Integumentary Flashcards
1
Q
A 75 y/o patient presents to PT with a large cut on his forearm. He reports he hit his arm on his kitchen table prior to coming to his appointment. What integumentary changes are most likely to have increased his risk of integumentary damage?
A
- Skin thickness decreases w/ age (~70 full thickness)
- Thinner skin layers
- Reduced vascularity
- Reduced elastin/collagen
- Reduced metabolism
2
Q
A patient sustains a superficial integumentary wound on her hand from a clean kitchen knife while cooking 7 days ago. Upon inspection, the wound appears completely closed with no signs of infection. This is most likely classified as what type of tissue union?
a. Secondary
b. Primary
c. Tertiary
A
Primary; no major loss of connective tissue; closure time 3-7 days; no contamination
3
Q
A 65 y/o male with a BMI of 37 presents to PT with a diagnosis of chronic venous insufficiency. He currently has a mid-size ulceration approx. 5 cm above his medial malleolus that is producing copious amounts of drainage. With appropriate management, this wound’s healing will most likely be classified as what type of tissue union?
a. Secondary
b. Primary
c. Tertiary
A
Secondary: full thickness, little epithelialization; chronic wounds, pressure injuries, venous ulcerations, and other open wounds health through secondary intention
4
Q
A 45 y/o farmer sustained a large laceration on his R anterior thigh from a large piece of equipment. The patient reports there was significant dirt and debris in the wound initially. The wound was closed 5 days after the initial injury to allow drainage. This is most likely classified as what type of tissue union?
a. Secondary
b. Primary
c. Tertiary
A
Tertiary: used for contaminated wounds; closure will result in too much tension; usually closed within 5-7 days of initial injury
5
Q
Describe the general process of tissue healing for an epidermal (superficial or partial-thickness) wound
A
- Heals through regeneration
- Epithelial cells proliferate & migrate from wounds margin; need a clean wound border to migrate
–> usually heals w/out scarring - If dermal tissue is involved, then granulation occurs simultaneously
- Moist wounds epithelialize much quicker than wounds left open to air
6
Q
Describe the general process of tissue healing for a dermal (full-thickness) wound
A
Four overlapping phases:
1. homeostasis (after growth factors released): vasoconstriction to reduce loss/prevent infection; fibrin plug formation; 10-15 minutes; growth factors released
- Inflammation (24-48 hrs): cardinal signs present; phagocytosis + neovascularization begin @ end of this cycle; key cells: platelets, leukocytes, macrophages, mast cells
- Granulation/Proliferation/Fibroblastic phase: angiogenesis, granulation formation, wound contraction, epithelialization; Key cells: myofibroblasts,
- Maturation/Matrix Formation: Collagen synthesis & alignment
7
Q
Discuss factors that may result in delayed wound healing
A
- Advanced age
- Impaired oxygenation
- Poor nutrition (↓ protein/vitamins/minerals or poor caloric intake)
- Comorbidities
- Wound bioburden
- Infection
- Medications (chemo, NSAIDs, steroids)
- Disease (diabetes, kidney disease, HTN, CVD, CPD, hyperlipidemia)
- Stress
- Cool temperatures (reduce cellular metabolism)
- Iatrogenic (excessive pressure, sheer, desiccation, moisture)
- Smoking
8
Q
A 55 y/o with a known history of DM type II presents to PT following a TKA. He complains of severe itching that has become quite bothersome. What is the term for this & what conditions is it usually associated with?
A
Pruritis
Common in: diabetes, drug hypersensitivity, hyperthyroidism
9
Q
A 25 y/o female presents to PT following an ACL reconstruction. When her bandages are removed to inspect the surgical incision, there is notable red elevated patches of skin where the adhesive was in contact with the skin. What is the term for this & what condition(s) is it usually associated with?
A
- Urticaria
- Common in: allergic response to drugs or infection
10
Q
A patient is experiencing localized redness and eruption on the skin and complains of itchiness after receiving a new medication; What is the term for this & what condition(s) is it usually associated with?
