Exam 1 Flashcards
when looking at the limb of apperance what are you looking at
- compare contralateral limb
- edema
- color changes
what are the 2 types of wounds
acute and chronic
what are be allowed to debrided
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
what supplies blood to the epidermis
papillary= capillary supplies vascular and nourishment t o epidermis through osmosi
what is the corneum
top layer
waterproof characteristic, protection from infection
what is elevational pallor
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
what are different types of irrigation
- high pressure irrigation
- pulsativle lavage
what si serous exduate
clear but can have a yellow ting
what does the subcutaneous/ hypodermis contain
-adipose
what is ABI
ankle brachial index
Comparison of perfusion pressures in the lower leg and upper arm using BP cuff and Doppler probe.
what is colonized
bioburden present in a wound bed (normal)
-presence of proliferating bacteria without a host response.
what is primary excision
Surgical debridement of necrotic tissue to achieve viable wound base
what types of gaze are ther and how is it made
4x4’s, Kerlix, may be woven or non-woven
what is anaerobic bacteria
can survive without O2
how much support for stockings is needed for – lymphedema
50-60 mmHg
what are some indications for composites
partial and shallow full-thickness wounds, minimal to heavy exudate
what is the precaution for transparent films
not for infected wounds or wounds with mod-heavy exudate
what is CVI
chronic venous insufficiency (AKA venous stasis)
how do you apply wet to dry debridement
Apply saline moistened gauze to wound bed and allow it to dry, then pull it off
what is topical antibiotics
- 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
what is a stage 1 pressure injury
intact skin with non blanchable redness of a localized area
when shoudl maggots be considered
Considered for use in wounds that have not responded to other forms of debridement
what doesnt a stage 2 pressure injury have
NOT: ----Skin tears ----Tape burns ----Maceration ----Excoriated perineal tissue Does not have slough or eschar present NO undermining or tunneling present
what do neuropathic/ diabetic ulcers look like
Well defined border, often with a callus
Pale or red wound bed
Little to no granulation
Minimal to moderate exudate
what is a open technique with topical medication
apply ointment only not covering
How do you manage a arterial ulcer
- hyperbaric oxyen
- lifestyle changes
- topicla therpya
- surgical options
What is PVD
peripheral vascular disease
what is proliferation
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
what is autolysis debridement
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
what is non-viable tissue
- Eschar
- Slough
what is the 1st type of burn
superficial
what can a pt do for a burn patient
Improve impaired mobility and ROM that resulted from injury.
Assist pt to return to his/her PLOF
Interventions:
where shoudl caution with maggots happen
Caution to avoid contact with healthy skin.
what is hemostasis
Vasoconstriction
Platelets aggregate to form a clot
how does the neuropathy from a burn affect someone
polyneuropathy (multiple sites) vs local (usually from tx for burn)
what is hemosiderina staining for venous ulcers
- 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
what is an unstageable pressure injury
- 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
what is Granulation
= beefy red new growth, cobblestone
what does a pressure injury depend on
Duration and Intensity of pressure
Low pressure for a prolonged period of time
High pressure for a short period of time
what fx fo the skin can burn affect
all of them
why are foam dressing good to use
Non-adherent, conformable
what is a caution with conservative sharp debridement
Use caution with pts on anticoagulants
what are the stages a pressure injury can be
stage 1, 2, 3, 4, deep tissue injury, unstageable
what is the foam dressing
Semi-permeable hydrophilic foam
what does transparent films look like
Thin, transparent polyurethane film
what are some traumatic wounds types
Degloving injuries
Amputation
when is a wound culture indicated
- s/s of infections
- clean wound does not show progress in healing for 2 weeks
what is venous dermatitis for venous ulcers
Inflammation of the epidermis and dermis
Results in scaling, crusting, weeping erosions and intense itching and discomfort
how is dakins solution applied
Applied as a wet-dry dressing, BID
what are some contraindications for compression therapy
to high level sustained compression
- uncompensated heart failure
- co-existing peripheral arterial disease
what is laser debridement
- 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
what is full thickness
- 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
how long is dakins solution used for
Used for less than 10-14 days
how much is the arms rule of nines in a child
.
