Wound Care Assessment for LPNs and RNs
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What is the primary reason an LPN may not measure, irrigate, and pack a wound with undermining and/or tunneling?

  • The wound is too complex
  • The wound is not improving
  • The back or base of the wound is not visible (correct)
  • The LPN lacks the necessary training

    • What is the primary indication of a worsening wound condition?

  • Ineffective wound management
  • Improvement in wound size
  • Presence of undermining and/or tunneling
  • Discovery of a new area of undermining and/or tunneling (correct)

    • What is the purpose of using a clock to describe wound orientation?

  • To provide a visual reference for abnormal findings (correct)
  • To measure the length and width of the wound
  • To determine the wound's depth
  • To track the wound's improvement

    • What is the correct method for measuring the width of a wound?

    <p>Measuring perpendicular to the length, using the widest width</p> Signup and view all the answers

    What is the primary goal of wound assessment?

    <p>To determine if the wound is improving, treatment is effective, and if treatment is still necessary</p> Signup and view all the answers

    What type of wound is most commonly associated with undermining and/or tunneling?

    <p>Diabetic foot ulcer</p> Signup and view all the answers

    What is the characteristic of granulation tissue?

    <p>Red and moist with a slight bumpy appearance</p> Signup and view all the answers

    What is the indication of possible infection in a wound?

    <p>Exposed bone and/or tendon</p> Signup and view all the answers

    What is the characteristic of epithelial tissue?

    <p>Dry, pale pink, white or silver</p> Signup and view all the answers

    What is the characteristic of necrotic slough?

    <p>Wet dead tissue that is stringy and stuck to the wound bed</p> Signup and view all the answers

    What is the purpose of placing a sterile cotton-tip applicator into the deepest part of the wound bed?

    <p>To assess the depth of the wound</p> Signup and view all the answers

    What is the primary characteristic of necrotic eschar?

    <p>Dry, dead tissue</p> Signup and view all the answers

    What is the indication of possible infection in a wound?

    <p>Exposed bone and/or tendon</p> Signup and view all the answers

    What is the characteristic of granulation tissue?

    <p>Red, moist, and bumpy</p> Signup and view all the answers

    What is the purpose of using a sterile cotton-tip applicator?

    <p>To place against a ruler to measure depth</p> Signup and view all the answers

    What is the characteristic of epithelial tissue?

    <p>Dry, pale pink, white, or silver</p> Signup and view all the answers

    What is the primary mechanism of mechanical debridement?

    <p>Physical removal of foreign material and dead tissue</p> Signup and view all the answers

    What is a common complication of mechanical debridement?

    <p>Damage to healthy tissue</p> Signup and view all the answers

    What is the purpose of a wet-to-dry dressing?

    <p>To remove dead tissue and debris</p> Signup and view all the answers

    What is a characteristic of mechanical debridement?

    <p>Usually painful</p> Signup and view all the answers

    Where can a wet-to-dry dressing be placed?

    <p>Only on surface wounds</p> Signup and view all the answers

    What is a primary concern during surgical debridement?

    <p>Managing the patient's pain</p> Signup and view all the answers

    What is a characteristic of surgical debridement?

    <p>Aggressive removal of tissue</p> Signup and view all the answers

    What is a potential drawback of surgical debridement?

    <p>Removal of both viable and non-viable tissue</p> Signup and view all the answers

    What is used during surgical debridement?

    <p>Surgical instruments</p> Signup and view all the answers

    What is the role of the physician/surgeon during surgical debridement?

    <p>Perform the procedure</p> Signup and view all the answers

    What is the primary mechanism of autolytic debridement products?

    <p>Enzymatic digestion of dead tissue and collagen</p> Signup and view all the answers

    What is a characteristic of wounds treated with autolytic debridement products?

    <p>Less painful debridement</p> Signup and view all the answers

    What is the effect of autolytic debridement products on collagen?

    <p>It breaks down collagen</p> Signup and view all the answers

    What is an advantage of using autolytic debridement products?

    <p>Less painful option</p> Signup and view all the answers

    What is unique about autolytic debridement products?