A
- Rash
- Common in: inflammation, skin diseases, chronic alcoholism, vasomotor disturbances, fever, and diaper rash/heat rash/drug rash
11
Q
Define xeroderma and the condition(s) it is most likely associated with
A
- excessively dry skin w/ shedding of epithelium
- thyroid deficiency, diabetes
12
Q
Splinter hemmorages seen under nails may indicate what?
A
cardiac or renal dysfunction
13
Q
Discuss Stemmer’s Sign
A
- Skin pinch test on dorsum of second finger or second toe
- Early sign of primary lymphedema
14
Q
A 56 y/o female with a history of chronic alcohol abuse presents with wrist pain. Upon examination, her palms appear to be a bright, cherry red color bilaterally. What may this indicate?
A
Liver or renal issues
15
Q
When examining a patient for cyanosis, what is one way to differentiate between central and peripheral impaction?
A
- Central: look at lips, oral mucosa, tongue
- Peripheral: look at nail beds
16
Q
Liver spots may be associated with what?
A
Age, uterine or liver malignancies, pregnancy
17
Q
Hyperhidrosis may result from what?
A
Fever, pneumonic crisis, drugs, hot drink ingestion, exercise
18
Q
Hypohidrosis may result from what?
A
Dehydration, ichthyosis, hypothyroidism
19
Q
Define hirsutism and what some potential causes are?
A
- Male pattern hair growth (facial & body)
- May indicate PCOS, Cushing’s, tumor, or be inherited
20
Q
Differentiate the following types of wound drainage:
Serous
Serosanguineous
Sanguineous
Purulent
A
Serous: watery serum, clear/yellow
Serosanguineous: mix; pinkish in color
Sanguineous: containing blood; red or reddish
Purulent: containing pus
21
Q
An ulcer that is slow to heal but is not painful would likely be categorized as what?
A
Indolent ulcer
22
Q
Actinic dermatitis causes include
A
- photosensitivity, reaction to sunlight, ultraviolet light
23
Q
Contact dermatitis causes include
A
chemicals, harsh soaps, adhesives, etc.
24
Q
Atopic dermatitis is caused by what?
A
Etiology unknown; associated w/ allergic, hereditary, or psychological disorders
25
What are some precautions or contraindications associated with dermatitis?
- Some physical therapy modalities
- Avoid use of alcohol
26
Discuss cellulitis, its causes, presentation, management, and consequences of non-treatment
- Inflammation of cellular or connective tissue
in or close to the skin
- Tends to be poorly defined & widespread
- Strep or staph usually the cause
- Skin is hot, red, & erythematous
- Management: antibiotics, elevation, cool, wet
dressings
- Untreated: gangrene, lymphangitis, abscess,
sepsis
27
Discuss the typical presentation of herpes zoster (shingles)
- Caused by varicella-zoster
- Pain & tingling in spinal or cranial nerve dermatome
- Progresses to red papule along distribution/infected nerve
- Other sxs: fever, chills, malaise, GI probs
- Management: no curative agent, antiviral drugs to slow progression, symptomatic tx
- Heat/ultrasound contraindicated
28
Fungal infections such as tinea corporis or tinea pedis warrant what type of precautions?
Observe standard precautions
29
What is the treatment for candidiasis?
