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4 acute care > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

when looking at the limb of apperance what are you looking at

A
  • compare contralateral limb
  • edema
  • color changes
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2
Q

what are the 2 types of wounds

A

acute and chronic

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3
Q

what are be allowed to debrided

A

PT scope of practice allows only remove non-viable tissue, so bleeding should be minimal
Non-excisional
====Only need forceps—removing loose blistered skin
Excisional (Sharp)
====Use of scissors or scalpel to aid in removal of necrotic tissue
====Includes cross-hatching of eschar

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4
Q

what supplies blood to the epidermis

A

papillary= capillary supplies vascular and nourishment t o epidermis through osmosi

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5
Q

what is the corneum

A

top layer

waterproof characteristic, protection from infection

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6
Q

what is elevational pallor

A

Raise leg to 60º for 15-60 seconds, note time it takes for visible color change/ pallor

Within 25 seconds = severe occlusive disease
Within 25-40 seconds = moderate occlusive disease
Within 40-60 seconds = mild occlusive disease

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7
Q

what are different types of irrigation

A
  • high pressure irrigation

- pulsativle lavage

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8
Q

what si serous exduate

A

clear but can have a yellow ting

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9
Q

what does the subcutaneous/ hypodermis contain

A

-adipose

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10
Q

what is ABI

A

ankle brachial index

Comparison of perfusion pressures in the lower leg and upper arm using BP cuff and Doppler probe.

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11
Q

what is colonized

A

bioburden present in a wound bed (normal)

-presence of proliferating bacteria without a host response.

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12
Q

what is primary excision

A

Surgical debridement of necrotic tissue to achieve viable wound base

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13
Q

what types of gaze are ther and how is it made

A

4x4’s, Kerlix, may be woven or non-woven

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14
Q

what is anaerobic bacteria

A

can survive without O2

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15
Q

how much support for stockings is needed for – lymphedema

A

50-60 mmHg

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16
Q

what are some indications for composites

A

partial and shallow full-thickness wounds, minimal to heavy exudate

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17
Q

what is the precaution for transparent films

A

not for infected wounds or wounds with mod-heavy exudate

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18
Q

what is CVI

A

chronic venous insufficiency (AKA venous stasis)

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19
Q

how do you apply wet to dry debridement

A

Apply saline moistened gauze to wound bed and allow it to dry, then pull it off

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20
Q

what is topical antibiotics

A
  • Presumed to be effective if the invading organisms have not developed resistance
  • Agent should be carefully selected based on wound culture results
  • –Gram (+) = muprocin, garamycin
  • —Gram (+) or (-) = bacitracin, neomycin, sulfamylon, mafenide acetate
  • –Anaerobic = mafenide acetate, metronidazole
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21
Q

what is a stage 1 pressure injury

A

intact skin with non blanchable redness of a localized area

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22
Q

when shoudl maggots be considered

A

Considered for use in wounds that have not responded to other forms of debridement

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23
Q

what doesnt a stage 2 pressure injury have

A 
NOT:
----Skin tears
----Tape burns
----Maceration
----Excoriated perineal tissue
Does not have slough or eschar present
NO undermining or tunneling present
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24
Q

what do neuropathic/ diabetic ulcers look like

A

Well defined border, often with a callus
Pale or red wound bed
Little to no granulation
Minimal to moderate exudate

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25
Q

what is a open technique with topical medication

A

apply ointment only not covering

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26
Q

How do you manage a arterial ulcer

A
  • hyperbaric oxyen
  • lifestyle changes
  • topicla therpya
  • surgical options
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27
Q

What is PVD

A

peripheral vascular disease

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28
Q

what is proliferation

A

Collagen is secreted to form connective tissue
Granulation tissue formation
Wound contraction via myofibroblasts
Epithelialization occurs from migrating wound edges
Skin regrowth occurs with continued differentiation of cells
Very fragile tissue at the end of this phase

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29
Q

what is autolysis debridement

A

Lysis of necrotic tissue by the body’s white blood cells and enzymes which enter the wound site during the normal inflammatory process

Selective, Recommended only for non-infected wounds with limited volume of necrotic tissue, Slower, Done by carefully selecting dressings and topicals (TheraHoney), Monitor for s/s of infection, cellulitis, maceration, etc.
pg 177-178

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30
Q

what is non-viable tissue

A
  • Eschar

- Slough

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31
Q

what is the 1st type of burn

A

superficial

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32
Q

what can a pt do for a burn patient

A

Improve impaired mobility and ROM that resulted from injury.
Assist pt to return to his/her PLOF
Interventions:

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33
Q

where shoudl caution with maggots happen

A

Caution to avoid contact with healthy skin.

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34
Q

what is hemostasis

A

Vasoconstriction

Platelets aggregate to form a clot

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35
Q

how does the neuropathy from a burn affect someone

A

polyneuropathy (multiple sites) vs local (usually from tx for burn)

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36
Q

what is hemosiderina staining for venous ulcers

A
  • Another classic sign of LEVD
  • Discoloration of the soft tissue that results when extravasated RBCs break down and release pigment hemosiderin
  • Results in grey-brown staining of the lower leg
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37
Q

what is an unstageable pressure injury

A
  • Full thickness loss in which the base of the ulcer is covered by slough or eschar
  • Wound CANNOT be numerically staged until necrotic tissue is debrided
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38
Q

what is Granulation

A

= beefy red new growth, cobblestone

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39
Q

what does a pressure injury depend on

A

Duration and Intensity of pressure

Low pressure for a prolonged period of time
High pressure for a short period of time

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40
Q

what fx fo the skin can burn affect

A

all of them

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41
Q

why are foam dressing good to use

A

Non-adherent, conformable

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42
Q

what is a caution with conservative sharp debridement

A

Use caution with pts on anticoagulants

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43
Q

what are the stages a pressure injury can be

A

stage 1, 2, 3, 4, deep tissue injury, unstageable

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44
Q

what is the foam dressing

A

Semi-permeable hydrophilic foam

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45
Q

what does transparent films look like

A

Thin, transparent polyurethane film

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46
Q

what are some traumatic wounds types

A

Degloving injuries

Amputation

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47
Q

when is a wound culture indicated

A
  • s/s of infections

- clean wound does not show progress in healing for 2 weeks

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48
Q

what is venous dermatitis for venous ulcers

A

Inflammation of the epidermis and dermis

Results in scaling, crusting, weeping erosions and intense itching and discomfort

