Wound Types
What is an intentional wound vs an unintentional wound?
Intentional: Surgical incision
Unintentional: Accidental
How is a wound dressing chosen?
The type of wound drainage, location of the wound, cost/reimbursement, presence of infection, prescriber order, and client mobility.
What are signs and symptoms of an infected wound?
Purulent drainage (exudate), Odor, Erythema, Warmth, Tenderness, Edema, Pain, Fever, Increased WBC Count, foul odor, delayed wound healing, and discoloration of granulation tissue.
Wound irrigation: What is this? How would you perform this?
When you use sterile water/sterile saline to flush pathogens/debris from a wound bed.
Hold the syringe 6 inches above the wound bed. Flush the wound with about 35 mL of sterile water/saline. Irrigate from clean to dirty. Irrigate until the prescribed limit is reached or until the water runs clear.
What does RITTA stand for? What is it used for?
Used for peri-wound assessments. Redness, induration, temperature, tenderness, and approximation.
Open vs Closed wounds
Which has the greater risk of infection? Why?
Open: Break in the skin allowing microorganisms to enter. Greater risk for infection.
Ex: laceration, abrasion, incision, puncture, etc.
Closed: No break in skin. The wound is underneath. (Internal tissue damage/hemorrhage) Ex: Hematoma, bruise
What are gauze dressings used for? What do we want to caution with gauze dressings?
Can be used as a primary dressing or can be used to pack a wound. If unmoistened, the gauze can harm the new granulation tissue. If the wound is fragile and has scant drainage, moisten the dressing with sterile saline/sterile water.
Hemorrhage
A damaged blood vessel causing the blood to leak into the surrounding area/outside of the body.
Hematoma: Internal hemorrhage. When the blood vessel becomes damaged and leaks into the surrounding tissue area.
Check the dressings frequently every 24 hours and change the dressing a minimum of 8 hours.
Describe the RYB method
Red: Healthy granulation tissue. leave it alone.
Slough: Yellow exudate. Clean the wound
Black: Dead, necrotic tissue. May need to debride the wound bed.
What are the four types of wound drainage?
Serous, sanguineous, serosanguinous, and purulent drainage.
Serous: Clear, watery-like discharge
Serosanguineous: Mix of serous and sanguineous drainage. Red, bloody fluid mixed with clear watery fluid.
Sanguineous: Red, bloody drainage
Purulent: Yellow/green, thick discharge with an odor. May indicate an infection.
Acute vs chronic wounds
Acute: Lasts less than or equal to 30 days. Wounds that go through the normal healing process
Chronic: Lasts greater than 30 days. These wounds don't go through the normal healing process.
Foam Dressings: What are they used for?
They're used to insulate the wound, they're very absorbent, can "wick" the exudate away from the wound bed, and they can be nonadherent. You may require another wound dressing.
May be used for partial or full thickness wounds and around tubes/drains.
Dehiscence
Partial or total separation of wound closure. Caused by too much stress on an unhealed wound.
The patient may report the feeling of "something giving out," and there may be increased drainage from during the wound especially on day 4 or 5 of recovery.
Place the patient in low fowlers, cover the wound with sterile moistened gauze, and notify the physician.
What do you know about a Penrose drain? Is it open or closed?
An open drain that wicks the exudate from the wound bed out to an absorptive dressing. There is no collection device with these. They're secured to the dressing with a large sterile safety pin.
How do you measure a wound? How do you document the length?
Measure the length, width, and depth of a wound. Use a sterile cotton swab to measure any undermining or tunneling. Measure the wound in cm.
Use the "clockface method" to document the wound. (head is 12:00, feet is 6:00)
Primary Intention, Secondary Intention, and Tertiary Intention. What are they?
Primary: Intentional, surgical wounds. Edges are well approximated and closed with sutures, glue, staples, etc. The wound heals under the closure.
Secondary: Non-approximated wounds. These wounds heal from the inside out by producing granulation tissue until it heals. They're left open on purpose for healing, and they take longer to heal. Increased risk for infection. Ex: Pressure ulcers, burns, deep traumatic wounds
Tertiary: Wounds left open for a period of time to drain. Edges are approximated and are closed later. Ex: reopening a primary intention wound to drain because of infection
Hydrocolloid vs hydrogel
Hydrocolloid: foam/pad-like dressing with a surface repellant to water and bacteria. Used for partial-thickness or shallow full-thickness wounds, thicker hydrocolloids can absorb moderate drainage. Is used as a primary dressing and shouldn't be used for infected wounds. Used for wound protection and insulation.
Hydrogel: A clear moist dressing used to moisten the wound bed. These are used for wounds with scant to minimal exudate. There is minimal absorption with these dressings.
Evisceration
The wound completely separates and there is a protrusion of visceral tissue through the incisional area. The most serious complication of dehiscence.
The patient may report the feeling of "something giving out," and there may be increased drainage from during the wound especially on day 4 or 5 of recovery.
Place the patient in low fowlers, cover the wound with sterile moistened gauze, and notify the physician.
Explain the process of culturing a wound.
Clean the wound bed and use the cotton swab to swab back and forth. If there's tunneling or undermining use a separate swab, so you don't cross-contaminate the wound. Label the specimen, place it in a biohazard bag, send it to the lab, and then start antibiotic treatment if ordered.
What terminology could you use to measure wound drainage? What acronym would you use to describe the wound?
Scant: Drainage on dressings is not measurable.
Minimal: Drainage on dressing is less than 25%
Moderate: Drainage on dressing is 25-75%
Copious: Exudate covers more than 75% of dressing
COCA the wound: Color, odor, consistency, and amount. You also want to use RYB to identify the type of drainage and know how to treat it.
What type of wounds are usually clean wounds? What types of wounds are usually sterile wounds?
(Intentional/unintentional, open/closed, acute/chronic)
Clean: Wounds free of debris, purulent drainage, and foreign bodies. Usually unintentional, open, and chronic wounds.
Sterile: A wound made under sterile conditions. Usually intentional, closed/open (depending on circumstance), and acute.
Transparent dressings: What are they used for?
Used for wounds with minimal to no exudate. They lock in the moisture. May be used for partial thickness or dry, necrotic wounds.
Fistula
An abnormal passageway from an internal organ/vessel to another area.
Usually caused by an infection turning into an abscess causing an abnormal passageway in the body.
Jackson Pratt vs Hemovac drains
Both are closed drainage systems. When the device is compressed, it slowly sucks the exudate out of the wound bed.
Jackson Pratt: Bulb-shaped. Can hold 100-200mL full.
Hemovac: Circular shaped. Can hold 500mL.
Empty when it's 2/3 full
What are the four stages of pressure injuries? How would you know which stage to document?
Stage 1: Nonblanchable, red area where prolonged pressure has occurred.
Stage 2: Partial thickness, loss of skin (fat is not showing)
Stage 3: Full thickness where fat is visible, but tendon, cartilage, and muscle are not.
Stage 4: Structures underneath the adipose tissue layer are exposed. Ex: bone, tendon, muscle, ligaments, etc.
Unstageable: slough or eschar obscures the wound so that tissue loss cannot be assessed
Deep tissue injury= form of pressure injury in which there is a localized purple or maroon discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The discoloration hides the progression of damage to the underlying tissues