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127 Cards in this Set

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What is the goal of wound care?
to promote tissue repair and regeneration so that skin integrity is restored
What are the 2 methods of caring for wounds
open and closed method
Open method of wound care
a dressing is used as a protective cover over the wound
Closed method of wound care
no dressing is used
what is the best environment for wound healing?
a moist environment
Benefits of placing a dressing over a wound
the wound fluid keeps the surface of the wound moist. As a result, epidermal cells migrate more rapidly maximizing healing
How many layers do most dressings consist of?
3 layers
What are the 3 typical dressing layers?
The contact layer, the middle layer, and the outer layer
function of the contact layer
allows drainage to pass into the middle layer. It should be able to be removed withoud causing further tissue damage
Function of the middle layer
absorbs drainage
Function of the outer layer
keeps the 2 inner layers in place
purposes of dressings
*Provide physical, psychological, and aesthetic comfort
*Remove necrotic tissue
*Prevent, eliminate, or control infection
*Absorb drainage
*maintain a moist wound environment
*Protect the wound from further injury
*Protect the skin surrounding the wound
Problems with dressings in general
*they can rub or stick to the wound, causing further superficial injury
*they can creat a worm, damp, and dark environment conducive to the growth of organisms and subsequent potential development of an infection
Whose responsibility are dressing changes?
mostly nursing responsibility, however, the surgeon traditionally does the first dressing change after surgery
Where is the proceure for dressing changes for a patient listed?
in the plan of care
Standard supplies for dressing changes
cleaning agents, dressing materials, and materials used to secure the dressing and support the wound
Cleaning agents for wound dressing
usually 0.9% sodium chloride solution, although various antiseptic cleaning agents could be used
drawbacks of using solutions other than 0.9 NS for dressing changes
may have a caustic effect on skin, tissues, and granulation tissue
What is in incision line usually covered with?
Sterile petrolatum gause or a special gauze called telfa
What is Telfa and how is it used?
Telfa is a special gauze with a shiny surface on one side. The shiny outer surface is applied to the wound and allows drainage to pass through and be absorbed by the center absorbent layer
Importance of using Telfa or petrolatum gauze on an incision wound
both these protective dressings prevent outer dressings from adhering to the wound and causing further injury when removed
What is usually used to cover wounds
gauze dressings
How are gauze dressings available?
various sizes (2x2,4x4, and 4x8)and packaged as single units or in packs
Sofwick
special dressing precut halfway to fit around drains or tubes
Larger dressings
8x10 bandages, abdominal pads (ABDs), Surgipads
use of larger dressings
they are placed over smaller gauze dressings and absorb drainage and protect the wound from contamination or injury
Use of transparent dressings
applied directly over a small wound or tube. Often used over IV sites, subclavian catheter insertion sites, and noninfected healing wounds
Advantages of transparent dressings
these dressings are occlusive, decreasing the possiblilty of contamination while allowing visualization of the wound
nursing diagnoses for "Patient with a Wound"
*Impaired skin integrity
*Risk for infection
*Acute pain
*Disturbed body image
Tape sizes
typically 1-4 inches
Types of tape
Adhesive; paper, plastic, acetate; microfoam
Purpose of adhesive tape
used for strength, support, and economy; To secure dressings and splints; to strap joints to prevent athletic injuries; to immobilize or stabilize body parts; to provide pressure; to approximate wound edges
Purpose of plastic, paper, and acetate tape
increased comfort, decreased allergic and skin problems; to close small wounds; to secure dressings
Purpose of microfoam tape
Used for compression or pressure dressings
Problems with adhesive tape use
can cause occlusion, allergy, skin maceration, shearing
basic steps in cleaning a wound and applying a clean dressing
explain what will be done; provide privacy; use aseptic technique;
one of the most common causes of nosocomial infections is...
carelessness in practicing asepsis during dressings
Important considerations in cleaning a wound
do not reach over the wound; keep soiled side of dressing away from patients view; assess amoun, type, and odor of drainage; use aseptic technique;
direction to clean when cleaning a wound
from top to bottom or from center outward
considerations for checking dressings and wounds
check every shift, record dressing change and appearance of cound and describe any drainage in chart
when should dressings be changed?
no standard frequency. Usually daily or PRN. Frequency is noted on plan of care
How and when is the first dressing changed after surgery
usually 24-48 hours after, customarily by the surgeon
Avoid dressing saturation because...
microorganisms travel through a moist medium. If the dressing saturates through, bacteria from the outside can move into the wound.