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49
Q

how is dakins solution applied

A

Applied as a wet-dry dressing, BID

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50
Q

what are some contraindications for compression therapy

A

to high level sustained compression

  • uncompensated heart failure
  • co-existing peripheral arterial disease
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51
Q

what is laser debridement

A
  • Form of surgical sharp debridement
  • Uses focused beams of light to cauterize, vaporize, or slice through tissue
  • Advantages: wound bed is sterilized and blood vessels are cauterized
  • Precautions: risk of injury to adjacent healthy tissue
  • Not available in all settings
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52
Q

what is full thickness

A
  • Damage to the epidermis and dermis and extending into the subcutaneous tissue, muscle, or bone
  • Heal with granulation tissue formation, contraction, and then re-epithelialization
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53
Q

how long is dakins solution used for

A

Used for less than 10-14 days

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54
Q

how much is the arms rule of nines in a child

A

.

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55
Q

when will wet to dry debridement not be effective

A

If the gauze is moistened before removal, it’s not as effective

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56
Q

what are some factors that impair healing

A 
Edema
Vasoconstriction
Vascular Disease
Smoking
Infection
Sepsis
Renal Disease
Diabetes
Obesity
Corticosteroids
Age
Stress
Malignancy
Pulmonary Disease
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57
Q

what are some skin graft basics

A

Usually sutured, held by steri-stips, or stapled to the wound bed
Needs good vascular supply to adhere successfully
Area needs to be immobilized, offloaded, and often compressed to prevent separation
May have NPWT placed for 5-7 days after graft placement
NEVER take off a dressing over a graft unless instructed to do so by the surgeon who placed the graft.
If you are instructed to remove dressing, take extreme caution not to remove the graft itself from the wound bed.
Survival depends on:
Circulation, inosculation, and penetration of host vessels into graft site

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58
Q

what is friction force

A

= skin rubbing across a surface

Friction alone does not cause pressure ulcers

Friction DOES remain a risk factor that may contribute to or exacerbate pressure ulcer development due to the shear it creates.

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59
Q

what is the granulosum

A

middle layer

responsible for water retention

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60
Q

how do you get hydrogel

A

Available as an amorphous gel (in a tube), or as a sheet

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61
Q

what does the wound pain look like

A
  • can be constant or only with dressing changes

- ensure adequate pain relief during dressing changes

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62
Q

how do you know if you have venous issues

A

edema, varicosities, hemosiderin staining, and dermatitis, irregular boarders

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63
Q

what is the spinosum

A

middle layer

adds layer of protection

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64
Q

what is the zone of coagulation

A

the area where the burn was

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65
Q

at what time does scar tissue mature

A

Scar tissue matures in 12-18 months

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66
Q

what is the lifestyle changes for arterial ulcers

A

Stop smoking, ideal weight, adequate nutrition

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67
Q

what are some disadvantages of maggots

A

Patients report crawling sensation as main disadvantage

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68
Q

what are some indications for gaze

A

partial and full thickness wounds, infected wounds, wounds with tunnels

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69
Q

what are some facts of the epidermis

A
  • no blood vessel presen t
  • sheds and regenerates
  • 80-90% of cells are kerationcytes
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70
Q

what are some precautions with whirlpool

A
  • vasodilatation and increased circulation to the wound (not good for venous ulcers)
  • Diabetics with loss of protective sensation
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71
Q

how much is the head rule of nines

A

.

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72
Q

what is the 3nd type of burn

A

deep partial

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73
Q

what is tunneling

A
  • Opening that leads away from a wound

- Can lead to abscess formation if not properly packed

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74
Q

what does damage to the motor nerves causes

A

causes structural deformities and gait abnormalities

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75
Q

what are the part to the dermis

A

collagen and elastin

  • primary cells are fibroblasts
  • lyer that granulates
  • need proteins to make collagen
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76
Q

how do describe the location of the wound

A

using anatomical indicators

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77
Q

was are the indication for Negative pressure wound therapy

A

acute and chronic wounds with depth, partial and full thickness wounds, partial thickness burns, over grafts

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78
Q

what are some uses of silver nitrate

A

To control hypergranulation
Epibole (rolled wound edges)
Aids in hemostasis

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79
Q

how do you asses the skin temp of the leg

A

palpate moving form proximal to distal and compare right to left

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80
Q

what is the fx of the skiin

A 
Temperature regulation
Secretion of oils for moisture
Portal for sweat glands and hair follicles
Vitamin D synthesis
Identity
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81
Q

what type of hydrocolloid are there

A

Duoderm, Exuderm

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82
Q

primary or secondary for alginate

A

Primary dressing

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83
Q

what are arterial ulcers caused by

A

Due to severe tissue ischemia, extremely painful

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84
Q

how often do you need to change a foam dressing

A

Changed daily, or up to 3x/ week

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85
Q

when is wet to dry debridement used

A

Used ONLY for heavily necrotic, or infected wounds

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86
Q

how do you medically manage a burn

A
  1. Establish and maintain and airway
  2. Prevent cyanosis, shock, or hemorrhage
  3. Establish baseline data such as extent and depth of burn
  4. Prevent or reduce fluid loss
  5. Clean the injury—includes early debridement by physician/PT, possible whirlpool therapy
  6. Examine injuries
  7. Prevent pulmonary and cardiac complications
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87
Q

what is infection bacteria

A

bacteria penetrate into viable parts of tissue and elicit a host response.

