Maturation - Scar tissue replaces the granulation tissue over several months,
until the full thickness of the skin is restored.
Complications of wound healing;
Systemic infection - The wound has to compete with the infection for white
cells and nutrients. Healing may not be able to continue, until the body has
dealt with the infection.
Hypertrophic Scars - These occur because of extreme fibrous tissue response
during the healing process, which results in a large deposition of Collagen,
leaving a thick wound scar.
More common in large burns and traumatic injury. Will usually flatten out in
time.
Keloids - Similar to Hypertrophic Scars exept that they take some time to
form and may occur years after the initial injury. They do not flatten out in
time.
Contractures - Contraction is part of the normal healing process, but
occasionally contraction will continue, resulting in scar contraction. This can go
on to joint contracture and subsequent loss of mobility and poor cosmetic
result.
The age of the patient may effect the healing process. Elderly patients skin
may be more fragile, with less efficient collagen tissue, making the wound
healing slower.
Circulatory disease can result in poor blood supply, which can lead to the
development of pressure sores. It will effect the amount of oxygen available
for normal tissue activity, so the healing process will again be slower and less
efficient.
Diabetic patients have a delayed cellular response to injury, and will cause a
defect in collagen production and wound strength. This can lead to amputation,
as the wound will rot before it has a chance to repair.
If the immune function is compromised due to for example Leukaemia or
Cancer, the body's ability to fight infection will be effected.
Obesity can deter healing because adipose tissue is poorly vascularized,
increasing the risk of wound breakdown.
Underweight patients could have vitimin and mineral deficiencies needed to
fight any infection.
2. Why is it so important to observe a patient's fingers and toes after the
application of a plaster cast and a bandage?
To monitor for possible impairment of circulation. Undue swelling could impede
the arterial flow to distal parts of the limb, which could result in tissue
necrosis. The swelling would create pressure to the nerves and could cause
permanent nerve damage.
It is also to monitor for cyanosis, and extreme pallor which would indicate
improper positioning or surgical damage.
3. Describe the types of dressings used in your department, include functions,
techniques of preparing, applying, securing them and hazards.
Mefix
A non-woven polyester fabric, coated with acrylic adhesive and protected in a
roll of release paper backing.
The tape is permeable to water vapour, so unlikely to be effected by sweating.
Used in Orthopaedics to hold dressings in place over joints. Stays in position
for long periods of time, as it is very wear resistant. Good for fixing
absorbant pads,
To apply, cut to length required, and pull gently on each edge to split the
perforated line in the middle. Carefully pull paper back one side at a time.
Immediately place over dressing.
Hazards - Should not be applied to patients who are known to be sensitive to
acrylic adhesives.
Opsite flexigrid
This is a waterproof dressing coated with an acrylic adhesive. Allows air in,
but keeps micro-organisms out. Mainly used in Orthopaedics to protect wounds
from infection. To apply, peel off paper backing and press on carefully,
ensuring there are no ripples.
Opsite
Similar to flexigrid, but has an absorbant dressing attached. Designed to
absorb any leakage from the wound and keep micro-organisms out, and offers a
waterproof protection.
In Orthopaedic surgery the Ioban drape is peeled back at the end of surgery,
just enough to make room for the dressing. A betadine soaked swab is used to
clean the wound and dressing is applied. Once in place, the rest of the Ioban
drape can be removed, as the wound is then protected from infection.
Hazards - Can cause blistering or tear delicate skin if not carefully removed.
Inadine
This is a topical wound dressing, which is impregnated with 10% povidine iodine
ointment. The dressing also contains polyethylene glycol and purified water.
Prevents infection from bacterial, protozoal and fungal organisms.
To apply, the wound is cleaned and dried.
The Inadine is removed from the package with sterile forceps. Then the
backing paper is removed and the dressing peeled off from the remaining
backing paper and applied directly to wound.
When the dressing turns white, it means there is a loss of antiseptic
efficiency, so should be changed at this stage. With highly infected wounds,
this may need to be up to two times daily.
Hazards - Must not be used on new borns to 6 month old infants, as providine
may be absorbed through unbroken skin.