when will wet to dry debridement not be effective
If the gauze is moistened before removal, it’s not as effective
what are some factors that impair healing
Edema Vasoconstriction Vascular Disease Smoking Infection Sepsis Renal Disease Diabetes Obesity Corticosteroids Age Stress Malignancy Pulmonary Disease
what are some skin graft basics
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
what is friction force
= 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.
what is the granulosum
middle layer
responsible for water retention
how do you get hydrogel
Available as an amorphous gel (in a tube), or as a sheet
what does the wound pain look like
- can be constant or only with dressing changes
- ensure adequate pain relief during dressing changes
how do you know if you have venous issues
edema, varicosities, hemosiderin staining, and dermatitis, irregular boarders
what is the spinosum
middle layer
adds layer of protection
what is the zone of coagulation
the area where the burn was
at what time does scar tissue mature
Scar tissue matures in 12-18 months
what is the lifestyle changes for arterial ulcers
Stop smoking, ideal weight, adequate nutrition
what are some disadvantages of maggots
Patients report crawling sensation as main disadvantage
what are some indications for gaze
partial and full thickness wounds, infected wounds, wounds with tunnels
what are some facts of the epidermis
- no blood vessel presen t
- sheds and regenerates
- 80-90% of cells are kerationcytes
what are some precautions with whirlpool
- vasodilatation and increased circulation to the wound (not good for venous ulcers)
- Diabetics with loss of protective sensation
how much is the head rule of nines
.
what is the 3nd type of burn
deep partial
what is tunneling
- Opening that leads away from a wound
- Can lead to abscess formation if not properly packed
what does damage to the motor nerves causes
causes structural deformities and gait abnormalities
what are the part to the dermis
collagen and elastin
- primary cells are fibroblasts
- lyer that granulates
- need proteins to make collagen
how do describe the location of the wound
using anatomical indicators
was are the indication for Negative pressure wound therapy
acute and chronic wounds with depth, partial and full thickness wounds, partial thickness burns, over grafts
what are some uses of silver nitrate
To control hypergranulation
Epibole (rolled wound edges)
Aids in hemostasis
how do you asses the skin temp of the leg
palpate moving form proximal to distal and compare right to left
what is the fx of the skiin
Temperature regulation Secretion of oils for moisture Portal for sweat glands and hair follicles Vitamin D synthesis Identity
what type of hydrocolloid are there
Duoderm, Exuderm
primary or secondary for alginate
Primary dressing
what are arterial ulcers caused by
Due to severe tissue ischemia, extremely painful
how often do you need to change a foam dressing
Changed daily, or up to 3x/ week
when is wet to dry debridement used
Used ONLY for heavily necrotic, or infected wounds
how do you medically manage a burn
- Establish and maintain and airway
- Prevent cyanosis, shock, or hemorrhage
- Establish baseline data such as extent and depth of burn
- Prevent or reduce fluid loss
- Clean the injury—includes early debridement by physician/PT, possible whirlpool therapy
- Examine injuries
- Prevent pulmonary and cardiac complications
what is infection bacteria
bacteria penetrate into viable parts of tissue and elicit a host response.
how much support for stockings is needed for – varicose veins
20-30 mmHg
what are skin substitutes
Cultured epidermal autografts
Cultured autologous composite grafts
Allogenic skin substitute
Cultered dermis—temporary and definitive
how do you know venous filling time
- 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.
