Braces/Wound Care Flashcards
What motions does a Philadelphia brace restrict?
flexion and extension restriction
What motions do the aspen and miami J brace restrict?
rotation and lateral flexion as well as flexion and extension
What is the ultimate restriction device for cervical mobility?
halo - screwed into head
Do’s and Don’ts of pillows during positioning
DO: float heels, elevate UE, use for sidelying, prevent ER in supine
DON’T: place under knees, keep neck flexed
What cushion provides good stability but worst for pressure relief?
foam
What cushion has moderate pressure relief?
gel
What cushion provides best pressure relief but has the least stability?
air flow chamber
Wounds that are partial-thickness that only go into layer of dermis are _________. Deep wounds are considered _________. Why?
partial-thickness - very painful - nerves are in dermis
deep wounds - painless
Which type of wound will have decreased pedal pulse and which type of wound has pedal pulse present?
decreased pedal pulse - arterial
pedal pulse present - venous
Which type of wound will have wet wounds and which type of wound has dry wounds?
wet wounds - venous
dry wounds - arterial
arterial wound characteristics (6)
- decreased pedal pulse
- intermittent claudication
- anteriolateral foot/ankle, toes
- full thickness w/ well defined borders
- dry
- shiny, anhydrous, pale
venous wound characteristics (5)
- pedal pulse present
- LE edema
- irregular shaped, shallow wound
- wet
- trophic changes
diabetic foot ulcer characteristics (5)
- absent pedal pulse
- painless w/ decreased temp
- located at pressure points of foot/toes
- pale and dry
- trophic changes
pressure injury characteristics (4)
- pulse intact
- painful if sensation intact
- varying depth and appearance
- stage 1-4
What type of wound heals rapidly through regeneration of the epithelial cells?
superficial
Which wound involves dermal layers and is associated with vessel damage?
partail thickness
Which wound involves subcutaneous fat and deeper and takes the longest to heal?
full-thickness
stage 1 pressure wound
Intact, reddened skin that does not lighten when palpated
stage 2 pressure wound
Partial thickness with exposed, viable dermis; no slough (yellow) or eschar (black crusty) – have open wound
stage 3 pressure wound
- full thickness
- slough and eschar present
- tunneling, undermining, epibole - rolled edges
stage 4 pressure wound
- full-thickness w/ exposed muscle, fascia, bone, etc
- tunneling, undermining, epibole - rolled edges
- slough, eschar
unstageable pressure injury
Slough/eschar covers full-thickness wound, unable to detect depth
deep tissue pressure injury
Intact or nonintact skin appearing as non-blanchable red, maroon, or purple in color.
acute vs chronic wounds
acute - known cause and goes through proper recovery stages
chronic - result from underlying condition and does not go through recovery stages
epibole
rolled over edge w/ dry skin
hyperkeratosis
excess of skin
serous, serosanguineous, sanguineous, purulent
serous - clear
serosanguineous - mix of blood
sanguineous - bloody
purulent - pus
What is critical colonization? What is required?
bacteria is replicating and antibiotics are required
sharp debridement
carefully cut off part of wound
Non-selective
autolytic debridement
dressing placed on wound and body natural enzymes used
- moisture accumulates, old tissue swells up and separates from the wound
Selective
enzymatic debridement
add certain enzymes to dressing
Selective
mechanical debridement
dry dressing put on and soaks up wound and then ripped off
Non-selective
What braces limit spinal flexion and are used for a compression fracture on anterior part of the vertebrae?
Jewett and CASH brace
Sterile vs clean technique
sterile - sterile field, equipment, PPE and for high-risk patients
clean - clean gloves, clean field and for non-immunocompromised patients
What is the Braden scale? Scoring?
- asses wound risk
- lower score = more risk (max score 18)
Sever risk < or = 9
High risk 10-12
Moderate risk 13-14
Mild risk 15-18
repositioning schedules for bed and chair
bed - every 2 hours
chair - every 1 hour and weight shifts every 15 min
Braden scale 6 risk factors
- sensory perception
- moisture
- activity level
- mobility level
- nutrition
- friction/shear
What is used to assess protein metabolism or nutritional status of a patient?
