Exam 1- Wounds 2 Flashcards
Predisposing factors for Arterial Wounds (9)
~Atherosclerosis ~BP issues ~PVD ~cholesterol ~Raymond's ~obesity ~sedentary lifestyle ~diabetic ~smoking
Predisposing factors for Venous Wounds (6)
~Obesity ~PVD ~CHF ~varicose veins ~people up on their feet all their time (in a dependent position all the time) ~lack of exercise
Predisposing factors for Neuropathic/ Diabetic Wounds (3)
~Obesity
~diabetics type I or type II
~any other thing that would cause sensory loss
Anatomic location for Arterial wound (3)
~LE
~on the lateral side more distal
~lateral mal,dorsum of foot, tips of foot, head of toes, occasionally in between toes
Anatomic location for Venous Wound (2)
~LE on medial
~more proximal, but can go all the way down
Anatomic location for Neuropathic/ Diabetic Wounds (2)
~Over top of weight bearing surfaces
~planter surface, met heads, heels (very flat arch), hammer toes (knuckles of the toes)
Other features of Arterial Wounds (3)
~Skin- dry, thin, shinny, hairless, pale, white, cold
~toes nails- very thick
~fat pads will die off
Other features of Venous Wounds (6)
~Veins will dilate/ varicose veins- not coming back to the heart
~interstitials fluid
~gets hard feeling- brawny, looks like cankles, there will be weeping (the IF will have to go somewhere)
~macerated/ breaks down the skin
~warm skin
~feel fatigue (caring lbs of fluid in the legs)
Other features of Neuropathic/ Diabetic Wounds (6)
~Fat pads will die off ~calluses formation- leave them (protection) ~cold, dry skin ~hair loss ~thick toenails ~should still be able to find a pulse
Margins of Arterial Wounds (3)
~white
~pale
~regular/ very even pattern
Margins of Venous Wounds (2)
~heaped edges
~irregular
Margins of Neuropathic/ Diabetic Wounds (3)
~even
~round
~typically small and deep
*will be fine one day and the next will go all the way down to the bone
Color of the Wound- Arterial
Pale
Color of the Wound- Venous
Granular, reddish brown
Color of the Wound- Neuropathic/ Diabetic
Pale
Color of the Periwound- Arterial
~blanched
~black
~gangrene (dead tissue)
Color of the Periwound- Venous
~hyperpigmentation (hemoglobin)
~Hemosideran staining- get little red dots all over you (the heme breaks down and causes red dots; does not go away)
Color of the Periwound- Neuropathic/ Diabetic (3)
~pale
~inelastic
~firm
Pain level for Arterial Wound
there will be the most pain with this wound (unless the wound goes far enough down that the nerves have been killed)
Pain level for Venous Wound
little to no pain
Pain level for Neuropathic/ Diabetic Wound
little to no pain
Exudate level for Arterial Wound
Minimal (will normally have to add moisture)
Exudate level for Venous Wound
Moderate to max (weeping)
Exudate level for Neuropathic/ Diabetic Wound
dry (you will be adding fluid)
Depth level for Arterial Wound
Deep
Depth level for Venous Wound
Shallow
Depth level for Neuropathic/ Diabetic Wound
Deep
Other for Arterial Wound (3)
~gangrene
~necrosis
~cellulitis
Other for Venous Wound (1)
~80% of what we look at
Other for Neuropathic/ Diabetic Wound (2)
~cellulitis
~osteomyelitis
What are some things you can do for CHF/ be careful bc of CHF?
(chronic heart failure) ~give a water pill ~wrap and elevate ~have a catheter ~be careful with pushing out the water so that you do not push too much fluid into their heart- "drown" the pts heart
Do we cut pts nails?
NEVER!
what are ways that we can measure arterial insufficiency?
~pulse
~ABI
~cap refills
Diabetics should never go to..
water parks, pools, NAIL SALONS
Fem-Pol surgery
~when you do a bypass around the femoral inguinal part that is not getting blood supply
~this will be a painful for the pt bc they did not have good blood flow; he nerves were dying off and now they are waking back up (you will come in and walk them- they are in pain from the nerves waking back up)
what is cellulitis?
infection (wide spread) over the skin; can get it from bug bites
Why do diabetics get osteomyelitis?
