated after it is emptied.
Which of the following may indicate an increased risk for wound dehiscence?
There is an increase in serosanguineous drainage from the wound.
Transparent Wounds Dressing
Thin layer of plastic that covers the wound area. - Provides no absorption. -Creates a barrier to the environment. -Allows some oxygen exchange and a moist environment to promote healing and autolytic debridement. -Commonly used for wounds with necrosis or superficial skin tears.
Maturation Phase of wounds healing
This phase begins day 21 may take more than a year. Beginning and overlapping with the proliferation phase. Works to reorganize collagen within a scar to help increase strength and skin integrity. Scare tissue (no capillaries) changes in color. Light skin= scar turns pink or red to white. Dark skin= scar is more pigmented than surrounding skin.
Necrosis
Tissue death
Why does a wound bed need to stay moist?
To support healing by enabling granulation tissue to grow.
The nurse is teaching the nursing assistive personnel (NAP) in a nursing home about daily routine measures to reduce the incidence of pressure injuries within the agency. Which of the following should the nurse include in the teaching? (Select all that apply.)
Turning patients at least every 2 hours. Use of pillow bridging when needed. Positioning patient in the 30-degree lateral position. Using a turn sheet to reposition patients.
The nurse inspects all wounds for signs of infection. When might a contaminated or traumatic wound show signs of infection?
Two to three days after injury
Unstagable ulcer
Ulcer covered with slough or eschar in the base so would stage is not able to be determined.
Hydrocolloid Dressings
Used for autolytic debridement. -Benefit for some absorptive capabilities, while maintaining a moist environment. -Not recommended for infected wounds, but helpful for wounds that are vulnerable to infection. -Not for dry gangrene or ischemic wounds. -Not transparent. -Can usually leave for up to 7 days unless the dressing is compromised.
Autolytic Debridement
Using body's enzymes to break down tissue
Sensitivity
What's going to kill it (antibiotics)
Secondary Intention Wound Healing
When a wound is allowed to remain open and heal by granulation, epithelialization, and contraction. BOdy's natural healing course.
Friction
When skin is rubbed over a surface and the epithelial tissue is irritated or injured.
Hyperkeratotic rim
Where you have excessive tissue around wound
Slough
White, yellow dead tissue.
The nurse is caring for a client who had head and neck sx. Which complication will the nurse try to prevent by positioning the clients head in functional alignment after surgery?
Wound dehiscence
Wound Fillers
Wound fillers are manufactured as pastes, powders, gels, and beads for providing a moist healing environment beneath dressings. -Some help soften underlying necrotic tissue to speed up debridement. -Fillers are helpful for deep wounds with some exudate and are less useful with dry wounds.
Primary Intention Wound Healing
Wounds is surgically closed. Stitches or staples.Also involves epithelialization.
It is suspected that a patient is developing a wound infection. Which assessment data would support this conclusion? (Select all that apply.)
Yellow-tinged drainage. Temperature 100.3° F (37.94° C). Increased complaints of pain at wound site. White blood cell count 13,000 mm3 (elevated). Wound edges pink to normal skin color. Foul odor noted from previous dressing.
Passive Irrigation
a method that involves a solution and gravity. -Top to bottom of wound irrigation.
Purosanguineous
a mixed drainage of pus and blood (newly infected wound)
Proliferative Phase of wound healing
begins day 3- 21 Restores skin integrity by filling in the wound with new tissue. New blood vessels form (angiogenesis). Granulation tissue forms, epithelialization occurs, fibroblasts deposit collagen that works with granulation tissue to form scar, contraction of wounds edges start.
