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76 Cards in this Set
- Front
- Back
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what are some techniques for managing pain during wound interventions
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drugs, dressings, relaxation techniques, pt education
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describe wound cleansing
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NOT debridement. Remove loosely attached cellular debris and bacteria from wound bed, while protecting healthy granulation. ALWAYS clean the wound before measuring and applying a new dressing.
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what is the general technique for wound cleansing
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always use standard precautions. Use sterile gauze pad with cleansing agect. Always work outward from within wound. Clean approximately 1" beyond end of the new dressing or 2 " beyond wound margins if not applying dressing.
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what cleansing agents is usually used for pressure ulcers
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saline
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what is the problem with cleansers
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can be cytotoxic
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procedures for wound cleansing if the wound is healthy
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cleanse with normal saline. DON'T use antimicrobrial solution or skin cleansers
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Procedures for wound cleansing if the would is infected
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cleanse with normal saline or use a 10-14 days cleansing regime with an antimicrobial solution
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when should you use hydrogen peroxide
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if the wound is REALLY dirty, if burns DON'T use because killing healthy tissu
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what is the purpose of hydrotherapy
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removal of gross contaminants, loosening of necrotic tissue.
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is hydrotherapy appropriate for EVERYONE with a wound
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NO, not for clean wounds. May lead to maceration
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Is scrubbing recommended
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NO, only in cases of burns because can delay wound healing due to microbrasians
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if you are performing irrigation, what is required (for PPE)
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protective eyeware, gloves, gown and face mask
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For irrigation, what is considered a low pressure
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<4 psi,such as pouring or a bulb syringe
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For irrigation, what is considered a high pressure
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4-15 psi, using a 35mL syringe with 19 gauge needle and pulse lavage
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what pressure is recommended for irrigation
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high pressure 4-15 psi
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describe pulsed lavage with suction
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cleans and debris though pulsatile irrigation using saline.
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what is the purpose of pulsed lavage
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removes bacteria and debris through negative pressure (suction)
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what are the benefits of pulsed lavage
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increase saftey, comfort, efficency of PT, decreases treatment time, and cross contamination. Able to control pressure, avoid periwound maceration, treats tunnels and undermining, minimal clean up, no desctruction to granulation tissue
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What are the precautions to using pulsed lavage
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insenstate patient, anticoagulant medications, wounds with tunnels/undermining, treatment near major vessels, cavity linings, bypass graft sites when outside of hospital
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what do you do if the pulsed lavage causes patient pain
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STOP, should not cause pain
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how often do you use pulsed lavage if there is <50% necrotic tissue
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daily
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how often do you use pulsed lavage if there is >50% necrotic tissue
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twice a day
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how much suction should be set for pulsed lavage
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60-100 mmHG
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how much pressure should be set for pulsed lavage
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4-15 psi
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when do you discontinue pulsed lavage
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if it causes the patient pain, wound in closed, no increase in granulation/epithelization in 1 week or no decrease in necrotic tissue in 1 week
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What is the purpose of wound debridement
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asses true depth, size of wound, remove necrotic tissue or foreign matter from the wound bed, prevent infection, corect abnormal wound repair, increase the rate of wound healing
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Describe non-selective debridement
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removes viable and non-viable tissue
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what are the indications of non-selective debridgement
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severly necrotic wounds with minimal or no healty tissue present
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what are the contraindications of non-selective debridement
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clean wounds that have granulating and epithliazing tissues
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what are the 3 techniques for non-selective debridement
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pulsed lavage with suction, wet-to-dry gauze, whirlpool
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describe the wet-to-dry gauze technique
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mositen gauze with saline, place in wound, cover withdry laters of gauze, remove dried gauze. Chagne every 8 hours
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what are the problems with wet-to-dry cause technique
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causes pain and granulation tissue is traumatized
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how does whirlpool debride wounds
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mechanical action via turbulence
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What beneftis does whirlpool have
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has analgesic effects and enhances local perfustion
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what are some cons to whirlpool
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damages fragile epithelial cells
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what are the indications of whirlpool
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wounds with loosely adherent necortic tissue, exudates and debris. Psoriasis, extensive burns, Kaposi's sarcoma with mulitple tumors.