where are neuropathic/ diabetic ulcers found
on the foot
- Plantar surface over metatarsal heads
- Toes and sides of feet
how loong do you keep gaze on
Changed as needed based on saturation, usually daily, BID, or TID
what is a trac
small underminining that does not connect to another wound area
where is 12 oclock pointing to
the head of the pt
how long can a contact layers be on
Contact layer stays in place up to 7 days, absorptive layers are changes as needed
what is edema with the venous system for venous ulcers
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
what is LEVD
lower extremity venous disease
how does the heterotopic ossification from a burn affect someone
from immobilization, most common in elbows, hips, and shoulders
what is the best way to manage the same class in the classroom
Compression Therapy
Limb Elevation
Surgical Procedures
Physical Therapy
what is hight pressure irrigation
- 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
how do you handle the scar management for a burn
Silicone gel sheet
Masks
Scar Massage
what do you need to asses with burns
- 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
what is granulation tissue
Red buds which are beginning of new skin formation
Made from connective tissue and capillaries
what is gram (+)
Staph (MRSA/MSSA)
Strep
Enterococcus
Many others
what depth does the superficial go to
epidermis
what are some surgical wound types
Dehisced
Tertiary Intention
Flaps/ Grafts
what is the general assessment of the lower leg
- appearance of the limb
- perfusion
- sensory fx
- range of motion
- pain
- pulse
what are the characteristics of superficial
pain
redness
mild swelling
no scarring
what are some precautinos for hydrogel
not for heavily exudating wounds, monitor for maceration or yeast development
what is viable tissue
- Granulation
- Non-granular
- Muscle or subcutaneous tissue
what are some cons to wet to dry debridement
Painful
Not good for heavily exudative wounds
what is hydrocolloid
Adhesive, absorptive, impermeable barrier, can be used for autolytic debridement
what are come compressions types
- non-elastic
- elastic
what are the precautions of foam dressing
not for dry wounds or those with tunnels
what is chemcial debridement
Enzymes, Dakin’s Solution, Maggots, Silver Nitrate
why is conservative sharp debridement preferred
Preferred method of debridement for infected wounds
is whirlpool selective or non
Non-selective
what are the risk factor fo rvenous ulcers
- valve dysfunciotn
- calf muscle dysfunction
what is impregnated gauze made of
Woven gauze impregnated with petroleum, zinc, saline, etc.
how often does the impregnated gauze need to be changed
changed daily
what are the values for the abi
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
what can cause chronic wounds
Underlying pathology
Prolonged inflammatory phase
Low levels of growth factors
Miscellaneous host factors
-Ischemia
-Malnutrition
-Co-morbidities (such as diabetes)
Denervationwhat is the order of the skin
epidermis
dermis
sub Q
what is dependent rubor
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
what are some indication for hydrogel
partial or full thickness wounds, dry to minimal exudate, necrotic wounds (assists with autolytic debridement), infected wounds
what are the characteristics of ful
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
where are the 2 leg pusles
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.
what does damage to the sensory nerves cause
loss of protective sensation
what is topcial elemental antimicrobials
- 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
what is cleaning of a wound infection need
- 4-15 psi with water or normal saline
- aimed at reducing surface contaminant rather than curing infections
what is a stage 4 pressure injury
- 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
what is a enzymes
Collagenase Santyl
what is slough
= yellow, tan, or gray, slimy, moist
what types of contact layers are there
Mepitel Silicone Dressing, Tegapore, Sorbact
what depth does the deep partial got to
dermis : reticular region
what is elastic
Profore
Surepress
Support Stockings
what is serosanguineous exudate
yellow with red ting
what is critically colonized
clinically assessed as pint wound is about to be infected
what is a disadvantage of conservative sharp debridement
Can be uncomfortable for the patient
what are some common medicatino for topical medication ffor burns
Silver sulfadiazine (Silvadene) Sulfamyalon Silver Nitrate solution and sticks Bacitracin/Polysporin Collagenase (Santyl®)
what are the type sof compression for burns
Elastic wraps (ACE)
Tubular bandages (Tubi-grip)
OTC garments
Custom garments
what are some precautions of gaze
adheres to wound tissue for non-selective debridement, may dry out wound
when do you change the hydrogel
changed dailiy
what is aerobic bacteria
needs O2 to survive
what is atrophie blanche lesion for venous ulcers
Smooth, white plaques of thin, atrophic tissue speckled with tortuous vessels
Represents spontaneously developing lesions
High risk for ulceration
what is an acute wound
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
how much is the head rule of nines in a child
.
