Wound Drainage Systems/Healing
What is the Jackson-Pratt™?
a soft pliable tube with multiple perforations and a bulb that can recreate low negative pressure vacuum, designed so that body tissues are not sucked into the tube, decreasing risk of bowel perforation
What is a Pressure ulcer?
A localized injury to the skin and/or underlying tissue caused by unrelieved pressure over the bony prominence (usually)
What is Arterial Ulcers? and Common causes
Blocked arteries are common causes of arterial ulcers.
They’re also referred to as ischemic ulcers. The arteries are responsible for delivering nutrients and oxygen to different tissues.
Clogged arteries prevent nutrient-rich blood from flowing to the extremities. This results in an open wound.
Common causes: age, diabetes, smoking, high BP, kidney failure...
On the REEDA scale, What would you score a patient with a closed wound that has serum drainage, no etchymosis, perineal oedema of <1cm and no redness
Score of 2
What is a Unstageable Wound?
Full thickness tissue loss in which wound base is covered by slough
-Yellow, tan, gray, green, or brown
-Or eschar
-Tan, brown, or black
The wound base needs to be visible to properly stage the pressure injury to truly know the extent of the tissue damage
Can be moist and stringy with excess drainage or dry, hard, and leathery
What is a Hemovac™?
A high negative pressure drain used for larger draining amounts
What is stage 1 of a pressure injury?
Stage 1 (The skin is intact)
There is usually a warm and redness area over a bony prominence.
The colour does not return to normal when skin is relieved of pressure. Nonblanchable. May also appear pale, white, and shiny in darker skin tones.
Patient complains of discomfort, burning, or itching.
What is Venous Ulcers? And common causes
Venous ulcers are the most common type of leg ulcer.
They’re caused by damage to the veins. The veins are responsible for bringing blood from various parts of the body to the heart through one-way valves. This results in damage to the vein and leakage of fluid and blood cells, causing edema, or swelling.
This is thought to prevent adequate blood flow to the tissue in the leg. As a result, this tissue will die, and ulcers will begin to form.
Common causes: diabetes, DVT, lupus, high BP...
On the REEDA scale, What would you score a patient with a wound that has a skin separation of <3 mm, serum drainage, 0.25cm Bilaterally ecchymosis, no edema, and 0.25cm redness bilaterally?
Score of 4
First Line of Defense: YOU
-Good skin care
-Clean and dry
-Moisturize to keep skin healthy
-Massage to help stimulate blood flow
-Offer fluids frequently and encourage to eat
-Reposition
-Remove bedpan ASAP
-Remind clients to ambulate/move if they can
-Pillows, pillows, pillows
-Head of bed < 30 degrees (if possible)
-Immediately notify supervisor
Complications of Wound Healing
Internal:
-Distention or swelling of the affected body part
-Infection
-Signs of hypovolemic shock
-Hematoma: localized collection of blood underneath the tissue
-Adhesions
-Contractures
External:
Dehiscence or evisceration
Risk of hemorrhage is great during first 24-48 hours after surgery or injury
Excess granulation tissue
What is stage 2 of a pressure injury?
Stage 2 (Partial-thickness skin loss)
Skin cracks, blisters, or peels
Leg and foot appearance? Venous ulcer
Appearance of venous ulcers:
-Edema in tissue give swollen appearance.
-Skin may appear shiny and stretched.
-Walking may be painful and difficult.
-Venous ulcer may weep fluid.
-Healing is slow, infection is a great risk.
-If edema lasts for a long period of time, skin will change in appearance and texture—becomes dry, brown, leathery, and hard.
-Itching is common.
On the REEDA scale, What would you score a patient with a wound that has a skin and subcutaneous fat separation,>0.5 cm bilaterally redness, perineal edema of >2cm, bloody discharge and no ecchymosis?
What are the 3 phases of wound healing?
1. Inflammatory phase (3 days):
Bleeding stops- A scab forms over the wound
Blood supply increases, bringing nutrients and healing substances to area
Redness, swelling, heat, or warmth may be present
May have some loss of function and pain
2. Proliferative phase (day 3 to day 21):
Tissue cells multiply to repair the wound
3. Maturation phase (day 21 to 1–2 years after injury):
The scar gains strength
What is a Penrose™?
flat ribbon-like drain, gauze is applied to external end to absorb drainage, can be colonised by bacteria if left in situ for an extended period of time.
What is stage 3 pressure injury?
Stage 3 (Full-thickness skin loss)
Skin is gone with visible fat, there may be drainage from the area
Patient complains of discomfort, burning, or itching on the edges
Leg and foot ulcer- Arterial ulcer
Treatment and prevention
The doctor treats the disease causing the ulcer.
The doctor orders:
-Drugs and wound care
-A walking and exercise program
-Professional foot care
On the REEDA scale, What would you score a patient with a wound that has a skin and subcutaneous fat and fascial separation, 0.5cm of redness, >1cm of ecchymosis, and serosanguineous drainage. edema is measuring at >2cm.
Score of 13
How is drainage measured?
2 ways:
Noting the number and size of dressings with drainage
-The amount and kind of drainage on each dressing is noted
Measuring the amount of drainage in the collection
container if closed drainage is used
Dehiscence VS Evisceration
Dehiscence: partial or total separation of wound layers
Evisceration: With total separation of wound the visceral organ protrudes through the wound opening
What is stage 4 pressure injury?
Stage 4 (Full-thickness tissue loss)
Muscle, tendon, and bone exposure
Leg and foot ulcer- what is it? what it looks like- how it occurs
Some diseases affect blood flow to and from the legs and feet.
-Edema
-Swelling caused by fluid collecting in tissues
-Gangrene
-A condition in which there is death of tissue
-Infection and gangrene can result from an open wound and poor circulation.
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What does REEDA stand for?
Redness
Edema
Etchymosis
drainage/discharge
Approximation