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Medcon Rehab IV > Common Wounds > Flashcards

Common Wounds Flashcards

1
Q

Arterial Wounds USUALLY due to _________

A

Peripheral Artery Disease

PAD

*VERY PAINFUL!!!

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2
Q

Type of wound:

Arterial (usually due to PAD)

A
  • can be ANY arteries
  • initial buildup of sclerotic (scarred) tissue
  • *REMEMBER*
    • ​Blood NOT getting to peripheral system
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3
Q

Arterial Wounds

Describe the Pain

and what is it WORSE w/?

A
  • SEVERE
  • Worse w/ Amb.
    • ​bc blood wont make it to periph. aa’s
  • Worse w/ Leg Elevation
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4
Q

Arterial Wounds

Describe the Location

A
  • LE
    • ​FURTHEST from the heart
      • ​bc blood has to travel far & cannot make it
  • Toes, LATERAL malleolus, or ANT. leg
    • ​LESS likely Medial (venous wounds)
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5
Q

Arterial Wounds

Presentation— in general…

A

Small, shallow

Round, regular

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6
Q

Arterial Wounds

Presentation

Granulation tissue vs. Necrotic tissue

A
  • Granulation tissue
    • usually Pale
  • Necrotic tissue
    • black eschar
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7
Q

Arterial wounds can dev. ___________ w/ advanced disease

A

Gangrene

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8
Q

Exudate w/ Arterial wounds?

A

Minimal—>NO exudate

*bc not enough blood there!

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9
Q

What will those w/ PAD and Arterial wounds most likely describe the pain as?

A

“Ants in pants” feeling

Throbbing ALL the time

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10
Q

Arterial wounds

Describe the Periwound (around)

A
  • DECd perfusion
  • Epidermis thin, shiny, dry
  • Loss of hair
  • thick/brittle nails
  • MM atrophy***
  • Pale, dusky, cyanotic
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11
Q

Arterial Wounds

Pulses?

A

Absent, thready, weak Dorsalis Pedis AND Post. Tib

*the DISTAL pulses!!!

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12
Q

Arterial wounds

Temperature

*this is CLASSIC SIGN*

A

COOLER ****

*NOTE: use back of hand

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13
Q

GOLD STANDARD MEASUREMENT FOR PAD

A

ABI

(Ankle systolic pressure)/(brachial systolic pressure)

*blood/beat making it to ankle

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14
Q

Arterial Wounds

Other examinations?

A
  • ABI==GOLD STANDARD
  • Cap. refill
  • Rubor of Dependency
  • Look @ leg:
    • ​hairless, dry, atrophy, cool, pale, thin
  • Chart review*
    • CAD, PAD, renal artherosclerosis
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15
Q

Arterial Wounds

Some Ex’s and WHY

A

see below

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16
Q

PT Tx for Arterial wounds:

A

Debridement

BUT complex decision tree to go thru

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17
Q

Venous wounds usually due to:

A

Chronic Venous Stasis/Disease/Insuff.

CVD

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18
Q

RISK FACTORS for Venous Wounds

A

see below

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19
Q

Venous Wounds

Describe the Pain

A

Dull, aching

ANNOYING

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20
Q

VENOUS WOUNDS

Pain gets WORSE w/

A

WORSE in dependent pos.

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21
Q

Venous wounds

Pain BETTER/IMPROVES w/?

A

IMPROVES w/ elevation (bc better venous return)

IMPROVES w/ compression (GOLD STANDARD)

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22
Q

VENOUS WOUNDS

Position? Usually?

A

Medial aspect LOWER leg

BUT can be anywhere on LOWER leg

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23
Q

Venous wounds

Presentation

starts as?

shape?

A
  • STARTS as superficial and MAY progress to full thick.
  • Irregular shape
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24
Q

Venous wounds

Drainage?

A

Mod–> Copious drainage

“Weeping Wounds”

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25
Q

Weeping Wounds think….

A

Venous Wounds!!!!

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26
Q

Venous wounds

Granulation tissue vs. Necrotic tissue

A
  • Granulation tissue
    • ​Beefy Red
  • Necrotic tissue
    • ​loose wet slough
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27
Q

Progression of Venous Wounds

tissue wise

A
  • can PROGRESS to subcutaneous tissue BUT DOES NOT extend to tendon or bone******
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28
Q

Venous Wounds

Describe the Periwound

A
  • Ill-defined wound borders
  • Indurated (hard/firm) periwound
  • Edema**
  • Wet**
  • Hemosiderin staining
    • ​HgB+RBCs stain skin
  • Fibrotic thick skin**
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29
Q

Venous Wounds

If you are considering using Compression Therapy

What MUST you do?