what makes up vascualr ulcers
70-75% are primaryily due to chronic venous insufficieny
25-30% are attributed to arterial or mixed disease
what is hydrogel amde of
Composed of water or glycerin
how much support for stockings is needed for – treatment for venous ulcers and lymphedema
40-50 mmHg
how does Negative pressure wound therapy work
Black or white foam is placed in the wound, sealed with semi-occlusive drape, and connected to pump
what is chronic wound
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
what are the characteristics of deep partial
white leathery relatively painless growth is slow grafting is preferred treatment high risk of infection severe scarring can convert to full thickness
Wound vac application
slide 97
how do you know if you have arterial issues
thinning of the epidermis, loss of hair growth, thickened nail
what are the different categorizes of wounds
⚫ Chronic ⚫ Pressure Ulcers ⚫ Arterial ⚫ Venous ⚫ Neuropathic/ Diabetic ⚫ Traumatic ⚫ Surgical ⚫ Burns ⚫ Other
what are some concerns with whirlpool
cross-contamination between patients who use the whirlpool
what are the objectives of physiologic wound environment
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
what is a compression therapy
- 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
what is Negative pressure wound therapy
Wound V.A.C.
other modaliliteis notes
slide 82
what skin grafts are temporary
Allografts and xenografts are temporary until skin is availabe for autograft
what is a secondary dressing
used to increase the ability for the wound needs to be adequately met and/ or secure the primary dressing
what is used with whirlpool treatment
Water is most commonly used, optimal temperature 37ºC
when should enzymes stopped being used
once viable tissue is revealed and necrotic tissue is removed
what is allograft
taken from a cadever
what should the wearing schedule be for compression with a burn
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
what forms does alginate come from
Rope or pad form
what is the recurrence rate of venous ulcers
Recurrence rates as high as 57-97%
what can the periwound skin look like
- Normal
- Hypopigmented
- Light red/ pink
- Tape Stripped/ Denuded
- Macerated
- Excoriated
- Indurated
- Boggy
- Elevated temperature
- Edema
how much support for stockings is needed for – venous ulcer treatment
30-40 mmHg
what are some treatment of a wound infection
- oral antibiotics
- cleaning
- debridement
- topicla therapy
how much support for stockings is needed for – ted hose
15-17 mmHg
what does it mean with unilateral coolness and sudden coolness form proximal to distal of the leg
arterial disease
how do the maggots work
The larvae secrete proteolytic enzymes and break down necrotic tissue
how shoudl a culture be taken
form a clean, healthy-appearing tissue, not form pus, slough, eschar, or necrotic materail
what is PAD
peripheral arterial disease
how does the metabolic from a burn affect someone
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);
what are some facts of the dermis and what does it contain
- Responsible for vascular supply and nourishment to skin/epidermal layer
- Nerves
- Glands
- Fibroblasts
how much are the legs rule of nines in a child
.
what are the different types of wound care dressings
Alginate Composites Contact Layers Foam Dressings Gauze Hydrocolloid Hydrogel Transparent Film Negative Pressure Wound Therapy (NPWT)
what is contact layers not used for
not for use in shallow or dry wounds, or with viscous exudate
what types of foam dressing are there
Allevyn, Lyofoam, Mepilex
what is a Hypertrophic scar
- Confined to area of original injury
- Commonly over joints
- May regress spontaneously
- Associated with contractures
what is non- elastic
Unna Boot
Circ-Aid
Comprilan (lymph wraps)
how does the infection from a burn affect someone
leading cause of death in combination with organ system failure, can develop sepsis, MDROs
wha tis necrotic tissue
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
what is sanguineous exudate
red or bloody
what is antiseptics
- 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)
what depth does the full
hypodermis (subcutaneous tissue)
what is the scar massage for burns
start just moving skin with no friction; begin with skin is durable enough to not blister
what are the zones aroudn the burn
- zone of coagulation
- zone of stasis
- zone of hyperemia
what does damage to the autonomic nerves cause
decreased sweating cause cracks, fissures, and callus
what are the indication for impregnated gauze
partial or full-thickness wounds, infected wounds, wounds with tunnels
how do you get enzymes treatment
prescription
what depth does the superficial partial go to
dermis: papillary region
what are the layers of the epidermis
- corneum
- lucidum
- granulosum
- spinosum
- basale
what is alginate good for
full thickness, undermining, tunnel, moderate to heavy exudate, infected wounds, malodorous wounds
what types of alginate are their
Aquacel, Sorbsan, etc
what is stage 2 pressure injury
- 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
how often do you change hydrocolloid
Changed up to 3x/ week
what are some methods of debridement
- autolysis
- chemical
- mechanical
- sharp
what is mechanical debridement
Wet-to-Dry Debridement, Irrigation, Whirlpool
how do you pick a wound care dressing
using the 8 objective of physiologic wound enviroment
what is a stage 3 pressure injury
- 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
what are some characteristics of arterial ulcers
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!
