Integ. Case Study Prep Flashcards
With the Clock Method, how is the wound measured?
Length x Width x Depth in cm
- Length: measurement from “head to toe” direction (from 12 o’clock to 6 o’clock)
- Width: perpendicular to length. Usually measured at its max width from 9 o’clock (ish) to 3 o’clock (ish)
- Depth: Using a cotten tipped applicator, bottom of wound is probed until max depth is recorded
With Tissue Types, what is Eschar?
- Non-Viable/Nectrotic tissue
- Usually a black/brown appearance
- Varies in texture (hard, dry)
With Tissue types, what is Slough?
- Non-viable subcutaneous tissue
- Result of autolytic debridement
- Soft yellow tissue
With Tissue types, what is Granulated tissue?
- Viable tissue
- Usually noted to be a “beefy red” appearance
- Composed of ECM and capillaries
Are muscle and bone Viable or Non-Viable tissue?
Both can be non-viable tissue
- Based on nuritional characteristic
What tissue type are Tendons?
Are they Viable or Non-viable?
These can be non-viable
- They can be visualized with full thickness wounds
- Viable tendon must remain moist to prevent desiccation or dryness as this would decrease the viability of the tissue
(Still characterized as viable if it still contains is surrounding peritenon sheath, if it looks shiny)
What tissue type are Adipose Tissue?
Are they viable or non-viable?
This can be non-viable
- Characterized by shiny globules when viable and has a dull yellow appearance when non-viable due to delayed vascularization
- Adipose tissue is slow to vascularize which may cause it to be non-viable
What is Hypergranulation tissue?
- This is characterized as granulation tissue that overrides the tissue surface and is a sign of abnormal healing
- Although red which is generally referred to as healthy tissue will cause an inability to heal as the edges will not be able to approximate up over the edges of the granulation tissue
In reference to the amount of drainage, what does scant mean?
Small remnant of drainage on dressing after removal
In reference to the amount of drainage, what does minimal drainage mean?
~ 25% of the dressing is covered
In reference to the amount of drainage, what does Moderate drainage mean?
~ 50% of the dressing is covered
In reference to the amount of drainage, what does Heavy drainage mean?
~ 100% of the dressing is covered
In reference to the amount of drainage, what does Copious mean?
Multiple layers of dressing are covered
In reference to the amount of drainage, what does Strike Through mean?
Drainage visable through the last layer of dressing (unable to be contained by the dressing)
In reference to the Type of Drainage, what is Serous?
Clear serum
- Normally occurs in the inflammatory stage of healing
In reference to the Type of Drainage, what is Sanguineous?
“Bloody”
In reference to the Type of Drainage, what is Serosanguineous?
A mixture of serous and sanguinous
(Clear and bloody)
- Usually more pinkish
In reference to the Type of Drainage, what is Purulent?
Thick, and viscous, may be smelly; “pus”
When removing the dressing of a wound sometimes the wound will have an odor. What type of odor is Pseudomonas?
This is characterized as sweet odor
- “Corn Tortilla”
This is also a type of bacteria that has a green appearance
When removing the dressing of a wound sometimes the wound will have an odor. What type of odor is Wet Gangrene?
This is characteristically a foul odor
After a diagnosis is obtained, we establish a prognosis. What takes place in the prognosis?
- Predicted expected outcomes
- Estimation of therapy frequency/duration
Common prognosis:
-Wound closure
-Clean and stable wound
-Wound not expected to improve
After the prognosis, goals are made (using SMART)
With ABI, what does the value 1.00 - 1.4 mean?
Normal
- Adequate Blood supply
With ABI, what does the value > 1.4 mean?
Non-compressible arteries
This is still considered abnormal
With ABI, what does the value 0.91- 0.99 mean?
Borderline Occlusion
Abnormal
With ABI, what does the value 0.80 - 0.90 mean?
Mild Occlusion
- Compression Therapy = No greater than 30-40 mmHg
Abnormal
With ABI, what does the value 0.50 - 0.79 mean?
Moderate Occlusion
- Reduced Compression Therapy = No greater than 23-30 mmHG
Abnormal
With ABI, what does the value ≤ 0.49 mean?
Severe Occlusion
- Any compression therapy is contraindicated
- Vascular Referral
What are the Clinical Presentations of Arterial Insufficiency wounds?