Dressing pad
Made of absorbant cotton or viscose fibre gauze and mainly used as a
secondary dressing to put pressure on the wound. It also acts as a barrier to
bacteria.
Hazards - If liquid seeps through the surface of the dressing, the barrier has
been compromised, so must be changed regularly.
Algosteril
Made of Alginate which is known for its healing properties. It is made of
natural mixed salts of alginic acid which comes from certain species of
seaweed. Used in open wounds, where it heals from the bottom of the wound
upwards.
Hazards - If applied to a relatively dry wound, the patient may experience a
burning sensation, so moistening the dressing will avoid this occurance.
Velband and Crepe
Used in conjunction with each other. The Velband is used to absorb any blood
or fluids secreted from the wound, and to distribute the pressure from the
bandaging, while the Crepe bandage offers support to joints.
For example with knee replacements, two layers of each are applied
alternatively.
Crepe is made from lightweight cotton fabric and possesses elastic properties
to ensure the dressing is held in close proximity to the wound.
The support it offers prevents any change in shape of the tissue due to
swelling or sagging. Also compresses to reduce any swelling.
Hazards - If applied to tightly it could cause restriction of circulation and
impede the arterial flow, so hindering repair or causing nerve damage.
4. Describe in detail passive, active, naso-gastric and chest drains, include:
functions, techniques of preparing, attaching and securing them and hazards.
Chest drains (underwater seal)
This drain is used for the pleural cavity. It is used to ensure air, blood, pus
and any other fluid can drain away, but at the same time, stops air or fluid
returning to the pleural space. This could detroy the negative pressure which
the lung needs to inflate.
Two chest drainage tubes are used. One at the top of the lung to drain air and
one at its base to drain fluid.
The drainage bottle which must be placed at a level lower than the chest, has
an inlet for the drain, which ends below the saline seal in the bottle, and an
outlet or vent portal in its cap.
A one-way valve mechanism provided by the water seal, stops air and fluid
escaping from the pleural cavity, and with gravity, and the postive pressure
that breathing produces, means it can not return.
If a patient needs to be moved, the drain can be held above chest height and
the tube can be clamped, but only for short periods of time. If left too long,
the patient can suffer from tension pneumothorax.
This is because gas can enter the pleural cavity, but because it cant escape the
intrapleural pressure increases.
This means the lungs can not function correctly, which in turn effects the
respiration and cardiac systems, so could be life threatening.
Active
A vacuum within a sealed container is attached to the drain. Its the
subatmospheric pressure which draws the fluids away, via the tubing. They are
inserted by a sharp metal probe, which is attached to the drainage tubing.
Once in place this is cut off and discarded. The drain is sometimes stitched in
place on the patients skin, but not in orthopaedic surgery. Examples of this
would be the Exu-drain or the Redivac drains.
Hazards - May become dislodged or displaced. Surrounding tissue can grow
into the drains, making removal difficult.
Passive
This is similar to the active drain but the fluids flow freely into the drainage
container, and instead of a vacuum, gravity or capillary action is used. For
example the Soft drain and the Portex corragated wound drain.
Other passive drains allow free drainage into the dressing.
Hazards - If container is not kept lower than the patient at all times, fluids
could return into the wound.
Naso-gastric
This is a tube which is placed in the Intestinal tract, via the patients nose, to
remove fluid and gas, obtain a specimin of gastric contents, or occasionally
used for administration of medications or feedings.
The Naso-gastric (NG) tube is kept in the fridge to make it more pliable and
easy to handle. It is lubricated with KY jelly.
The tip of the patients nose is tilted back and the tube aligned to enter the
nostril. The mouth is opened to view the tube at the back, and magill forceps
used to feed the tube down the oesophagus and stomach, until it reaches the
Intestinal tract.
A bile bag is attached, and when the gastric fluid enters the bag, this confirms
the tube is in the correct place.
The NG tube is then secured to the nose to make sure it does not become
dislodged.
Hazards - Fluid volume deficit, including dry skin, mucous membranes, and
decreased urinary output.
Pulmonary complications, because coughing and clearing the pharynx can be
impaire.
Irritation of the mucous membrane, sore throats.