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88
Q

how much support for stockings is needed for – varicose veins

A

20-30 mmHg

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89
Q

what are skin substitutes

A

Cultured epidermal autografts
Cultured autologous composite grafts
Allogenic skin substitute
Cultered dermis—temporary and definitive

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90
Q

how do you know venous filling time

A
  • visual assessment of time it take for foot veins to fill while leg is in dependent position
    —–Normal = 15-20 seconds
    > 20 seconds indicates occlusive disease
  • capillary refill
  • —–Blanche toenail with pressure for several seconds and release. Refill in > 2-3 seconds may indicate arterial occlusion. **Cold room temp may increase capillary refill time.
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91
Q

where are neuropathic/ diabetic ulcers found

A

on the foot

  • Plantar surface over metatarsal heads
  • Toes and sides of feet
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92
Q

how loong do you keep gaze on

A

Changed as needed based on saturation, usually daily, BID, or TID

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93
Q

what is a trac

A

small underminining that does not connect to another wound area

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94
Q

where is 12 oclock pointing to

A

the head of the pt

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95
Q

how long can a contact layers be on

A

Contact layer stays in place up to 7 days, absorptive layers are changes as needed

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96
Q

what is edema with the venous system for venous ulcers

A

Classic indicator of LEVD
Worsens with dependency and improves with elevation
May become “brawny” (non-pitting) due to fibrosis of the soft tissues
Primarily affects the lower leg

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97
Q

what is LEVD

A

lower extremity venous disease

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98
Q

how does the heterotopic ossification from a burn affect someone

A

from immobilization, most common in elbows, hips, and shoulders

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99
Q

what is the best way to manage the same class in the classroom

A

Compression Therapy
Limb Elevation
Surgical Procedures
Physical Therapy

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100
Q

what is hight pressure irrigation

A
  • Irrigation of necrotic wound with fluid delivered at 8-12 psi
  • Can use 35-mL syringe with 19-gauge angiocatheter
  • Provides enough force to remove debris without damaging healthy tissue
  • Most often uses saline
  • Must wear PPE (gown, gloves, mask, goggles) for potential splash
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101
Q

how do you handle the scar management for a burn

A

Silicone gel sheet
Masks
Scar Massage

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102
Q

what do you need to asses with burns

A
  • wound assessment
  • —-what does it look like
  • —- what type of wound
  • wound measuremnets
  • – Lx WxE, undermining/ tracts, girth
  • LE wounds
  • —-palpate/ doppler pulses
  • photo- after obtaining consent
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103
Q

what is granulation tissue

A

Red buds which are beginning of new skin formation

Made from connective tissue and capillaries

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104
Q

what is gram (+)

A

Staph (MRSA/MSSA)
Strep
Enterococcus
Many others

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105
Q

what depth does the superficial go to

A

epidermis

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106
Q

what are some surgical wound types

A

Dehisced
Tertiary Intention
Flaps/ Grafts

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107
Q

what is the general assessment of the lower leg

A
  • appearance of the limb
  • perfusion
  • sensory fx
  • range of motion
  • pain
  • pulse
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108
Q

what are the characteristics of superficial

A

pain
redness
mild swelling
no scarring

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109
Q

what are some precautinos for hydrogel

A

not for heavily exudating wounds, monitor for maceration or yeast development

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110
Q

what is viable tissue

A
  • Granulation
  • Non-granular
  • Muscle or subcutaneous tissue
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111
Q

what are some cons to wet to dry debridement

A

Painful

Not good for heavily exudative wounds

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112
Q

what is hydrocolloid

A

Adhesive, absorptive, impermeable barrier, can be used for autolytic debridement

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113
Q

what are come compressions types

A
  • non-elastic

- elastic

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114
Q

what are the precautions of foam dressing

A

not for dry wounds or those with tunnels

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115
Q

what is chemcial debridement

A

Enzymes, Dakin’s Solution, Maggots, Silver Nitrate

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116
Q

why is conservative sharp debridement preferred

A

Preferred method of debridement for infected wounds

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117
Q

is whirlpool selective or non

A

Non-selective

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118
Q

what are the risk factor fo rvenous ulcers

A
  • valve dysfunciotn

- calf muscle dysfunction

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119
Q

what is impregnated gauze made of

A

Woven gauze impregnated with petroleum, zinc, saline, etc.

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120
Q

how often does the impregnated gauze need to be changed

A

changed daily

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121
Q

what are the values for the abi

A

ABI > 1.3 = Abnormally high, due to calcification of vessel wall due to diabetes, renders test invalid
ABI ≥ 1.0-1.3 = Normal
ABI ≤ 0.6-0.8 = Borderline perfusion
ABI ≤ 0.5 = Severe ischemia, wound healing not likely without surgical revascularization
ABI ≤ 0.4 = Critical limb ischemia

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122
Q

what can cause chronic wounds

A 
Underlying pathology
Prolonged inflammatory phase
Low levels of growth factors
Miscellaneous host factors
     -Ischemia
     -Malnutrition
      -Co-morbidities (such as diabetes)
Denervation
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123
Q

what is the order of the skin

A

epidermis
dermis
sub Q

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124
Q

what is dependent rubor

A

Place leg in dependent position, look for rubor (purple-red discoloration due to retention of deoxygenated blood in dilated skin capillaries). Normal = no color change

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125
Q

what are some indication for hydrogel

A

partial or full thickness wounds, dry to minimal exudate, necrotic wounds (assists with autolytic debridement), infected wounds

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126
Q

what are the characteristics of ful

A 
charred
insensate
eschar formation 
involves all level of skin 
can not re-epithelialize 
will need graft for areas without wound contraction 
surgical debridement 
diabiliyt 
no pain 
no viable nerve endings
high risk for infection
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127
Q

where are the 2 leg pusles

A

dorsalis pedis
=You can feel this pulse by positioning your index and middle fingers in the middle of the anterior part of his foot.

posterior tibial pusle
=To feel this pulse, position your index and middle fingers at the back of his right or left ankle, specifically behind the medial malleolus.