precautions for hydrocolloid
not for 3rd degree burns, or wounds with heavy exudate, or wounds with depth, may contribute to hypergranulation
what do composites combine
impermeable barrier, an absorptive layer, a non-adherent contact layer, and an adhesive border
what is a pressure injury
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
how is more vulnerable for pressure injuries
Elderly (over 65 y.o.) Spinal Cord Injuries Children in the ICU Surgical Patients Patients dependent for mobility Patients with incontinence
when does the transparent films need to be changed
Changed up to every 7 days
what is pseudomonas exudate
has bright green tinted exudate and sweet but foul oder — they need antibotics
do you need a secondary dressign for alginate
Secondary dressing is required
what is the rule of nines
.
how to take a photo of a wound
- pt identifier in the picture
- have disposable tape measure in the picture
is wet to dry debridement selective and non
non-selective
where does it come from alginate
Derived from seaweed
what are the types of burns
Scalds- liquid,grease,steam Contact burns Fire-flash and flame burns Chemical Electrical Radiation
what are the different odors can there be in a wound
absent
mild
moderate
strong
what are some complication form a burn
Infection Pulmonary Metabolic Cardiovascular Heterotopic Ossification Neuropathy Pathological Scars
what does debridement of a wound infection need
removes dead tissue to facilitate healing
how do you describe the extent of tissue involvement
- ONLY use “number stages for pressure ulcers
- use superficial, partial and full thickness for all other wounds
what is sharp debridement
Conservative Sharp Debridement, Surgical Sharp Debridement, Laser Debridement
what causes neuropathic/ diabetic ulcers
damage to —
- sensory nerves
- motor nerves
- autonomic nerves
what is tertiary intention
- 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
what are the characteristics of superficial partial
very pain blisters spiotchy skind severe swelling good blood supply no scars
how does the reticular layer attach to the subQ
with fibrous connective tisse
what is autograft
taken from pts own skin, allograft
what are some other wound types
Necrotizing Fasciitis Extravasation injuries Fistula Pyoderma Granulosum Calciphylaxis
what are the tocial therapy for arterial ulcers
Keep dry if possible
Debride only if infected
what is pulsatile lavage
- 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
what is the lucidum
middle layer
only present in thicker areas soles of feet, palms, and pads of fingertips
what are the types of wound closure
- primary intention
- secondary intention
- tertiary intention
what is shear force
= combination of friction and gravity
Sliding down the bed when HOB is elevated greater than 30º
Common in sacral area
what are local signs of infeciton
increased purulent exudate
- induration
- warmth
- pain or tenderness
- erthema
Does contact layers need a 2n layer
Requires secondary dressing
what is the basale
bottom layer
contains cells that allow epidermis to regenerate and melanocytes which give the skin its color.
