Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Fundamentals > Chapter 48/Wound Care > Flashcards

Chapter 48/Wound Care Flashcards

1
Q

surface abrasions, abrasions confined mostly to the epidermis, usually heal quickly with no scarring

A

epidermal wounds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

deep abrasions, wounds that destroy or remove the epidermis and possibly part of the upper portion of the dermis, new epidermis is created, usually heal without scarring

A

partial-thickness wounds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

both the epidermis and the dermis are destroyed or removed, these wounds heal with a scar

A

full-thickness wounds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

scrapes that remove epidermis; serious incidences can also remove the dermis and sometimes sub-cue tissue, Usually broad, shallow wound with irregular edges

A

Abrasions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

tears in the tissue, differs by the object used to make the tear

A

lacerations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

compression wounds, damages the skin and underlying tissue

A

contusions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

wounds in which tissue has been torn out

A

avulsions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

wounds made by external destructive energy (e.g. heat) or by external chemicals (e.g. acid)

A

burns

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

burns that are superficial and red, do not blister, sloughs off as new epithelium grows underneath

A

first-degree

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

partial-thickness burns that include damage to the dermis and produce blisters, tissue under blisters is moist and pink and extremely sensitive; Superficial:heals within 2-3 weeks, minor scarring Deeper: heals in 3 to 6 weeks leaves significant scars

A

second-degree

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

full-thickness burns that go deeper than the dermis and produce dry, dead tissue, look grey, white, brownish, painless, no blisters

A

third-degree

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

a wound reopens before it is effectively sealed

A

dehiscence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are the 3 R’s of healing?

A

Reaction
Regrowth
Remodeling

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are the 4 phases of healing?

A

Hemostasis
Inflammatory
Proliferative
Maturation/Remodeling

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What happens in the reaction phase?

A
  • blood clots seal the wound, creating hemostasis

- the normal inflammatory reaction begins to remove bits of dirt and debris

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

hardened exudates

A

scab

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

pale yellowish viscous exudate which dries forming a crust, can be stringy

A

slough

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

phase in which new cells grow into the wound and begin to lay down the collagen and other exracellular fibers that will give newly forming cells, blood vessels, and loose extracellular matrix (granulation tissue)

A

regrowth/proliferative phase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

granulation tissue that is ____________ enables epithelial cells to move more quickly

A

moist

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

when the wound area is not too large, epithelial cells repopulate the entire surface and generate a new epidermal covering

A

re-epithelialization

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

obstruct wound healing

A

infection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What are the signs of infection?

A

fever; pus; abscess; abnormal smell; cellulitis; persistent inflammation with an exudate; warmth and redness; delayed healing; continued or increasing pain; edema; weak, crumbly granulation tissue that bleeds easily

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

a restriction in blood supply to tissues, causing a shortage of O2 and glucose needed for cellular metabolism

A

ischemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

what does a wound history include?

A

cause of the wound, description of the environment in which it occurred, chronic illnesses, medical conditions, current medicines, and allergies, immunization history for tetanus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What are 4 ways to obtain wound hemostasis?

A

-direct pressure
-elevation above level of heart
-electrical cautery
chemical cautery (topical silver nitrate)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

sutures, staples, glues, tapes,

A

primary wound closure/primary intention healing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

allows the wound to contract and to re-epithelialize on its own, greatly

A

secondary wound closure/secondary intention healing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

lets the wound remain open initially and later closes it with sutures or staples, used for highly contaminated wounds that may need repeated debridement or may need to be treated with antibiotics before being closed

A

delayed primary closure/healing by third intention/tertiary wound repair

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

When would secondary wound closure be considered?

A
  • already infected
  • very dirty
  • made by animal or human bites
  • many hours old at the time of treatment
  • made by crushes, explosions, or other forces causing extensive tissue damage
  • on the bottom of a foot, especially wounds made when stepping in organic matter
  • chronic wounds such as diabetic foot ulcers, arterial ulcers, venous stasis ulcers
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

non-draining wound cover

A

occlusive (impermeable) or semi-occlusive (semi-permeable) dressing such as a wound film

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

wound cover for wound draining 1 to 2ml fluid/day

A

semi-occlusive or absorbent (nonadherent) dressing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

wound cover for a wound draining .3ml fluid/day

A

very absorbent dressing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

What dressings are good for a primary, non-adherent layer?