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128
Q

what does damage to the sensory nerves cause

A

loss of protective sensation

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129
Q

what is topcial elemental antimicrobials

A
  • The formulation and concentration of the agent is important to it effectiveness
  • Use should be limited to 2-4 weeks
  • Silver sulfadiazine cream, silver impregnated dressings (good for MRSA), copper, zinc, cadexomer iodine
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130
Q

what is cleaning of a wound infection need

A
  • 4-15 psi with water or normal saline

- aimed at reducing surface contaminant rather than curing infections

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131
Q

what is a stage 4 pressure injury

A
  • Full thickness tissue loss with exposed bone, tendon, or muscle
  • Slough or eschar may be present on some parts of the wound
  • Often includes undermining or tunneling
  • Can vary in depth based on location
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132
Q

what is a enzymes

A

Collagenase Santyl

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133
Q

what is slough

A

= yellow, tan, or gray, slimy, moist

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134
Q

what types of contact layers are there

A

Mepitel Silicone Dressing, Tegapore, Sorbact

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135
Q

what depth does the deep partial got to

A

dermis : reticular region

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136
Q

what is elastic

A

Profore
Surepress
Support Stockings

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137
Q

what is serosanguineous exudate

A

yellow with red ting

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138
Q

what is critically colonized

A

clinically assessed as pint wound is about to be infected

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139
Q

what is a disadvantage of conservative sharp debridement

A

Can be uncomfortable for the patient

140
Q

what are some common medicatino for topical medication ffor burns

A 
Silver sulfadiazine (Silvadene)
Sulfamyalon
Silver Nitrate solution and sticks
Bacitracin/Polysporin
Collagenase (Santyl®)
141
Q

what are the type sof compression for burns

A

Elastic wraps (ACE)
Tubular bandages (Tubi-grip)
OTC garments
Custom garments

142
Q

what are some precautions of gaze

A

adheres to wound tissue for non-selective debridement, may dry out wound

143
Q

when do you change the hydrogel

A

changed dailiy

144
Q

what is aerobic bacteria

A

needs O2 to survive

145
Q

what is atrophie blanche lesion for venous ulcers

A

Smooth, white plaques of thin, atrophic tissue speckled with tortuous vessels
Represents spontaneously developing lesions
High risk for ulceration

146
Q

what is an acute wound

A

normal healing within 21 days

  • traumatic or surgical origin
  • heal rapidly and predictably through the repair process
  • durable closure
  • can develop complications that can turn it into chronic
147
Q

how much is the head rule of nines in a child

A

.

148
Q

what makes up vascualr ulcers

A

70-75% are primaryily due to chronic venous insufficieny

25-30% are attributed to arterial or mixed disease

149
Q

what is hydrogel amde of

A

Composed of water or glycerin

150
Q

how much support for stockings is needed for – treatment for venous ulcers and lymphedema

A

40-50 mmHg

151
Q

how does Negative pressure wound therapy work

A

Black or white foam is placed in the wound, sealed with semi-occlusive drape, and connected to pump

152
Q

what is chronic wound

A

something that does not heal within 30 days and does not have a normal healing process

  • fail to close in a timely manner or fail to resut in a durable closure
  • by vascular compromise, chronic inflammatoin, or repetitive insults to the tissue
153
Q

what are the characteristics of deep partial

A 
white
leathery 
relatively painless
growth is slow 
grafting is preferred treatment 
high risk of infection 
severe scarring 
can convert to full thickness
154
Q

Wound vac application

A

slide 97

155
Q

how do you know if you have arterial issues

A

thinning of the epidermis, loss of hair growth, thickened nail

156
Q

what are the different categorizes of wounds

A 
⚫ Chronic
⚫ Pressure Ulcers 
⚫ Arterial 
⚫ Venous 
⚫ Neuropathic/ Diabetic 
⚫ Traumatic 
⚫ Surgical 
⚫ Burns 
⚫ Other
157
Q

what are some concerns with whirlpool

A

cross-contamination between patients who use the whirlpool

158
Q

what are the objectives of physiologic wound environment

A

1) Prevent and manage infection
2) Cleanse the wound
3) Remove non-viable tissue
4) Maintain appropriate level of moisture
5) Eliminate dead space
6) Control odor
7) Eliminate or minimize pain
8) Protect the surrounding skin

159
Q

what is a compression therapy

A
  • Application of externally applied pressure to facilitate normal venous flow
  • Acceptable to use even with acute dermatitis
  • Only controls the underlying venous insufficiency; most patients require long-term therapy to prevent recurrent ulceration
  • No stocking until wounds healed
160
Q

what is Negative pressure wound therapy

A

Wound V.A.C.

161
Q

other modaliliteis notes

A

slide 82

162
Q

what skin grafts are temporary

A

Allografts and xenografts are temporary until skin is availabe for autograft

163
Q

what is a secondary dressing

A

used to increase the ability for the wound needs to be adequately met and/ or secure the primary dressing

164
Q

what is used with whirlpool treatment

A

Water is most commonly used, optimal temperature 37ºC

165
Q

when should enzymes stopped being used

A

once viable tissue is revealed and necrotic tissue is removed

166
Q

what is allograft

A

taken from a cadever

167
Q

what should the wearing schedule be for compression with a burn

A

23 hours/day, 7 days a week
Wear until scars mature
Could need for 8 months – 1-2 years
Remove only to bathe and if interferes with therapy.
Mature scar- soft, pliable, flat, and skin color is close to normal skin tone

168
Q

what forms does alginate come from

A

Rope or pad form

169
Q

what is the recurrence rate of venous ulcers

A

Recurrence rates as high as 57-97%

170
Q

what can the periwound skin look like

A
  • Normal
  • Hypopigmented
  • Light red/ pink
  • Tape Stripped/ Denuded
  • Macerated
  • Excoriated
  • Indurated
  • Boggy
  • Elevated temperature
  • Edema
171
Q

how much support for stockings is needed for – venous ulcer treatment

A

30-40 mmHg

172
Q

what are some treatment of a wound infection

A
  • oral antibiotics
  • cleaning
  • debridement
  • topicla therapy
173
Q

how much support for stockings is needed for – ted hose

A

15-17 mmHg

174
Q

what does it mean with unilateral coolness and sudden coolness form proximal to distal of the leg