What should be done to avoid dressing saturation?
dressing change or reinforcement
when are drains, catheters, or tubes inserted in or near a wound?
when it is anticipated that a collection of fluid in a closed area could delay healing
How are drains, catheters, and tubes inserted?
either directly into the incision, or through a separate opening called a "stab wound"
What is a "stab wound"
a separate opening near an incision site through which a tube, catheter, or drain is inserted to drain the wound.
How are drains and tubes secured?
some may be sutured in place, but not all
Penrose drain
an example of an open drainage system consisting of a hollow open-ended tube
When is a safety pin used on a drain
on an open-ended drain to keep the drain from slipping into the wound
How are Penrose and other open-ended drains secured?
they are not sutured in place. They only have a safety pin to keep them from slipping into the wound
Precaution with open-ended drains
Care must be taken not to disloddge them during dressing changes since they are not sutured in place
How do you shorten a Penrose drain?
Grasp the end of the drain w/ sterile forceps, pull it out a short distance while using a twisting motion, and cut off the end of the drain with sterile scissors
Which general type of drain is used most often?
closed drainage systems
How can the infection rate be reduced in wounds with drainage?
Place drains only when necessary and through a separate stab wound rather than in the incision itself
Closed drainage systems
drainage tube that may be connected to an electrical suction device or have a portable built-in reservoir to maintain constant low suction
examples of closed drainage systems
Jackson-Pratt; Hemovac
How are closed drainage systems secured?
They are usually sutured to the skin
Advantages of a closed drainage system
prevents microorganisms from entering the wound from saturated dressings. Also, allows accurate measurement of drainage
What should you do if assessment of the wound indicates a possible infection?
Obtain a specimen of the drainage and send it to the laboratory for C&S
What is wound irrigation?
directed flow of solution over tissues
What are the purposes of irrigation?
cleaning the area of pathogens and other debris and applying local heat or an antiseptic to the area
When are nonsterile solutions used in wound irrigation?
if the wound is closed
when is sterility maintained during irrigation?
When the wound is open, even in the presense of an infection
Possible irrigation solutions
Sterile 0.9% NS or sterile water, antiseptic, or an antibiotic solution, depending on the condition of the wound and the doctor's order
What is used to direct the flow of the irrigation
A sterile, large-volume syringe
Why might packing of a wound be ordered after irrigation?
to allow granulation tissue formation and healing by secondary intention to take place
What should you do if wound care is uncomfortable for the patient?
administer a prescribed analgesic 30-45 minutes before dressing changes
When should you plan dressing changes and why?
midway between meals so the patient's appetite and mealtimes are not disturbed
Skin care for skin around draining wounds
apply a protective ointment if appropriate after cleansing. Remove the ointment at least daily using as little rubbing as possible, and reapply
Charactistics of the first layer of dressing applied to a draining wound
it is often nonabsorbent but hydrophilic to allow drainage from the wound to move into overlying absorbent layers of dressing
hydrophilic (definition)
capable of carying moisture
What problems does the use of a hydrophilic, non-absorbent first prevent?
It helps prevent maceration and reinfection and is less likely to stick to the wound
When collecting a wound culture using a culturette, what should you be sure to do?
crush the ampule of medium at the bottom of the tube
What technique is used when collecting a wound culture?
Sterile technique
when labeling the wound culture tube, what information should be included?
Patient's name, date, time, nature of specimen
How soon after collection should a wound culture specimen be sent to lab?
within 20 minutes
Why should a wound culture specimen be sent to lab within a specific time?
to avoid overgrowth of other organisms
What is the second layer of dressing over a draining wound?
Material ot absorb and collect drainage.
How does the second layer of dressing for a draining wound work?
it acts as a wick, pulling drainage our by capillary action
What solution should be used for wound irrigation?
Prescribed irrigating solution warmed to body tempurature or 30-37 degrees
What technique should be used in wound irrigation?
Sterile technique
What kinds of infected wounds often cause extensive damage?