~in a diabetic would, will get break down over a body prominence and the wound will be deep.
~we do not have that much depth in the foot, so it is easy to get all the way to the bone
What are some Don’ts for arterial wounds? (5)
~don’t elevate and compression (bc they do not have enough blood)
~don’t wear tight socks/ shoes, etc (causes compression)
~don’t sit in the lazy boy with the legs up (they like to do this bc they feel less pain, but they should be in the dependent position and get more blood to their legs)
~Don’t cross your legs
~don’t use sharp debridement
What are some DOs for arterial wounds?
~keep calluses (good for protection)
~whirl pool (can increase blood flow and add moisture; makes sure to check the temperature)
~educate about smoking
~dressing- add moisture
What are some things you can do for a venous wound?
~there is too much moisture (edema)
~compression wrapping/ garments (make sure to check cap refill and pain)
~vasonumatic pump
~elevation
~walk them, and then put their legs up (get their blood moving before elevating
~clean the wound out (make sure you are cleaning out more slough than is being produced)
~don’t stand them for long periods of time
What are some things you would do for a diabetic wound?
~PREVENTION! (this really shouldn’t happen if they are doing what they are supposed to do)
~Education (keep the sugar low; keep you sugars where they are supposed to be)
~Foot inspections
~avoid pressure points (have a mat, insoles, special shoes- to spread the pressure from one point)
Pressure ulcers (two other names)
~bed sores
~decubitus ulcers
Pressure ulcers (where do you get them) (12)
*almost always over top of bony prominences ~Occiput ~spine of scapula ~spinous processes (C7, t-spine) ~acromion ~elbow ~ribs ~sacrum, ~ischial tub ~greater troh ~knees (med and lat) ~malleoli (med and lat) ~heel (back of the heel)
What type of wounds do you stage?
pressure ulcers
How many stages are there when staging a wound?
5: 1, 2, 3, 4, unstageable
Details of a stage 1 wound
~Epidermis is intact- good to catch to wound NOW, protect!!
~Changes in your skin- temperature, inflammation or pooling of blood
~Over a boney prom
~Not as good blood flow
~Unblanchable redness in light skinned people
~Induration- nonblanchable, different firmness (not firm, not bogey)
Details of a stage 2 wound
~Epidermis is being disrupted (lifted up- not where is it supposed be)
~May or may not involve partial thickness of the dermis
~Can have a blister- NEVER POP IT- it doesn’t have infection; protect it at all cost
~Shallow crater if any
Details of a stage 3 wound
~All the way through the dermis and epidermis
~Subcu fat may be visible (not any deeper)
~Tunneling and undermining
~Deep crater (very deep depending on the weight of the pt and the place)
~Not through the fascia
Details of a stage 4 wound
~Though the fascia (subcut, etc)
~May see joint capsule, tendons, ligaments, muscles, etc
~Deep crater going out even more (and/or tunneling/ undermining)
~Basement membrane will be muscle or bone
Details of an unstageable wound
~If you can’t see the bottom of the crater- eschar, slough, necrotic tissue in the way
~May have to clean it out before you can clean it out
~As a pressure ulcer heals, it does not go back (healing stage 3 or healed stage 3); have to heal from bottom up and it does not heal the same tissue (can more replace muscle, etc) (The grades can get worse- a stage 3 can become a stage 4, but a stage 4 cannot become a stage 3 {healing stage 4/ healed stage 4})
~Can occur in the same spot bc it is not the same type of tissue/ not as strong
People who are likely to get wounds
~Spinal cord ~Coma/ TBI ~Elderly ~Obese/ thin ~Stroke ~Diabetes ~bed ridden ~Motor Loss and/or Sensory Loss
What do you do for a pt that is bed ridden to try and avoid wounds?
~Can only leave someone in that position for 2 hours; will rotate the patient side to side in the 2 hours; basement structures will not get nutrients/ etc to the underlying
What is a fistula?
a tunnel that has been created between the intestines or urinary canal or other organs (reproductive organs) and the wound
Undermining
there will be a flap of skin on top of the dugout wound
Rule of 30
~do not elevate the bed higher than 30* (will create shear on the back/ cause bad alignment)
~elevate the head higher than 30*
~rotating the pt to 30* (on the buttocks, not greater trochanter or the ischial tubs)