A
  • petrolatum gauze (vaseline gauze or adaptic)
  • medicated petrolatum gauze (Xeroform)
  • water=based colloid (Aquaflo or Hydrogel)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Absorbent Dressings:Wound fillers

A

fill to below top of wound, as filler will expand
changed every 1-3 days
use secondary dressing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Pastes, beads, gels, powders, granular

A

wound fillers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Absorbent Dressings: Nonocclusive:Alginates

A

moderate to heavy drainage

form gel upon contact with fluid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Absorbent Dressings:Nonocclusive:Gauze

A

use many layers
can wick drainage through to secondary dressing
do not cut

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Absorbent Dressing:Occlusive:moisture retentive foams

A 
wick away excess fluid
good for venous ulcers
moderate to heavy drainage
not for eschar or burns
some require covering
e/g/ Optifoam, Polymem
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Absorbent Dressing:Occlusive:Composite dressings

A 
minimum to heavy drainage
change as needed, usually 3 x week
require border of intact skin
do not cut
e.g. island dressings
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Absorbent Dressing: Occlusive: Specialty absorptive

A

absorb most of exudate
multilayered
for heavy drainage
e.g. Combiderm, Aquacell

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Nonabsorbant dressings:Hydrogels

A 
nonadherenent to wound
painful wounds
granulating wounds
dry or slightly moist wounds
radiation burns
some not waterproof
change daily to3x/week
42
Q

When are non-absorbent dressing indicated?

A
  • occlusive/primary dressing
  • promote moist healing
  • promote autolytic debridement
  • protect from environment
  • most are waterproof
43
Q

Types of hydrogels

A

sheet, gel, gauze that is impregnated

44
Q

When are absorbent dressings indicated?

A
  • full or partial thickness wounds
  • may need secondary dressing
  • moderate to heavy drainage
45
Q

Nonabsorbent dressings:transparent thin film

A 
allow moisture out
use as blister roof
protect from bacteria
not for fragile skin
not if suspect infection
change 3x/week
46
Q

Nonabsorbent dressings:hydrocolloids

A 
various shapes, sizes
can be cut
some with odor control
for non-infected wounds
ideal for incontinent patients
not for fragile skin
not for heavy drainage
not for diabetic foot use
47
Q

When are anti-microbial dressings indicated?

A 
for infected wounds
reduce microbes in wound
absorptive or non-absorptive
use for limited time
primary dressing (some are combination)
48
Q

Antimicrobial Dressings:Silver (gels or sheets)

A 
may interfere with granulation
may interact with cleaning agents
kills bacteria
check renal lab values
e.g. Silverlon , Silvasorb
49
Q

Antimicrobial Dressings:Baceriostatic

A

e.g. hydrogera blue (good for MRSA and E coli contaminated wounds)

50
Q

When are interactive dressings indicated?

A

add factors to simulate growth/healing
sheets, gels, liquids
used for stalled wounds
various types for full or partial-wounds

51
Q

Interactive Dressings:Platelet-derived growth factors

A 
good for neuropathic lower extremities
need good circulation
cover with moist dressing
change daily
e.g. regranex gel
52
Q

Interactive Dressings:Bioengineered skin

A

acts as scaffolding

provides nutrient-rich dermal layer

53
Q

Interactive Dressings:Collagen

A
  • organize new fibers
  • build tissue fast
  • for skin grafts, donor sites, necrotic or granulating wounds, tunneling wounds
  • not for 3rd-degree burns, blackened wounds
  • do not use if sensitive to bovine products
  • require secondary dressing
  • change daily or varies
54
Q

Interactive Dressings:Medicinal honey

A
  • from flower of tea tree family
  • helps stalled wounds
  • clears biofilm
    e. g. Medihoney
55
Q

Interactive Dressing:Collagenase

A 
digest collagen in dead tissue
debrides enzymatically
chronic ulcers or burns
treat infection first
affected by silver and certain detergents
apply daily
e.g. Santyl
56
Q

Interactive Dressing:Activated charcoal dressing

A
  • use as secondary dressing to eliminate odor
  • for malodorous wounds due to necrosis, infection, or cancer
  • deactivated by contact with moisture, drainage
57
Q

When are contact layer dressings indicated?