Skin care (reduce moisture), antifungal ointments, and potentially silver-infused dressing for skin folds
30
Parasitic infections such as lice or scabies warrant what type of precautions
Observe standard precautions
Avoid direct contact
31
Physical therapy management of lupus erythematosus
Skin care, prevention of deconditioning/secondary MSK impairments, joint pain relief, fatigue management, patient education on lifestyle
32
Discuss systemic sclerosis (scleroderma), including characteristics, PT management, and precautions
- Chronic, autoimmune diffuse disease of connect tissues --> fibrosis of skin, joints, blood vessels, & internal organs
- Usually accompanied by Raynaud's
- Skin is taut, firm, edematous, & firmly bound to subQ layer
- PT management: skin management (hydration & pressure relief), exercise, joint protection, prevention of contractures/deformities
- Precautions: pressure, acute HTN (monitor vital signs), pulmonary HTN may lead to right-sided heart failure
33
Discuss polymyositis & dermatomyositis
- Polymyositis: autoimmune myopathy characterized by edema, inflammation, & proximal muscle degeneration
- dermatomyositis: Polymyositis presentation + characteristic skin rash (immunologically different, but present the same)
- Unknown etiology
- Variable onset, can be fatal
- RED FLAG: additional muscle damage (rhabdomyolysis) may occur w/ excessive exercise; contractures + pressure injuries may result from rest/inactivity
- PT management: fatigue management, energy conservation, low-level aerobic & resistance exercise, avoid overload, skin care & positioning, monitor for medication side effects (e.g. steroids)
34
Discuss the ABCDEs of clinical examination of malignant melanomas
- Asymmetry: uneven edges, lopsided
- Border: irregular, poorly defined edges, notching
- Color: variations, especially mixtures of black, blue, or red
- Diameter: > 6 mm
- Elevation (or evolving): usually elevated, but may be flat; moles that changed over time
35
Discuss Kaposi's sarcoma (KS)
- Lesions of vascular ednorlialt cell origin
- Associated w/ HIV/AIDs
- Common on lower extremities
- Itching & pain common
- PT management: wound care, pulsed lavage with suction for local lesions, skin care, avoid positions that cause edema/shear force/contractures
36
Differentiate the following:
Contusion
Ecchymosis
Petechiae
Abrasion
Laceration
Contusion: injury where skin is not broken; pain, swelling, discoloration
Ecchymosis: bluish discoloration of skin caused by extravasation of blood into subcutaneous tissues; the result of trauma to underlying blood vessels or fragile vessel walls
Petechiae: tiny red or purple hemorrhagic spends on the skin
Abrasion: scraping away of skin due to injury or mechanical abrasion (e.g. dermabrasion)
Laceration: an irregular tear of the skin that produces a torn, jagged wound
37
Discuss the etiology of venous ulcers
- Associated w/ chronic venous insufficiency, valvular incompetence, DVT, venous HTN, calf muscle pump failure
- High recurrence rate
- Arterial insufficiency may coexist
38
Review the common clinical features of venous ulcers
- Can occur anywhere in the lower leg
- Common over medial malleolus
- Normal pulse
- May be painful in dependent position
- Color: normal or cyanotic; hemosiderin staining common; lipsclerosis possible
- Temperature: normal
- Edema: present, often marked
- Skin changes: pigmentation, stasis dermatitis, atrophy blanche lesions
- Ulceration: wet, high exudate
- Gangrene: absent
39
Discuss the differential diagnosis of arterial and venous ulcers
Etiology: arteriosclerosis/atheroembolism vs. valvular incompetence/venous HTN
Appearance: arterial ulcers usually irregular, deep, & have little to no granulation tissue; venous ulcers tend to be dark & shallow with good granulation
Location: arterial ulcers appear on toes, feet, lateral malleolus, & anterior tibia; venous most common on medial malleolus
Pedal pulse: arterial --> absent; venous --> usually present
Pain: arterial ulcers usually painful, especially with elevation; venous ulcers usually very little & not affected by elevation
Drainage: arterial --> none; venous --> copious
Gangrene: arterial --> may be present; venous --> absent
Associated signs: arterial --> trophic changes, pallor on elevation, rubor on dependency; venous--> edema, stasis dermatitis, cyanosis on dependency
40
Discuss interventions for venous ulcers
- short-stretch bandages (worn day & night)
- compression pump as adjunct (45-60 mmHg)
- Limb elevation
- Exercise/weight control
- compression garments: 20-55 mmHg at ankle; use least amount of pressure effective
41
Contraindications for compression therapy include what?