Staph aureus, beta-hemolytic strep, and clostridium perfringens (gas gangrene)
What are thick, absorbant pads used for?
the top layer if there is heavy drainage
Since they require frequent changes, how should the dressing for a draining wound be secured?
using montgomery straps so that the tape does not need to be secured to the patient's skin.
strips made from tape or purchased commercially
Montgomery straps
Gauze in a draining wound should be...
losely packed to facilitate wicking action pulling drainage away from the wound
What type of packing for open wounds is recommended?
moist rather than wet
what is the solution of choice for moist packing of open wounds?
0.9% NS
How should packing be applied in an open wound?
losely and only to the edges of the wound
What should be done if the moist packing for an open wound dries?
it should be soaked with 0.9% NS before removal
Why should dry dressings be saturated before removal?
to prevent it from sticking to the heling tissue and causing injury
Why is a moist surface recommended for open wounds?
Because cellular migration is increased and healing is facilitated
What color classification is used for describing wounds?
R (red) Y (yellow) B (black)
What should be done if all colors are present in a wound?
the wound is treated frist for the most serious color (black), followed by yellow and finally red.
When packing a wound...
use sterile forceps, don't pack tound excessively
Why should packing not be inserted to tightly?
this may impede blood flow and delay healing
What technique should be used when handling soiled dressings?
a no-touch technique, lift them with a clamp or forceps
How should soiled dressings be disposed of?
place them in a miosture-proof bag, which is then closed securely, double-bagged, and incinerated without being opened
What should you wear when changing soiled dressings?
Gown, mask, and sterile gloves
Red wounds
are in the proliferative stage of healing and reflect the color of normal granulation tissue
Intervention for red wounds
Protection, gentle cleansing, use of moist dressings, application of a transparent or hydrocolloid dressing, and changing of the dressing only when necessary
characteristics of yellow wounds
oozing from the tissue covering the wound, often accompanied by purulent drainage
cleaning yellow wounds
irrigating; using wet-to-moist dressings; using non-adherent, hydrogel, or other absorptive dressings and consulting with the physician about using a topical antimicrobal medication
Black wounds
are covered with thick eschar which is usually black but may be brown, gray or tan
What should be done with eschar in a black wound
it must be debrided before the wound can heal
What are the 3 types of debridement
sharp debridement, chemical debridement, autolytic debridement
sharp debridement
cutting away mechanically
Chemical debridement
using enzymes
Autolytic debridement
Using dressing that contains wound moisture to thelp the body produce enzymes to break down the eschar
Red wounds
are in the proliferative stage of healing and reflect the color of normal granulation tissue
Intervention for red wounds
Protection, gentle cleansing, use of moist dressings, application of a transparent or hydrocolloid dressing, and changing of the dressing only when necessary
characteristics of yellow wounds
oozing from the tissue covering the wound, often accompanied by purulent drainage
cleaning yellow wounds
irrigating; using wet-to-moist dressings; using non-adherent, hydrogel, or other absorptive dressings and consulting with the physician about using a topical antimicrobal medication
Black wounds
are covered with thick eschar which is usually black but may be brown, gray or tan
What should be done with eschar in a black wound
it must be debrided before the wound can heal
What are the 3 types of debridement
sharp debridement, chemical debridement, autolytic debridement
sharp debridement
cutting away mechanically
Chemical debridement
using enzymes
Autolytic debridement
Using dressing that contains wound moisture to thelp the body produce enzymes to break down the eschar
How is a black wound treated after debridement?
first as a yellow wound, then as a red wound as healing progresses
What techniques may be used for chronic wounds?
Moisture-retentive materials, and vacuum assisted closure therapy
What is vacuum assisted closure therapy?
the application of negative pressure to pull the cells closer together
What does vacuum-assisted closure therapy do?
it alows epithelial cells to multiply rapidly and form granulation tissue so that healing can begin. Also increases cell proliferation, stimulates blood flow to wounds, and stimulates the growth of new blood vessels.
When is Vacuum-assisted closure therapy used
on chronic open wounds, surgical incisions with dehiscence, and stage III and IV pressure ulcers
What is eschar
Necrotic tissue
Does vacuum-assisted closure therapy hurt?
it is painless