Exam 2 Flashcards
What are the five intervention principles?
- discern inflammation vs. infection
- determine if the wound is acute or chronic
- control/create the ideal wound environment
- control epithelialization
- check the client and the wound every day
How do you create the ideal wound environment?
- free from necrotic tissue and exogenous pathogens
- free from excess exudates
- moist
- warm/sufficient blood perfusion
- acidic/maintenance of voltage gradients
- protected
T/F: There is never an indication for a dry wound.
True
Principles of Moist Wound Healing
- cover the wound with a barrier that preserves adequate wound hydration
- limit water loss from the wound surface while dressing is in place
- allow gaseous exchange
- maintain peri-wound tissue integrity
- control heavy exudates
- remove dressing when exudate begins to leak out from edges of dressing (usually 3-5 days)
Guidelines for whirlpool use
- treat small areas for short periods (10-15 mins)
- minimal or no agitation
- aim for neutral warmth
Indications for whirlpool use
- wounds that need intensive cleaning
- thermal injuries that need water cleansing
- soften tissue when other methods are not effective
- stimulate peripheral circulation on selected patients
- heat large areas to raise core temp to normal
Surfactants need to be diluted ____ before using on a wound
1:10
Contraindications for surfactant on a wound
psi ≥ 8-8.6 or clean wounds that are ready to be dressed
When is Providine-Iodine (Betadine®) indicated?
when staph aureus is present in a wound; requires a punch biopsy to determine
When is sodium hypochlorite solution indicated?
infected wounds; surgery prep
When is Dakin’s solution indicated?
staph and/or strep are present in the wound
When is acetic acid solution indicated?
pseudomonas auruginosa is present in the wound; contraindicated when there are exposed metal implants and CAI
When is hydrogen peroxide contraindicated?
absence of infection, a tunneling wound, or when there is granulation tissue
When are OTC antibiotic/antimicrobial creams and ointments contraindicated?
healing wounds
When are prescription antibiotic/antimicrobial creams and ointments indicated? Contraindicated?
usually following surgery as a precaution; CAI, on sensitive skin, or in patients with renal failure
When are growth factors indicated? Contraindicated?
indicated in chronic wounds, but contraindicated in infected wounds and those with a hx of skin cancer
When is zinc indicated? Contraindicated?
indicated in venous leg ulcers, but contraindicated in infected wounds d/t the compression
When is chlorazine indicated? Contraindicated?
indicated in infected wounds and in patients who are immunosuppressed, but is contraindicated in the absence of infection
When is silver nitrate indicated? Contraindicated?
indicated to stop over-granulation, in burn patients, and has a wide antibacterial spectrum. However, it does not penetrate eschar and should not be used on clean, granulating wounds
When is silvadene indicated? Contraindicated?
indicated in burn patients, has a wide antibacterial spectrum, and can be used to soften eschar. However, it should not be used in patients who are allergic to sulfa or on clean, granulating wounds. It must also be removed frequently about every 8 hrs.
When is sulfamylon indicated? Contraindicated?
used as a partner to silvadene and is indicated in burn wounds and as an alternative to silvadene. It also has a wide antibacterial spectrum. However, it should not be used in clean, granulating wounds or in patients with a sulfa allergy. It may be painful following application.
When is medical grade honey indicated? Contraindicated?
indicated in inflamed/infected wounds, poorly granulating wounds, or in wounds with odor. However, it should not be used in patients with a bee pollen allergy and may cause a stinging in some patients
What are the advantaged and disadvantages of gauze?
allows visual drainage and varying levels of protection, but is not permeable to air/bacteria, is painful to remove, fluids are removed with gauze, gauze fibers are left behind, requires the cost of secondary dressings, and costs are more than advanced dressings
What are the advantaged and disadvantages of telfa?
keeps the wound moist, but is greasy, should not be used on granulating wounds, and is not absorbative
What are the advantaged and disadvantages of calcium alginates?
useful for wounds with moderate to high amounts of exudate, but requires a secondary dressing and should not be used on dry wounds
What are the advantaged and disadvantages of film dressings?
will only stick to the dry skin and can be left in place for 3-5 days, but may come off with sweating and may leak out under film when needed to be removed; does not have absorptive qualities and may macerate skin
What are the advantaged and disadvantages of foam dressings?
absorptive, soft, protective, and somewhat occlusive, but cannot be used on a dry wound
What are the advantaged and disadvantages of hydrogels?
provides moderate absorption, helps with debridement (either autolytic or sharp), but cannot be used on infected wounds
What are the advantaged and disadvantages of hydrocolloids?
can be used with infected wounds or maggot therapy, but have a normal color and odor changes in the dressing can occur when wetted with exudates
What are the advantaged and disadvantages of hydrofiber?
becomes a gel and absorbs heavily draining wounds, have all the advantages of alginates, but are cheaper; disadvantages are they require a secondary dressing and can’t be used on a dry wound
What are the advantaged and disadvantages of Unna boots?
