Moist Wound Healing
Reason moisture is necessary for proper wound healing
What is moisture facilitates the formation of granulation tissue?
Four phases of wound healing
What is: hemostasis, inflammatory, proliferative, and maturation?
tissue death due to an absent oxygenated blood supply
necrosis
One of the primary goals of wound dressings is to protect the wound from bacteria and contaminants to this end.
What is prevention of infection?
8 components of wound assessment
What are location, type, degree of tissue damage, wound bed, wound size, wound edges and periwound skin, signs of infection and pain?
The reason that pain is assessed prior to dressing change
What is that dressing change and wound cleaning can aggravate pain receptors increasing pain? Assessment prior allows for pain treatment to make the dressing change and wound cleaning more tolerable.
Indication to discontinue irrigation
What is return fluid is clear?
The normal, non-injured skin immediately surrounding the wound
What is periwound?
Swelling associated with the second phase of wound healing
What is erythema?
dark brown/black, thick and leathery dead tissue in a wound base that should usually be removed to facilitate healing
What is eschar?
nonadherent dressing used on moderately to highly exudative wounds, nontraumatic to wound bed, promotes moist wound environment, can be used to prevent pressure injuries
what are silicone-based dressings?
should be described using anatomical terms and numbering
What is wound location?
explain PQRSTU assessment of pain
P-provocative, palliative
Q-quality, quantity
R-region, radiation
S-severity
T-timing, treatment
U-understanding
post-operative surgical management to remove fluid, prevent infection and enhance wound healing
What are drain management systems?
Method for keeping deep wounds and tunneling wounds moist.
What is sterile gauze moistened with normal saline or hydrogel-impregnated dressings?
During this phase, vasodilation occurs so that white blood cells in the bloodstream can move into the wound and start cleaning the wound bed, appears to the observer as edema, erythema and exudate.
What is the inflammatory phase?
Removal of nonviable tissue (sometimes necrotic tissue or eschar) from the wound
What is debridement?
Normal saline delivered with a syringe or commercial cleaners during dressing change
What is irrigation?
Descriptive wording for amount of wound exudate
What is no exudate, scant amount, minimal, moderate or large or copious amount?
Supplies needed for dressing change
What are nonsterile gloves, sterile gloves, wound cleaning solution or sterile saline, sterile 2x2 gauze for cleaning, sterile 4x4 gauze for dressing, scissors, tape, sterile bowl, sterile tweezers, sterile pad or barrier to provide sterile field?
consists of drainage tubes perforated to allow fluid to drain from wound and a sterile collection system/reservoir
What are Hemovac (up to 500 mL of drainage) and Jackson-Pratt (25-50 mL of drainage)?
Ways to manage proper moisture in a wound
What is use of dressings such as alginate or hydrofiber?
During this phase lasts up to 60 minutes (depending on wound severity), clotting factors form clots that stop bleeding and act as a barrier, platelets release growth factors that alert various cells to start the repair process at the wound location
What is hemostasis?
methods of wound debridement
What is autolytic, enzymatic or sharp?
creates a moist wound environment in wounds with little or no exudate, changed daily, cover only the wound and not surrounding tissue to prevent maceration
what are hydrogels?
Types of wound drainage
9 rules of sterile field
What are: 1. Sterile water only in sterile bowl, 2. Fluids flow in the direction that gravity pulls, 3. Skin is never sterile, 4. Do not turn your back, 5. must be wearing sterile garb to touch items on sterile field, 6. sterile field has 1-inch nonsterile border, 7. limit time the sterile field is open, 8. Honesty if sterile field is broken, 9. Nothing sterile below waist?
method of preventing drains from being accidentally removed
What is they are sutured to the skin?
The softening and wasting away of skin due to excess moisture
What is maceration?
The redness associated with the second phase of wound healing.
What is erythema?
when moist topical dressings foster the breakdown of necrotic tissues
autolytic debridement
applied over open wounds and covered with a secondary dressing, nontraumatic to skin and wound base, may be applied to skin tears, change every 24-48 hours to prevent drying and adherence
What is nonadherent dressings or petroleum impregnated gauze?
Way to measure size and depth of wound
What is side to side at widest point laterally and with a sterile cotton tipped applicator and then measured in centimeters?
The number of times hand hygiene is performed during a dressing change visit
What is 3 (upon entering room, upon removing non-sterile gloves, upon removing sterile gloves)?
method for wound irrigation
What is hold syringe 1-inch above wound, and flush gently with continuous pressure, exudate should be removed while leaving healthy granulation intact
Why might alginate dressings be confused with purulent drainage?
What is they have a slightly greenish tint?