- Round and small with smooth regular borders (“Hole Punch”)
- Lacks in granulation tissue (usually pale)
- Pink Periwound
- Usualy occurs on the distal digits first
- Painful especially with elevation
- May have hair loss
- May have muscle atrophy
- Dependent Hyperemia may be present, which may be seen during the Rubor of Dependency Test
With Aterial Insufficiency Treatment, what can be done for Protection?
- The application of PRAFO (Protection, Relief, Ankle, Foot, Orthosis)
- Heel Cushions
- Pressure relief
- Clean/Sterile bandaging
With Aterial Insufficiency Treatment, (other than protectio) what are other treatment options for the patient?
- Infrared Light
- Debridement (stable eschar is NOT to be debrided!)
What are the Clinical S/S of Venous Insufficiency?
{Location, onset, appearance, pain, etc}
- Location: Above Malleoli (Gaiter area)
- Onet: Insidious
- Appearance: Uneven edges, shallow, little eschar
- Periwound: Increased thickness, hemosidian staining
- Moderate to Copious serous, purulent drainage (usually this happens if there is no arterial insufficiency)
- Pain: minimal
What is the Gold Standard Treatment for Venous Insufficiency?
Compression
- Not for use with active CHF or excessive PAD (Severe arterial insufficiency), CONTRAINDICATION!!!!
- Spiral
-50% stretch and 50% overlap
-Use for patients who are bed bound or do not require a lot of compression - Figure 8
-50% stretch and 50% overlap
-Provides 2x as much compression as spiral
-Used for patients who are regularl ambulatory and have good ABI values
According to the NPUAP
What is stage 1 of Pressure Injury?
Superficial
Nonblanchable erythema of intact skin
According to the NPUAP
What is stage 2 of Pressure Injury?
Partial-thickness loss with exposed dermis
According to the NPUAP
What is stage 3 of Pressure Injury?
Full thickness skin loss; bone/tendon/muscle NOT exposed
- Evidence of necrotic tissue automattically characterizes the wound as stage 3
According to the NPUAP
What is stage 4 of Pressure Injury?
Full thickness skin and tissue loss; with exposed fascia/bone/tendon/muscle
According to the NPUAP
What is the Unstageable Pressure Injury?
Obscured full-thickness skin and tissue loss; base of wound covered with slough or eschar
- Until wound is debrided, the full depth cannot be ascertained
According to the NPUAP
What is the Suspected Deep Tissue Injury Pressure Injury?
Persistent non-blanchable deep red, maroon or purple discoloration
What Interventions can be done for Pressure Injuries?
Pressure Relief:
- PRAFOs (Protection Relief Ankle Foot Orthosis), Weightshifting/Repositioning
Pressure redistribution support surface
- Roho cushions
- Air mattresses
- Pressure mapping systems
Care for moisture prone areas
- Prevent “maceration”
- Barrier creams
Reduce friction/shearing forces
Interactive Dressing
What are Film Dressings?
- These dressings are coated with acrylic adhesive
- They are not absorbent but are permeable to oxygen and air, but impermeable to microorganisms
-
They are flexible, elastic, extendsible and transparent
(So they can adjust to the movement of the body part and we can continue to assess the wound without removing the dressing)
What are the Effects and Indications of using Film Dressings?
- They provide a moist wound environment
- They assist with autolytic debridement
- Provide protection for microorganisms
- Provide gaseous exchange of O2, CO2 and water vapor
-Disadvantage is that they are not very absorbant, so they can promote the accumulation of excessive exudate
Indications:
- Minor Burns
- Simple injuries (abrasions, skin tears)
- Post-op dressing
Interactive Dressing
What are Foam Dressings?
- These are made of polyurethane, soft, open sheets
- They may have 1 or more layers
- Similar in appearance to hydroactive polymer products
- May have a waterproof backing or be impregnated with charcoal
What are the Effects of Foam Dressings?
- Provide moist environment
- Provide high absorbency (for moderate/high exudate)
- Confrom to body shape
- Provide protection and cushioning
- It does NOT adhere to the wound
- Provides thermal insulation
- Transmits moisture vapor out of dressing to avoid maceration
What are the Indications for Foam Dressings?
- When there is Moderate to High Exudating wounds
- Superficial and cavity types of wounds
- LE ulcers, such as venous ulcers
- Pressure injuries
Interactive Dressing
What are Hydrogels?
- This is made up of Complex organic polymers with high water content
- They are 3 dimensional, water swollen structures
2 types:
- Amorphous: Free-flowing, easily fills a cavity space
- Sheet: Thin, flexible sheets that swell as they absorb fluid
What are the Effects of Hydrogels?
