Wound Care and Dressings Overview

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Questions and Answers

What is the primary purpose of using a dry sterile dressing?

To facilitate immediate surgical intervention

To absorb drainage and protect the wound (correct)

To promote rapid wound healing

To enhance the visibility of the wound

Which type of wound healing involves the tissue edges being approximated?

Healing by secondary intention

Healing by delayed intention

Healing by primary intention (correct)

Healing by third intention

What is a common characteristic of wounds healing by secondary intention?

Minimal tissue loss

Sutured or stapled edges

Regular shaped edges

Presence of considerable tissue loss (correct)

For which scenario is a wet-to-dry dressing typically used?

To debride a wound by removing dead tissue Signup and view all the answers

Which type of dressing would most likely be used to protect a wound from mechanical injury?

Dry sterile dressing Signup and view all the answers

What is a key criterion for deciding when to change a dry sterile dressing?

When the dressing becomes wet or according to facility policy Signup and view all the answers

What is the potential risk associated with secondary wound healing?

Increased scarring and longer healing time Signup and view all the answers

Which of the following principles is important for wound management?

The method of dressing should ensure a moist environment when appropriate Signup and view all the answers

What should be done if a dressing adheres to the wound?

Moisten the dressing with saline. Signup and view all the answers

When cleaning a closed wound, which area should be considered the cleanest?

The center of the wound. Signup and view all the answers

What is the correct order of cleansing steps for a well-approximated closed wound?

Top to bottom, center, side, side. Signup and view all the answers

What must be done immediately after removing gloves during a dressing change?

Perform hand hygiene. Signup and view all the answers

When documenting the condition of a wound, which of the following should NOT be included?

Personal reflections on healing. Signup and view all the answers

Which of the following actions should be taken to reduce contamination during wound cleansing?

Use one stroke per sterile gauze pad. Signup and view all the answers

For a cleansing of an open wound with an incision, which area should you begin cleaning?

Least contaminated area. Signup and view all the answers

What is the appropriate action regarding the positioned patient during a dressing change?

Ensure the patient is comfortable. Signup and view all the answers

What does the acronym 'COCA' stand for in wound assessment?

Color, odor, consistency, amount. Signup and view all the answers

What is a normal expectation in the appearance of a well-approximated wound during the first 48 hours?

Slight redness and mild edema. Signup and view all the answers

What is a characteristic of serous wound drainage?

Clear and watery Signup and view all the answers

What should be done prior to packing a wound?

Saturate packing material with saline solution Signup and view all the answers

Which statement is true regarding negative pressure wound therapy?

It removes fluid and stimulates granulation tissue formation. Signup and view all the answers

What is the primary purpose of wound irrigation?

To cleanse the wound and remove debris Signup and view all the answers

What is crucial to maintain while applying a sterile dressing?

Maintain sterility of the instruments and dressing Signup and view all the answers

What is a consequence of overpacking a wound?

Impeded circulation and delayed healing Signup and view all the answers

Dehiscence refers to which of the following?

Total separation of a wound or surgical incision Signup and view all the answers

When should a drainage tube be used?

To facilitate continuous suction of wound drainage Signup and view all the answers

Which fluid should be used to cleanse a wound prior to packing?

Sterile solution ordered by the HCP Signup and view all the answers

What sensation might a patient report if they experience wound dehiscence?

A pulling or tearing sensation Signup and view all the answers

What is a common characteristic of purulent drainage?

Thick and colored, often yellow, green or brown Signup and view all the answers

What factor can negatively affect wound healing in older adults?

Poor nutritional status Signup and view all the answers

During wound packing, how should the packing material be applied?

Lightly packed to the surface of the wound Signup and view all the answers

Which is a basic principle of wound irrigation?

Maintain a closed system during irrigation Signup and view all the answers

Study Notes

Purposes of Dressings

Aid in hemostasis (stopping blood flow)
Protect wound from microorganisms and contamination
Absorb drainage
Support or splint the wound site
Protect the patient from seeing the wound if perceived as unpleasant
Protect wound from mechanical injury
Provide a moist environment for open wounds
Debride wound (remove foreign matter and dead tissue)

Types of Wounds

Closed Wounds: Tissue surfaces have been approximated (closed)
- Surgical, even edges
- Sutured, Stapled, Steri-Strips
- Minimal or no tissue loss
- Examples: Incision line, closed fracture
Open Wounds: Uneven edges, irregular shape, considerable tissue loss
- Wounds that cannot close completely, edges may not be together; may be wide open
- Examples: Burn, pressure ulcer, severe laceration
- May be touched only with sterile gloves or sterile forceps per CDC guidelines

Compare and Contrast: Primary and Secondary Wound Healing

Primary Healing: Wound edges approximated
- Healing time is shorter
- Less scarring
- Decreased risk for infection
Secondary Healing: Wound edges open
- Healing time is longer
- Scarring is greater
- Increased risk for infection