- High compression contraindicated w/ ABI < 0.7
- All sustained compression contraindicated w/ ABI < 0.6 or active DVT
42
Discuss the etiology of arterial ulcers
- Chronic arterial insufficiency, arteriosclerosis obliterans, thromboangitiitis obliterans, and atheroembolism
- Hx of minor non-healing trauma
43
Discuss the clinical features of arterial ulcers
- Can occur anywhere on lower leg
- Most common: toes, feet, bony prominences
- Preceded by s/s of arterial insufficiency: poor/absent pulse, intermittent claudication
- Pain often severe, exacerbated by elevation
- Color: pale or cyanotic, pale on elevation, rubor on dependency
- Temperature: cool
- Skin changes: thin, shiny skin; hair loss, thickened nails
- Can be deep ulcers
- Gangrene: black, gangrenous skin adjacent to ulcer can develop
44
Discuss intervention strategies for arterial ulcers
- Manage BP, cholesterol, triglycerides, & BG
- Exercise: walk 3-5x/wk; 30-60 min; if claudication occurs, rest & resume when symptoms subside
- Exercise contraindications: ischemic pain @ rest, ulceration, gangrene, ABI < 0.4
- Patient education: skin care, avoiding mechanical trauma, footwear, nail care, skin inspection, avoid thermal or chemical injury
45
Discuss the etiology of a diabetic ulcer
- Atherosclerotic peripheral artery disease and peripheral neuropathy
- Caused by: loss of protective sensation, muscle coordination + mechanical stress + autonomic dysfunction
46
Discuss the clinical features of a diabetic ulcer
- Similar occurrence pattern with arterial ulcers
- Most common: plantar surface of foot/toes
- Pain: not typically d/t sensory loss
- Pulse: may be present or diminished
- infection is more common; sepsis &/or gangrene can develop
47
Discuss intervention strategies for diabetic ulcers
- Off-loading*****
- Wound care
- Patient education: skin/nail care, avoid lotion between toes to prevent maceration,
48
A patient presents to PT with little a history of uncontrolled diabetes; based on this information, what Wagner Classification System grade would this patient fall under?
Grade 0: no open lesions, foot deformity, or cellulite may be present; high-risk for ulcer development
49
A patient presents with T2 diabetes presents with a small, shallow ulcer on the plantar surface of his second toe. What Wagner Classification System grade would this patient fall under?
Grade 1: superficial ulcer
50
A patient presents to PT with a long history of peripheral neuropathy. He has been dealing with an ulcer on the medial aspect of his great toe and has recently noticed he can see the joint capsule. What Wagner Classification System grade would this patient fall under?
Grade 2: Tendon, capsule, or bone exposed
51
A patient presents to PT with a history of peripheral neuropathy. She has been dealing with an ulcer on the plantar aspect of her first metatarsal. Upon examination, it appears there is an abscess now associated with the ulcer. What Wagner Classification System grade would this patient fall under?
Grade 3: ulcer with abscess, osteomyelitis, or joint infection
52
A patient presents to PT to follow up after his initial wound examination. At this time, his second toe appears to be turning black in color, but no other structures appear to be involved. What Wagner Classification System grade would this patient fall under?
Grade 4: localized gangrene
53
A patient presents to PT for her follow-up visit after her initial evaluation for a diabetic ulcer located on her lateral malleolus. Upon examination, the patient's skin distal to the malleoli appears riddled with blackened flesh. What Wagner Classification System grade would this patient fall under?
Grade 5: non-localized gangrene
54
A 78 y/o patient admitted to a skilled nursing facility after a CVA presents with a nonblanchable, erythematous area of skin near the sacrum. The skin appears warmer than the surrounding area and feels boggy upon palpation. What stage of pressure injury is most likely to apply?
Stage I
- Nonblachable erythema of intact skin; may include change sin skin temperature (warm or cool), tissue consistency (firm or boggy), and/or sensation (pain/itching); more difficult to distinguish with darker skin, redness may not be visible in darker skin (look for dark-blue-purple tint)
55
A patient presents with a partial thickness skin loss involving both the dermis & epidermis on her heel. The wound appears to be superficial, a shallow crater. What stage of pressure injury is most likely to apply?
Stage II
- Partial-thickness skin loss: involves epidermis, dermis, or both; ulcer is superficial; presents clinically as an abrasion, blister, or shallow crater
56
A patient presents to PT for wound care with an ulcer located 2 cm above the sacrum. Upon inspection, the PT can easily view fat tissue, but no signs of infection are present. What stage of pressure injury is likely to apply?
Stage III
- Full-thickness skin loss: involves damage to or necrosis of subcutaneous tissue. may extend down to, but not through underlying fascia; presents clinically as a deep crater
57
A patient presents to PT with a wound on her tailbone. Upon examination, the PT is able to visualize muscle tissue and identifies several small sinus tracts along with some undermining at the wound bend. What stage of pressure injury is likely to apply in this case?