A
  • NEED:
    • ABI results to ensure adequate perfusion**
      • ​MILD PAD==precaution
      • SEVERE PAD==contraindication
    • Pregnancy status
      • ​Pregnancy== precaution
        • bc blood vol INCs==venous pooling
    • CHF
      • ​Controlled Stage I== precaution
      • Uncontrolled Stage II, III, IV==contraindication
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30
Q

Venous Wounds

Some Ex’s and WHY

A

see below

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31
Q

Diabetic Wounds

Usually from…

A

Type I or Type II DM

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32
Q

Diabetic Wounds

RISK FACTORS

A

SEE BELOW

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33
Q

Diabetic Wounds

Describe the Pain

A
  • Painful OR
  • NOT painful due to loss or diminished pain sensation
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34
Q

Diabetic Wounds

Certain deformities develop from Motor Polyneuropathy from Diabetes:

A
  • Pes Planus
  • Claw toes
  • Hammer toes
  • PF foot
  • Hallux Valgus
  • Charcot Foot
  • Intrinis mm wasting of feet
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35
Q

Diabetic Wounds

Position of the wounds?

A

SAME AREAS WHERE ARTERIAL ULCERS ARE:

  • Toes
  • LATERAL malleolus
  • ANT leg
36
Q

Diabetic Wounds

Areas of Altered Pressure Points

Where???

A
  • On Plantar aspect of foot, toes, heels
    • _​_Motor Neuropathy
37
Q

Diabetic Wounds

Explain the Presentation:

A
  • Round
  • Frequently Deep
    • ​bc progress FAST!!!
  • MIN. drainage
  • HIGH infection rate
    • ​THIS IS UNIQUE TO DIABETIC WOUNDS
      • ​bc sugar irritation
38
Q

Diabetic Wounds

Peri-wound

A
  • DRY (sometimes Very dry)
  • Elevated rim of wound**
39
Q

Diabetic wounds

Pulses?

A

DIMINISHED

40
Q

Diabetic Wounds

Temp.

A
  • Neuropathic foot is warm and dry
    • ​bc Autogenic Neuropathy
      • ​==> autoreg. of temp affected
41
Q

Diabetic Wounds

Other Examinations???

A

SENSATION TESTING!!!

  • Lt. touch
  • Protective sensation
    • microfilament testing
  • Sharp touch
  • Proprio testing
  • 2-pt discrim.
  • Temp
  • Vibration

Assess for foot deformities== Motor Testing

42
Q

Diabetic Wounds

Some Ex’s and other cond‘s that follow (foot deformities)

A

see below

43
Q

PT Tx: Compression Therapy for Venous Wounds

A

What to DO:

44
Q

Pressure Ulcers

Usually due to:

A
  • Diminished sensation OR inability to vocalize pain (delirium)
  • INCd moisture OR incontinence
  • Immobility**BIG ONE!
  • Inad. nutrition OR inability to absorb nutrition
  • Friction/shear forces**
45
Q

Stage 1 Pressure Ulcer

Describe Stage 1

A
  • Intact skin w/ localized area erythema
  • Area=non-blanchable
  • DECd sensation
  • INCd firmness
  • Temp changes: warm or cool
46
Q

Stage 1 Pressure Ulcers are NOT:

A

NOT Open

NOT scar tissue

NOT erythema purple or maroon discoloration

47
Q

What is the MOST IMPORTANT THING we want to remember w/ Stage 2 Pressure Ulcers?

A

*THIS IS WHEN WE WANT TO CATCH THEM!!

*Tissue is physiologically reversible over time IF caught @ this stage!!!*

48
Q

Stage 2 Pressure Ulcers

Describe this stage:

A
  • wound bed is viable
  • Pink OR red tissue
  • Moist
  • Blister
  • NO granulation tissue
  • NO necrotic tissue
49
Q

Stage 3 Pressure Injury

What is going on in this stage?

A
  • Full thickness loss of skin in which adipose (fat) is visible
    • ​Granulation tissue
    • Necrotic tissue MAY be present
    • undermining, sinus track, tunneling MAY occur
    • ***NO fascia, mm, tendon, lig, cartilage and/or bone exposed***
50
Q

Stage 3 Pressure Ulcer

Epibole often present

what is this ?

A

Epibole (rolled wound edges) often present

51
Q

Stage 3 pressure ulcer

Healing capacity?

A

Wound will go thru stages of healing (if tx’d) and form scar tissue

52
Q

Stage 3 Pressure injury

What makes it an “Unstageable Pressure Injury”

A
  • If slough or eschar obscures (makes it so you cannot tell) the extent of tissue loss == Unstageable
53
Q

Stage 4 Pressure Injury

What is going on in this Stage?

A
  • Full thick. loss of skin now WITH exposed fascia, mm, tendon, lig, cart., bone
    • ​SO undermining, sinus track, tunneling MAY occur
    • Necrotic tissue (slough and/or eschar) MAY be present
54
Q

Stage 4 Pressure Injury

Epibole?

A

Epibole (rolled wound edges) often present

55
Q

Stage 4 Pressure Injury

Healing?

A

Wound will go thru stages of healing (if tx’d) and form scar tissue

56
Q

Stage 4 pressure injury

What makes this an “Unstageable Pressure Injury?”

