FHA Wound Care Pre-Lab PDF

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WEEK 11 LEARNER PREPARATION WOUND CARE

MY NURSING LAB – SKIN INTEGRITY AND WOUND CARE Chp. 35 & CARING FOR PERIOPERATIVE PATIENTS Chp. 36 Kozier, B., Erb, G., Berman, A., Snyder, S. J., Frandsen, G., Buck, M., … Stamler, L. L. (2018). Skin integrity and wound care. Fundamentals of Canadian nursing: Concepts, process, and practice. (4th Canadian ed.), pp. 930-982. Toronto, ON: Pearson

1. A wound is a disruption of normal anatomical structure and function. Skin wounds are classified by: (Give examples of each classification) Status of skin integrity:  Open  Closed (after surgery)  Acute (in a traumatic injury, incision)  Chronic (pressure ulcers) Cause:  Intentional  Unintentional Severity:  Partial thickness (epidermis, dermis)  Full thickness (skin, fat, muscles, bones) Cleaniness:  Clean: no pathogen (in a surgical site)  Clean contaminated: also surgical wounds but resp, urinary,genital and GI tract are entered under controlled conditions and without unusual contamination  Contaminated: open, fresh, pathogens are present from outside sources  Dirty/Infected: old or new with dead tissue, infection or perforated viscera Descriptive qualities:  Laceration: tearing of tissues with irregular wound edges.  Abrasion: superficial scraping or rubbing  Contusion: closed wounds that look like bruises with swelling

2. A pressure ulcer (pressure sore, decubitus ulcer or bedsore) is a chronic wound caused by prolonged pressure. What are some other causes of skin breakdown with immobile clients? Fecal and urinary incontinence, decreased level of awareness, elevated body heat, incorrect positioning, repeated injections in the same area, hard support surfaces, incorrect application of pressure-relieving devices, poor lifting techniques.

3. The Registered Nurses Association of Ontario (RNAO) uses the NPUAP staging system for pressure ulcers. Describe the 6 stages Stage 1: nonblanchable erythema signaling potential ulceration Stage 2: partial-thickness skin loss (abrasion, blister, or shallow crater) involving the epidermis and possibly the dermis

Nursing Professional Practice: Fundamental Healing Arts Georgian College Practical Nursing Program – June 2017

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Stage 3: full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without indermining of adjacent tissue Stage 4: full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures, such as a tendon or joint capsule. Undermining and sinus tracts may also be present. Stage 5: Unstageable/Unclassified: full-thickness skin or tissue loss – depth unknown: actual depth of the ulcer is completely obscured by slough (yellow/tan/gray,green, or brown) and/or eschar (tan, brown, or black) in the wound bed Stage 6: Suspected deep tissue injury – depth unknown: purple or maroon localized area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and’or shear. This may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar.

4. Wound healing is the process leading to total wound closure. All wounds follow a healing process. What is the process of primary intention and secondary intention? (Give examples). Primary intention (surgical) – little or no tissue loss as in a clean incision, skin edges are well approximated, or close and the risk of infection is low. Healing occurs quickly with minimal scar formation. 3 phases:  Inflammatory  Proliferative  Maturation Secondary Intention (burn, pressure ulcer, severe laceration) – often left open and the wound edges cant be approximated. The wound fills with scar (granulation) tissue which can lead to loss of tissue function that is permanent. Inflammation can be chronic.

5. The 3 phases of wound healing are: Inflammatory  Proliferative  Maturation 6. The 4 types of exudates or wound drainage are: (Describe what each would look like).    

Serous – clear serum with a little blood Purulent – thick, yellow, blue, green, tan or brown (presence of WBCs); often smells  sign of infection Serosanguineous – dark pink (clear serous drainage + blood); often seen in fresh post surgery Sanguineous – bright fresh blood with no or little serous drainage  means still actively bleeding and should be monitored for hemorrhage

7. When charting wound exudates the nurse would describe: T – Type A – Amount C – Colour C – Consistency O – Odour

8. Complications of wound healing are: (Give a short description of each complication).      

Hemorrhage – large/copious amount of blood soaking the dressing  urgent Infection – delays wound healing; purulent drainage and bad odour. All chronic wounds are considered contaminated with bacteria. Maybe swab wound to test bacteria growth Dehiscence – Partial or total separation of wound layers. Increased amount of serosanguineous fluid. Watch for proximation, a not closing wound is considered unapproximated Evisceration – total seperation of the wound and organ comes out Fistula – epithelialized connection of organ with organ or outside Delayed wound closure

Nursing Professional Practice: Fundamental Healing Arts Georgian College Practical Nursing Program – June 2017

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9. Several types of drains are used for surgical or trauma wounds that have been closed operatively. They are used to decrease fluid accumulation within the tissues thereby decreasing the risk of infection and assisting in healing. What are some types of wound drainage devices and what precautions should be taken when changing dressings?  Open-Wound Drainage System (eg. Penrose aka pin through drain  shortened daily as 

wound heals, doctor will provide order to remove; essential to clean around the drain thoroughly and redress the drain to prevent infections. Closed-Wound Drainage System (eg. Jackson-Pratt, Hemovac  need to monitor, record, empty the content

10. Name the types of devices used to close surgical wounds. Which one is the least irritating to tissues?  Staples (least irritating)  Sutures  Retention sutures  Wound closures (steri strips, surgical glue) 11. What does the nurse chart about closures? R - Redness E - Edema E - Ecchymosis D - Drainage A - Approximation 12. What are the 3 principles in cleansing a wound or around a drain? What solution would should be used?  noncytotoxic solution and sterile gauze   

Clean to dirty Gentle friction When irrigating, pour solution from clean to dirty

13. Why must the nurse never occlude a wound opening when they are using a syringe to irrigate the wound? This results in the introduction of irrigating fluid into a closed space. Pressure of the fluid coud cause tissue damage and discomfort.

14. Wounds (pressure ulcers) may undergo debridement in the long term care setting. What are the types of eschar (necrotic tissue) debridement used and how are they done? What areas are not usually debrided?  Sharp debridement: extensive and aggressive removal of tissue (often both viable and 

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nonviable tissue)  urgent (eg. Advancing celluitis or sepsis); serious risk of bleeding, potentially injure nervous tissue Conservative sharp wound debridement: removal of loose, devascularized tissue or

callous or hyperkeratotic tissue with the aid of a scalpel, scissors or a curette above the level of viable tissue  rapid, cost-effective but tissue damaged, pain, further tissue trauma, infection, high-risk=high trained Mechanical debridement: removal of foreign material and devitalized or contaminated tissue from a wound by using physical forces (eg. Wet-to-dry dressing and wound irrigations)  slow, painful

Nursing Professional Practice: Fundamental Healing Arts Georgian College Practical Nursing Program – June 2017

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Chemical/Enzymatic debridement: topical application of proteolytic substances (enzymes) to break down devitalized tissues  slow but helpful for patients cant undergo sharp debridement Autolytic debridement: using moist wound healing that allows removal of eschar by the action of the enzymes present in wound fluid  slow but most selective and causes the least damage to healthy surrounding and healing tissue Biological debridement: the larvae of green butterfly digest the necrotic tissue and secrete bactericidal enzymes  uncomfortable, psychological impact hence unpopular in North America

15. What are the purposes for wound dressings?  

Thermal insulation and moisture maintainance Aiding hemostasis (pressure dressing), prevent hemorrhage

16. In long term care medical asepsis or clean technique is often used. Clean but not sterile supplies are used. What principles of sterile technique would you still employ?

Nursing Professional Practice: Fundamental Healing Arts Georgian College Practical Nursing Program – June 2017

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