Integ

Question 1

Proliferation phase

Answer 1

stimulate angiogenesis and fibroplasia

growth factor release stimulates fibroblasts to the area

WOUND BED MATRIX ESTABLISHED

Question 2

epithelialization

Answer 2

cells close around wound in leapfrog fashion

Question 3

Remodeling /maturation

Answer 3

scar becomes avascular and white

decreased capillaries

Question 4

questions for eval

Answer 4

will the pt have nromal healing time?

factors against normal healing times?

is it infected?

Question 5

measureing wound for documentation order

Answer 5

Top to bottom and Left to Right

Question 6

Serous exudate

Answer 6

CLEAR

normal during inflammatory and proliferation phase

Question 7

serosanguineous

Answer 7

pink and watery

normal in early stages

Question 8

seropurulent

Answer 8

cloudy to yellow

first signal of wound infection

Question 9

purulent

Answer 9

Yellow, green, thick

wound infection; may be with odor

Question 10

Inflammation characteristics

Answer 10

Edema = well defined
increased temp = AT wound site
odor = necrotic tissue
Exudate = gradual decrease over 3-5 days
exudate type = bleeding and serous
pain = variable

Question 11

Infection characteristics

Answer 11

edema = diffuse
systemic fever
odor = specific to bacterial organism
exudate = large amounts and remains high
exudate type = seropurulent
pain = persistent

Question 12

contamination

Answer 12

presence of non-proliferating bacteria on wound surface

Question 13

colonization

Answer 13

presence of proliferating bacteria on with no immune response from the host

Question 14

increasing clinical problems progression of infection

Answer 14

contamination –> colonization –> critical colonization –> infection

Question 15

when to monitor for infection

Answer 15

contamination and colonization

Question 16

when is intervention required for infection progression

Answer 16

critical colonization and infection

Question 17

critical colonization

Answer 17

presence of bacteria in stalled wounds in the absence of classical signs of inflammation

Question 18

What is likely cause of infection in boots

Answer 18

Pseudomonas

Question 19

Tx for pseudomonas

Answer 19

Acetic acid

Question 20

Levine swab method

Answer 20

done on healthy granulation tissue

press swab into tissue and ROLL a few times before depositing

Question 21

Colony count for infection

Answer 21

5 Zeros is key for infections

Question 22

Odor is associated with what oganisms

Answer 22

ANAEROBIC

Question 23

types of anaerobic organisms

Answer 23

Streptococcus, enterobacter, E-coli

Question 24

Aerobic organisms

Answer 24

Staphlococcus Aureus, MRSA - resistance to vancomycin,

Question 25

used to treat MRSA

Answer 25

Mupirocin (bactroban)

Question 26

Macerated skin

Answer 26

Wrinkled and wet can breakdown and cause increase to size of wound

Question 27

max time to use antimicrobial solution with suspected infections

Answer 27

10-14 days

Question 28

when to not clean?

Answer 28

if majority of wound is healthy granulation scant drainage without residue or odor

Question 29

when is hydrotherapy appropriate

Answer 29

Only appropriate for large amounts of necrotic tissue cleaning of residual topical agents like silvadene soften eschar to promote debridement

Question 30

cons to hydrotherapy

Answer 30

damage healthy tissue dependent position increased metabolic demands overhydration and change in pH the trauma may increase inflammation and prolong healing

Question 31

pulsed lavage use, pressure, and benefits

Answer 31

irrigation and debridement reduce bacterial counts and infections negative pressure is good for granulation tissue 8-15 PSI time efficient cross-contamination is eliminated

Question 32

How often to clean wound?

Answer 32

Go for MAX of 1 debridement per day Wound dressing change needs to be 2x per day

Question 33

how long does IV morphine last

Answer 33

30 minutes

Question 34

Nonselective vs selective debridement

Answer 34

nonselective removes everything selective control over what is removed

Question 35

autolytic debridement

Answer 35

Traps exudate in wound to allow Macrophages and endogenous enzymes to perform debridement LITTLE pain with this method

Question 36

Sharp debridement

Answer 36

novice should use forceps, tweezers, and scissors may need to premedicate DONT cut what you cant see

Question 37

puncture wounds

Answer 37

might require packing or wicking of the wound fill entire tunnel but not too tight with packing may need to pack from both sides wicking keeps the exit wound open

Question 38

temperature for Hydrotherapy and venous disease

Answer 38

80-92 degrees

Question 39

temperature for Hydrotherapy and peripheral vascular Dx, sensory impairment, or full body immersion

Answer 39

92-96 degrees

Question 40

temperature for Hydrotherapy and CV or pulmonary disease

Answer 40

96-98 degrees

Question 41

temperature for Hydrotherapy and optimize cell functions and enzymatic and biochemical reactions

Answer 41

99 degrees

Question 42

temperature that causes significant stress in circulatory, nervous, and CP systems

Answer 42

99+ degrees

Question 43

temperature for whirlpool considered hot not recommended

Answer 43

100-104

Question 44

How long before seeing pts with oral meds

Answer 44

30 minutes

Question 45

morphine and bp

Answer 45

LOWERS

Question 46

debridement options slow to fast

Answer 46

autolytic / biologic chemical mechanical sharp

Question 47

debridement least to most pain

Answer 47

autolytic Biologic chemical / sharp mechanical

Question 48

Bacteria biofilm

Answer 48

invisible layer that is formed by an ECM that binds to the wound base