A

IF slough or eschar obscures extent of tissue loss== Unstageable

57
Q

A wound can NEVER heal if what is present?

A

W/ Eschar present

58
Q

Unstageable Full Thick. Pressure Injury

2 components that make it Unstageable

A
  1. Obscured full thick. skin and tissue loss
  2. Extent of tissue damage w/in ulcer cannot be confirmed
59
Q

Unstageable Full Thick Pressure Injury

Black eschar obscures the full thick of skin and tissue loss

What is the role of eschar?

A
  • Eschar is body’s natural cover of phys. and immune protection
    • ​a wound can NEVER heal w/ eschar present
  • Removing stable eschar in the poorly perfused area results in an open wound prone to infection
60
Q

Deep Tissue Pressure Injury (DTI) OR

A

Prolooonged deep bruise

61
Q

Deep Tissue Pressure Injury

DTI

what is this?

A
  • Persistent non-blanchable deep red, maroon or purple discoloration OR epidermal separation revealing a dark wound bed OR blood filled blister
62
Q

Deep Tissue Pressure Injury (DTI)

Pain and temp?

A

Pain and temp change often preced skin color changes

63
Q

Deep Tissue Pressure Injury (DTI)

What does this result from?

A
  • Results from intense and/or prolonged pressure and shear forces @ bone-muscle interface
64
Q

PT’s role in Pressure Ulcers

A

PT’s prevent pressure ulcers!!!!

65
Q

Physical Tx for Pressure Ulcers

We want to Off-Load 3 things:

A
  1. Offload– change pts pos’ing q2h
  2. Offload– improve surf. selection
    1. ​bed, shoes, bandage
  3. Offload– improve wt. distribution during Function
    1. ​shoes (CAM shoes)
66
Q

Physical Tx for Pressure Ulcers

We want to DECREASE what?

A

DECREASE Moisture

  • speak w/ nurse about catheter/fecal tube
  • obtain commode
  • PT INTERVENTION: commode transfers
67
Q

Physical Tx for Pressure Ulcers:

Encourage pt to_________

A

Encourage pt to assist in mobility to prevent shear forces

68
Q

Physical Tx for Pressure Ulcers

Interdisciplinary Care?

A
  • Optimize nutrition w/ nutritionist
  • INC arousal via reviewing meds w/ pharmacist
  • Encourage nursing assist. or family to assist w/ meal prep AND motivation to eat PRO-based foods**
    • ​NEED PRO FOR WOUND TO HEAL!!!
  • Optimize IND @ meals w/ OT**
69
Q

Burns

usually result from…

A

Trauma!!!

70
Q

SUPERFICIAL burn

Involves:

A

ONLY Epidermis

71
Q

SUPERFICIAL Partial Thick. Burn

Involves….

A

Epidermis AND some of the Papillary dermis

72
Q

DEEP PARTIAL Thick Burn

Involves….

A

damages tissue that extends INTO Reticular layers AND MAY INCLUDE Fat domes of Subcutaneous layer

**NOTE how it says MAY include subcutaneous**

73
Q

FULL Thick. Burn

Involves…..

A

ENTIRE thickness of skin down to AND including Subcutaneous tissue

*NOTE how it says and includes Subcutaneous tissue**

74
Q

________type of wound can get infected, BUT ______________ MOST susceptible to infections

A

ANY type of wound can get infected, BUT Diabetic wounds are MOST susceptible to infections!!!

bc sugar irritation**

75
Q

wounds+infection

A

ANY wound can become infected!!!

Diabetic wounds most susceptible to infections!!!

76
Q

Local evidence of infection:

A
  • ODOR*** (ALWAYS)
  • Streaking
  • Redness
  • Erythema
  • Induration (firm)
  • Cellulitis== skin infection
  • INCd pain
  • INCd drainage/purulence
    • ​REALLY opaque
    • white, yellow, gree, THICC drainage
77
Q

LOCAL infection pot. difficult to tell in pts w/ _________

A

Darker skin pigmentation

BUT odor always there**

78
Q

How can we confirm a local infection?

A

Wound culture/biopsy for organisms

EX. Bronchoscopy –> suction out stuff from base of lungs & observe

79
Q

If the infection moves….HOW is it usually moving?

A

Wounds are a direct route to the bloodstream

80
Q

IF infection moves to Bone ====

A

Osteomyelitis

81
Q

IF infection moves to Blood ===

A

Bacteremia

82
Q

IF infection moves to Heart ===

A

Endocarditis

*infection of Inner valves

83
Q

Systemic infection ===

A

SEPSIS

*infection ALL OVER BODY**

84
Q

Systemic evidence of infection

*confirms SEPSIS —–>

A
  • ELEVATED WBC
  • ELEVATED HR
    • ​== Tachycardia
  • ELEVATED body temp
    • ​== Fibrile
  • >22 breaths per min.
    • == Tachypnea
  • SBP <100
  • Altered Mental Status (AMS)
85
Q
A

Medcon Rehab IV (18 decks)

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