Commonly called pus
What is exudate?
when prescribed topical agents, like collagenase ointment, are directly applied to wound bed daily or more frequently if dressing becomes soiled to cause debridement
What is enzymatic debridement?
used as an occlusive dressing to prevent contaminants, promote a moist wound environment and cause autolytic debridement
what are hydrocolloids?
These are signs of infection
What are erythema, induration, pain, edema, purulent exudate and odor?
Activities completed after basic essentials but prior to donning sterile gloves
What are assess wound pain, prepare the environment (raise bed, position patient, ensure proper lighting, proper body mechanics, premedicate (if necessary), perform hand hygiene, create and fill sterile field with sterile supplies
uses a vacuum system to withdraw fluids and collect them in a reservoir, drainage must be emptied and measured routinely
What is a closed system?
Ways of preventing maceration of the periwound skin
What are skin barrier creams, skin protective wipes, skin protective wafers, apply moist dressings carefully to maintain wound bed moisture while protecting the peri wound skin?
During this phase, collagen continues to strengthen the wound to prevent reopening
What is maturation?
invasive procedure performed by a trained healthcare provider at bedside or in an operating room involving a scalpel or scissors to remove necrotic tissue and leave only viable tissue
What is sharp debridement?
can be used as a primary dressing or moistened to use for packing, inexpensive, must be changed daily, unless moistened may stick to wound
what is gauze or Kerlix?
passageways underneath the skin surface extending from a wound that can take twists and turns
What is tunneling?
How to don sterile gloves
What is remove outer covering without compromising inner packaging, touching only the 1-inch border, open flaps in order they are presented, exposing both gloves, using non-dominant hand, grab glove for dominant hand by wristband (portion that will end up inside), lifting glove and inserting dominant hand, using non-dominant hand on non-sterile portion, twist hand into place and pull glove over wrist. Then, using gloved dominant hand, place fingers under the wristband of second glove (sterile side), lift glove out and, without touching second hand, insert second hand into opening, twisting hand into place without touching skin or nonsterile side of glove with dominant, gloved hand until second glove is in place. Keep gloved hands above waist.
Reason that sterile technique for sterile removal indicates removing every second staple at first
What is prevention of dehiscence in case wound is not healed enough to stay closed on its own?
The reason that packing materials should be easy to remove during dressing change
What is that granulation tissue is fragile and difficult to remove dressings can pull fragile granulation tissue off with them?
Begins within a few days after injury and includes epithelialization, angiogenesis, collagen formation and contraction
What is the proliferative phase?
The only time eschar should not be removed
What is when it is stable, dry eschar on a patient's heel that should be left in place until patient's vascular status is determined?
Can be used on wounds with little or no exudate to retain moisture, commonly used to secure other dressings such as foam
What are transparent films?
A condition that occurs when the tissue under the wound edges becomes eroded resulting in a pocket beneath the skin at the wound edge
What is undermining?
Process for cleaning and dressing reapplication after donning sterile gloves
What is pick up sterile forceps, use them to grab moistened gauze from bowl and, in a circular motion without too much pressure, lightly rub gauze 1x around wound, dispose of gauze immediately without compromising sterile field, repeat these steps until wound is properly cleaned, use forceps to pick up dry gauze and drop onto wound, repeating until wound is properly covered, use forceps to place secondary covering over gauze, tape 3 sides, label 4th tape with initials, date and time, tape 4th side, remove gloves correctly, perform hand hygiene, perform 5 safety measures prior to leaving room, document procedure
Procedure for removal of sutures/staples
What is: gather supplies, perform safety steps upon entering room, explain procedure, prepare environment, apply nonsterile gloves, remove wound dressing, assess wound, determine if ready for suture/staple removal, count staples prior to removal, irrigate wound, remove gloves, perform hand hygiene, create sterile field with necessary equipment, apply sterile gloves, for staple removal: place sterile 2x2 beside wound to collect staples, remove staples (every second at first), place lower tip of extractor beneath staple, without pulling, close handle, move side to side until both ends of staple are visible, then lift and place staple on 2x2 by releasing handle, place steristrips where every staple is removed before moving on to the rest, repeat these steps for the remaining staples. for sutures: hold scissors in dominant hand and forceps in non-dominant hand, grasp the knot with forceps, gently pull up, slipping scissors under knot near skin, examine knot, snip 1 side of knot close to skin while maintaining hold of knot with forceps, pull gently to remove suture (every second one), place on 2x2, assess wound healing for each suture and apply steristrips where each suture is removed,
when all sutures/staples have been removed and steristrips attached, apply a sterile dressing, tape and label, remove sterile gloves and perform hand hygiene, perform 5 safety functions prior to leaving room, document procedure