Intro to Wound Care Flashcards
1
Q
What are the phases of wound healing?
A
Hemostasis –> inflammation –> proliferation –> remodeling
2
Q
Characteristics of hemostasis
A
Platelets are primary players; involves activation of the clotting cascade and PLT aggregation (minutes)
3
Q
Characteristics of inflammation
A
Involves increased presence of WBCs & cytokines to invade tissue space, clear debris - usually lasts 1-3 days
4
Q
Characteristics of proliferation
A
Involves process of laying down granulation tissue and epithelization; fibroblasts are the key player (usually around 10 days)
5
Q
Characteristics of remodeling
A
Involves increasing tissue tensile strength and formation of collagen (100 days or more)
6
Q
Factors that limit healing of chronic wounds
A
Infection, malnutrition, edema, ischemia, pressure necrosis
7
Q
What percentage of surgical wounds subsequently develop complications?
A
~5%
8
Q
ISTAP type 1
A
skin tear without tissue loss
9
Q
ISTAP type 2
A
skin tear with partial tissue loss
10
Q
ISTAP type 3
A
skin tear with deep tissue loss
11
Q
What is the MC reason why DFUs do not heal?
A
Inadequate offloading techniques
12
Q
What percentage of DFUs Wagner Score 3+ do not heal?
A
~70%
13
Q
Marjolin’s ulcer
A
malignancy that occurs @ the site of a long-standing wound
14
Q
Signs/symptoms of wound infection
A
SIRS criteria, purulence, pain, necrosis, odor, fever, lymphangitis, PW rubor
15
Q
How many cm beyond PW is considered clinically-significant cellulitis?
A
> 2cm
16
Q
At what ABI level can full compression techniques be used?
A
ABI >0.70
17
Q
General protein intake guidelines for wound healing
A
Protein: 1.75-2g/kg/day
18
Q
General protein intake guidelines for patients with ESRD
A
0.75 g/kg/day
19
Q
Absolute contraindications to NPWT
A
active untreated osteomyelitis/infection, malignancy, unexplored fistulas, necrotic tissue
20
Q
When are skin substitutes indicated?
A
Wounds that have not healed by >50% in a 30 day span despite use of conventional therapy
21
Q
BRADEN score characteristics
A
mobility, sensory perception, moisture, activity, nutrition, friction & shear
22
Q
Uses of hyperbaric O2
A
ANEMIA, burns, CO poisoning, crush injuries, gas gangrene, hearing loss, osteomyelitis, Wagner 3+ DFUs, radiation skin necrosis, skin grafts at risk of necrosis
23
Q
Hyperbaric O2 MOA
A
delivers 3x the normal [O2] in blood plasma to affected areas, resulting in higher [O2] at end-organ areas
24
Q
Hyperbaric O2 ADRs
A
ocular toxicity, transient myopia, cataract growth, barotrauma, CNS toxicity, oxygen toxicity, flash pulmonary edema, confinement anxiety, paresthesias
25
Absolute CI to hyperbaric O2
untreated pneumothorax
26
Relative CIs to hyperbaric O2
patients previously treated with bleomycin & doxorubicin & cisplatin; disulfiram, amiodarone, sulfamylin, chronic sinusitis, seizure disorders, emphysema with CO2 retention, active malignancies, pregnancy
27
Characteristics of wound bed in chronic wounds (>4 weeks)
Exudate of chronic wounds contains higher levels of MPP; suggests slower tissue regeneration & delayed wound closure
-prolonged inflammatory phase --> impaired angiogenesis & neovascularization
28
What phase of wound healing do chronic wounds stay in?
Inflammatory phase
29
Transcutaneous oximetry (TCOM)
estimates the partial pressure of oxygen on the skin surface using non-invasive electrodes
30
What can TCOM be used for?
screening tool for PAD
31
What TCOM is typically referenced as representative of tissue hypoxia sufficient to delay wound healing?
TCOM <40 mmHg
32
What TCOM value is referenced as suggestive/indicative of critical limb ischemia?
TCOM <30 mmHg
33
Emergent hyperbaric O2 indications
acute CO poisoning, arterial gas embolism, decompression sickness
34
Urgent hyperbaric O2 indications
acute PAD, compartment syndrome, crush injuries, Central retinal artery occlusion, gas gangrene, compromised skin grafts/flaps, pyogenic & invasive fungal intracranial abscesses, acute blood loss anemia
35
Elective hyperbaric O2 indications
DFUs, chronic refractory osteomyelitis, soft tissue radiation skin necrosis, osteonecrosis of the jaw
36
Indications for air breaks during hyperbaric O2 therapy
prevents cumulative effects of hyperbaric O2 toxicity
37
PUSH tool
Assesses wounds via 3 characteristics: (1) size, (2) exudate type & amount, (3) tissue characteristics
38
BWAT tool
Assesses wounds using 15 characteristics
-size, depth, edges, UM, necrosis, exudate, PW skin color, peripheral tissue edema, induration, granulation tissue, epithelization
39
After how long (when acquired) is a wound considered a hospital or system acquired PI?