    <p>They use enzymes to break down tissue</p> Signup and view all the answers

    What is the primary mechanism of hydrocolloid dressings in wound debridement?

    <p>Hydration of the wound to facilitate autolysis</p> Signup and view all the answers

    What is the benefit of hydrocolloid dressings in terms of wound pain management?

    <p>They provide a cushioning effect to reduce discomfort</p> Signup and view all the answers

    How do hydrocolloid dressings protect the wound from external factors?

    <p>They protect the wound from air and moisture</p> Signup and view all the answers

    What is the advantage of hydrocolloid dressings in terms of wound bed contours?

    <p>They form well to body contours</p> Signup and view all the answers

    What is the benefit of hydrocolloid dressings in terms of wound adhesion?

    <p>They are self-adherent and fit well on uneven skin surfaces</p> Signup and view all the answers

    What is the primary purpose of alginate dressings?

    <p>To promote granulation and epithelization</p> Signup and view all the answers

    What is the characteristic of alginate dressings when exposed to wound drainage?

    <p>They form a gel that traps the exudate</p> Signup and view all the answers

    What is the benefit of alginate dressings in terms of wound bed management?

    <p>They can be left on the wound bed for an extended period</p> Signup and view all the answers

    What is the mechanism by which alginate dressings promote wound healing?

    <p>By trapping the exudate and promoting a clean wound environment</p> Signup and view all the answers

    What is the primary advantage of using alginate dressings in wound management?

    <p>They are highly absorbent and reduce bacterial infections</p> Signup and view all the answers

    What is the primary mechanism of biological debridement?

    <p>Digestion of necrotic tissue by larvae</p> Signup and view all the answers

    What is unique about biological debridement?

    <p>It uses larvae to digest necrotic tissue</p> Signup and view all the answers

    What is the primary advantage of biological debridement?

    <p>It targets only necrotic tissue</p> Signup and view all the answers

    What is a limitation of biological debridement?

    <p>It is not widely accepted</p> Signup and view all the answers

    What type of tissue is targeted by biological debridement?

    <p>Necrotic tissue</p> Signup and view all the answers

    What is the primary purpose of wound irrigation?

    <p>To remove deeper debris and assist with visual examination</p> Signup and view all the answers

    What should you do before irrigating a wound?

    <p>Position the patient to promote gravitational flow of fluid</p> Signup and view all the answers

    What is the result of continuous irrigation until the return is clear?

    <p>The wound is fully cleansed and ready for assessment</p> Signup and view all the answers

    What is the primary mechanism by which wound irrigation promotes wound healing?

    <p>By removing debris and exudate from the wound surface</p> Signup and view all the answers

    What is the most common solution used for wound irrigation?

    <p>Normal saline</p> Signup and view all the answers

    Why should you take specimens before wound cleansing?

    <p>To avoid altering the sample</p> Signup and view all the answers

    When are sutures and staples typically removed after a surgical operation?

    <p>7-14 days post-op</p> Signup and view all the answers

    What is the primary purpose of retention sutures?

    <p>To support the wound for an extended period</p> Signup and view all the answers

    What technique is usually employed during the removal of sutures and staples?

    <p>Aseptic technique</p> Signup and view all the answers

    What is the recommended approach when removing sutures 'all at once'?

    <p>Remove every other suture initially</p> Signup and view all the answers

    What instruments are used during the removal of sutures and staples?

    <p>Staple extractor, forceps, and scissors</p> Signup and view all the answers

    What is the first step in the suture removal process?

    <p>Perform hand hygiene and apply clean gloves</p> Signup and view all the answers

    How should you grasp the knot of the suture during removal?

    <p>With forceps</p> Signup and view all the answers

    What should you do after removing every other suture from the incision?

    <p>Observe healing level and assess</p> Signup and view all the answers

    Why should you apply steri-strips?

    <p>If there is any separation greater than 2 sutures/staples in width</p> Signup and view all the answers

    What should you use to clean the incision line?

    <p>Antiseptic swabs</p> Signup and view all the answers

    What should you do with the removed suture?

