Skills Final S17

Front 1

If drainage accumulates in the wound bed, wound healing is _________

Back 1

If drainage accumulates in the wound bed, wound healing is delayed. (Perry 935)

Front 2

A JP drain collects fluid that is in the amount of _________

Back 2

A JP drain collects fluid that is in the range of 100 to 200 mL/24 hr (Perry 935)

A closed-drain system such as the Jackson-Pratt (JP) drain or Hemovac drain relies on the presence of a vacuum to withdraw accumulated drainage from around the wound bed into the collection device.

Front 3

A Hemovac drain accommodates usually up to ________

Back 3

A Hemovac drain accommodates usually up to 500 mL/24 hr.

Front 4

Pinning drainage tubing to the patients gown will prevent _______

Back 4

Pinning drainage tubing to the patients gown will prevent tension or pulling on tubing and insertion site. (Perry 937)

Front 5

The Hemovac needs to be ________ to create a vacuum.

Back 5

Compressed

Compression of surface of hemovac creates vacuum. (Perry 937)

Front 6

Apply a _______ dressing to control bleeding.

Back 6

A pressure dressing is applied to control bleeding. (Perry 943)

Front 7

Use an _______, _______, or a ______ dressing in a non-infected wound that is draining a moderate to large amount of exudate. (table 38-3 936)

Back 7

Use an Alginate, Gauze, or Foam dressing in a non-infected wound that is draining a moderate to large amount of exudate. (table 38-3 936)

Front 8

__________ dressings are used for wound healing by primary intention with little drainage.

Back 8

Steri-strip dressings are used for wound healing by primary intention with little drainage.Step 15b page 934

Front 9

The primary purpose of moist-to-dry dressings is to ______________ a wound.

Back 9

Moist-to-dry dressings (also called wet-to-dry or damp-to-dry) are gauze moistened with an appropriate solution.

The primary purpose is to mechanically debride wounds, specifically full-thickness wounds healing by secondary intention and wounds with necrotic tissue (Perry 946)

Front 10

Hydrocolloid dressings provide a ______ environment for wound healing.

Back 10

Hydrocolloid dressings maintain a moist environment by forming a gelatinous mass (Perry 926)

Autolytic debridement: Autolytic debridement can be accomplished by providing moisture via semiocclusive dressing to the wound to begin to loosen the nonviable tissue (Perry 924)

Front 11

Hydrogel dressings are useful for ________

Back 11

Hydrogel dressings are useful for Partial and full thickness wounds, dry to minimal exudate, or necrotic tissues. Table 38.3 936

Provides moisture to wound bed (Perry 926)

Front 12

A dry dressing may be the dressing of choice for the management of a wound healing by __________ with little drainage.

What kind of intention?

Back 12

Dry gauze dressings are for wound healing by primary intention with little drainage (Perry 946)

Front 13

A dry dressing protects the wound from _____, reduces ______, and ______.

Back 13

The dressing protects the wound from injury, reduces discomfort, and speeds healing (Perry 946)

Front 14

The purpose of packing wound is to _______

Back 14

The purpose of packing wound is to fill dead space and avoid the potential of abscess formation by a wound closing too soon (Perry 946)

Front 15

Primary Intention

Back 15

Healing by primary intention occurs when the edges of a clean surgical incision remain close together. The wound heals quickly, and tissue loss is minimal or absent. The skin cells regenerate quickly, and capillary walls stretch across under the suture line to form a smooth surface as they join. (Perry 922)

Healing by primary intention eliminates need for dressing. (Perry 934)

Dry gauze dressings are for wound healing by primary intention with little drainage (Perry 946)

Front 16

Secondary intention

Back 16

Wounds that are left open and allowed to heal by scar formation are classified as healing by secondary intention. There is tissue loss and open wound edges. Granulation tissue gradually fills in the area of the defect. This process is typical of severe laceration or massive surgical intervention with skin loss. (Perry 922)

Front 17

What type of care will primary vs secondary need?

Back 17

a Wound healing by primary intention (surgical wound):

(1) Assess anatomic location of wound on body.(2) Note if incisional wound margins are approximated or closed together. The wound edges should be together with no gaps.

(3) Observe for presence of drainage. A closed incision should not have any drainage.

(4) Look for evidence of infection (presence of erythema, odor, or wound drainage).