absorbs wound drainage, manages edema, and are comfortable; can leave on 5-7 days if wound is not infected
disadvantages include not being able to see the wound and can’t use in the presence of infection
What are the advantaged and disadvantages of amorphous gel?
promotes autolytic debridement, but requires secondary dressing
What are the advantaged and disadvantages of bioengineered tissues?
made from porcine collagen, bovine serum, or neonatal foreskin
indicated for burn patients or in patients with venous leg ulcers after 30 days of conventional treatment, but are contraindicated because of cost and billing procedures or in patients who are sensitive to porcine collagen or bovine serum
What are the advantaged and disadvantages of ionic silver as dressings?
partial thickness burns, incisions, skin grafts, donor sites, lacerations, abrasions, stage I-IV pressure ulcers, and vascular, venous, and diabetic ulcers; active for up to 28 days and have a wide spectrum of antimicrobial activity
disadvantages are they are more expensive than non-silver dressing
What are the signs of potential infection?
- change in amount or color of wound drainage
- change in would odor
- peri-wound redness or warmth
- increase in pain or tenderness
- change in quality of granulation tissue
- failure to produce good quality tissue
- no measurable wound contraction over time
- fever, loss of appetite, unusual fatigue, depression
- tissue culture/punch biopsy
What are the options for cleansing a wound in terms of greatest to least harm to a wound?
whirlpool, pulsed-lavage, surfactant, and saline rinse
A bulb syringe has a psi of __
<4
What is an important consideration about a necrotic wound?
it will get bigger before it gets smaller
What are the three types of non-selective debridement techniques?
- wet to dry dressings
- surgical debridement
- forceful irrigation
What are the four types of selective debridement?
- sharp
- chemical/enzymatic
- maggot debridement therapy
- autolytic
What are the ABI values for interpretation of atherosclerosis?
1.0-1.3 = normal
0.9-1.0 = minimal symptoms
0.5-0.9 = claudication
0.3-0.5 = ischemic rest pain
<0.3 = gangrene
Foam
not recommended to relieve pressure; should only be used for patients who aren’t at risk
High-density Foam
okay to use for patients at minimal risk of a pressure injury (pts with an average BMI, patients who are mobile, etc)
Water
not often recommended because they are heavy, cold, must be used correctly; only for the patient at minimal risk
Gel
okay to use but heavy and expensive; for the patient moderately or maximally at risk
Static Air PRD
generally okay, but changes in the bed position can render them ineffective, they come pre-inflated and are not user friendly; should be used in the patient at minimal risk
Dynamic Air PRD
best and inexpensive; alternating pressure and should be used for the patient moderately or maximally at risk with manageable ulcers; does not bottom out when the pt moves
Low Air Loss PRD
good for very large patients, adjustable air flow through segments
Air Fluidized PRD
noisy, hot expensive, have to use hoyer lift to transfer patient in and out, air is blown through silicon beads to set them in motion; good for short periods of time (2-8 weeks)
Ultrasound
biocompatible modality that uses sound waves to stimulate a sluggish wound; stimulates fibroblasts to secrete collagen and effects elastin to strengthen scar
Ultraviolet
a form of radiation between X-ray and visible light; increases blood flow, decreases bacteria, stimulates Vit D production, and thickens the stratum corneum
Electrical Stimulation
electrical impulses that restore balance of voltage gradients in the dermis; facilitates granulation in chronic wounds
promotes inflammation, which is required for granulation
Topical and Hyperbaric oxygen therapy
method of delivering oxygen at pressure greater than atmosphere; deliver oxygen to hypoxic tissue, induce angiogenesis, enhance growth factors
Thermal and non-thermal diathermy
shortwave and radiowave frequency electrical current; increased collagen formation and increased blood flow to wound bed
pulsed, non-thermal most popular
Cold laser
use of light in the infrared energy spectrum; decreases pain, increases circulation, and increases sensation (reverses the symptoms of peripheral neuropathy), but the effects aren’t long lasting
Negative Pressure Wound Therapy (NPWT)
application of open cell foam with suction; claims to increase granulation, removes fluids, and promotes wound edge contraction
What are the relative contraindications to compression?
- DVT
- infection
- CHF - Cor Pulmonale
- fluctuating edema
- acute dermatitis
- ABI < 0.8
What are the three important concepts of scar control?
- pressure
- friction massage
- garments
How much protein is lost per day with an average wound?
90-100 grams
How many calories are lost for every 1˚ change in temperature?
12
What four vitamins and minerals are needed in a healing wound?
- protein
- vitamin C
- zinc
- magnesium
- iron
What components should be included in a home program?
- wound care
- prevention
- scar message
- exercise
- edema control
When should you not remove a heel wound?
when ABI is < .7-.8
What type of wraps should be used in patients with CVI?
low-stretch