    <p>Discard it properly</p> Signup and view all the answers

    What is the correct sequence of steps in staple removal?

    <p>Apply clean gloves, then inspect incision and staple line</p> Signup and view all the answers

    What is the purpose of using antiseptic swabs in staple removal?

    <p>To clean the staples and incision line</p> Signup and view all the answers

    What is the correct technique for removing staples?

    <p>Place the lower tips of the staple remover under the staple and close the handle</p> Signup and view all the answers

    What should be placed nearby the incision line during staple removal?

    <p>A 4x4 gauze</p> Signup and view all the answers

    What is the final step in the staple removal process?

    <p>Apply steri strips to the incision line</p> Signup and view all the answers

    Study Notes

    Wound Care Roles and Responsibilities

    • An LPN (Licensed Practical Nurse) cannot blindly probe into a wound bed when undermining and/or tunneling are present.
    • An RN (Registered Nurse) must measure, irrigate, and pack areas with undermining and/or tunneling where the back or base is not visible.
    • An LPN can measure, irrigate, and pack areas with pre-existing undermining and/or tunneling if the back/bed is visible.
    • If an LPN detects new undermining and/or tunneling, an RN must assess the area, even if the back/bed is visible, as it indicates a worsening condition and ineffective management.

    Wound Assessment and Treatment

    • Wound assessment aims to determine if the wound is improving, treatment is effective, or if treatment needs to be changed.
    • Signs of improvement must be present; otherwise, further investigation and consultation may be necessary.

    Wound Orientation and Measurement

    • The face of a clock is used to provide a visual aid for wound orientation and to identify abnormal findings.
    • Wound measurement involves:
      • Length: measuring the longest length of the wound with the ruler placed over the wound, considering the top as 12 o'clock towards the patient's head.
      • Width: measuring perpendicular to the length, using the widest width, generally from 3 o'clock to 9 o'clock.

    Assessing Wound Depth

    • To measure wound depth, place a sterile cotton-tip applicator into the deepest part of the wound bed

    Wound Bed Characteristics

    • Granulation tissue: red, moist, and slightly bumpy
    • Epithelial tissue: new skin surface, dry, pale pink, white, or silver in color

    Identifying Necrotic Tissue

    • Necrotic eschar: dry, dead tissue, black, brown, or grey in color
    • Necrotic slough: wet, dead tissue, white, grey, brown, yellow, or beige in color, stringy and stuck to wound bed

    Identifying Exposed Bone and/or Tendon

    • Exposed bone: indication of possible infection
    • Exposed tendon: white, tight strings across the wound bed

    Assessing Wound Depth

    • To measure wound depth, place a sterile cotton-tip applicator into the deepest part of the wound bed

    Wound Bed Characteristics

    • Granulation tissue: red, moist, and slightly bumpy
    • Epithelial tissue: new skin surface, dry, pale pink, white, or silver in color

    Identifying Necrotic Tissue

    • Necrotic eschar: dry, dead tissue, black, brown, or grey in color
    • Necrotic slough: wet, dead tissue, white, grey, brown, yellow, or beige in color, stringy and stuck to wound bed

    Identifying Exposed Bone and/or Tendon

    • Exposed bone: indication of possible infection
    • Exposed tendon: white, tight strings across the wound bed

    Mechanical Debridement

    • Mechanical debridement is the removal of foreign material and dead tissue by physical forces.
    • This method is accomplished through irrigation and wet dressings.
    • It can cause damage to healthy tissue, so caution is required.
    • Mechanical debridement is usually painful.

    Wet-to-Dry Dressing

    • A wet-to-dry dressing is a type of mechanical debridement technique.
    • The dressing is applied wet and allowed to dry out.
    • When removed, a layer of debris is pulled off the wound.
    • Wet-to-dry dressings can be placed on a surface wound.

    Surgical Debridement

    • Performed by a physician/surgeon to aggressively remove tissue, including non-viable tissues and potentially healthy tissue.
    • Utilizes surgical instruments to remove tissue.
    • Requires consideration of patient's pain management during the procedure.

