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