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29 Cards in this Set

  • Front
  • Back
Assessment of Wound Color:
*RED: proliferative stage (healthy granulation tissue--protect)
*YELLOW: oozing purulent
*BLACK: debride
Wound Assessment and Documentation: how to describe wound appearance
* LOCATION: side of body, where it is in relation to something else
* SIZE: Length, Width, Depth
* EDGES: Color, defined, or uneven (like a scrape), closed/open
* COLOR: is it necrotic?
* SWELLING--gentle palpation; separation of wound edges; pain/tenderness
Wound Assessment: Drainage-Type
1) Serous: clear
2) Serosanguinous: bloody/pink
3) Purulent: yellow pus/green, thick foul smelling
*AMOUNT: fully saturated? 50% of dressing type, size of quarter? OB: how many pads saturated
* where is the wound/where are the stresses? ex: abdominal wounds sometimes have sinus pocket on each end
Wound assessment: closure, drains
*type of closure: staples, sutures--are they intact?
*nurse responsible for maintaining the patency of the draining system, measuring output, assessing type and color of drainage
3 Types of Drains
1) penrose drain: function by gravity and have an open end that drains onto the dressing
2) Jackson Pratt and 3) Hemovac are closed suction drainage systems that draws out exudate from wound with gentle suction--these are put in the wound in the OR
Removing Sutures
*cut as closely as possible to one side and then pull through--never pull exposed suture (contaminated) through skin.
Purpose of Dressings
Provides 1) warmth and moisture, 2) keeps the wound clean guarding against infection 3) protects the wound from further physical trauma/injury 4) homestasis-keeps fluid balance 5) Absorption of drainage
6) debridement 7) support (skin graph or ace bandage
Purpose of Cleansing the Wound--types of solution
* Remove debris and bacteria with as little trauma to the healthy tissue as possible
* common solutions: normal saline (isotonic), betadine (antiseptic), H2o2/ns (debridement), Acetic Acid (vinegar deodorizes), povidone iodine (antiseptic)
Cleansing the Wound: basic principles
Always going from the least contaminated to the most contaminated; solutions warmed to room or body temperature
Common Types of Wound Dressings
* Gauze, telpha (non-stick), wet-dry, transparent film (protection for elderly with frail skin), colloid (from seaweed-high in NACL), collagens/gel, polyurethane foams around tubes, tapes--always stick to eachother, never the skin
intact skin: defined area of persistent redness, or red/blue/purple in darker skin tones
Partial thickness involving the epidermis, dermis, or both (abrasions, blister, shallow crater)
Full thickness involving damage of subcutaneous tissue, may extend to but not through fascia
Full thickness with extensive damage to muscle, bone or supporting structures
When eschar is present, ulcer cannot be staged
Assessment of Pressure Ulcers: Braden Scale
Braden and Norton Scales exist to predict risk of pressure ulcers and include factors such as: sensory perception, moisture, activity level, mobility, nutrition, friction and shear, mental condition, incontinence
4 Debridement Methods
1) Surgical, 2) Mechanical (wet-to-dry dressings, whirlpool,etc), 3) Enzymatic or chemical, 4) Autolytic (enhancing body's own enzymes)
5 Purposes of Bandages and Binders (types: gauze and elastic)
1) Pressure to support incision
2) Immobilization
3) Support
4) Decrease edema
5) Secure a splint
Dressing Change 101
* MD order specifying details
* Pain meds beforehand
* Wash hands, assemble equipment, assess for drains, remove old dressing with regular gloves
* Cleansing drain sites or wound with sterile gloves, care of sutures, patient teaching, securing dressing
Basics of application of Roller Bandages
* cover with pad before bandage
* bandage the part in a normal position
* non-constricting pressure (2 finger-widths underneath)
* equal tension on all turns
* no tape on skin
Interventions to prevent pressure ulcers
1) skin inspection
2) control incontinence
3) bathing
4) positioning, avoid pressure areas, support surfaces, movement/turning
Moist wound healing: topicals
1) enzymes
2) hydrogel
3) calcium alginate
Vacuum Assisted Closure
*use of negative pressure to encourage wound healing (used for acute and chronic wounds)
Wound Categorization by cleanliness of wound
1) clean: intentional wounds that were created; no inflammation, no contamination by respiratory, alimentary, genitourinary and oropharyngeal tracts
2) clean, contaminated: intentional wounds that were created by entry of one of the above tracts
3) contaminated: open, traumatic wounds or intentional wounds that there was a break in aseptic technique (e.g. spillage from GI tract),
4) dirty and infected: traumatic wounds with retained dead tissue or intentional wounds where purulent drainage is present
Partial thickness wounds
1st - 2nd degree wounds involveing the epidermis and upper dermis
Full thickness wounds
3rd degree: skin loss extends through the epidermis and dermis into subcutaneous fat and deeper structures
Inflammatory Response
Assessment: local heat, edema, pain, temporary loss of function, leukocytosis, exudate, tissue repair
8 Factors that effect tissue repair
1) age
2) nutrition
3) circulation & oxygenation--localized ischemia
4) drug therapy
5) diabetes
6) general health status
7) stress on the wound
8) smoking
5 Complications of Wound Care
1. infection
2. fistula
3. pain
4. anxiety/fear
5. body image change