Integumentary: Eval/prognosis & interventions Flashcards
What fasting glucose levels and A1c levels indicate diabetes?
glucose above 115???
A1c >6 %
If a patient has an Ankle Brachial Index of .65 what does this indicate?
patient has abnormal status: PAD likely
normal=1+
.9-.99=borderline
<.9=abnomral
<.5=severe PAD
if > 1.4=calcified arteries
List what ABCDE stands for
A=asymmetrical
B=border (are edges irregular)
C=color (is it same or different)
D=Diameter (is it bigger than 6 mm (size of pencil eraser)
E=evolving (has it changed in size/appearance)
Describe exudate types
Serous=clear (normal)
Sanguineous=red/bloody discharge
Purulent=yellow/green–>INFECTION
A patient has a bulls eye rash and a fever and nausea what pathology is likley?
Lyme disease
Tx=antibiotics
What are perks of occlusive dressing?
Maintain moist wound, helps w/ autolytic debridement,
cons=no absorption
Should wet to dry dressings be used for debridment?
NO–>takes away good and bad, should avoid always
Pros and cons of gauze?
Pros=cheap, can use with topical meds, mechanical debridement
cons=need 2ndary dressing
Alginates
Pros=for mod-high exudate
cons=can dry wound bed, need 2ndary film on top
Foam dressing pro/cons
pros=absorb high exudate, padding
cons=need 2ndary dressing, don’t use with dry eschar wounds
Hydrocolloid dressing por/cons
Maintains moist area, bacterial barrior, autolytic debridment
cons=not for infected wounds, lack of absorbtion
An Unna Boot is a kind of what dressing?
semi rigid dressing impregnated with ointments
commonly used for venous insuffiency & edema control
What meds when used with ionto help wound healing?
Zinc or histamine
When placing HVAC on a wound what does the anode and cathode do/attract?
Anode (+)–>promotes cell migration
cathode (-)–>used to promote granulation, control inflammation
List phases of wound healing
Inflammatory: 0-5 days (redness/heat/swelling/pain, loss of function)
Proliferative: 3-21 days (granulation buds, wound contraction)
Maturation: 14 days to 2 years (collagen replacement, scar healing)
Wound healing can be delayed to these intrinsic & extrinsic factors
intrinsic=aging, other disease, circulatory issues, malnutrition
Extrinsic=meds (steroids), necrotic tissue, wrong dressing
you see a tissue 10 days post injury that is a beefy red appearance, what should you do?
Nothing, this is a normal phase of healing that shows healthy healing
List characteristics of stage 1-4 pressure ulcer
Stage 1=nonbankable, reversible with help
stage 2=partial thickness skin loss (epidermis & dermis), abrasion/blister
3=full thickness skin loss into fat layer (NOT fascia)
4=full thickness skin loss into muscles (tendon/capsule often exposed)
5=unstageable=wound is covered in necrotic tissue and can’t ID what stage
Tx for stage 1-5 ulcers
1=pressure/friction & moisture alleviating measures
2=dermis exposure; apply appropriate dressing
3=debride if needed, proper dressing
4=surgery/grafting common
List parts of venous insuffiency & Tx
Will have good distal pulses,
edema present, skin is stained (hemosiderin staining)
*ulcers on medial ankle
Tx: control edema (unna boot/compression), active exercises
List parts of AI ulcers & Tx
deep & painful ulcers
skin=pale & cold
*on lateral malleous & toes
Tx=bed rest & wound care
ABI
Burn wound stages (3)-describe them
zone of coagulation=cells are irreversibly damaged & skin death (middle part)
zone of stasis=injured cells that may die soon if no Tx
zone of hyperemia=outside? (minimal cell damage)