Stage IV
- Full-thickness skin loss: involves extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Undermining and sinus tracts may be present
58
A patient presents to PT with an ulcer on the posterior aspect of her calcareous. The wound bed is occluded with black eschar that is strongly adhered to the wound bed. What stage of pressure injury is likely to apply in this case?
Unstageable
- Tissue depths obscured due to slough or eschar and extend of damage cannot be determined
59
A patient presents to PT with a large red-purple area of skin on the left glute region. The patient recently sustained an SCI and has been working with the inpatient therapy team on WC transfers. What stage of pressure injury is most likely to apply?
Deep tissue injury
- Discolored area of tissue (e.g. bruise) that is not reversible and will likely progress to a full-thickness injury
60
Discuss risk factors that may contribute to a pressure injury?
- Poor nutrition
- prolonged pressure, shear forces, friction, repetitive stress
- Maceration
61
Discuss the clinical features of a pressure ulcer
- Location: occurs over bony prominences
- Color: red, brown/black, or yellow
- Pain: may be painful if sensation is intact
- Inflammatory response with necrotic tissue; :fever, hyperemia, increased WBC count
62
Discuss the three zones of a burn wound
1. Zone of coagulation: cells are irreversibly injured, cell death occurs
2. Zone of stasis: cells are injured; may die without specialized treatment, usually within 24-48 hrs, sensitive to infection & trauma (e.g. pressure, & shearing forces during transfers)
3. Zone of hyperemia: minimal cell injury; cells should recover
63
Review the Rule of Nines (For an adult patient)
Head & neck
Anterior trunk
Posterior trunk
Arms
Legs
Perineum
Head & neck: 9%
Anterior trunk: 18%
Posterior trunk: 18%
Arms: 9% each
Legs: 18% each
Perineum: 1%
64
Review the Lund-Browder charts for estimating burn areas***
65
Define the burn classification & provide an example based on the following characteristics:
- Damage to epidermis only
- Pink or red appearance, no blistering, minimal edema
- Tenderness, delayed pain
- Spontaneous healing in 3-7 days
- No scarring
First degree (epidermal) burn
e.g. minor sunburn
66
Define the burn classification & provide an example based on the following characteristics:
- Damage to epidermis & upper dermis layers
- Bright pink or red appearance
- Blanching w/ brisk capillary refill
- Blisters, moist/wet surface
- Moderate edema
- Painful, sensitive to touch, temp changes
- Spontaneous healing in 7-21 days
- Minimal or no scarring, discoloration
Superficial partial-thickness/second degree burn
e.g. blister from hot water spilling on hand, moderate sunburn
67
Define the burn classification & provide an example based on the following characteristics:
- Severe damage to epidermis + dermis w/ injury to nerve endings, hair follicles, & sweat glands
- Mixed red or white, waxy appearance
- Blanching w/ slow capillary refill
- Broken blisters, wet surface
- Marked edema
- Sensitive to pressure but insensitive to light touch or soft pin prick
- Healing is slow, occurs through scar formation & re-epithelialization
- Excessive scarring without preventative tx
Deep partial-thickness (second-degree)
68
Define the burn classification & provide an example based on the following characteristics:
- Complete destruction of epidermis, dermis, & subcutaneous tissues, may extend into muscle
- White (ischemic), charred, tan, or black
- No blanching, poor distal circulation
- parchment-like, dry leathery surface; depressed area
- Little to no pain
- Removal of eschar and skin grafting are necessary d/t destruction of dermal and epidermal tissue
- Hypertrophic scarring and wound contracture are likely to develop w/out intervention
Third-degree (full thickness burn)
69
Define the burn classification & provide an example based on the following characteristics:
- Complete destruction of epidermis, dermis, with involvement of subcutaneous tissues & muscle
- Charred appearance
- Destruction of vascular system, may lead to additional necrosis
- Additional complications likely wit electrical burns: ventricular fibrillation, acute kidney damage, spinal cord damage
- Heals w/ skin grafts + scarring
- Extensive surgery required, may include amputation
Fourth-degree (subdermal) burn
70
Discuss pulmonary complications that may result from burn injuries
- Pulmonary edema
- Airway obstruction
- Restrictive lung disease (burns to trunk)
- Pneumonia
71
Discuss metabolic complications that may result from burn injuries
- Increased metabolic & catabolic activity can lead to weight loss, negative nitrogen balance, and decreased energy
- Hypermetabolic state can persist for months to years after major burn
72
Burns greater than ___% TBSA result in decreased renal perfusion and increased risk for acute kidney failure.
