e+i Flashcards
how long must a wound be present before medicare will reimburse it as “chronic”?
30 days
what are 4 common barriers to wound healing?
inadequate microcirculation
prolonged pressure from interstitial edema
bacterial infection
absence of adequate electrical potential
presence of bacteria is called what?
bioburden
bioburden, perfusion defects, nonviable tissue, moisture, nutrients, and oxygen are considered what kind of factors in wound healing?
local/intrinsic
factors that affect whole body, cormorbid disease, nutritional status, age, obesity are considered what kind of factors in wound healing?
systemic/intrinsic
what four types of products maintain moisture in a wound?
films
hydrocolloids
hydrogel sheets
amorphous gels
what type of product helps add moisture to a wound?
biocellulose
what four types of products absorb moisture?
foams
collagen
alginates
superabsorbents
what types of products help manage fluid in wound healing?
hydropolymers
what does a retention product do in wound healing? examples?
holds dressing in place
film dressings, tapes, stretch gauze
what type of products are made to come in contact with the wound?
impregnated gauzes
perforated plastics
silicone coated meshes
what type of dressing touches the wound surface?
primary dressing
what type of dressing attaches a primary dressing to the patient?
secondary dressing
what type of dressing is constructed with something absorbent in the middle of something adhesive?
island dressing
what are 5 wound needs? as in what in common does all wound healing have?
optimal ph (slightly acidic), control of bacteria, freedom from necrotic tissue, thermal insulation, adequate hydration
frequent repositioning of the patient is required for what type of wound? how often?
pressure ulcer
every 2 hours
diabetic ulcers require what types of treatment?
offloading of pressure
good glucose control
test w hemoglobin, A1c
arterial ulcers require what type of treatment?
establishment of adequate circulation through movement and exercise
how are venous ulcers treated? is this reversible?
use of a compression system
no
what is stage 1 biofilm?
free-floating and solitary (planktonic) microorganisms
reversible
what is stage 2 biofilm?
bacteria multiple and become sessile
what is stage 3 bioflim?
bacteria secrete extracellular polymeric substance (eps) (slime)
components shed and attach to other parts of the wound bed or other wounds
develops within 6-12 hours and in 2-4 days =mature biofilm
what are 5 types of medication that impede healing?
nicotine
anti-neoplastics
anti-coagulants
corticosteroids
what constitutes a stage 1 pressure injury?
intact skin
area of non-blanchable erythema
what constitutes a stage 2 pressure injury?
partial thickness loss of skin w exposed dermis
wound bed: viable, pink, red, moist
may be intact or ruptured serum-filled blister
what constitutes a stage 3 pressure injury?
full thickness loss of skin
adipose is visible in ulcer
granulation tissue and epibole are present
what constitutes a stage 4 pressure injury?
full thickness loss of skin
exposed fascia, muscle, tendon, ligament, cartilage or bone
what constitutes an unstageable pressure injury?
full thickness but cannot be assess due to obstruction by slough or eschar
what constitutes a deep tissue injury?
intact or non-intact skin w localized area of non-blanchable deep red, maroon, purple discoloration or epidermal separation
muscle pump failure, pericapillary fibrin deposits, which result in thrombosis, obstruction, dilation, and hemorrhage are from what kind of ulcer?
venous insufficient ulcer
what are some characteristics of a venous insufficient ulcer?
pain relieved w elevation
irregular edge
medial side of ankle
hemosiderin staining: orange/brown, 6-8 mmm above medial malleolus
where are lymphatic ulcers found?
arms
legs
most common: ankle
how does one describe lymphatic ulcers?
firm, fibrotic surrounding skin
small ulcers that ooze or are blistered
usually bilateral
what is different about dressing arterial wounds than other types?
DRY dressings
What types of wounds have an inadequate blood supply, low ankle/brachial index of less .5 not likely to heal, 20/10 pain, pain decreases w dependent position, has eschar/necrosis?
arterial insufficient ulcer
where are arterial insufficiency ulcers found?
toes, fingers, interdigital spaces
what type of ulcers are generally found on the lateral side of the calf?
vasculitic ulcer
how can you identify a surgical wound?
straight wound margins
what are three characteristics of traumatic wounds?
generally irregular wound margins
visible inflammatory response margin
indurated wound margin
what is a plantar ulcer, a deep neutrotrophic ulcer of the sole of the foot, resulting from repeated injury because of lack of sensation or bony deformity seen with diseases, such as…?
diabetic foot ulcer
6 factors associated with diabetic foot ulcer?
peripheral neuropathy pressure friction and shear peripheral vascular disease limited joint mobility (foot deformities, decreased ROM in heel cord, decreased heel strike) loss of protective sensation
what is a way to describe the appearance of a dfu?
round punched out lesion w elevated rim
are dfu’s painful?
no, not until bone is infected
what is a 0 on the wagner scale? what is the wagner scale for?
pre-ulcerative lesion, healed ulcers, presence of bony deformity
what is a 1 on the wagner scale measuring?
superficial ulcer w/o subcutaneous tissue involvement
what is a 2 on the wagner scale measuring?
penetration through subcutaneous tissue, may expose bone, tendon, ligament or joint capsule
what is a stage 3 on the wagner scale measuring?
osteitis
abscess
osteomyselitis
what is stage 4 of the wagner scale considered?
gangrene of digit
what is stage 5 of the wagner scale measuring?
gangrene of foot requiring disarticulation
what does serum albumin measure? what is a normal level? too little?
protein over 90 days
>3.5 g/dL, <2.5g/dL
what does prealbumin measure? normal? too little?
protein over a few days
15-43 mg/dL normal
0-5 mg/dL severe depletion
what is the normal range of hemoglobin for a female? `
12–15. gm/dL (males slightly higher)
what is the normal percent of hematocrit for a female?
