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PTAP Woundcare > Basic Wound Care > Flashcards

Basic Wound Care Flashcards

1
Q

The most common wounds that are
treated by a wound care Physical
Therapist are:

A
  • Stage III, IV pressure ulcers (pressure injury).
  • Diabetic wounds
  • Chronic wounds
  • Venous and/or arterial wounds
  • Extremity wounds with edema
  • Non-healing surgical wounds
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2
Q

What are the members of the wound care team?

A
  • a physician
  • nursing
  • physical therapists
  • registered dietitians
  • case managers
  • orthotics/prosthetists
  • podiatrists
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3
Q 
outer most layer
formed by keratinocytes
regenerates every 4-6 weeks
protects against water loss and physical damage
sensation
A

epidermis

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4
Q

Components of the Dermis layer

A
  • collagen
  • elastin fibers
  • extracellular matrix
  • blood/lymphatic vessels
  • nerve endings
  • hair follicles
  • sebaceous/sweat glands
  • fibroblasts
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5
Q

Components of the SubQ/Hypodermis layer

A
  • adipose and connective tissue
  • major blood/lymphatic vessels
  • nerves
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6
Q

What are the functions of the skin?

A 
Protection
Excretion
Sensory Perception
Thermoregulation
Metabolism
Absorption
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7
Q

Which vitamin does the skin synthesize?

A

Vitamin D

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8
Q

Type of wound closure that involves a delayed primary closure. used in case of infection.

A

Tertiary Intention

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9
Q

Migration of cells over the wound edge, begins to

occur within 24 hours of injury.

A

Epithelialization

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10
Q

Formation of a new tissue and capillaries around the

wound edge-usually pink in color.

A

Granulation

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11
Q

Phase 1: Inflammation

A
  • 1-5 days
  • edema and necrosis
  • initial vasoconstriction
  • phagocytes cells to clean wound
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12
Q

What are some causes for abnormal inflammatory responses in wounds?

A
  • Immunosuppressive medications
  • Arterial Insufficiency
  • Medical conditions that alter the immune response
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13
Q

Phase 2: Proliferation

A
  • 3-20 days
  • fibroblasts secrete collagen (type III)
  • angiogenesis
  • granulation
  • epithelialization
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14
Q

Phase 3: Remodeling / Maturation

A
  • 9 days to 2 years
  • type III collagen converts to type I
  • decreased capillaries
  • scar tissue contracts and matures
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15
Q

Involves some degree of tissue loss, needs a second change to get it right. Formation of granulation tissue to fill in scar.

A

Secondary Intention

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16
Q

In the early inflammation stage
immediately following an injury, which
comes first? Vasoconstriction or Vasodilation?

A

Vasoconstriction

17
Q

The development of new blood vessels

A

Angiogenesis

18
Q

Type of wound that involves pain, swelling and discoloration. The skin is not broken.

A

Contusion

19
Q

Mass of blood usually caused by a break in a blood vessel

A

Hematoma

20
Q

Darkening of skin due to accumulation of iron-containing pigment. Common in venous ulcers

A

Hemosiderin staining

21
Q

What should you evaluate in the Peri-wound area of a wound?

A

– Sensation
– Peripheral Pulses
– Skin temperature
– Dryness of surrounding tissue

22
Q

Abnormal exudation that are signs of infection.

A
  • seropurulent: cloudy, opaque, yellow or tan, thin watery

- Purulent: yellow or green, thick, viscous

23
Q

Intrinsic factors that cause abnormal wound healing

A 
– COPD-Hypoxemia
– DM: loss of protective sensation
– CA: Decreased Immune Function
– Peripheral artery disease or Venous 
insufficiency
24
Q

Medications that can cause poor or prolonged inflammatory response

A 
anti-inflammatory
immunosuppressive
steroids
anti-coagulants
oral contraceptives
25
Q

Signs of Infection

A
  • bright red streaks
  • change in drainage
  • swelling
  • increased pain
  • fever, nausea, fatigue or loss of appetite
26
Q

abnormal passage between an

organ or vessel and another organ, vessel,or area

A

Fistula

27
Q

Most important external factor in optimal

wound healing

A

Moisture

28
Q

Nutrients necessary for wound healing

A
  • iron
  • vitamin B12
  • vitamin C
  • zinc
  • high protein
  • folic acid
29
Q

Pressure relief support surfaces

A
  • air and foam mattresses
  • avoid synthetic sheep skin pads, donuts
  • natural sheepskin may assist in prevention
  • use a pressure redistributing seat cushion
30
Q

Explain the rule of 30 for Pressure Injury Prevention

A

Positioning: Rule of 30 (>30 = increased
shearing)
˃ In supine: 30 degrees incline bed
˃ In sidelying: 30 degrees offloaded, so weight
on the buttocks, not the bones- use wedges
and pillows to protect all bony prominences

31
Q

Intact skin
˃ Non-blanchable redness in localized area
(usually bony prominence)
˃ Different that surrounding skin
May be different color
May be painful, firm, soft, warmer, cooler
˃ Darkly pigmented skin: May be difficult to
detect

A

Stage 1 Pressure Injury

32
Q

Partial thickness loss of dermis
shallow open ulcer with red-pink wound bed, without slough.
Shiny or dry without bruising

A

Stage 2 Pressure Injury

33
Q

Full thickness tissue loss
subcutaneous fat may be visible.
Bone, tendon, muscle not exposed.
Slough possible but does NOT obscure depth of tissue loss

A

Stage 3 Pressure Injury

34
Q

Full thickness tissue loss with visible but
bone, tendon or muscle exposed.
Slough and eschar present. Often has tunneling and undermining. Can extend into muscle

A

Stage 4 Pressure Injury

35
Q

Full thickness skin or tissue loss - depth unknown.

Depth completely obscured by slough/eshcar.

A

Unstageable Pressure Injury

PTAP Woundcare (9 decks)

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