A 
wound liner, nonadherent
prevent secondary dressing from adhering
protect fragile tissue
thermal insulation
partial to full thickness wounds
aid moist wound healing
decrease pain at dressing change
some for fistulas, stomas
some for burns
donor sites; split thickness grafts
over newly closed incision
occlusive type: for scant to moderate drainage
nonocclusive type for moderate to heavy damage
58
Q

Contact layer dressings:Silicone sheet

A

non-occlusive
moderate to heavy drainage
e.g. Mepitel

59
Q

Contact layer dressings:Gauze impregnated with light oil emulsion

A

some bacteriostatic
occlusive, fine mesh (Xeroform, Vaseline, Idoform)
Non-occlusive, open mesh (Adaptic)

60
Q

Secondary dressing

A

thick, dry sterile gauze held in place by tape and/or rolled gauze

61
Q

an outer layer of dressing that helps hold the wound closure in place and can reduce tension across the healing scar

A

bandage

62
Q

Tetanus-prone wounds include:

A 
wounds contaminated with dirt, saliva, or feces
wounds untreated for >6 hours
puncture wounds (including nonsterile injections)
bullet wounds
burns
frostbite
avulsions
crushes
63
Q

passive rabies immunization

A

injection of anti-rabies immune globulin; effect begins immediately and lasts for a few weeks

64
Q

Wounds at high-risk for infection commonly treated with antibiotics include:

A
  • bite wounds
  • overwhelmingly contaminated wounds
  • sutured intraoral lacerations
  • orocutaneous wounds (mouth wounds that open out into the skin)
  • crush wounds
  • wounds involving tendons, bones, or joints
  • delayed-treatment wounds
  • wounds in people at risk for developing infections
65
Q

Rule of nines (adult)

A 
head and neck, 9%
upper extremities, 9% each
trunk (front and back), 18% each
lower extremities, 18% each
perineum, 1 %
66
Q

Rule of nines (child)

A 
head and neck, 18%
upper extremities, 9% each
trunk (front back), 18% each
lower extremities, 13.5% each
perineum, 1%
67
Q

Why should a burn be cleansed with cold tap water?

A

it will lower the temperature in the burned area, irrigate the injury, reduce the pain, minimize edema, and slow some of the developing damage

68
Q

Proper time to remove sutures: Face

A

3-4 days

69
Q

Proper time to remove sutures:Scalp or trunk

A

7-10 days

70
Q

Proper time to remove sutures:Arms or legs

A

7-14 days

71
Q

Proper time to remove sutures: Joints

A

14 days

72
Q

Signs of infection in follow-up wounds

A 
pus, yellow, greenish or thick white in wound
increased redness in wound
redness radiating out into skin around wound
red lines progressing up an extremity
increasing pain or tenderness
swelling
wound getting warmer than normal skin
fever
73
Q

Why should patients with a healing wound not take aspirin or other NSAIDs in the first 1-2 weeks?

A

they decrease the strength of the scar and increase the risk of developing a hematoma

74
Q

How long do scars take to mature?

A

6-9 months

75
Q

What is a hypertrophic scar?

A

scar which are thick but do not grow outside the edges of the wound, form in wounds that are under tension, scars that form too much collagen

76
Q

What is a keloid?

A

benign tumor that grows beyond the bounds of the wound and do not regress

77
Q

What are sepsis signs/symptoms?

A

fever or hypothermia, tachycardia, decreased blood flow to internal organs. If untreated may lead to shock, altered mental status, organ failure, jaundice, and death.

78
Q

What is a chronic wound?