37-48%, males slightly higher
what is an average lymphocyte count?
1000-4000mL
what vitamin levels are important to measure in determine wound care?
A, K, D
what two lower extremity locations should you check for pulses? are these biphasic or monophonic?
dorsalis pedis
posterior tibial
what are two tests to examine arterial insufficiency?
capillary refill
rubor of dependency
how is a capillary refill test conducted? what is the normal time associated with this test?
pinch great toes and count seconds for the skin to return to normal color
should within 2 seconds
how is rubor of dependency determined?
lie your patient supine, elevate foot to a 30 degree angle, if skin pales (palor on elevation), it is a positive sign of arterial insufficiency
have your patient sit upright w foot in dependent position, dramatic red color change indicates severe tissue ischemia
-color changes should occur within 30 sec
What is the thresh hold for an emergency ABI? (according to Professor Unger)
.5
patient seen by specialist that day
What are 5 locations in the ankle that are used for circumferential measurements?
arch
figure 8 ankle
10 cm above medial malleolus
20 cm above medial malleolus
what is one test to examine the risk of diabetic foot ulcers (lops)? how much force does it utilize?
5.07 semmes-weinstein monofilament
10 grams of force to bend it when you touch a patient’s skin
what are three high risk persons at risk for friction injuries?
agitated
spastic
sliding down in bed
how often should a bed-bound individual be be repositioned?
every 2 hours
how often should a chair-bound individual be repositioned?
every 15 min
how many degrees should a person be turned to remove pressure from the sacrum?
40 degrees
what height should a hospital bed be kept to reduce friction and shear?
avoid more than 30 degrees of head-of-bed elevation unless medically needed
what are four ways to reposition a patient that do not include a bed covering?
teach individual to reposition using trapeze
use lifting devices to move individuals who cannot assist
place pillows or wedges between knees and ankles (top leg in front of bottom)
heels elevated off bed, but avoid hyper-extension of knees
what constitutes a dmerc category 1 support surface? who qualifies?
static overlays
mattresses: foam, air, gel
patients who are RISK of pressure injury
what constitutes a dmerc category 2 support surface
alternating pressure and air floatation
what constitutes a dmerc category 3 support surface? what kind of injury qualifies?
stage 4 pressure injury on multiple surfaces or skin graft
$200/day for rental
what are four things to check when assessing the performance of a support surface?
bottoming out (surface totally compressed)
memory foam shape remains
bunching in gels
deflation in air filled
what is one way to measure the size of a pressure injury? what parts of the body do you use for these determinants?
longest length * width, cm squared
head as reference to determine which is length and which is height
what is one way to measure the size of a pressure injury using a clock? benefit?
top of pressure injury is 12 oclock, etc
acetate tracing
can describe locations of specific type of tissues within injury
what are four aspects of a wound you will evaluate?
size
color
odor
consistency
what is the odor of anaerobic organisms?
fecal
what is the odor of aerobic organisms?
various including fish
what is the color of a pseudomonas?
aquamarine
how would you describe slough?
stringy runny nose of small child that is extended w a wipe
soft yellow or tan
how would you describe eschar?
thick black or brown
avascular
how would you describe granulation?
bumpy
shiny red
how would you describe epithelial tissue?
dry
usual skin color
how would you describe fibrin tissue?
white that won’t come off to touch
when describing skin surrounding pressure injury, what factors are you taking into account?
erythema maceration edema tape injury induration crepitus pain warmth fluctuance
What is tunneling? How to do you document it?
tissue loss parallel to the skin surface
may or may not have exit site
document clock location and depth of undermining
what is a fistula?
abnormal passage between two organs or between and organ and the outside of the body
what can permeate a semi-occulsive dressing?
not bacteria and liquids
oxygen and carbon dioxide can
moisture vapor can
what are 5 benefits of semi-occulsive dressings?
help create optimal local wound environment increase healing rates decrease cost of care reduce pain improve cosmesis
what is a popular type of semi-occulsive dressing?
hydrocholid
what are 7 potential way to do harm to a pressure injury?
dehydration reinjury hypergranulation (too much fluid) maceration granuloma skin stripping contact dermatitis
what are 5 things a wound needs?
adequate hydration thermal insulation freedom from necrotic tissue control of bacteria optimal ph
is the ideal ph for a wound acidic or alkaline?
acidic
what are 6 materials used to make dressing?
water polymer collagen cellulose hydropolymer "top secret" patented ingredient
what three wound contact layers in a dressing?
impregnated gauzes
perforated plastics
silicone coated meshes
what types of dressings maintain moisture?
films
hydrocolloids
hydrogel sheets
amorphous gels
what are three physiological benefits of response to gentle pulsatile lavage?
increased granulation tissue formation
increased rate of wound closure and resolution of fibrosis
decreased wound bioburden
when taking tegaderm off, how should you remove it?
lift corner and pull towards you
how does an autolytic dressing cause debridement?
uses body own processes to remove devitalized tissue
what are four types of autolytic dressings?
transparent films
hydrocolloids
hydrogels
what are two benefits to using an autolytic dressing?
minimal trauma
less frequent dressing changes
what is one contraindication for wound debridement?
several arterial insufficiency
order of preparing for wound debridement?
- wash hands
- prep skin first with betodine
- flush w saline
- if part of medical order, can use analgesic
- 1/4 strength betodine
- debride
