Acute Wounds and Drains

  1. anatomy of the skin
    • epidermis: top layer of the skin
    • dermis: inner layer of the skin. contains collagen, blood vessels and nerves
  2. parts of the epidermis from top to bottom
    • stratum corneum (flattened dead keratinized cells. protect from chemical exposure. other layers build to get here)
    • stratum lucidum
    • stratum granulosum
    • stratum spinosum
    • stratum basale
  3. where are melanoytes found
    stratum spinosum/stratum basale
  4. elderly skin differences
    • decreased peripheral circulation
    • delayed inflammatory response
    • less elasticity
    • more vulnerable to tears
    • decreased subQ fat
    • less layers so more prone to breakdown
  5. wounds
    • injury to the skin
    • etiology dictates how we will manage it
  6. onset and duration of wound
    • can be acute- sudden onset, heals quickly
    • or chronic- gradual, lasts longer
  7. how to classify wounds
    • can be by onset and duration (acute/chronic)
    • can be by the phase of healing
    • can be by extent of tissue injury (partial or full thickness)
  8. acute wounds
    • occur suddnely
    • result from accidents/surgery
    • heal within 8-12 weeks as long as no secondary infection/condition
  9. what does heal time of acute wound depend on
    • size
    • depth
    • extent of damage
    • patient's underlying physical condition
  10. example of acute wound
    trauma/surgical wound
  11. Phases of wound healing
    • hemostasis
    • inflammatory phase
    • proliferative phase
    • remodeling phase
  12. full thickness wound
    • epidermis and dermis are affected
    • extends into the durmis and even subcutaneous tissue sometimes
    • heals by fibrous (scar) tissue
  13. partial loss wound
    • epidermis and superficial dermis affected
    • heals by regeneration of epidermis
    • more shallow
  14. Wound healing processes
    • primary intention
    • secondary intention
    • tertiary intention
  15. primary intention wound healing and example
    • wound edges are approximated
    • heals quickly with minimal scarring
    • wound that is closed 
    • heals by epithelial generation
    • ie: clean surgical insicion or abrasion
  16. secondary intention wound healing and example
    • heals by build up of granulation tissue
    • takes longer to heal so higher chance of infection
    • open wound, not approximated
    • example: pressure ulcer
  17. tertiary intention wound healing
    wound that is intentially left open to resolve an infection then they close it
  18. factors affecting wound healing
    • wound type
    • nutrition - certain nutrients help heal (vitamin C and zinc)
    • tissue perfusion
    • immunosuppression- immune cells cant get to site delays healing
    • infection- lengthens healing
    • age- more comprimised skin integrity/healing process
    • psychosocial impact- may not be caring for themselves, pick at it or affects body image
    • hydration- bc of fluid loss
    • caloric intaie= you need more energy to heal
  19. Complications of wound healing
    • hemorrhage
    • infection
    • dehiscence
    • evisceration
  20. hemorrhage
    • highest risk is 24-48hrs after injury
    • can be internal (ie sutures come out, hematoma- looks blue or swelling) which can affect perfusion or external (ie frequent dressing saturation)
    • monitor vital signs and patient
  21. infection
    • bacteria gets into the wound tissue
    • delays healing
  22. dehiscence
    • partial or full separation of layers
    • collagen supplies tension strength
    • if it hasnt had time to heal it this can happen
    • whos at risk for this: elderly, infected, immunocompromised, those who are too active after wound
  23. evisceration
    • organ is protruding from the wound
    • keep them calm and NPO
    • cover with sterile dressing and call provider
  24. what is splinting
    putting pressure on a wound when coughing, sneezing, etc
  25. when to do wound assessment
    • on admission
    • everytime you do wound care
    • anytime pt condition changes
    • on interview
  26. things to look for in wound assessment
    • location and appearance: be very descriptive
    • measurement: length, diameter, depth
    • wound closure: and whats been used to close it
    • wound drainage: color volume smell
    • drains: type condition, quality
    • dressings: and frequency of their change
    • when, where how it happened: and any associated symptoms
  27. Wound appearance colors
    • Red: granulation tissue which is healthy regeneration of tissue. protect this. the budding blood vessels and new tissue that is generating
    • Yellow: purulent drainage and slough. cleanse this for healing
    • Black: eschar that hinders healing and requires removal. debride this
  28. slough
    dead keratinized cells and debri
  29. why do we measure wounds
    • to detect changes that occur and assess how the wound is healing
    • length, width and depth
    • is it tunneling, undermining, etc
  30. types of wound closures
    • staples
    • sutures
    • wound adhesives (dermabond for ex. to approximate edges)
    • steri-strips (help with closure and speed healing)
  31. what if there is pink around wound edges
    • this is the inflammatory process and normal. it will slowly dissappear over time