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What are the contraindications of whirlpool
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compromised cardiovascular or pulmonary function, decreased mental status, B/B incontinence, clean granulating wounds, new skin graft or flap, venous ulcers, LE edema, febril conditions
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what water temperature should the whirlpool be set at if the patient has a PVD and limited body area
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80-92 F
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what water temperature should the whirlpool be set at if the patient is medically compromised
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92-96
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What water temperature should the whirlpool be set at is the patient had no medial complications and limited body area
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96-104
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explain the whirlpool technique
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educate pt on procedure, check thermometerfirst, turn turbine away from pt before starting agitation, stay within an earshot and is done daily for 5-20 min
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when do you discontinue whirlpool
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clean or no measureable change in wound
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describe selective debridement
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surgical or sharp debridement. Is the removal of non-viable tissue with sterile instruments, most aggressive, effective and fastest.
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With sharp debridement… when in doubt…
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leave alone
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when do you stop shar debridement
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pain, tendon, bone, nerve, vascular tissue, fistula, or tunnel in another plane revealed
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what do you do if eschar is present
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debride in stages, first soften with occulsive dreassing and enzymatic debriding agents. Use scaple to make cross-hatch to allow better penetration of agent
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if during debridement, what should you do if bleeding occurs
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stop, compression, elevation and use silver nitrate
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benefit of using enzymatic debridement
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harmless to normal tissues
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Types of enzymatic debridement
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papain-urea debriding ointment (accuzyme), collagenase (santyl)
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describe the technique of enzymatic debridement
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cross hatch the area with a scaple, apply thin film of enzyme with tongue depressor to devitalized tissue only, cover with saline soaked gauze. 1-2X for a few days to several weeks
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Describe autolytic debridement
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natural form of debridement (breakdown by body's own WBC), most selective, painless, no harm to healthy tissues (risk of maceration to surrounding skin)
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describe the technique of autolytic debridement
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cross hatch or sharp debride eschar. Use moisture-retentive dressing to create environment that allows cells to digest devitalziled tissue by releasing proteolytic and collagenolytic enzymes normally present in wound fluids
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what are the contraindications for autolytic debridement
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requries quick elimination of necrotic tissue
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what is the disadvantage of using autolytic debridement
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stinks
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explain biosurgical debridement
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sterile larvae from common green bottle fly
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benefit of using biosurgical debridement
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allow for debridement, disinfection and promotion of healing
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what is a con of using biosurgical debridement
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negative perception and yuk factor
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what are the goals of topical agents
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hemostasis, reduce infection, limit inflammation, pain relief, remove necrotic tissue, promote wound closure/faster healing
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what is the concern with using anti-microbals
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can inhibit function of fibroblasts,keratinocytes, and other cells, resistance
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when are anti-microbals recommended to use
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if no healing or still producing exudate after 2-4 weeks of optimal care
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for wounds when do you use anti-inflammatories
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nonhealing wound with chronic inflammation, may use corticosteriods
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for wounds what is used for anesthetic and analgesia
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EMLA cream
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what is tissue glue
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dermoband or adhesize
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what is the purpse of growth factors for wound care
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promotes recruitement, proliferation of wound repair cells, stimulatates collagen formation, accelerate healing
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what is the criteria for wound dressings
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should remove exudate, maintain high humidity, allows gaseous exchange, provide thermal insulation, afford protection from secondary infection, be free from contamination, allow removal without trauma at dressing change.
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How do you maintain adequate moisture in the wound : balanced
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if seems balanced, use clear film and hydrocolloid dressings
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How do you maintain adequate moisture in the wound : too much exudate
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use calcium alginates or foams
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How do you maintain adequate moisture in the wound : too dry
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use hydrogels
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if there is bacteria in the wound, what can you incorporate onto the dressings
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silver
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How many layers of dressing swhould you have
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3, Contact: directly over wound bed, non adherent. Absorbent: reduce risk for strike-through Secondary (outer): consider fragility or adjacent skin
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describe different types of skin substitutes
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diverse group of substances aid in the temoprary or permanent closure of wounds.
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Describe xenografts
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xenograft- different species
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describe autografts
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autografts- split or full-thickness skin grafts, cultured autologous skin (cultured epidermal autografts)
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describe allografts
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grafts transplanted between genetically non-identical individuals of the same species. Human amniotic membrane: alloderm,graft jacket, dermaMatric,demograft,apligraft
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describe synthetic subsitutes
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serve as dermal templates that promote ingrowth of host tissue to repair defects
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describe skin sealants
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act as a barrier to protect maceration or mechanical shearing
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