30%
73
Emergency local burn care includes what?
- Immersion in cold water or use of cold compress if area is small
- Sterile bandage
- No ointments or creams
74
With severe burns requiring surgical management and potentially grafts, what is a red flag the PT should monitor for?
Compartment syndrome in the involved and uninvolved extremity
75
Discuss basic principles of wound cleansing & debridement in regards to burn management
1. Use infection control techniques at all times
2. Maintain temperature of wound by warming cleansing solutions & avoiding lengthy exposure of wet wound surfaces
3. Cleanse with disinfectant soap & warm water
4. Excessive immersion is contraindicated
5. Wound debridement: autolytic dressings, sharp debridement, enzymatic debridement, mechanical debridement
76
Discuss general rehabilitation management for patients with burn injuries
- Overall goals: limit ROM losses, reduce edema, prevent contractures, prevent complications of immobilization
- Typically PT 2x/day coordinated w/ meds & dressing changes
- Exercises to promote deep breathing/chest expansion
- Anticontracture positioning & splinting: from day one --->
- Common areas: anterior neck, shoulder, elbow, hand, hip, knee ankle
- Edema control
- Take all joints through passive ROM
77
Therapy should be discontinued for how long after a skin graft procedure?
3-5 days to allow grafts to heal
78
When should therapy be timed to allow for medication to have an appropriate effect?
Meds 30-45 minutes before session
79
What two components are critical for wound healing to occur?
1. Most wound healing
2. Removal of bioburden
80
Review the "T" in the TIME Principles for wound bed preparation
T--> Tissue viable or nonviable?
Viable: chose dressing that promotes moist wound healing & fills dead space
Nonviable: choose the best type of debridement to remove necrotic tissues, slough, or bioburden
81
Review the "I" in the TIME Principles for wound bed preparation
I--> Infection/inflammation
Address infection (local or systemic), excessive colonization, or edema
82
Review the "M" in the TIME Principles for wound bed preparation
M --> Moisture balance
- Dry or desiccated wounds: choose dressing that hydrates &/or promotes a moist wound environment
- Excessive moisture: (maceration present); choose dressing that absorbs mod to heavy drainage
83
Review the "E" in the TIME Principles for wound bed preparation
E --> Edge of wound
- Healthy wound edges promote healing
- Scarring, necrotic tissue, undermining, tunneling must be addressed for proper epithelial migration
84
Discuss infection control interventions when managing wounds
- Topical antimicrobial agents (silver nitrate, silver sulfadiazine, erythromycin, gentamicin, neomycin, triple antibiotic)
- Wound cleansing
- Removal of bioburden & non-viable tissue
- Hand washing of HCP
- Clean or sterile technique as indicated
- Negative pressure wound therapy as indicated
85
Discuss NPWT
- 125 mmHg below ambient pressure (typical)
- Open-cell foam dressing placed into wound
- Helps maintain moist wound environment, control edema, increase blood flow, remove exudate, & reduce bioburden
- Contraindications: exposed organs, exposed nerves/vessels, untreated osteomyelitis, significant eschar
86
Hyperbaric oxygen therapy is contraindicated for which individuals?
- Those on neoplastic medicaitons
- Untreated pneumothorax
-
87
Review the basic steps/principles of wound cleansing
- Removal of loos cellular debris, metabolic rates, bacteria, topical agents
-Cleanse wound initially & at each subsequent dressing change
- Normal saline recommended for most ulcers
- Cleansing topical agents (be cautious as some solutions may be toxic)
- Use extreme caution with cleansing methods that utilize pressure/mechanical force as to not damage newly forming granulation tissue.
- Pulsed lavage/irrigation (4-15 psi)
88
What method of debridement is nearly always contraindicated, except for perhaps in some cases of burn injuries requiring extensive debridement?