A

a wound that fails to heal when expected, usually stalled in the inflammatory (late reaction) phase

79
Q

Problem secondary to broader health disorder, such as diabetes, venous blockage, arterial insufficiency, malnutrition, cigarette smoking, or excess alcohol consumption

A

chronic wounds

80
Q

biofilm

A

a slimy layer of bacteria

81
Q

what does a grey or pale wound bed usually mean

A

lack of vital tissue and circulation

82
Q

highly selective but slow form of debridement, involves the body’s own macrophages and enzymes to selectively reduce eschar and necrotic tissue from healthy tissue, uses dressing which retain moisture, safest form of debridement, contraindicated in patients with compromised immunity or if large amounts of necrosis are present, or if a large pressure ulcer with undermining

A

autolytic debridement

83
Q

debridement using a collagenase enzyme applied to necrotic tissue areas, only to be used when there is no urgent clinical need for removal of necrotic tissue

A

enzymatic debridement

84
Q

debridement uses sterile maggots applied to the wound bed, these larva produce a mixture of enzymes and broad spectrum antimicrobials, faster than autolytic or applied enzyme debridement and is selective, usually 1-3 days but up to 4-5 days

A

biological/biosurgical debridement

85
Q

by far the fastest method of debridement, requires sterile instruments and aseptic technique and should always be preceded by pain control and patient consents

A

sharp/surgical debridement

86
Q

What are the 3 types of lower extremity ulcers commonly seen are:

A

arterial ulcers, venous leg ulcers, and diabetic/neuropathic ulcers

87
Q

a decrease in blood flow in the arteries which become blocked or narrowed. Caused by ischemia, O2 and nutrient deprivation and decreased circulation

A

arterial ulcers

88
Q

where are arterial ulcers usually found?

A

on tips of toes, between the toes, over the phalangeal heads just proximal to the toes, at sites subjected to pressure or rubbing shoes, and around the outer (lateral) malleolus

89
Q

what do arterial ulcers look like?

A

punched out with even margins, wound bed is pale and deep, tissue around the wound is blanched or purpuric, minimal exudates, loss of hair decreased temperature and diminished/absent pedal pulses

90
Q

pooling of the blood in the veins, blood leaks backwards in the veins, stagnating in the lower extremities, buildup of fluids creates hemosiderin staining (darkened brownish coloration in the lower leg)

A

Venous leg ulcers

91
Q

Risk factors for development of venous ulcers

A

hypertension, obesity, history of DVT, decreased activity, pregnancy, advanced age, and congestive heart failure

92
Q

what do venous leg ulcers present as?

A

wound margins are irregular, wounds are superficial, with fine slough. Exudate is frequently moderate to heavy. Wound bed is ruddy with granular texture. Usually occur on medial (inner) leg, ankle, medial malleolar area, moderate to little pain,

93
Q

what is e-stim used for?

A

used in stalled or dry wounds to mimic the body’s bioelectrical system “current of in jury”, to jump=start or speed up the wound healing

94
Q

what effects are attributed to e-stim?

A

increased oxygen and nutrient transport to the wound, reduction of edema and pain, and increased fibroblast and collagen development

95
Q

When is e-stim use called for?

A

pressure ulcers, venous ulcers, surgical wounds, donor sites, and burn wounds

96
Q

When is e-stim contraindicated?

A

presence of a pacemaker, malignancy, osteomyelitis, when electrodes would be placed near the heart, larynx, and carotid sinus

97
Q

How is ultrasound used in wound healing?

A

increases the elasticity of collagen, decreases muscle and joint stiffness, decrease pain and muscle spasms, decrease edema, increase O2 transport, accelerate wound healing

98
Q

When is ultrasound (US) used?

A

chronic wounds, pressure ulcers, venous ulcers, trauma wounds

99
Q

When is ultrasound contraindicated?

A

infection, osteomyelitis, profuse bleeding, sever arterial insufficiency, or necrotic wounds

100
Q

granulation tissue:

A

contains newly growing blood vessels

Fundamentals (11 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions