Wound Care Assessment for LPNs and RNs

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Questions and Answers

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?

Measuring perpendicular to the length, using the widest width Signup and view all the answers

What is the primary goal of wound assessment?

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

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

Diabetic foot ulcer Signup and view all the answers

What is the characteristic of granulation tissue?

Red and moist with a slight bumpy appearance Signup and view all the answers

What is the indication of possible infection in a wound?

Exposed bone and/or tendon Signup and view all the answers

What is the characteristic of epithelial tissue?

Dry, pale pink, white or silver Signup and view all the answers

What is the characteristic of necrotic slough?

Wet dead tissue that is stringy and stuck to the wound bed 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?

To assess the depth of the wound Signup and view all the answers

What is the primary characteristic of necrotic eschar?

Dry, dead tissue Signup and view all the answers

What is the indication of possible infection in a wound?

Exposed bone and/or tendon Signup and view all the answers

What is the characteristic of granulation tissue?

Red, moist, and bumpy Signup and view all the answers

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

To place against a ruler to measure depth Signup and view all the answers

What is the characteristic of epithelial tissue?

Dry, pale pink, white, or silver Signup and view all the answers

What is the primary mechanism of mechanical debridement?

Physical removal of foreign material and dead tissue Signup and view all the answers

What is a common complication of mechanical debridement?

Damage to healthy tissue Signup and view all the answers

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

To remove dead tissue and debris Signup and view all the answers

What is a characteristic of mechanical debridement?

Usually painful Signup and view all the answers

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

Only on surface wounds Signup and view all the answers

What is a primary concern during surgical debridement?

Managing the patient's pain Signup and view all the answers

What is a characteristic of surgical debridement?

Aggressive removal of tissue Signup and view all the answers

What is a potential drawback of surgical debridement?

Removal of both viable and non-viable tissue Signup and view all the answers

What is used during surgical debridement?

Surgical instruments Signup and view all the answers

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

Perform the procedure Signup and view all the answers

What is the primary mechanism of autolytic debridement products?

Enzymatic digestion of dead tissue and collagen Signup and view all the answers

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

Less painful debridement Signup and view all the answers

What is the effect of autolytic debridement products on collagen?

It breaks down collagen Signup and view all the answers

What is an advantage of using autolytic debridement products?

Less painful option Signup and view all the answers

What is unique about autolytic debridement products?

They use enzymes to break down tissue Signup and view all the answers

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

Hydration of the wound to facilitate autolysis Signup and view all the answers

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

They provide a cushioning effect to reduce discomfort Signup and view all the answers

How do hydrocolloid dressings protect the wound from external factors?

They protect the wound from air and moisture Signup and view all the answers

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

They form well to body contours Signup and view all the answers

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

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

What is the primary purpose of alginate dressings?

To promote granulation and epithelization Signup and view all the answers

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

They form a gel that traps the exudate Signup and view all the answers

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

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

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

By trapping the exudate and promoting a clean wound environment Signup and view all the answers

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

They are highly absorbent and reduce bacterial infections Signup and view all the answers

What is the primary mechanism of biological debridement?

Digestion of necrotic tissue by larvae Signup and view all the answers

What is unique about biological debridement?

It uses larvae to digest necrotic tissue Signup and view all the answers

What is the primary advantage of biological debridement?

It targets only necrotic tissue Signup and view all the answers

What is a limitation of biological debridement?

It is not widely accepted Signup and view all the answers

What type of tissue is targeted by biological debridement?

Necrotic tissue Signup and view all the answers

What is the primary purpose of wound irrigation?

To remove deeper debris and assist with visual examination Signup and view all the answers

What should you do before irrigating a wound?

Position the patient to promote gravitational flow of fluid Signup and view all the answers

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

The wound is fully cleansed and ready for assessment Signup and view all the answers

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

By removing debris and exudate from the wound surface Signup and view all the answers

What is the most common solution used for wound irrigation?

Normal saline Signup and view all the answers

Why should you take specimens before wound cleansing?

To avoid altering the sample Signup and view all the answers

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

7-14 days post-op Signup and view all the answers

What is the primary purpose of retention sutures?

To support the wound for an extended period Signup and view all the answers

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

Aseptic technique Signup and view all the answers

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

Remove every other suture initially Signup and view all the answers

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

Staple extractor, forceps, and scissors Signup and view all the answers

What is the first step in the suture removal process?

Perform hand hygiene and apply clean gloves Signup and view all the answers

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

With forceps Signup and view all the answers

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

Observe healing level and assess Signup and view all the answers

Why should you apply steri-strips?

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

What should you use to clean the incision line?

Antiseptic swabs Signup and view all the answers

What should you do with the removed suture?

Discard it properly Signup and view all the answers

What is the correct sequence of steps in staple removal?

Apply clean gloves, then inspect incision and staple line Signup and view all the answers

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

To clean the staples and incision line Signup and view all the answers

What is the correct technique for removing staples?

Place the lower tips of the staple remover under the staple and close the handle Signup and view all the answers

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

A 4x4 gauze Signup and view all the answers

What is the final step in the staple removal process?

Apply steri strips to the incision line 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.