what does Negative pressure wound therapy do
wound closure
how fast is the enzymes treatment
slow
what is maturation
Remodeling of scar tissue occurs for one year post wound closure
Scar tissue will only regain ~2/3rds the original strength
how to tell stage 1 in darker pigmented skins
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
how is aggressive is conservative sharp debridement
Most aggressive form of debridement that can be done by non-physicians
how do you help a dry eschar with enzymes
must be cross hate\ched and wound must be kept moist
what are some systemci signs of infection
- fever
- malaise
- chills
- confusion
how is pressure injury stages
using numbers and NEEDS to be done right
– you can never go backward
what are pressure injury prevention plans
Risk Assessment ---Formal and Informal Skin Inspection Pressure Redistribution Positioning Support Surfaces Nutritional Support Holistic Care
what structure determines how easily skin can tear
Rete pegs ( btw epidermis and dermis - size decreases wth age and skiin is more likely to tear/ blister
what is maggots
Biologic debridement
Sterile fly larvae are placed in the wound
what are some surgical management for burns
- primary excision
- skin grafts
- skiin substitutes
- correction of scar contrature
what is a primary dressing
therapeutic or protective covering applied directly to the wound bed
how does the cardiovascular from a burn affect someone
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
what is closed technique with topical medication
cover with dressing if drainage presents
what is purulent exudate
infected wounds will have pussy tan/ yellow
what is primary intention
- 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
what is dakins solution
Diluted sodium hypochlorite (bleach)
what are some issues with using enzymes
transient erythema or burning
what is the indication for transparent films
partial thickness, minimally draining or closed wounds, stage I pressure ulcers, skin tears, promotes autolysis
what is limb elevation
this is a simple way to reduce edema
-essential for pts that cannot adhere or tolerate compression therapy
what are some contraindicated for debridemnet
- Dry, stable ischemic wounds or those with dry gangrene
- Stable eschar covering heels
how do you use the silicone gell sheet for burns
used alone or under compression if compression alone is not effective; can be washed daily and re-used
what are the valve dysfunction for venous ulcers
Obesity
Pregnancy
Thrombophlebitis
Leg trauma
what is secondary intention
- 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
what is the management of venous ulcers
Management includes short-term wound healing and long-term disease management to prevent recurrence.
what debridement
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
what is partial thickness
- damage to the epidermis and partial dermis
- heal primarily by re epithelialization
what are arterial ulcers prone to
Prone to infection and gangrene
Potential for amputation
what is a deep tissue injury pressure injury
- 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
what is eschar
= hard, black, leathery, dry
how much is the trunk and back rule of nines in a child
.
is an enzymes treatment selective or non
selective
what is inflammation
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
what types are there for hydrogel
Vigilon, Hypergel
is dakins solution selective or non and what makes the treatment easy
Non-selective due to cytotoxic properties
Denatures protein making it more easily removed
how much is the arms rule of nines
.
what doyou need to assess when looking at the periwound
Induration Redness Erythema Is it Blanchable? Callus Venous changes Edema Dry skin
what are the precautions for Negative pressure wound therapy
active bleeding, over fistulas or exposed blood vessels, over untreated osteomyelitis, in wounds with >20% necrotic tissue, malignancy in the wound
what does a topical therapy for wound infection need
topical antimicrobial are sometimes indicated to reduce wound bioburnden
what is the 4th type of burn
full
how do you asses the dimensions of a wound
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
what type of skin graft are there
Autograft, allograft, xenograft
STSG, FTSG, sheet graft, mesh graft
what are the different amount of exudate you can state the pt has
scant
min
mod
large
what are ohter modalities in woundcare
- e stim
- ultrasoudn
- mist low frequency non contact us
how have maggots become popular
Becoming more popular with the rise of antibiotic resistance infections
what is contact layers made of
Non-adherent woven silicone net placed over wound bed
what are the calf muscle dysfunction for venous ulcers
Sedentary lifestyle
Jobs that require prolonged standing
Reduced mobility/ shuffling gait
Advanced age
What is a Keloid Scar
- 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
how much are the legs rule of nines
.
what is a venous ulcer
-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
go through all under slide notes
before exam
what is conservative sharp debridement used for
Removes necrotic tissue quickly, can be done in a serial manner
what are other components you must assess when looking at the area of the wounds dimensions
- undermining
- tunneling
what color changes in the leg are you looking for
elevational pallor
-dependent rubor
what type of composites are there
Mepilex, Optifoam Gentle
what is the hyperbaric o2 therapy for arterial ulcers
Increases the amount of oxygen dissolved in the plasma, which results in the delivery of oxygen-rich blood to the tissues.
what is LEND
lower extremity neuropathic disease
what are the forces that lead to skin breakdown
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.