    Autolytic/Enzymatic Debridement

    • Autolytic/enzymatic debridement products are applied to wounds to facilitate the breakdown of dead tissue through enzymatic digestion
    • The enzymes in these products digest not only dead tissue but also the collagen of necrotic tissue
    • This method is considered a less painful option for debridement
    • There are several different product options available for autolytic/enzymatic debridement

    Autolytic/Enzymatic Debridement: Hydrocolloids

    • Remain in place for a fixed duration, allowing for sustained wound care
    • Absorb wound drainage by transforming into a gel-like substance
    • Hydrocolloids contribute to wound hydration and debridement
    • Provide protection from air exposure and moisture
    • Self-adherent properties enable secure attachment to the wound, adapting to uneven skin surfaces
    • The cushioning effect reduces pain and protects the wound
    • Conforms well to body contours, ensuring a comfortable fit

    Autolytic/Enzymatic Debridement - Alginates

    • Alginate dressings are derived from algae or seaweed, making them lightweight and non-woven fabrics.
    • Designed for moderately to heavily exudating wounds, alginate dressings are highly absorbent and can reduce bacterial infections.
    • These dressings can stay on the wound bed for days, promoting a favorable environment for healing.
    • When exposed to wound drainage, alginate dressings form a gel that traps the exudate, creating a protective barrier.
    • The gel-forming property of alginate dressings promotes granulation and epithelialization, enhancing the wound healing process.

    Wound Assessment and Management

    • LPN may not blindly probe into a wound bed, RN must measure, irrigate, and pack areas with undermining and/or tunneling where the back or base is not visible.
    • LPN may measure, irrigate, and pack areas with undermining and/or tunneling where the back or base is visible.
    • A new area of undermining and/or tunneling must be assessed by an RN, even if the back/bed is visible.

    Complex Wounds

    • Diabetic Foot Ulcers and Advanced Pressure Injuries are examples of complex wounds.

    Wound Orientation and Measurement

    • A clock face is used to provide a visual reference for wound orientation and abnormal findings.
    • Wound measurement includes:
      • Length: measured with a ruler placed over the wound on the longest length (typically from 12 o'clock towards the patient's head).
      • Width: measured perpendicular to the length, using the widest width (typically from 3 o'clock to 9 o'clock).

    Debridement

    • Surgical Debridement:
      • Performed by a physician/surgeon.
      • Aggressive removal of tissue, including healthy tissue.
      • Uses surgical instruments.
    • Mechanical Debridement:
      • Removal of foreign material and dead tissue by physical forces.
      • Accomplished by irrigation and wet dressings.
      • Can damage healthy tissue and be painful.
    • Autolytic/Enzymatic Debridement:
      • Products applied to wounds to allow enzymes to self-digest dead tissue.
      • Less painful option.
      • Several different options, including:
        • Hydrocolloids:
          • Absorbs drainage by forming a gel.
          • Hydrates and debrides wounds.
          • Protects from air and getting wet.
          • Self-adheres to wound and fits well on uneven skin surfaces.
          • Cushion effect diminishes pain and protects.
          • Forms well to body contours.
        • Alginates:
          • Light, nonwoven fabrics derived from algae or seaweed.
          • Highly absorbent, reduces bacterial infections, and can stay on the wound bed for days.
          • Forms a gel when exposed to wound drainage that traps the exudate.
          • Promotes granulation and epithelization.
    • Biological Debridement:
      • Not very popular.
      • Involves the use of larvae (maggots) that digest necrotic tissue.

    Wound Bed Characteristics

    • Granulation: red, moist, and slightly bumpy appearance.
    • Epithelial: new skin surface, dry, pale pink, white, or silver.
    • Necrotic Eschar: dry, dead tissue, black, brown, or grey in color.
    • Necrotic Slough: wet dead tissue, white, grey, brown, yellow, or beige in color, and can be stringy and stuck to the wound bed.
    • Exposed Bone and/or Tendon: exposed bone indicates possible infection, tendons are white, tight strings across the wound bed.

    Wound Irrigation

    • Wound irrigation is a steady flow of a solution across an open wound surface to achieve wound hydration, remove deeper debris, and assist with visual examination.
    • Provide pain medication prior to irrigation if required.

