Chapter 48/Wound Care Flashcards
1
Q
surface abrasions, abrasions confined mostly to the epidermis, usually heal quickly with no scarring
A
epidermal wounds
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
3
Q
both the epidermis and the dermis are destroyed or removed, these wounds heal with a scar
A
full-thickness wounds
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
5
Q
tears in the tissue, differs by the object used to make the tear
A
lacerations
6
Q
compression wounds, damages the skin and underlying tissue
A
contusions
7
Q
wounds in which tissue has been torn out
A
avulsions
8
Q
wounds made by external destructive energy (e.g. heat) or by external chemicals (e.g. acid)
A
burns
9
Q
burns that are superficial and red, do not blister, sloughs off as new epithelium grows underneath
A
first-degree
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
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
12
Q
a wound reopens before it is effectively sealed
A
dehiscence
13
Q
What are the 3 R’s of healing?
A
Reaction
Regrowth
Remodeling
14
Q
What are the 4 phases of healing?
A
Hemostasis
Inflammatory
Proliferative
Maturation/Remodeling
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
16
Q
hardened exudates
A
scab
17
Q
pale yellowish viscous exudate which dries forming a crust, can be stringy
A
slough
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
19
Q
granulation tissue that is ____________ enables epithelial cells to move more quickly
A
moist
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
21
Q
obstruct wound healing
A
infection
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
23
Q
a restriction in blood supply to tissues, causing a shortage of O2 and glucose needed for cellular metabolism
A
ischemia
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
25
What are 4 ways to obtain wound hemostasis?
-direct pressure
-elevation above level of heart
-electrical cautery
chemical cautery (topical silver nitrate)
26
sutures, staples, glues, tapes,
primary wound closure/primary intention healing
27
allows the wound to contract and to re-epithelialize on its own, greatly
secondary wound closure/secondary intention healing
28
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
delayed primary closure/healing by third intention/tertiary wound repair
29
When would secondary wound closure be considered?
- 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
30
non-draining wound cover
occlusive (impermeable) or semi-occlusive (semi-permeable) dressing such as a wound film
31
wound cover for wound draining 1 to 2ml fluid/day
semi-occlusive or absorbent (nonadherent) dressing
32
wound cover for a wound draining .3ml fluid/day
very absorbent dressing
33
What dressings are good for a primary, non-adherent layer?
- petrolatum gauze (vaseline gauze or adaptic)
- medicated petrolatum gauze (Xeroform)
- water=based colloid (Aquaflo or Hydrogel)
34
Absorbent Dressings:Wound fillers
fill to below top of wound, as filler will expand
changed every 1-3 days
use secondary dressing
35
Pastes, beads, gels, powders, granular
wound fillers
36
Absorbent Dressings: Nonocclusive:Alginates
moderate to heavy drainage
| form gel upon contact with fluid
37
Absorbent Dressings:Nonocclusive:Gauze
use many layers
can wick drainage through to secondary dressing
do not cut
38
Absorbent Dressing:Occlusive:moisture retentive foams
```
wick away excess fluid
good for venous ulcers
moderate to heavy drainage
not for eschar or burns
some require covering
e/g/ Optifoam, Polymem
```
39
Absorbent Dressing:Occlusive:Composite dressings
```
minimum to heavy drainage
change as needed, usually 3 x week
require border of intact skin
do not cut
e.g. island dressings
```
40
Absorbent Dressing: Occlusive: Specialty absorptive
absorb most of exudate
multilayered
for heavy drainage
e.g. Combiderm, Aquacell
41
Nonabsorbant dressings:Hydrogels
```
nonadherenent to wound
painful wounds
granulating wounds
dry or slightly moist wounds
radiation burns
some not waterproof
change daily to3x/week
```
42
When are non-absorbent dressing indicated?
- occlusive/primary dressing
- promote moist healing
- promote autolytic debridement
- protect from environment
- most are waterproof
43
Types of hydrogels
sheet, gel, gauze that is impregnated
44
When are absorbent dressings indicated?
- full or partial thickness wounds
- may need secondary dressing
- moderate to heavy drainage
45
Nonabsorbent dressings:transparent thin film
```
allow moisture out
use as blister roof
protect from bacteria
not for fragile skin
not if suspect infection
change 3x/week
```
46
Nonabsorbent dressings:hydrocolloids
```
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
When are anti-microbial dressings indicated?
