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Integ > Integ > Flashcards

Integ Flashcards

1
Q

Proliferation phase

A

stimulate angiogenesis and fibroplasia

growth factor release stimulates fibroblasts to the area

WOUND BED MATRIX ESTABLISHED

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2
Q

epithelialization

A

cells close around wound in leapfrog fashion

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3
Q

Remodeling /maturation

A

scar becomes avascular and white

decreased capillaries

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4
Q

questions for eval

A

will the pt have nromal healing time?

factors against normal healing times?

is it infected?

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5
Q

measureing wound for documentation order

A

Top to bottom and Left to Right

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6
Q

Serous exudate

A

CLEAR

normal during inflammatory and proliferation phase

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7
Q

serosanguineous

A

pink and watery

normal in early stages

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8
Q

seropurulent

A

cloudy to yellow

first signal of wound infection

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9
Q

purulent

A

Yellow, green, thick

wound infection; may be with odor

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10
Q

Inflammation characteristics

A 
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
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11
Q

Infection characteristics

A 
edema = diffuse
systemic fever
odor = specific to bacterial organism
exudate = large amounts and remains high
exudate type = seropurulent
pain = persistent
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12
Q

contamination

A

presence of non-proliferating bacteria on wound surface

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13
Q

colonization

A

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

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14
Q

increasing clinical problems progression of infection

A

contamination –> colonization –> critical colonization –> infection

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15
Q

when to monitor for infection

A

contamination and colonization

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16
Q

when is intervention required for infection progression

A

critical colonization and infection

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17
Q

critical colonization

A

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

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18
Q

What is likely cause of infection in boots

A

Pseudomonas

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19
Q

Tx for pseudomonas

A

Acetic acid

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20
Q

Levine swab method

A

done on healthy granulation tissue

press swab into tissue and ROLL a few times before depositing

21
Q

Colony count for infection

A

5 Zeros is key for infections

22
Q

Odor is associated with what oganisms

A

ANAEROBIC

23
Q

types of anaerobic organisms

A

Streptococcus, enterobacter, E-coli

24
Q

Aerobic organisms

A

Staphlococcus Aureus, MRSA - resistance to vancomycin,

25
Q

used to treat MRSA

A

Mupirocin (bactroban)

26
Q

Macerated skin

A

Wrinkled and wet

can breakdown and cause increase to size of wound

27
Q

max time to use antimicrobial solution with suspected infections

A

10-14 days

28
Q

when to not clean?

A

if majority of wound is healthy granulation

scant drainage without residue or odor

29
Q

when is hydrotherapy appropriate

A

Only appropriate for large amounts of necrotic tissue

cleaning of residual topical agents like silvadene

soften eschar to promote debridement

30
Q

cons to hydrotherapy

A

damage healthy tissue

dependent position

increased metabolic demands

overhydration and change in pH

the trauma may increase inflammation and prolong healing

31
Q

pulsed lavage use, pressure, and benefits

A

irrigation and debridement

reduce bacterial counts and infections

negative pressure is good for granulation tissue

8-15 PSI

time efficient

cross-contamination is eliminated

32
Q

How often to clean wound?

A

Go for MAX of 1 debridement per day

 Wound dressing change needs to be 2x per day
33
Q

how long does IV morphine last

A

30 minutes

34
Q

Nonselective vs selective debridement

A

nonselective removes everything

selective control over what is removed

35
Q

autolytic debridement

A

Traps exudate in wound to allow Macrophages and endogenous enzymes to perform debridement

LITTLE pain with this method

36
Q

Sharp debridement

A

novice should use forceps, tweezers, and scissors

may need to premedicate

DONT cut what you cant see

37
Q

puncture wounds

A

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

38
Q

temperature for Hydrotherapy and venous disease

A

80-92 degrees

39
Q

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

A

92-96 degrees

40
Q

temperature for Hydrotherapy and CV or pulmonary disease

A

96-98 degrees

41
Q

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

A

99 degrees

42
Q

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

A

99+ degrees

43
Q

temperature for whirlpool considered hot

not recommended

A

100-104

44
Q

How long before seeing pts with oral meds

A

30 minutes

45
Q

morphine and bp

A

LOWERS

46
Q

debridement options slow to fast

A

autolytic / biologic

chemical

mechanical

sharp

47
Q

debridement least to most pain

A

autolytic

Biologic

chemical / sharp

mechanical

48
Q

Bacteria biofilm

A

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

Integ (3 decks)

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