A

arterial disease

175
Q

how do the maggots work

A

The larvae secrete proteolytic enzymes and break down necrotic tissue

176
Q

how shoudl a culture be taken

A

form a clean, healthy-appearing tissue, not form pus, slough, eschar, or necrotic materail

177
Q

what is PAD

A

peripheral arterial disease

178
Q

how does the metabolic from a burn affect someone

A

Metabolic demand increases with burn injury with increased TBSA, decrease in body weight and energy stores, causes increase in core body temp~2 degrees, (helps to keep room warmer ~86 degrees so pt doesn’t lose excessive amount of body heat which will reduce metabolic activity, protein from muscle is used for energy causing muscle atrophy (in addition to bedrest);

179
Q

what are some facts of the dermis and what does it contain

A
  • Responsible for vascular supply and nourishment to skin/epidermal layer
  • Nerves
  • Glands
  • Fibroblasts
180
Q

how much are the legs rule of nines in a child

A

.

181
Q

what are the different types of wound care dressings

A 
Alginate
Composites
Contact Layers
Foam Dressings
Gauze
Hydrocolloid
Hydrogel
Transparent Film
Negative Pressure Wound Therapy (NPWT)
182
Q

what is contact layers not used for

A

not for use in shallow or dry wounds, or with viscous exudate

183
Q

what types of foam dressing are there

A

Allevyn, Lyofoam, Mepilex

184
Q

what is a Hypertrophic scar

A
  • Confined to area of original injury
  • Commonly over joints
  • May regress spontaneously
  • Associated with contractures
185
Q

what is non- elastic

A

Unna Boot
Circ-Aid
Comprilan (lymph wraps)

186
Q

how does the infection from a burn affect someone

A

leading cause of death in combination with organ system failure, can develop sepsis, MDROs

187
Q

wha tis necrotic tissue

A

Can be loose or adherent
Usually yellow, but can also be brown, tan, black, or green
Needs to be removed to allow good tissue to form IF pt has adequate blood flow
Occasionally requires surgical debridement

188
Q

what is sanguineous exudate

A

red or bloody

189
Q

what is antiseptics

A
  • Non-selectively kills or inhibit the growth on the external surfaces of the body
  • Use is generally discouraged because their cellular toxicity exceeds their bactericidal activity
  • Use should be restricted to 1-2 weeks for specific indications
  • Alcohol, acetic acid, betadine, hydrogen peroxide, hypochlorite (Dakin’s solution)
190
Q

what depth does the full

A

hypodermis (subcutaneous tissue)

191
Q

what is the scar massage for burns

A

start just moving skin with no friction; begin with skin is durable enough to not blister

192
Q

what are the zones aroudn the burn

A
  • zone of coagulation
  • zone of stasis
  • zone of hyperemia
193
Q

what does damage to the autonomic nerves cause

A

decreased sweating cause cracks, fissures, and callus

194
Q

what are the indication for impregnated gauze

A

partial or full-thickness wounds, infected wounds, wounds with tunnels

195
Q

how do you get enzymes treatment

A

prescription

196
Q

what depth does the superficial partial go to

A

dermis: papillary region

197
Q

what are the layers of the epidermis

A
  • corneum
  • lucidum
  • granulosum
  • spinosum
  • basale
198
Q

what is alginate good for

A

full thickness, undermining, tunnel, moderate to heavy exudate, infected wounds, malodorous wounds

199
Q

what types of alginate are their

A

Aquacel, Sorbsan, etc

200
Q

what is stage 2 pressure injury

A
  • Partial thickness loss of dermis
  • Shallow opening or crater
  • May present as an intact or ruptured blister
  • Shallow ulcer without slough or bruising
  • Red or pink wound bed
201
Q

how often do you change hydrocolloid

A

Changed up to 3x/ week

202
Q

what are some methods of debridement

A
  • autolysis
  • chemical
  • mechanical
  • sharp
203
Q

what is mechanical debridement

A

Wet-to-Dry Debridement, Irrigation, Whirlpool

204
Q

how do you pick a wound care dressing

A

using the 8 objective of physiologic wound enviroment

205
Q

what is a stage 3 pressure injury

A
  • Full thickness tissue loss
  • Subcutaneous fat may be visible
  • Slough may be present but does not obscure the depth of tissue loss
  • May include tunneling or undermining
  • Bone, tendon, or muscle is NOT exposed
  • Can vary in depth based on location
206
Q

what are some characteristics of arterial ulcers

A 
Located on tips of toes and pressure points on feet
“Punched out” well defined borders
Pale wound bed
Little to no granulation
Minimal to no exudate
Black toes
Leave dry, stable eschar INTACT!
207
Q

precautions for hydrocolloid

A

not for 3rd degree burns, or wounds with heavy exudate, or wounds with depth, may contribute to hypergranulation

208
Q

what do composites combine

A

impermeable barrier, an absorptive layer, a non-adherent contact layer, and an adhesive border

209
Q

what is a pressure injury

A

Localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear

Blood supply is decreased which leads to tissue anoxia and tissue death

210
Q

how is more vulnerable for pressure injuries

A 
Elderly (over 65 y.o.)
Spinal Cord Injuries
Children in the ICU
Surgical Patients
Patients dependent for mobility
Patients with incontinence
211
Q

when does the transparent films need to be changed

A

Changed up to every 7 days

212
Q

what is pseudomonas exudate

A

has bright green tinted exudate and sweet but foul oder — they need antibotics

213
Q

do you need a secondary dressign for alginate

A

Secondary dressing is required

214
Q

what is the rule of nines

A

.