sanguineous drainage
bloody drainage
serous drainage
clear, watery plasma
Contusion (bruise)
closed wound, skin appears ecchymotic (bruised) because of damaged blood vessels
Measuring wounds
in cms (proximal to distal, medial to lateral) tunneling- 12 o'clock is pt's head, 3 is pts left arm, 9 is pts right arm
serosanguineous drainage
mixture of serum and red blood cells
Incontience-associated dermatitis
moisture-associated skin breakdown caused by prolonged contact of the skin with urine or feces
Superficial wound
only involves the epidermis. Ex: shearing, friction, burns
Penetrating wound
open wound
Puncture
open wound
Abrasion
open wound involving skin
Incision
open wound; deep or shallow; once the the edges have sealed together as part of treatment or healing the incision becomes a closed wound
Laceration
open wound; edges are often jagged
Erythematous
pertaining to redness of the skin or erythema
T-tubes and Penrose drains
pts who had abdominal sx Not sutured in place Be careful not to pull with dressing changes Maintain how it comes to you Change dressing when soiled Dressing will be over that last picture on the right If there is a lot of drainage, skin will be macerated be cognoscente of that
RYB guide
red: protect/cover yellow: cleanse black: eschar, debridement
Abnormal reactive hyperemia
remains red longer than it should
Epibole
rolled wound edges
Impaired skin integrity
skin layers that are interrupted by wounds
Culture
something growing
Signs of localized infection
swelling, redness, heat, pain or tenderness, and loss of function in the affected body part
purulent drainage
thick green, yellow, or brown drainage (pus)
Reactive hyperemia
tries to compensate for having lack of blood flow by vasodilating and turning super pink( rapid increase of blood flow) Example: 1 hour pressure- 30/45 mins hyperemia will last
Negative Pressure Wound Therapy (NPWT) or Vacuum Assisted Closure (VAC)
uses negative pressure to remove excess wound fluid, stabilize the wound edges, and stimulate granulation tissue. reduce the bacteria count in the wound. Promotes granulation development but removes excess fluids Additional training needed dressing should be changed once every 48-72 hours
Signs of systemic infection
-fever -increased pulse and respiratory rate if the fever is high -malaise and loss of energy -anorexia and, in some situations, nausea and vomiting -enlargement and tenderness of lymph nodes that drain the area of infection
Dry Dressings
-May be chosen for management of a wound with little exudate/drainage -Appropriate dressing change for multiple types of wounds. -Can stick to the wound be of heavily exudative wounds or expose them to the outside environment. -Can be applied in a sterile and clean environments.
Extrinsic Factors that affect wound healing.
-Medications can affect wound healing. (Aspirin inhibits platelet action)(Corticosteroids suppress immune system). -Cancer treatments. -Inadequate nutrition. -Stress -Infection -Repeated trauma
Which of the following lab results or measurements indicate a risk for impaired wound healing? (Select all that apply.)
A BMI (body mass index) of 35 (elevated) Fasting blood glucose of 215 mg/dl (elevated) A serum albumin of 2.9 g/dl (decreased) A hemoglobin of 10.0 g per dL (decreased)
Which of the following patients is at greatest risk for developing a wound infection?
A diabetic obese patient who smokes
Which of the following is an example of healing by secondary intention? (Select all that apply.)
A full-thickness pressure injury. A surgical incision. A dog bite. A burn. A skin tear
The nurse is reading electronic documentation from the emergency room on a patient who is to be admitted to the unit. The documentation states that the patient has a hematoma on the right knee. What does the nurse expect to see?
A localized collection of blood underneath the tissues that often takes on a bluish discoloration.
Which technique would the nurse use to maintain surgical asepsis?
Change the sterile field after sterile is spilled on it
The nurse may use clean gloves for changing the dressing on which of the following?
Chronic pressure injury.
A nurse is explaining how to perform a dressing change. Which of the following sequences for changing a surgical wound dressing (wound drain present) indicates that the nurse requires further education regarding this procedure?
Cleanse wound. Use a separate swab for each cleansing stroke. Cleanse around drain by using a circular stroke starting near the drain and moving outward. Clean incision in direction of bottom to top.
Medical device related pressure injury
Injury that results from the use of devices designed and applied for diagnostic or therapeutic purposes.
Principles of wound healing
Intact skin is first line of defense Body responds systemically to any kind of trauma Adequate blood supply is essential for body's response to injury Normal healing is promoted when wound is free of foreign material Ability to care for wound is dependent on extent of damage and persons overall health Proper nutrition is essential Must have a moist (but not too moist) environment to heal
Mechanical Irrigation
Involves the use of gauze and a cleansing solution to clean contaminated wound areas.
Key factors for wound healing
Proteins, vitamin C and zinc important for wound healing 80 grams of protein Wounds will not heal and it will be delayed healing Hydration is key for adequate blood flow for new capillaries to grow
Nursing process outcomes for wounds
Pt will remain free of infection Verbalize pain control Be discharged home and manage wound care at home Demonstrate appropriate wound care Verbalize understanding of signs and symptoms to report
Suspected deep tissue injury
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