Whirlpool therapy
89
Define the following method of debridement along with its associated indications/contraindications:
Autolytic
- Selective method of natural debridement that uses body's own enzymes & moisture beneath occlusive or semi-occlusive moisture-retentive dressings
- Dressing types: hydrocolloids, hydrogels, transparent films
- Indications: pt on anticoagulation therapy, who can't tolerate other debridement types, all necrotic wounds in people medically stable
- Contraindications: infected wounds, immunosuppressed individuals, dry gangrene or dry ischemic wounds
90
Define the following method of debridement along with its associated indications/contraindications:
Enzymatic
- Selective chemical debridement that promotes liquefaction of necrotic tissue by applying topical preparation of collagenolytic enzymes to those tissues
- Indications: all moist necrotic wounds, eschar after cross-hatching, homebound individuals, those who can't tolerate surgical debridement
- Contraindications: Ischemic wounds unless adequate vascularization is confirmed, dry gangrene, clean/granulated wounds
91
Define the following method of debridement along with its associated indications/contraindications:
Mechanical
- Nonselective debridement that removes material with physical force; may also remove healthy tissue
- Indications: wounds with moist necrotic tissue or foreign material present
- Contraindications: Clean/granulated wounds
92
Define the following method of debridement along with its associated indications/contraindications:
Sharp
- Selective debridement using sterile instruments; no anesthesia & little to no bleeding induced in viable tissue
- Indication: scoring and/or excision of leathery eschar, excision of moist necrotic tissue, biofilm removal
- Contraindications:
93
Define the following method of debridement along with its associated indications/contraindications:
Sharp
- Selective debridement using sterile instruments; no anesthesia & little to no bleeding induced in viable tissue
- Indication: scoring and/or excision of leathery eschar, excision of moist necrotic tissue, biofilm removal
- Contraindications: Clean wounds, advancing cellulitis w/ sepsis, life-threatening infection, anticoagulant therapy/coagulopathy
94
Define the following method of debridement along with its associated indications/contraindications:
Surgical
- Performed by Surgeon, usually for stage III and IV pressure ulcers for example
- Indications: advancing cellulitis, immune-compromised, life-threatening infection, biofilm removal, etc.
- Contraindications: cardiopulmonary disease, diabetes, severe spasticity, those w/ a short life expectancy, QOL cannot be improved
95
Define the following method of debridement along with its associated indications/contraindications:
Biological
- Use of maggots to debride nonviable tissue
- Indications: can't tolerate other debridement, all non healing necrotic wounds in medically stable individuals
- Contraindications: psychological aversion, reports of increased pain, poor perfusion or exposed blood vessels
96
Define the following method of debridement along with its associated indications/contraindications:
Kilohertz Ultrasound
- Long-wave long frequency US (20-50 kHz)
- Selective debridement
- Indications: selective removal of necrotic tissue or biofilm, reduces bioburden, increase angiogenesis, wound bed preparation for grafting or flap closure
- Contraindications: vascular abnormalities, irradiated areas, organs, tumors
- Caution over nerves, infections, anesthetic areas
97
What special consideration should be taken with heel ulcers?
Do NOT debride if ulcer is dry without edema, erythema, fluctuant, or drainage
98
Ideal wound dressings do what?
- Maintain a moist environment
- Control excessive exudate
- facilitate gaseous exchange
- Insulate wound
- Protect against microorganisms
- Are non-traumatic to the wound
99
Individuals with wounds require how much water per day?
3+ liters
100
Repositioning in bed should occur how frequently?
at least every 2 hours
101
Repositioning in a wheelchair should occur how frequently?