24 hours
40
Approach to informed consent
(1) assess capacity
(2) if unable to consent, reach out to POA for consent
41
EBP grading - Category 1A
Well-supported & recommended for implementation
42
EBP grading - Category 1B
Has supporting evidence & is recommended for implementation
43
EBP grading - Category 1C
Industry standard
44
EBP grading - Category II
Has supportive clinical studies
45
EBP grading - Category III
Described in clinical studies
46
EBP grading - Category IV
Expert opinion
47
Goals of palliative wound care
Reduce pain, minimize risk of infection, control odor
48
Is palliative wound debridement allowed?
Yes - in terms of debridement to minimize risk of infection
49
Functions of the skin
acts as a protective barrier against outside pathogens; prevents moisture loss; reduces UV radiation effect; sensory organ; temperature regulation; vitamin D production
50
What are the primary cells of the dermis?
fibroblasts
51
Papillary dermis
superficial layer of the dermis composed of loose connective tissue that is highly vascularized
52
Functions of the hypodermis
connection, insulation, shock absorption for organs, energy storage
53
Reticular dermis
deeper layer of the dermis composed of thick connective tissue
54
Layers of the epidermis (deep to superficial)
stratum basale --> stratum spinosum --> stratum granulosum --> stratum lucidum --> stratum corneum
55
Primary healing
active healing via an additive mechanism (i.e. sutures or staples)
56
Secondary healing
healing that occurs via re-epithelization that cannot be closed via primary intention
57
Tertiary healing
healing via delayed primary closure
58
What (technically speaking) does an ulcer refer to?
A wound that has been present for >4 weeks; AKA a chronic wound
59
Causes of hypergranulation
topical skin infection, malnutrition, impaired inflammatory phase/state, microtrauma
60
Management of hypergranulation
chemical cautery(primary), topical steroids, debridement
61
1+ edema
2mm sized wheel and takes 10-15 seconds to return to baseline
62
2+ edema
4mm wheel and takes 10-15 seconds to return to baseline
63
3+ edema
6mm wheel and takes <1 minute to return to baseline
64
4+ edema
8mm wheel and takes 2-5 minutes to return to baseline
65
Signs/symptoms of infection
PW induration, rubor >2cm beyond margins, lymphangitic streaking, localized warmth & tenderness to palpation, purulence, odor, necrosis, hypergranulated tissue
66
MC sites for pressure injuries
MC site is the sacrum (heels: 2nd MC)
67
External mechanical forces that result in pressure wounds
pressure, shear & friction
68
Intrinsic factors that lead or precipitate pressure wounds
age, nutrition, moisturize, body temperature
69
Stage 1 pressure wound
characterized as non-blanchable tissue usually over a bony prominence
70
Treatment for S1 pressure wounds
offloading of the affected areas +/- skin prep
71
Stage 2 pressure wound
involves partial thickness skin loss (dermis)
72
Stage 3 pressure wound
Involves full thickness wound without exposed soft tissue or bone
73
Stage 4 pressure wounds
Involves soft tissue skin loss/exposure (exposed muscle, tendon, ligament, bone, capsule)
74
Unstageable pressure wound
wound base is completed covered by eschar or slough and therefore an appropriate stage cannot be determined
75
Deep tissue pressure injury
non-blanchable deep red/maroon-colored wound or epidermal separation revealing a dark wound bed due to extensive tissue necrosis; may resolve completely or unveil a S3 or S4 pressure wound
76
Kennedy terminal ulcer
the presence of a rapid-onset & rapidly-deteriorating wound (MC on the sacrum) due to end organ skin failure as a result of end of life skin changes
77
Why are lubricants essential in preventing pressure wounds?
lubrication allows for reduction friction & shear --> reduction of pressure wound occurrence
78
What are the criteria for using silicone sacrum dressings for pressure wound prevention?
BRADEN score <18 and ANY of the following:
-vasopressor use, trach'd or intubated, spinal cord injury, TBI, age >60 YO
79
Incontinence Associated Dermatitis (IAD)
presence of skin inflammation due to prolonged skin exposure to urine & stool
80
Does a normal ABI rule out presence of microvascular disease?
No - low sensitivity
81
Wagner scale 0
intact skin
82
Wagner Score 1
superficial skin loss (as deep as SQ)
83
Wagner Score 2
deep tissue loss (exposed tendon, bone, capsule)
84
Wagner Score 3
abscess, osteomyelitis, or tendinitis/deep space infection
85
Wagner Score 4
gangrene of toes and forefoot
86
Wagner Score 5
gangrene of the entire foot
87
Are Darco offloading shoes appropriate for open wounds?
No - only prevent formation of new ulcers
-existing ulcers require total contact casts or knee walkers
88
What percentage of DFUs will become infected?
~60% or greater
89
What is the gold standard technique/test for diagnosing acute osteomyelitis?
bone biopsy
90
What is the gold standard test for diagnosing acute wound infection?
tissue biopsy
91
Which sites are tested in the Semmes-Weistein Monofilament Test?