(5) Lightly palpate along incision to feel a healing ridge. The ridge will appear as an accumulation of new tissue presenting as firmness beneath the skin, extending to about 1 cm ( inch) on each side of the wound between 5 and 9 days after wounding. This is an expected positive sign (Perry 925)

Wound healing by secondary intention (e.g., pressure ulcer or contaminated surgical or traumatic wound):

(1) Assess anatomic location of wound.

(2) Assess wound dimensions: Measure size of wound (including length, width, and depth) using a centimeter measuring guide. Measure length by placing a ruler over wound at the point of greatest length (or head to foot). Measure width from side to side (Nix, 2012) (see illustration). Measure depth by inserting cotton-tipped applicator in area of greatest depth and placing a mark on applicator at skin level. Discard measuring guide and cotton-tipped applicator in a biohazard bag. (Perry 925-926)

(3) Assess for undermining: Use cotton-tipped applicator to gently probe wound edges. Measure depth and note location using the face of a clock as a guide. The 12 o'clock position (top of wound) would be head of patient, and the 6 o'clock position would be the bottom of the wound toward patient's feet. Document the number of centimeters that area extends from wound edge (e.g., underneath intact skin).

(4) Assess extent of tissue loss: If wound is a pressure ulcer, determine the deepest viable tissue layer in wound bed. If necrotic tissue does not allow visualization of base of wound, the stage cannot be determined.

(5) Notice tissue type, including percentage of tissue intact and presence of granulation, slough, and necrotic tissue.

(6) Note presence of exudate: Amount, color, consistency and odor. Indicate amount of exudate by using part of dressing saturated or in terms of quantity (e.g., scant, moderate, or copious).

(7) Note if any wound edges are rounded toward wound bed; this may be an indication of delayed wound healing. Describe presence of epithelialization at wound edges (if present) because this indicates movement toward healing.

(8) Inspect periwound skin: Include color, texture, temperature, and description of integrity (e.g., open macerated areas). Periwound assessment gives clues about the effectiveness of the wound treatment and possible wound extension (Perry 926)

Secondary intention:

Topical care options include light packing with a moist dressing covered with a dry dressing that is changed on a schedule to prevent the wound bed from drying out (Perry 924)

Flushing wound helps remove debris and facilitates healing by secondary intention. (Perry 928)

Front 18

Parts of a wound assessment

Back 18

Location: Note the anatomic position of the wound on the body.

Type of wound: If possible, note the etiology of the wound (i.e., surgical, pressure, trauma).

Extent of tissue involvement: Full-thickness wound involves both the dermis and epidermis. Partial-thickness wound involves only the epidermal layer. If it is a pressure ulcer, use the staging system of the European Pressure Ulcer

Type and percentage of tissue in wound base: Describe the type of tissue (i.e., granulation, slough, eschar) and the approximate amount.Wound size: Follow agency policy to measure wound dimensions, which includes width, length, and depth.Assess wound dimensions: Measure size of wound (including length, width, and depth) using a centimeter measuring guide. Measure length by placing a ruler over wound at the point of greatest length (or head to foot). Measure width from side to side.Measure depth by inserting cotton-tipped applicator in area of greatest depth and placing a mark on applicator at skin level (Perry 925-926)

Wound exudate: Describe the amount, color, and consistency. Serous drainage is clear like plasma; sanguineous or bright red drainage indicates fresh bleeding; serosanguineous drainage is pink; and purulent drainage is thick and yellow, pale green, or white.

Presence of odor: Note the presence or absence of odor, which may indicate infection.

Periwound area: Assess the color, temperature, and integrity of the skin.

Pain: Use a validated pain assessment scale to evaluate pain. (Perry 925)

Front 19

What is wound tunneling?

Back 19

When there is wound tunneling, a channel has formed that extends from any part of the wound through subcutaneous tissue or muscle. (Perry 946)

Front 20

What is wound irrigation used for?

Back 20

Wound irrigation cleanses and irrigates surgical or chronic wounds such as pressure ulcers. (Perry 926)

Wound irrigations promote wound healing by removing debris from a wound surface, decreasing bacterial counts, and loosening and removing eschar. Solutions used for irrigations include normal saline, warm water, and commercially available wound cleansers. (Perry 926)