at least every 15 minutes
102
Discuss the definition, indications, advantages, disadvantages, and considerations of the following dressing type:
Transparent Films
Clear, adhesive semipermeable membrane; permeable to atmospheric oxygen and moisture vapor, but impermeable to contaminants
Indications:
- Stage 1 & 2 pressure ulcers
- Secondary dressing
- Autolytic debridement
- Skin donor sites
- Cover for hydrophilic power
Advantages:
- Can see wound without removal
- Impermeable to outside contaminants
- Promotes autolytic debridement
- Minimize friction
Disadvantages:
- Nonabsorptivee
- Difficult application
- Wrinkles in film
- does not work for fragile surrounding skin or infected wounds
Considerations:
- Allow 1-2 inch border around wound bed
- Shave surrounding hair
- Avoid in wounds w/ infection, copious drainage, or tracts
- Secondary dressings not required
103
Discuss the definition, indications, advantages, disadvantages, and considerations of the following dressing type:
Hydrocolloids
Adhesive wafers containing hydro active/absorptive particles that interact with wound fluid to form a gelatinous mass over the wound bed; may be occlusive or semi-occlusive
Indications:
- Protection of partial-thickness wounds
- Autolytic debridement of necrosis or slough
- Wounds with mild exudate
Advantages: maintain moist environment, nonadhesive to healing tissue, impermeable to external contaminants, supports autolytic debridement, min to mod absorption, waterproof, easy to apply,
Disadvantages: nontransparent, may soften or change shape w/ temperature, curled dressing edges, not for fragile or infected wound areas
Considerations:
-yellow exudate + odor normal w/ removal, frequency of changing depends on exudate amount, usually every 3-7 days or with leakage, avoid in wounds with infection/tracts
104
Discuss the definition, indications, advantages, disadvantages, and considerations of the following dressing type:
Hydrogels
Water of glycerine based gels; insoluble in water; may be impregnated; variable absorptive capacity
Indications: partial & full-thickness wounds, wounds w/ necrosis/slough, burns & radiation damage
Advantages: soothing, cooling, fill dead space, rehydrate dry wound beds, promote autolytic debridement, min to mod absorption, conform to wound bed, transparent to translucent, many nonadherent, amorphous form can be used when infection is present
Disadvantages: most require secondary dressing, not for heavy exudate, may dry out & adhere to the wound, may macerate surrounding skin
Considerations: sheet form not for infected ulcers/may cause yeast or pseudomonas growth; dressing change every 8-48 hrs, use skin barrier wipe to reduce risk of maceration
105
Discuss the definition, indications, advantages, disadvantages, and considerations of the following dressing type:
Foams
Semipermeable membranes that are either hydrophilic or hydrophobic; vary in thickness, absorptive capacity, & adhesion
Indications: partial & full thickness wounds, min to mod exudate, secondary dressing for wounds w/ packing for extra absorption, protection & insulation
Advantages: isolate wounds, provide padding, non adherent, conformable, minimal to heavy exudate,
Disadvantages: nontransparent, non adherent foams require secondary dressing, don't conform to deep wounds, don't use on dry wounds
Considerations: change schedule varies 1-5 days, protect intact skin with skin sealant to prevent maceration
106
Discuss the definition, indications, advantages, disadvantages, and considerations of the following dressing type:
Alignates & hydrofibers
- Alginates are soft, absorbent, nonwoven dressings derived from seaweed; react w/ exudate to form viscous hydrophilic gel mass over wound; hydrofibers (auquacel) similar to alginates but composed of polymer
Indications: mod to heavy exudate, combination exudate + necrosis, wounds requiring packing + absorption, infected and noninflected exudating wounds
Advantages: absorb 20x their weight, fill dead space, support debridement, easy
Disadvantages: require secondary dressing, can dry wound bed
Considerations: may use dry gauze/transparent film as second dressing, change schedule varies from 8 hours to 2-3 days
107
Discuss the definition, indications, advantages, disadvantages, and considerations of the following dressing type:
Gauze
Indications: exudative wounds, dead space/tunneling/sinus tracts, combination exudate + necrotic tissue
Can be used wet-to-dry, continuous dry, continuous moist
Advantages: can be used w/ solutions, used on infected wounds, mechanical debridement, cost-effective filler, effective delivery of topicals
Disadvantages: delayed healing if improperly used, pain on removal, labor intensive, requires second dressing, avoid direct contact w/ granulating tissue, increase infection rates
Considerations: pack loosely, not too wet, use continuous roll when packing, wide mesh for debridement and fine mesh for protection
108
Review the Braden Scale
15-23 = mild to no risk
13-14 = moderate risk
10-12 = high risk
6-9 = very high risk
Lower score = greater risk
Considers: sensory perception, moisture, activity, mobility, nutrition, friction and/or shear