215
Q

how to take a photo of a wound

A
  • pt identifier in the picture

- have disposable tape measure in the picture

216
Q

is wet to dry debridement selective and non

A

non-selective

217
Q

where does it come from alginate

A

Derived from seaweed

218
Q

what are the types of burns

A 
Scalds- liquid,grease,steam
Contact burns
Fire-flash and flame burns
Chemical 
Electrical
Radiation
219
Q

what are the different odors can there be in a wound

A

absent
mild
moderate
strong

220
Q

what are some complication form a burn

A 
Infection
Pulmonary
Metabolic
Cardiovascular
Heterotopic Ossification
Neuropathy
Pathological Scars
221
Q

what does debridement of a wound infection need

A

removes dead tissue to facilitate healing

222
Q

how do you describe the extent of tissue involvement

A
  • ONLY use “number stages for pressure ulcers

- use superficial, partial and full thickness for all other wounds

223
Q

what is sharp debridement

A

Conservative Sharp Debridement, Surgical Sharp Debridement, Laser Debridement

224
Q

what causes neuropathic/ diabetic ulcers

A

damage to —

  • sensory nerves
  • motor nerves
  • autonomic nerves
225
Q

what is tertiary intention

A
  • Also known as: Delayed Primary Intention
  • Often used in abdominal incisions complicated by significant infection (i.e. ruptured appendix with peritonitis)
  • Wound is kept open for several days, then the superficial edges are approximated and the center of the wound heals by granulation tissue formation
226
Q

what are the characteristics of superficial partial

A 
very pain
blisters
spiotchy skind 
severe swelling 
good blood supply 
no scars
227
Q

how does the reticular layer attach to the subQ

A

with fibrous connective tisse

228
Q

what is autograft

A

taken from pts own skin, allograft

229
Q

what are some other wound types

A 
Necrotizing Fasciitis
Extravasation injuries
Fistula
Pyoderma Granulosum
Calciphylaxis
230
Q

what are the tocial therapy for arterial ulcers

A

Keep dry if possible

Debride only if infected

231
Q

what is pulsatile lavage

A
  • Machine that provides high-pressure irrigation (8-15 psi) combined with suction
  • Loosens necrotic tissue and facilitates removal by other forms of debridement
  • Can be costly, attachments are single-use
  • Use caution to avoid blood vessels, grafts sites, and exposed bone, muscle, and tendon. Also with pts on blood thinners
  • Must wear PPE
232
Q

what is the lucidum

A

middle layer

only present in thicker areas soles of feet, palms, and pads of fingertips

233
Q

what are the types of wound closure

A
  • primary intention
  • secondary intention
  • tertiary intention
234
Q

what is shear force

A

= combination of friction and gravity

Sliding down the bed when HOB is elevated greater than 30º

Common in sacral area

235
Q

what are local signs of infeciton

A

increased purulent exudate

  • induration
  • warmth
  • pain or tenderness
  • erthema
236
Q

Does contact layers need a 2n layer

A

Requires secondary dressing

237
Q

what is the basale

A

bottom layer

contains cells that allow epidermis to regenerate and melanocytes which give the skin its color.

238
Q

what does Negative pressure wound therapy do

A

wound closure

239
Q

how fast is the enzymes treatment

A

slow

240
Q

what is maturation

A

Remodeling of scar tissue occurs for one year post wound closure
Scar tissue will only regain ~2/3rds the original strength

241
Q

how to tell stage 1 in darker pigmented skins

A

Special consideration should be made to identify stage I ulcers in patients with darker pigmented skin.

In darker pigmented skin may be:
Painful
Firmer (indurated)
Softer (mushy or boggy)
Warmer or cooler
242
Q

how is aggressive is conservative sharp debridement

A

Most aggressive form of debridement that can be done by non-physicians

243
Q

how do you help a dry eschar with enzymes

A

must be cross hate\ched and wound must be kept moist

244
Q

what are some systemci signs of infection

A
  • fever
  • malaise
  • chills
  • confusion
245
Q

how is pressure injury stages

A

using numbers and NEEDS to be done right

– you can never go backward

246
Q

what are pressure injury prevention plans

A 
Risk Assessment	
---Formal and Informal
Skin Inspection
Pressure Redistribution 
Positioning
Support Surfaces
Nutritional Support
Holistic Care
247
Q

what structure determines how easily skin can tear

A 
Rete pegs ( btw epidermis and dermis 
- size decreases wth age and skiin is more likely to tear/ blister
248
Q

what is maggots

A

Biologic debridement

Sterile fly larvae are placed in the wound

249
Q

what are some surgical management for burns

A
  • primary excision
  • skin grafts
  • skiin substitutes
  • correction of scar contrature
250
Q

what is a primary dressing

A

therapeutic or protective covering applied directly to the wound bed

251
Q

how does the cardiovascular from a burn affect someone

A

shift in dynamics of fluid will lead to edema in interstitial spaces and leads to decreased cardiac output, require IV fluids to perfuse organ which leads to more edema

252
Q

what is closed technique with topical medication

A

cover with dressing if drainage presents

253
Q

what is purulent exudate

A

infected wounds will have pussy tan/ yellow

254
Q

what is primary intention

A
  • Surgical Wounds
  • Wounds are approximated and secured with sutures, staples, or adhesive tapes
  • Healing occurs by epithelialization and connective tissue deposition
  • Heal quickly with minimal scar formation
255
Q

what is dakins solution

A

Diluted sodium hypochlorite (bleach)

256
Q

what are some issues with using enzymes

A

transient erythema or burning

257
Q

what is the indication for transparent films

A

partial thickness, minimally draining or closed wounds, stage I pressure ulcers, skin tears, promotes autolysis

258
Q

what is limb elevation

A

this is a simple way to reduce edema

-essential for pts that cannot adhere or tolerate compression therapy

259
Q

what are some contraindicated for debridemnet

A
  • Dry, stable ischemic wounds or those with dry gangrene

- Stable eschar covering heels

260
Q

how do you use the silicone gell sheet for burns

A

used alone or under compression if compression alone is not effective; can be washed daily and re-used

261
Q

what are the valve dysfunction for venous ulcers

A

Obesity
Pregnancy
Thrombophlebitis
Leg trauma

262
Q

what is secondary intention

A
  • Pressure, vascular, and diabetic
  • Wound edges are not approximated
  • Healing occurs by granulation tissue formation, contraction of wound edges, and epithelialization
  • Heal slowly because of the volume of connective tissue required to fill the defect
  • More prone to infection since they lack the epidermal barrier to microorganisms
263
Q

what is the management of venous ulcers

A

Management includes short-term wound healing and long-term disease management to prevent recurrence.