    • be concerned if its bright red
  32. what to note about drainage (exudate)
    • note and document drainage on/in: wound itself and areas of induration, dressings, and drains
    • amount: scant, moderate, copious, or mLs
    • color
    • consistancy
    • odor: foul, earthy
    • frequency of dressing change
    • assess integrity of surrounding skin and the periwound area
  33. Serous drainage
    • light and pink
    • thin and watery
  34. purulent drainage
    • yellow, thick
    • may have an odor
  35. serosanguineous drainage
    mix of serous and blood
  36. sanguineous drainage
  37. why drain wounds
    accumulation of drainage delays healing and provides a medium for growth of microorganisms
  38. Placing and assessing drains
    • placed into or near wound if large amount of drainage
    • evacuation of drainage using a drain alone or a tube with suction
    • may be sutured in place to prevent dislodgement
    • caution with dressing change around not sutured ones to prevent dislodgement
    • asses number and type and document which number has how many mL
    • monitor skin integrity around drain insertion site- for leakage
    • ensure patency-
    • measure volume and assess characteristics of drainage
  39. what does it mean to ensure patency of a drain
    • that its draining
    • if it suddenly slows the wound could be drained or there could be a blockage
  40. types of drains
    • jackson pratt (jp): has tubing, emptying cap and port and collection reservior. you squeeze the balloon to creat negative pressure to pull the drainage out
    • penrose drain: drain put in the wound. a saftey pin stops the flow from going back
    • hemovac (accordion) drain: circular. accordion squeezed flat again to create suction from hold more volume than the JP but similar to it.
  41. why do we use dressings
    • applied to promote healing by absorbing drainage and to protect wound from microorganisms
    • they keep pressure to slow/stop bleeding
    • they establish a warm moist environment
    • the dressing type is determined by wound type
  42. types of dressings
    • gauze
    • transparent film
    • hydrocolloid (have gel forming agents)
    • hydrogel
    • foam
    • alginate
  43. packing a wound
    • promotes wound healing by providing a moist wound environment
    • uses sterile technique
    • assess size, shape depth of wound
    • use prescribed packing material
    • dont pack too tightly because you dont want to put pressure on healthy granulation tissue
  44. wound vac
    negative pressure wound therapy
  45. application of wound vac
    • black sponge to clean wound
    • cover with dressing
    • attach suction to hole in dressing
    • sucks drainage out
  46. how to secure dressings
    • tape: paper for skin as its breathable and hypoallergenic. silk is much more adhesive, shouldnt be used on skin. foam stretchy marshmallow tape- good for wounds in areas of mobility
    • ties: big bulky ties can secure dressing and avoid taping/retaping
    • bandages: ie elastic bandages. for pressure, prevent edema
    • binders: secure dressings
  47. cleaning incisions
    • follow providers orders
    • can be basic or involve irrigation
  48. basic incision cleaning
    from inside (cleanest) to out (dirtiest)- center of wound to surrounding skin
  49. irrigation
    • done to remove exudate and debri
    • only do if ordered
    • isotonic solutions are preferred (ie normal saline) or a specific antiseptic solution may be ordered
    • employ proper irrigation pressure
    • allow solution to flow from least to most contaminated area
  50. employing proper irrigation pressure
    • 8-15 PSI
    • done to ensure that you dont disrupt the healthy tissue
    • syringe size and catheter size affects irrigation pressure
  51. irrigation order
    • from least to most contaminated area- inside to out
    • solution flows from inside the wound out
    • if sutures/staples, drain still clean outwards s
  52. when does wound infection usually develop
    4th day and after
  53. suspecting wound infection
    • look at incision appearance and surrounding skin
    • note- temp, swelling, color (bright red), purulent drainage, tenderness on palpation, extension of erythema (red streaking)
  54. wound cultures
    • done if you suspect infection to identify the offending organism
    • dont culture from old drainage
    • make sure wound is clean from external flaura that may give false result
    • swab inside
    • do aerobic and anaerobic cultures
  55. promoting comfort in wound care
    • adminster analgesics 30-60min before dressing changes
    • carefully remove tape- provide counter traction to skin
    • gently clean wound edges
    • carefully manipulate dressings and drains to minimize stress on underlying tissues
    • turn and position patient carefully before and after dressing change
    • provide privacy
  56. common Nursing dx for wounds
    • infection risk
    • imbalanced nutrition (less than)
    • acute/chronic pain
    • impaired mobility
    • impaired skin integrity
    • risk for manipulated skin integrity
    • ineffective perfusion
    • impaired tissue integrity
    • deficient knowledge
  57. know potter and perry table 48.5
Card Set
Acute Wounds and Drains
Exam 2