Types of Dressings

Dry sterile: Dry gauze sponges
- Cover and protect wound
- Absorb drainage
- Change dressing according to facility policy or if wet (need order from HCP)
Wet-to-Dry: Moist dressing placed in wound and allowed to dry
- Used for wound debridement
- Need HCP order
- How often should this type of dressing be changed and why?
Drainage: Indicates wound status and potential infection
- Need HCP order for wound culture

Types of Wound Drainage

Serous: Clear, watery (plasma), due to mild inflammation
Purulent: Thick yellow, green, tan, brown, caused by the presence of bacteria, abnormal
Serosanguineous: Pale, pink, watery (mixture of clear and red fluid), common in surgical incisions
Sanguineous: Bright red (indicates active bleeding), abnormal

Measuring a Wound

Measure:
- Length
- Width
- Depth
- Diameter

Wound Management

Drains: Used when drainage interferes with healing
- Drain into dressing
- Drainage tube to continuous suction
- Surgical drains
Wound Irrigation: Cleanse wound with sterile solution ordered by HCP
Wound Packing: Gently debrides the wound when removed
- Packing material and instruments must be sterile
- Gently pack to the surface of the wound, do not pack too tightly:
  - Overpacking can cause too much pressure and impede circulation, delaying healing
  - Do not extend packing material over wound edges, onto healthy tissue
Wet-to-Dry Dressing: Contact layer applied moist (not wet)
- Saline, medicated solutions
- Dries and absorbs debris
- Mechanically debrides wound
- Removal of dressing gently pulls off debris
- May need to pre-medicate as it can be painful
Negative Pressure Wound Therapy (Wound VAC): Closed system that uses localized negative pressure to:
- Pull wound edges together
- Remove fluid from the area
- Stimulate granulation tissue formation

Dehiscence

Partial or total separation of a surgical incision or wound closure, usually on the abdomen
Often after suture removal
Feels like "pulling", "tearing", or "giving way" sensation
Risk factors: Poor nutritional status, infection, obesity

Evisceration

Protrusion of an internal organ (usually bowel) through a wound or surgical incision, especially in the abdominal wall
Preceded by a sudden discharge of serosanguineous fluid and a "tearing" sensation
Must cover organ with sterile saline-saturated dressings and seek treatment

Factors Affecting Wound Healing in Older Adults

Loss of skin turgor
Skin fragility
Decrease in peripheral circulation and oxygenation
Slower tissue regeneration
Decrease in absorption of nutrients
Decrease in collagen
Impaired function of immune system
Presence of chronic illnesses
Increased risk for infection

Implementing Dressing Change

Observe for dressing adherence, elevating hand above trash bag for disposal
Assess and observe characteristics of wound for:
- Wound edges: Approximated, intact skin around wound
- Drainage: COCA (color, odor, consistency, amount)
- Descriptive terms: Erythema (red), warm, pain, edema, purulent exudate, drainage
Prepare sterile field:
- Add dressings, instruments, cleansing agent and sterile cup OFF the field
Apply sterile gloves

Principles of Cleaning Wounds

Clean to Dirty: Clean in the direction from the least contaminated area of the wound to the most contaminated area
- Intact wound is considered the cleanest area
- Skin is "less" clean; opened areas are less clean
Gentle Friction: Use gentle friction when applying cleansing solutions
Keep Forceps Tips Lower Than Handle: While cleaning the wound

Cleaning Closed Wounds

One Stroke Per Sterile Gauze Pad: Clean wound from top to bottom
- Center (wound), side (skin), side (skin)
Three Steps:
1. Clean the wound with forceps and gauze
2. Clean around the wound with a separate gauze
3. Apply new sterile dressing

Closed Wound - Normal Healing Expectations

Well-approximated wound edges
Slightly reddened (inflamed) for the first 48 hours
May observe mild edema for the first 48 hours

Cleansing Open Wounds

Begin cleansing from least contaminated area to the most contaminated area
- "Dirtier" areas are usually due to infection or inflammation
Center, Side, Side: Clean wound with 3 gauze pads

Completing Wound Dressing Change

Add dressings to the incision/wound:
- 4x4’s, ABD, tape, Montgomery straps
Remove sterile gloves
Label dressing with date, time, and initials
Bag trash
Perform hand hygiene
Position patient for comfort
Rearrange bedside area as needed
Ensure patient safety
Ask "Is there anything else I can do for you?"

Wound Cleaning Documentation

COCA: color, odor, consistency, amount
Condition of wound
- Edges approximated
- Drainage or exudate
- Hemorrhage?

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Description

This quiz covers essential aspects of wound care, including the purposes and types of dressings. Explore the differences between closed and open wounds, as well as the stages of primary and secondary wound healing. Enhance your understanding of effective wound management practices.