    Important Considerations

    • Irrigation should not cause tissue irritation, discomfort, or damage.
    • Position the patient to promote gravitational flow of fluid.
    • Use a barrier to prevent cross-contamination.

    Equipment and Technique

    • Use a 30-60 ml syringe with an 18- or 19-gauge needle or catheter to provide needed pressure.
    • Avoid touching the wound bed with the irrigation device.
    • Cleanse from the area of least contamination to the area of most contamination.
    • Hold the tip 2.5 cm (1 inch) above the upper end of the wound and over the area being cleansed.
    • Irrigate using continuous pressure, flushing the wound.

    Goals of Irrigation

    • Continue irrigation until debris/drainage has been flushed out and the return is clear.
    • Use the amount of solution ordered.

    Wound Cleansing

    • Wound cleansing removes debris and makes the wound more visible for assessment and measuring.
    • Take any required specimens BEFORE cleansing to avoid altering the sample.

    Benefits of Wound Irrigation

    • Wound irrigation promotes wound healing by removing debris and exudate from the wound surface.
    • Decreases the number of bacteria.
    • Loosens and removes debris from the wound bed.
    • Normal saline is the most common solution used for irrigation.

    Suture Removal

    • Sutures and staples are removed 7-14 days post-operatively
    • Retention sutures are in place for 14-21 days
    • Removal of sutures may be ordered in different ways, including:
      • Removing all at once
      • Removing every other suture
    • Even when ordered to remove all at once, it's recommended to remove every other suture initially
    • Instruments used for removal, such as staple extractor, forceps, and scissors, are typically sterile
    • Aseptic technique is usually used during the removal process

    Suture Removal Preparation

    • Wear clean gloves, as per policy, to ensure a sterile environment.
    • Perform hand hygiene before applying gloves.
    • Inspect the incision and suture line to identify any potential issues.

    Suture Removal Process

    • Count and clean sutures and incision line with antiseptic swabs, using a new swab for each swipe.
    • Hold scissors in your dominant hand and forceps in your non-dominant hand.
    • Grasp the knot of the suture with forceps and pull up gently while slipping scissors under the suture near the skin.
    • Snip the suture as close to the skin as possible at the end distal to the knot.
    • If using continuous or blanket sutures, snip the first suture at the same spot and then snip the second directly following, pulling it out all together.
    • Grasp the knotted end with forceps and pull the suture through from the other side in one continuous smooth action.
    • Place the removed suture on a nearby gauze.

    Removing Remaining Sutures

    • Repeat the suture removal process until every other or every second suture is removed from the incision.
    • Observe the healing level and assess the incision based on the doctor's order.
    • Determine whether remaining sutures will be removed at this time.
    • Continue to remove sutures if applicable using the same steps above.

    Post-Suture Removal Care

    • Inspect the incision to ensure all sutures are removed and identify any trouble areas.
    • Clean the suture line again with antiseptic swabs.
    • Apply steri-strips if there is any separation greater than 2 sutures/staples in width, extending 4-5cm on each side of the incision.
    • Count the staples that have been removed to ensure the correct amount and discard of sharps properly.

    Staple Removal Procedure

    • Apply clean gloves, following policy, to ensure a sterile environment
    • Remove dressing if present and perform hand hygiene before applying gloves
    • Inspect the incision and staple line to assess the area
    • Clean the staples and incision line using antiseptic swabs, following the order: distal, proximal, and down the incision line, using a new swab for each swipe
    • Place a 4x4 gauze nearby the incision line for convenience
    • Position the staple remover/extractor under the first staple, ensuring control of the extractor, and close the handle to initiate removal
    • Once both ends of the staple are visible, move it away from the skin surface, release the handles, and continue until the staple is dropped from the extractor
    • Repeat the process, removing every other staple, until all staples are removed or as per doctor's order
    • Assess and clean the incision line before applying steri strips

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    Description

    This quiz assesses the role of LPNs and RNs in wound care, including measurement, irrigation, and packing of wound beds with undermining and tunneling.

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