Exam 1 Flashcards by Grace Garvey

Normal Wound Healing requires ___ calories/kg of body weight per day

30-35

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Patients with an open wound healing requires ____ mL of fluid per kilogram of BW/day

30-35 mL

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Normal serum albumin

2.5-5.5 g/dL

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normal serum prealbumin:

16-40 mg/dL

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Normal Total Lymphocyte Count (TLC):

Normal ≥ 2000 cells/mm^3

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Normal Blood Glucose/A1c

BG= 70-115 mg/dL
A1c < 6.0%

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normal Creatinine

.1-1.2 mg/dL

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known diabetics should have their A1c lower than

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Wound Size Direct Measure

Length x Width x Depth

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Tunneling

narrow passages created by separation/ destruction of tissues along facial planes

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undermining

occurs when tissue edges erode leaving a large wound with a small opening

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Sinus Tract

elongated cavity allowing purulent material from an abscess to drain to body surface

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clock method head/proximal

is at 12 oclock

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clock method feet/distal

6:00 oclock

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fissures

described by clefts/openings on each side

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granulation tissue

viable, bubbly bright beefy red tissue
good oxygen supply

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pink or dusty granulation tissue

ischemia or infection and is documented as “clean non-granular pink tissue”

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Necrotic tissue

non-viable tissue
breeding ground for bacteria, document by color, consistency and adherence

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slough

tan, yellow, green
stringy or mucinous
ease that is pulls away from wound base - non adherent, loosely adherent (some white) or firmly adherent

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when is eschar removed

when it covers some of the wound but if it is full eschar we won’t touch it, hoping that it falls off

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viable adipose tissue

yellow, globular, slippery

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non viable adipose tissue

grayish. hard/crunchy

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viable fascia

shiny, white, thick/thin sheath like

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non-viable fascia:

grayish, slimy, disintegrating

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viable bone tissue

white and solid

non-viable bone

yellow, brown, soft

if the wound is down the level of the bone ...

possible osteomyelitis and must be referred to a doctor

viable tendon

shiny, white, fibrous, cord like with straight collagen fibers

non-viable tendons

dull white/yellow/gray

viable ligaments

fibrous flat, yellow/white

non-viable ligaments

dull yellow/gray

viable muscle tissue

dull red, pink, striated, may contract when touched

non-viable muscle

grayish, loose fibers

how do you distinguish nerves from tendons

nerves don't move during muscle contractions

tissue perimeter is the _____

periwound

sudamonous odor:

foul, sweet, pungent

painful wounds have _______ blood flow

decreased

Stage I pressure ulcer

nonblachable erythema skin intact blue/purple appearance change in local tissue temperature, tissue consistency and sensation, boggy skin

Stage II pressure ulcer

superficial ulcer BLISTER

stage III pressure ulcer

deep ulcer crater may have undermining NECROSIS

if there is necrosis in a pressure ulcer what stage does it automatically go to

stage III

Stage IV pressure ulcer

Deep ulcer extensive necrosis undermining/tunneling/sinus tracts got a little extra something something

Unstageable ulcer

eschar or slough obscures it

severe pain at rest =

arterial insufficiency

Arterial insufficiency ABI

<0.90; if it is less than 0.5 refer

periwound condition in AI

ischemic, shiny, taut, thin, dry, alopecia, trophic changes (thick toe nails)

when do you refer to microvascular surgeon (ABI < ___)

0.5

Venous insufficiency periwound

white wound edges due to maceration; hemosiderin staining/lipodermatosclerosis; significant edema

ABI with venous insufficiency

1.0 or less; normal capillary refill with poor venous fill

Braden Scale risk for pressure sores

18 or less

Norton Risk Assessment score for pressure sore

16 or less

cardinal signs of infection

rubor, calor, pain, tumor, odor, system signs (fever, chills, sudden glucose shifts)

Advantages for Enzymatic Debridement

fast fairly selective many products

Disadvantages for Enzymatic Debridement

expensive MD orders possible adverse rxns many products

Advantages for Mechanical Debridement

easy, low cost

Disadvantages for Mechanical Debridement

not everything is as superficial as it seems

Disadvantages for Sharps Debridement

MD orders possible pain and bleedings special training and equipment

Advantages for sharps debridement and surgical debridement

very selective, fast and very effect

Advantages for autolysis

selective, safe, painless, effective

disadvantages of autolysis

slow process with potential for infection

what level of the lymphatics is responsible for transport of fluid to the collectors

pre-collectors

what is the function of the collectors in lymphatics

transport lymph to the lymph nodes and lymphatic trunks

which lymphatic system component is made of contractile muscle

collectors

what is the functional unit of the collectors

lymphangion

disadvantages for surgical debridement

costly decreased functional status may not return to therapy immediately

what is the major determinant of fluid movement in normal circulation

blood capillary pressure

what pressure favors absorption

plasma collodial osmotic pressure (COPp)

where does absorption happen

at the venous end of the capillary

which pressure favors filtration and where does it occur

blood capillary pressure (BCP) in the arterial side of the capillary

______ increases with lymphedema resulting in decreased ____

COPi, absorption

normal circulation results in net _____

filtration

what type of muscle do the precollectors contain

smooth