```
for infected wounds
reduce microbes in wound
absorptive or non-absorptive
use for limited time
primary dressing (some are combination)
```
48
Antimicrobial Dressings:Silver (gels or sheets)
```
may interfere with granulation
may interact with cleaning agents
kills bacteria
check renal lab values
e.g. Silverlon , Silvasorb
```
49
Antimicrobial Dressings:Baceriostatic
e.g. hydrogera blue (good for MRSA and E coli contaminated wounds)
50
When are interactive dressings indicated?
add factors to simulate growth/healing
sheets, gels, liquids
used for stalled wounds
various types for full or partial-wounds
51
Interactive Dressings:Platelet-derived growth factors
```
good for neuropathic lower extremities
need good circulation
cover with moist dressing
change daily
e.g. regranex gel
```
52
Interactive Dressings:Bioengineered skin
acts as scaffolding
| provides nutrient-rich dermal layer
53
Interactive Dressings:Collagen
- 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
Interactive Dressings:Medicinal honey
- from flower of tea tree family
- helps stalled wounds
- clears biofilm
e. g. Medihoney
55
Interactive Dressing:Collagenase
```
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
Interactive Dressing:Activated charcoal dressing
- use as secondary dressing to eliminate odor
- for malodorous wounds due to necrosis, infection, or cancer
- deactivated by contact with moisture, drainage
57
When are contact layer dressings indicated?
```
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
Contact layer dressings:Silicone sheet
non-occlusive
moderate to heavy drainage
e.g. Mepitel
59
Contact layer dressings:Gauze impregnated with light oil emulsion
some bacteriostatic
occlusive, fine mesh (Xeroform, Vaseline, Idoform)
Non-occlusive, open mesh (Adaptic)
60
Secondary dressing
thick, dry sterile gauze held in place by tape and/or rolled gauze
61
an outer layer of dressing that helps hold the wound closure in place and can reduce tension across the healing scar
bandage
62
Tetanus-prone wounds include:
```
wounds contaminated with dirt, saliva, or feces
wounds untreated for >6 hours
puncture wounds (including nonsterile injections)
bullet wounds
burns
frostbite
avulsions
crushes
```
63
passive rabies immunization
injection of anti-rabies immune globulin; effect begins immediately and lasts for a few weeks
64
Wounds at high-risk for infection commonly treated with antibiotics include:
- 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
Rule of nines (adult)
```
head and neck, 9%
upper extremities, 9% each
trunk (front and back), 18% each
lower extremities, 18% each
perineum, 1 %
```
66
Rule of nines (child)
```
head and neck, 18%
upper extremities, 9% each
trunk (front back), 18% each
lower extremities, 13.5% each
perineum, 1%
```
67
Why should a burn be cleansed with cold tap water?
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
Proper time to remove sutures: Face
3-4 days
69
Proper time to remove sutures:Scalp or trunk
7-10 days
70
Proper time to remove sutures:Arms or legs
7-14 days
71
Proper time to remove sutures: Joints
14 days
72
Signs of infection in follow-up wounds
```
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
Why should patients with a healing wound not take aspirin or other NSAIDs in the first 1-2 weeks?
they decrease the strength of the scar and increase the risk of developing a hematoma
74
How long do scars take to mature?
6-9 months
75
What is a hypertrophic scar?
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
What is a keloid?
benign tumor that grows beyond the bounds of the wound and do not regress
77
What are sepsis signs/symptoms?
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
What is a chronic wound?
a wound that fails to heal when expected, usually stalled in the inflammatory (late reaction) phase
79
Problem secondary to broader health disorder, such as diabetes, venous blockage, arterial insufficiency, malnutrition, cigarette smoking, or excess alcohol consumption
chronic wounds
80
biofilm
a slimy layer of bacteria
81
what does a grey or pale wound bed usually mean
lack of vital tissue and circulation
82
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
autolytic debridement
83
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
enzymatic debridement
84
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
biological/biosurgical debridement
85
by far the fastest method of debridement, requires sterile instruments and aseptic technique and should always be preceded by pain control and patient consents
sharp/surgical debridement
86
What are the 3 types of lower extremity ulcers commonly seen are:
arterial ulcers, venous leg ulcers, and diabetic/neuropathic ulcers
87
a decrease in blood flow in the arteries which become blocked or narrowed. Caused by ischemia, O2 and nutrient deprivation and decreased circulation
arterial ulcers
88
where are arterial ulcers usually found?
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
what do arterial ulcers look like?
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
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)
Venous leg ulcers
91
Risk factors for development of venous ulcers
hypertension, obesity, history of DVT, decreased activity, pregnancy, advanced age, and congestive heart failure
92
what do venous leg ulcers present as?
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
what is e-stim used for?
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
what effects are attributed to e-stim?
increased oxygen and nutrient transport to the wound, reduction of edema and pain, and increased fibroblast and collagen development
95
When is e-stim use called for?
pressure ulcers, venous ulcers, surgical wounds, donor sites, and burn wounds
96
When is e-stim contraindicated?
presence of a pacemaker, malignancy, osteomyelitis, when electrodes would be placed near the heart, larynx, and carotid sinus
97
How is ultrasound used in wound healing?
increases the elasticity of collagen, decreases muscle and joint stiffness, decrease pain and muscle spasms, decrease edema, increase O2 transport, accelerate wound healing
98
When is ultrasound (US) used?
chronic wounds, pressure ulcers, venous ulcers, trauma wounds
99
When is ultrasound contraindicated?
infection, osteomyelitis, profuse bleeding, sever arterial insufficiency, or necrotic wounds
100
granulation tissue:
contains newly growing blood vessels