264
Q

what debridement

A

Removal of non-viable tissue and foreign matter from a wound

Indicated for any wound, acute or chronic, when necrotic tissue or foreign bodies are present, or in the presence of infection

265
Q

what is partial thickness

A
  • damage to the epidermis and partial dermis

- heal primarily by re epithelialization

266
Q

what are arterial ulcers prone to

A

Prone to infection and gangrene

Potential for amputation

267
Q

what is a deep tissue injury pressure injury

A
  • Purple or maroon localized area of intact skin
  • May look like a blood-filled blister
  • Due to pressure or shear
  • May be difficult to detect in darker skin tones
  • Expected to evolve rapidly (into stage III or IV wound) even with optimal care
268
Q

what is eschar

A

= hard, black, leathery, dry

269
Q

how much is the trunk and back rule of nines in a child

A

.

270
Q

is an enzymes treatment selective or non

A

selective

271
Q

what is inflammation

A

Neutrophils (type of WBC) are first to scene and act along with Macrophages to remove the harmful substances

Growth factors are secreted by macrophages to stimulate new blood vessel growth (angiogenesis)

Edema is present

272
Q

what types are there for hydrogel

A

Vigilon, Hypergel

273
Q

is dakins solution selective or non and what makes the treatment easy

A

Non-selective due to cytotoxic properties

Denatures protein making it more easily removed

274
Q

how much is the arms rule of nines

A

.

275
Q

what doyou need to assess when looking at the periwound

A 
Induration
Redness
Erythema
Is it Blanchable?
Callus
Venous changes
Edema
Dry skin
276
Q

what are the precautions for Negative pressure wound therapy

A

active bleeding, over fistulas or exposed blood vessels, over untreated osteomyelitis, in wounds with >20% necrotic tissue, malignancy in the wound

277
Q

what does a topical therapy for wound infection need

A

topical antimicrobial are sometimes indicated to reduce wound bioburnden

278
Q

what is the 4th type of burn

A

full

279
Q

how do you asses the dimensions of a wound

A 
LxWxD
with using the clock 
length = 12-6
width = 9-3 
depth = the deepest part 
OR  you may doing tracings

NO quarter sized OR 2 1/2 always 2.5 cm

280
Q

what type of skin graft are there

A

Autograft, allograft, xenograft

STSG, FTSG, sheet graft, mesh graft

281
Q

what are the different amount of exudate you can state the pt has

A

scant
min
mod
large

282
Q

what are ohter modalities in woundcare

A
  • e stim
  • ultrasoudn
  • mist low frequency non contact us
283
Q

how have maggots become popular

A

Becoming more popular with the rise of antibiotic resistance infections

284
Q

what is contact layers made of

A

Non-adherent woven silicone net placed over wound bed

285
Q

what are the calf muscle dysfunction for venous ulcers

A

Sedentary lifestyle
Jobs that require prolonged standing
Reduced mobility/ shuffling gait
Advanced age

286
Q

What is a Keloid Scar

A
  • Extend beyond original wound border
  • Likely to occur on upper back, chest, deltoid, and -earlobes
  • Very rarely regress
  • Lack myofibroblasts and therefore not associated with contractures
287
Q

how much are the legs rule of nines

A

.

288
Q

what is a venous ulcer

A

-Occur as a result of impaired return of venous blood to the heart, or chronic venous insufficiency (CVI)

  • Normal Venous Function
  • —-Depends on competent valves in the veins and normally functioning calf muscle pump
  • Valve failure causes reflux of the blood which is clinically manifested as edema
  • When the calf muscle fails to contract effectively, the deep veins are incompletely emptied
-Located from mid-calf to ankle, often at medial malleolus
Irregular borders
Usually shallow, can have slough present
Generalized edema to lower leg
Moderate to heavy exudate
Hemosiderin staining of lower leg
289
Q

go through all under slide notes

A

before exam

290
Q

what is conservative sharp debridement used for

A

Removes necrotic tissue quickly, can be done in a serial manner

291
Q

what are other components you must assess when looking at the area of the wounds dimensions

A
  • undermining

- tunneling

292
Q

what color changes in the leg are you looking for

A

elevational pallor

-dependent rubor

293
Q

what type of composites are there

A

Mepilex, Optifoam Gentle

294
Q

what is the hyperbaric o2 therapy for arterial ulcers

A

Increases the amount of oxygen dissolved in the plasma, which results in the delivery of oxygen-rich blood to the tissues.

295
Q

what is LEND

A

lower extremity neuropathic disease

296
Q

what are the forces that lead to skin breakdown

A

1 shear
2 friction

Each clinician must consider all factors and determine to what extent friction played a role in the development of the pressure ulcer.

297
Q

what are some intervention for burns

A

Therapeutic exercises/ROM
Positioning/splinting
Resistive and conditioning exercises—monitor vitals signs
Ambulation
Scar Management—pressure dressings, Silicone gels, massage, camouflage makeup
Prior to discharge instruct in HEP, splinting and positioning program, and skin care routine

298
Q

what are the phases of healting

A
  • hemostasis
  • inflammation
  • proliferation
  • maturation
299
Q

what is the treatment focus for arterial ulcers

A

minimize risk of infection, ongoing assessment of wound deterioration, interventions to reduce pain

300
Q

what is gram (- )

A

Pseudomonas
Acinobacter
Enterobacter
Many others

301
Q

how do you asses the pulse of the leg

A
  • Compare right-left and proximal to distal
  • Noted as present or absent, weak, bounding
  • If unable to palpate, should use Doppler
  • Absence of bilateral pulses by Doppler is indicative of LEAD
302
Q

how do you do limb elevation

A

lay own and elevate the legs above the level of the heart of 1-2 hrs/day and at nigh t
-avoid prolonged sitting or standing