- They provide moisture to dry wounds
- They can provide or absorb moisture
- They aid in autolytic debridement
- Conform to body shape
- Does NOT adhere to wound
What are the Indications of using Hydogels?
- Dry and minimally draining wounds
- LE wounds, such as arterial ulcers
- Pressure injuries, Stages 2-4
- Full or partial thickness wounds
- Over tendons and other tissues to prevent tissue dehydration
- Infected and necrotic wounds
Interactive Dressing
What are Hydrocolloids?
- These are dressings that are a combination of gel-forming polymers with adhesives with a backing of a polyurethane film or a foam
- Wound exudate combines with the polymers to create a soft gel in the wound
- Dressing only adheres to surrounding tissues, not the wound itself
What are the effects and indications for Hydrocolloids?
- Provide a moist environment
- Aid in autolytic debridment
- Conform to body shape
- Protect from microorganims
- Provide a waterproof surface
- Not indicated for heavily exudating or deep cavity wounds
Indications:
- Superficial and small cavity wounds
- LE wounds, burns, pressure injuries
Interactive Dressing
What are Alginates?
- These are made of calcium or calcium/sodium salts of alginic acids from seaweed
- Available as textile fiber sheets or a loose packing ribbon
- Produce a hydrophilic gel in the wounds
- Provide calcium ions to the wound to promote hemostasis
What are the effects of Alginate dressings?
- Provide a moist environment
- High absroptive capacity
- Conform to body shape
- Protect from microbial contamination
- Promotes hemostasis
- Does not adhere to wound
What are the indications to use Alginates?
- With Heavily exudating wounds, including sanguinous exudate
- Infected wounds
- Cavity wounds
- LE wounds
- Pressure injuries
- Donor sites
Interactive Dressing
What are Hydroactive Dressings?
- These are multiple layers of highly absorbent polymer gel with adhesive backing
- Similar to hydrocolloidsm, but do not form gel in wound
- Semipermeable
- Adhere to surrounding skin
- Available in various forms, including cavity fillers, foams, and thin types
What are the effects of Hydroactive Dressings?
- Provide moist enviornment
- Aid in autolytic debridement
- High absorbency
- Waterproof surface
- Regain their shape when stretched
- Semipermable to water vapor
What are the Indications for using Hydroactive Dressings?
- Moderate to heavily exudating wounds
- LE ulcers, such as venous ulcers
- Pressure injuries
- Wound around joints
What do Collagen Matrix Dressings do?
- Contain collagen that stimulate fibroblast activity
What do Hydrofiber dressings do?
- These are activated by moisture, plymers absorb and trap moisture in their structures
-Look like alginates
What is Autolytic Debridement? What are the steps for this?
Endogenous healing of the wound
Steps:
- Cleansing
- Maintance of a moist environment
- Cross hatch eschar
- Cover with appropriate dressing to promote healing
What is Enzymatic Debridement? What are the steps for this?
Enzymes used to prepare the wound bed by allowing them to break down the nonviable tissue
Steps:
- Obtain physicians order for a collagenase
- Clease wound appropriately
- Apply enzyme directly to the nonviable tissue
- Cover with appropriate dressing (moist gauze)
- Apply 1x/2x per day
What is Mechanical Debridement? What are the different types?
This refers to some outside source to remove the non-viable tissue
- Wet to Dry Gauze dressings
- Scrubbing
- Hydrotherapy
- Low frequency ultrasound
- Pulsatile Lavage (Pressurized fluid irrigation)
-Gold Standard = 35-50cc syringe with a 19 gauge catheter to create 4-9psi
avoid > 15 psi
What is Sharp Debridement? What are the steps for this?
- The most rapid form of debridement
- May require multiple/sequential treatments to clean the wound bed
Steps:
- Pre-medicate as needed with lidocain/oral medication under supervision of physician
- Assemble necessary equipment including agents to stopn excess bleeding
- Clease wound
- Use scalpel blades (No. 10 or No. 15), curettes, scissors and/or forceps for removal or nonviable tissue
Identifying Factors: Abnormal Lab Values
If a person has increased HbA1C%, how may this affect wound healing?
What is considered Normal?
Blood sugar
- If the persons HbA1C% is increased this may indicate delayed wound healing
Normal is ≤5.7%
Examples of Goals
- “In 2 weeks, patient will demonstrate correct wound dressing application with independence”
- “In 4 weeks, wound will demonstrate 50% less necrotic tissue in order to improve wound healing and increase functional mobility”