what are some intervention for burns
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
what are the phases of healting
- hemostasis
- inflammation
- proliferation
- maturation
what is the treatment focus for arterial ulcers
minimize risk of infection, ongoing assessment of wound deterioration, interventions to reduce pain
what is gram (- )
Pseudomonas
Acinobacter
Enterobacter
Many others
how do you asses the pulse of the leg
- 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
how do you do limb elevation
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
what is dakins solution used for
Indicated for large amounts of slough and the wound is infected or malodorous
what are 2 scar formations that happen
- hypertrophic scar
- keloid scar
what is the indication for hydrocolloid
partial and full thickness wounds, minimal to moderate exudate, may be used in combination with other dressings (alginates, etc)
how is wet to dry debridement used
this is a conventional treatment
what is the zone of stasis
is a risk for further injury if pt does not have adeduate treatment w/i 24-28 hrs
what are chronic wound signs of infection
often lack classic signs
- new pain
- delayed healing despite optimal care
- friable granualtion tissue
- new area of breakdwon
- change in exudate
what is the components of wound assessment
- duration of wound
- location of wound
- extent of tissue involvement
- wound bed
- dimensions
- exudate
- odor
- periwound skin
- signs of infection
- wound pain
- photographs
how much is the trunk and back rule of nines
.
what is varicosisties for venous ulcers
- 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
what is surgical sharp debridement
- 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
how long does/ can Negative pressure wound therapy stay on
Changed 3x/ week
what is undermining
Tissue destruction along wound margins under intact skin
what is lipodermatosclerosis for venous ulcers
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
when should composites be changed
Changed every 2-3 days
what doyou need to filll out in a chart review of burns
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)
what is alginate not recommended for
not recommended for non-draining wounds
how does the pulmonary from a burn affect someone
inhalation injury to cause carbon monoxide poisoning, tracheal damage, airway obstruction, pulmonary edema, and pneumonia…may need ventilation or bronchoscopy
what types are their for impregnated gauze
daptic, Iodoform
what does it mean if there is an increase in temp around the ankle
venous disease
what are you looking at with perfusion of the leg
- venous filling time
- skin temp.
- pulses
- ABI
what are some topcial antimicrobial
- antiseptics
- topical antibiotics
- topical elemental antimictobial
what is the 2nd type of burn
superficial partial
what is edema
- 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
how do you know what type of burn they have
-calssification as they do not do the staging anymore
- superficail
- superficial partial
- deep partial
- full
what is whirlpool used for
Used for large wounds with significant amount of necrotic tissue
what types of transparent films
Tegaderm, Op-Site
what is LEAD
lower extremity arterial disease
what is the role of compression for burns
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
what are the best dressing selection for burns
Foam
Non-adherent
Gauze/Padding
Rolled gauze/netting
how do you asses a wound bed
in percentages
- viable
OR
-non-viable/ necrotic
what ae the surgical options for arterial ulcers
Blood flow needs to be re-established
If unable to re-establish—amputation is likely
what is xenograft
taken from another species (usually pig).
what are some characteristics of venous ulcers for venous ulcers
- edema
- atrophie blanche lesions
- hmeosiderin staining
- varicosities
- lipodermatosclerosis
- venousdermatitis
what are the precaution for impregnated gauze
dressing dependent
is conservative sharp debridement selective or non
selective
what are the different types of exudate
- serous
- serosanguineous
- purulent
- pseudomonas
what is the best way to augment healing for enzymes treatment
the appropriate dressing for good healing
what is non-granular
= pale red or pink, smooth
how often do you need to change alginate
Changed daily d/t highly draining wound
how much support for stockings is needed for – double layer of tubi grip
18-20 mmHg
what are some surgical management for edema
- indicted with severe lipodermatosclerosis or persistnet or recurrent ulcerations if they underlying pathology is valve incompetence
- Most common= ligation and stripping of the veins
what is contact layers used for
full thickness granular wounds, minimal to heavy exudate, over skin grafts, on painful wounds
what are the indication for foam dressing
partial and full thickness wounds, minimal to heavy exudate, infected wounds
