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Special Topics 1 > Day 2 > Flashcards

Day 2 Flashcards

1
Q

Pressure wound -At risk pts

A 
Elderly 
Immobile
Very sick, hypotension
SCI
CVA
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2
Q

Main causative factor of pressure sores

A

Immobility

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3
Q

Pathology of pressure due to

A

Intensity of pressure
Duration of pressure
Tissue tolerance

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4
Q

Capillary closing pressure

A

12-32 mmHG

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5
Q

Duration of pressure in conductivity w/ intensity

A 
Long/low = damage
Short/high = damage
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6
Q

Tissue tolerance

A

Skin and tissue ability to transmit load

-reduced by shear, friction , moisture, malnutrition, low BP, impaired perfusion, stress, smoking, fever, anemia

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7
Q

Deep tissue pressure injury

A

Persistent non-blanchable deep red, maroon or purple discoloration

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8
Q

Unstageable pressure injury

A

Obscured full thickness skin and tissue loss

Look at slides

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9
Q

Stage 1 pressure injury

A

Non blanchable erythema of intact skin

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10
Q

Stage 2 pressure injury

A

Partial thickness skin loss w/ exposed dermis

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11
Q

Stage 3 pressure injury

A

Full thickness skin loss

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12
Q

Stage 4 pressure injury

A

Full thickness and tissue loss

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13
Q

Wounds that are classified differently than pressure injury

A

Moisture associated w/ skin damage
Medical device related pressure injury
Mucosal membrane pressure injury

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14
Q

Tx cause of pressure injury

A

Help nursing ed and reposition every 2 hours
Keep pt off existing pressure injuries
Increase mobility and independence
Monitor skin closely during tax
Place decides on properly
Help w/ preventative measures and support surface adherence

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15
Q

Aging skin - physiological changes

A 
Decrease in keratinocyte proliferation 
Decrease in keratinocyte renewal rate 
Drop in melanocyte levels 
Decline in Langherhans cell count
Reduced vascularity 
Subcutaneous tissue flattens 
Collagen, elastin, and glycosaminoglycans are
altered, reducing skin strength and flexibility 
Reduced sebaceous gland output
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16
Q

Aging skin results of cellular changes

A

Dry skin (xerosis)
More susceptible to blisters
More susceptible to skin and deep tissue injury
Increased rate of skin cancers
Slow healing of wounds, whether simple or complex
Increased risk for wound infections Pro-inflammatory environment

17
Q

Urinary and fecal incontinence may lead to

A

Dermatitis
Fungal infection
Colliculitis

18
Q

Wound bed prep

A 
DIME
Debridement
Infection/inflammation
Moisture balance
Epithelialization advancement (edge)
19
Q

Debridement removes

A

Non vascular tissue
Bacteria
Cells that impede healing process

Stimulates healthy tissue formation
Faster wound closure

20
Q

Benefits of debridement

A

Reduce risk of infection
Reduce abscess formation risk
Reduce odor
Reduce inflammation

21
Q

Sharp debridement done by

A

Performed by PT,PTA,MD,PA,RN

RNs must be signed off by MD initially

22
Q

Types of debridement

A 
Sharp
Sx
Mechanical
Autolysis
Enzymatic
Biosx
Low frequency US
23
Q

Normal BUN

A

8-25 mg/dL

Elevated = delayed wound healing

24
Q

Glucose normal

A

70-120 mg/dL

25
Q

Hemoglobin norm

A

13-18 men
12-16 women

Decreased = less O2 carried to tissues, slower healing

26
Q

INR norm

A

0.9-1.2

>2 =relative contraindication to debridement

27
Q

Protime norm

A

11-13.5 seconds

Elevated = impaired clotting if bleeding occurs

28
Q

Platelets norm

A

130-400

Decreased impaired clotting if bleeding occurs

29
Q

Lab values for debridement

A

Hemoglobin <12
IRN >2
Platelets <130

30
Q

Sharp debridement precuations

A 
Low RBC, Hct, Hgb
Marginal platelet levels
Poor med status/prognosis
On Coumadin w/ marginal INR
Near deep structures
Hands, genital areas
31
Q

Sharp debridement contras

A 
Stable eschar
Poor med status/poor prognosis
Patient on IV heparin
Low platelet count
IRN above 2.0
Gangrene of toes or fingers
32
Q

Mechanical debridement

A

Non-discriminatory physical force to remove necrotic tissue
Gauze, whirlpool, pulsatilla lovage
May slow wound healing process

33
Q

Autolytic debridement

A

Promotes phagocytic activity and formation of granulation tissue
Achieved by a moist wound enviro, use of impermeable, semipermeable, or most dressings

34
Q

Enzymatic debridement

A

Active enzyme therapy that continuously removes necrotic tissue form wound
Collagenase selectively target collagen strands that hold cellular debris to wound bed
Collagenase saintly
May be used in conjunction w/ sharp debridement

35
Q

Biosx debridement

A 
Rapid but selective
Reduces bacterial burden
Possible control of MRSA
Stimulates granulation tissue formation
No reported toxicity

Special Topics 1 (12 decks)

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