303
Q

what is dakins solution used for

A

Indicated for large amounts of slough and the wound is infected or malodorous

304
Q

what are 2 scar formations that happen

A
  • hypertrophic scar

- keloid scar

305
Q

what is the indication for hydrocolloid

A

partial and full thickness wounds, minimal to moderate exudate, may be used in combination with other dressings (alginates, etc)

306
Q

how is wet to dry debridement used

A

this is a conventional treatment

307
Q

what is the zone of stasis

A

is a risk for further injury if pt does not have adeduate treatment w/i 24-28 hrs

308
Q

what are chronic wound signs of infection

A

often lack classic signs

  • new pain
  • delayed healing despite optimal care
  • friable granualtion tissue
  • new area of breakdwon
  • change in exudate
309
Q

what is the components of wound assessment

A
  • duration of wound
  • location of wound
  • extent of tissue involvement
  • wound bed
  • dimensions
  • exudate
  • odor
  • periwound skin
  • signs of infection
  • wound pain
  • photographs
310
Q

how much is the trunk and back rule of nines

A

.

311
Q

what is varicosisties for venous ulcers

A
  • Swollen, twisted veins that appear blue and close to the surface of the skin
  • May bulge, throb, and cause the legs to swell and feel heavy
  • Varicosities are a clear indicator of LEVD and a predictor of venous ulceration
312
Q

what is surgical sharp debridement

A
  • Used when you need to remove large amounts of tissue or involving life-threatening infection
  • Most often a one-time procedure
  • Risk to patients include: anesthesia, bleeding, sepsis, plus increased costs
313
Q

how long does/ can Negative pressure wound therapy stay on

A

Changed 3x/ week

314
Q

what is undermining

A

Tissue destruction along wound margins under intact skin

315
Q

what is lipodermatosclerosis for venous ulcers

A

Fibrosis or hardening of the soft tissue in the lower leg
Indicative of long standing venous disease
Typically confined to the gaiter or sock area, gives the leg the appearance of an inverted champagne bottle

316
Q

when should composites be changed

A

Changed every 2-3 days

317
Q

what doyou need to filll out in a chart review of burns

A 
Subjective
When wound started?
What has been done so far?
Have you had this type of wound before?
What is your pain level?
How is your diet?
Do you smoke?
How are your blood sugars?

Current reason for admission—does it relate?
Check PMH for comorbidities that may effect wound healing
Labs: Platelets, Hgb A1C, INR, WBC, Albumin, wound culture
Imaging: MRI/X-ray—checking for infection/abscess, vascular scans (arterial doppler/CTA)

318
Q

what is alginate not recommended for

A

not recommended for non-draining wounds

319
Q

how does the pulmonary from a burn affect someone

A

inhalation injury to cause carbon monoxide poisoning, tracheal damage, airway obstruction, pulmonary edema, and pneumonia…may need ventilation or bronchoscopy

320
Q

what types are their for impregnated gauze

A

daptic, Iodoform

321
Q

what does it mean if there is an increase in temp around the ankle

A

venous disease

322
Q

what are you looking at with perfusion of the leg

A
  • venous filling time
  • skin temp.
  • pulses
  • ABI
323
Q

what are some topcial antimicrobial

A
  • antiseptics
  • topical antibiotics
  • topical elemental antimictobial
324
Q

what is the 2nd type of burn

A

superficial partial

325
Q

what is edema

A
  • Assess for edema/ pitting edema
  • Press firmly for several seconds on the dorsum of each foot, behind the medial malleolus, and over the shins.
  • Edema is “pitting” if there is a visible depression that doesn’t rapidly refill and resume original contour
326
Q

how do you know what type of burn they have

A

-calssification as they do not do the staging anymore

  • superficail
  • superficial partial
  • deep partial
  • full
327
Q

what is whirlpool used for

A

Used for large wounds with significant amount of necrotic tissue

328
Q

what types of transparent films

A

Tegaderm, Op-Site

329
Q

what is LEAD

A

lower extremity arterial disease

330
Q

what is the role of compression for burns

A 
Protects skin
Increases circulation
Decreases pain/itching
Reduces amount of scarring 
Realigns collagen fibers
Used to prevent hypertrophic scarring
Increases skin length (provides pressure to contracture bands
331
Q

what are the best dressing selection for burns

A

Foam
Non-adherent
Gauze/Padding
Rolled gauze/netting

332
Q

how do you asses a wound bed

A

in percentages
- viable
OR
-non-viable/ necrotic

333
Q

what ae the surgical options for arterial ulcers

A

Blood flow needs to be re-established

If unable to re-establish—amputation is likely

334
Q

what is xenograft

A

taken from another species (usually pig).

335
Q

what are some characteristics of venous ulcers for venous ulcers

A
  • edema
  • atrophie blanche lesions
  • hmeosiderin staining
  • varicosities
  • lipodermatosclerosis
  • venousdermatitis
336
Q

what are the precaution for impregnated gauze

A

dressing dependent

337
Q

is conservative sharp debridement selective or non

A

selective

338
Q

what are the different types of exudate

A
  • serous
  • serosanguineous
  • purulent
  • pseudomonas
339
Q

what is the best way to augment healing for enzymes treatment

A

the appropriate dressing for good healing

340
Q

what is non-granular

A

= pale red or pink, smooth

341
Q

how often do you need to change alginate

A

Changed daily d/t highly draining wound

342
Q

how much support for stockings is needed for – double layer of tubi grip

A

18-20 mmHg

343
Q

what are some surgical management for edema

A
  • indicted with severe lipodermatosclerosis or persistnet or recurrent ulcerations if they underlying pathology is valve incompetence
  • Most common= ligation and stripping of the veins
344
Q

what is contact layers used for

A

full thickness granular wounds, minimal to heavy exudate, over skin grafts, on painful wounds

345
Q

what are the indication for foam dressing

A

partial and full thickness wounds, minimal to heavy exudate, infected wounds

4 acute care (4 decks)

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