nitrogen-balance study
Physical signs of dehydration (6)
- dry skin
- cracked lips
- decreased BP
- increased pulse rate
- constipation
- concentrated urine
Clinical signs of dehydration (5)
- increased lab values
- decreased BP
- increased pulse rate
- constipation
- concentrated urine
Pressure ulcer “Dos and Don’ts”
Do – skin checks, proper nutrition, position changes
Don’t – oily soaps/lotions, wrinkled sheets
Colonization vs Infection
Colonization – group of organisms living together in body prior to tissue invasion not causing infection
Infection – invasion of tissues by microorganisms resulting in systemic reaction
3 signs of infection
- local and systemic symptoms
- contamination and bacterial balance
- clinical abnormalities
surface swab culturing
cleansing wound w/o antiseptic solution
Needle aspiration
needle into tissue to aspirate fluid that contains organisms
Tissue biopsy
removal of tissue w/ scalpel or punch biopsy
benefits of a moist wound bed
- communication amongst cells
- communication w/ growth factors
- construction of collagen
- migration of new epithelium
steps to the healing process of wound
- What type of wounds is this done for?
injury - hemostasis (stopping of bleeding) - inflammation - proliferation - repair and remodeling - scar maturation
Only done for partial or full-thickness wounds
What are the barriers to healing in a chronic wound?
- Longer healing time w/ timelines based on wound site, cause of wound, and age/physical condition of patient
- Inflammatory process persists and wound immune defense is impaired
- Healing process stagnates and may require active wound treatment
What are the four primary types of chronic wounds?
- Pressure ulcers
- Venous ulcers
- Arterial ulcers
- Diabetic ulcers
Which type of chronic wound occurs from prolonged pressure, usually on a bony prominence?
pressure ulcer
Which type of chronic wound has minimal drainage, often occurs on the toes or dorsum of the foot, and is accompanied by a weak or absent pulse?
arterial ulcers
Which type of chronic wound most often occurs on the plantar surface of the foot, results from uncontrolled elevated blood glucose, and is a major cause of amputations?
diabetic ulcers
Which type has heavy drainage, irregular wound borders, and often results in hemosiderin stains around the lower leg/ankle?
venous ulcers
What are the secondary signs of infection? (7)
- Delayed healing
- Changes in color of wound bed
- Friable (easily crumbled) granulation tissue
- Absent or abnormal granulation tissue
- Increase or abnormal order
- Increased drainage
- Increased pain at wound site
active vs passive topical dressings
active - aid in changing biological or chemical environment in wound and may also have characteristics of passive dressings
passive - cover wound, maintain moisture balance, may protect form outside environment insults via physical barrier
Negative Pressure Wound Therapy (NPWT)
- Involves placing a dressing into wound cavity and applying a controlled sub-atmospheric pressure
- Removes chronic edema, leading to increased localized blood flow and applied forces result in enhanced formation of granulation tissue
What type of wound is contraindicated for negative pressure wound therapy?
ischemic wounds
What is the desired wound appearance that indicates the development of granulation tissue?
red and beefy and should increase in size w/ each wound reevaluation
what two colors indicate non-viable tissue?
Black/brown or yellow
How do you measure ABI and what are ranges?
ankle systolic pressure over the brachial systolic pressure
normal: 0.9-1.3
mild: 0.7-0.89
moderate: 0.4-0.69
severe: <0.4
values over 1.3 are non-compressible vessels
What are some hallmarks of superficial infections? (7)
- non-healing
- bright red granulation tissue
- friable and exuberant granulation
- new areas of breakdown and necrosis
- increased exudate
- bridging of soft tissue and the epithelium
- foul odor
What are some hallmarks of deep wound infections? (10)
- pain
- swelling, induration (growing hard/sclerosis)
- erythema (>2 cm)
- wound breakdown
- increased size of satellite areas
- undermining or tunneling
- probing to bone
- flu-like symptoms
- anorexia
- erratic glucose control
What are the most common areas for diabetic ulcers?
- plantar aspect of foot
- over metatarsal heads
- under heel
Which classification system provides percent of risk of foot ulcer and amputation based on medical status?
diabetic foot risk classification
Which classification system assesses ulcer depth along with presence of gangrene and loss of perfusion using six grades (0-5); does not fully address infection and ischemia.
Wagner Ulcer Classification
Which classification system assesses ulcer depth, presence of infection and presence of signs of LE ischemia using a matrix of four grades combined with four stages?
University of Texas Wound Classification System
Which classification system describes presence of infection and ischemia better and may help in predicting the outcome of the diabetic ulcer?
University of Texas Wound Classification System > Wagner Ulcer Classification System