10 total sites
-9 plantar (distal great toe, 3rd toe, 5th toe, 1st/3rd/5th metatarsal heads, medial foot, lateral foot, heel)
-1 dorsal (1st-2nd toe web space)
92
A positive Semmes-Weinstein monofilament test indicates:
polyneuropathy
-4 or more sites with lack of sensation is a positive result
93
Contraindications for sharp debridement
ABI <0.60, INR >1.5, factor Xa inhibitor use
94
How long does a factor Xa inhibitor need to be discontinued for prior to sharp debridement?
>48 hours prior to debridement
95
Risk factors for arterial ulcers
>65 YO, hx PAD/DM/HTN/Dyslipidemia, known atherosclerosis in other vessels
96
Pathophysiology of arterial ulcers
tissue ischemia with intermittent reperfusion leads to release of ROS --> oxidative damage to ulcer site
97
What percentage of venous ulcers recur after closure?
~70%
98
Risks of venous ulcer formation
CVD, obesity, prior leg injury, DVT, prolonged standing/sitting
99
Risks for delayed venous ulcer healing
ulcer presence >6 months, >50 YO, male, family history, BMI >33, location on the posterior ankle/calf
100
Population at risk for venous ulcer recurrence
DVT & thrombophilic disease
101
What are the characteristics of a simple venous leg ulcer?
area <100 cm^2, onset <6 months, limited comorbidities
102
What are the characteristics of complex venous leg ulcers?
area >100 cm^2, presence >6 months, <30% decrease in size after 4 weeks of therapy, lipedema, leg/ulcer infection, decompensated or severe heart failure, non-compliance, lymphovenous disease
103
When is an Unna boot not appropriate for a patient in the absence of arterial disease?
If the patient is immobile - Unna boot requires intact calf pump for venous return
104
Treatment of stasis dermatitis
moisturizers/creams, topical steroids, zinc/calamine rolled gauze
105
Ways to prevent venous ulcer recurrence
compression, leg elevation, weight control, proper skin care, smoking cessation, calf muscle exercises
-complex VLUs may require vascular surgery consultation/intervention
106
Characteristic specifically associated with pyoderma in terms of debridement
Pyoderma will worsen with debridement
107
Diagnostic criteria for pyoderma
Biopsy demonstrative of neutrophilic culture PLUS at least 4 of the following: exclusion of infection, pathergy, history of autoimmune disease, tenderness with erythema at ulcer site, multiple ulcers with rapid progression)
108
Management of pyoderma gangrenosum
steroids & treatment of the underlying disease
109
3 Ps of vasculitis
palpable, painful, purpura
110
Epidermolysis bullosa
group of rare skin diseases that cause fragile, blistering skin
111
Cryoglobulinemia
systemic inflammatory process of kidneys/joints/skin caused by immune deposition of cryoglobulin resulting in extremely erythematous skin lesions
112
Marjolin ulcer
type of squamous cell carcinoma (SCC) that arises in areas of chronic wounds or scars that features an everted wound margin & ulceration
-requires biopsy for diagnosis
113
Kaposi sarcoma
AIDS-defining skin malignancy that manifests as multiple brown or black patches
114
Melanoma ABCDE rule
A: asymmetry
B: borders
C: color
D: diameter
E: evolution
115
Fungating/ulcerating mass
complication of carcinoma with skin disfigurement associated with extreme pain & foul odor; often suggestive of end of life/near mortality
116
Calciphylaxis
life-threatening skin disorder characterized by microvessel occlusion in SQ adipose tissue & dermis; associated with ESRD
117
Management of Calciphylaxis
sodium thiosulfate, infection control/debridement, Calcium & Phosphorous management/repletion, Vitamin K1 therapy
118
LRINEC score
scoring criteria to help rule in/rule out presence of necrotizing fasciitis
119
LRINEC score criteria
CRP, WBC count, hemoglobin, sodium, creatinine, glucose
120
LRINEC score of 8+
highly specific for necrotizing fasciitis (~94%)
121
MC type of skin cancer
Basal Cell Carcinoma
122
Head (rule of nines)
9%
123
Arms (rule of nines)
9% each arm
124
Legs (rule of nines)
18% each leg
125
Torso (rule of nines)
18%
126
Back (rule of nines)
18%
127
Perineum (rule of nines)
1%
128
Goals of debridement
removal of biofilm/necrosis, mechanical barriers, initiates coordinated inflammatory response, removal of bioburden/MMPs, enhances GF stimulation
129
What is biofilm?
An aggregate of microorganisms with a matrix of ECM/substances which adhere to each other & wound surface that are impervious to washing & mechanical pressure
130
Sharp debridement & biofilm
sharp debridement of biofilm will make bacteria susceptible to antibiotic therapy within a therapeutic window (24-48 hours)
131
Contraindications to sharp debridement
unstable medical condition; hemodynamic instability; pyoderma gangrenosum; dry eschar without evidence of infection; ABI <0.6; presence of significant coagulopathy (INR >3.5, PPT >45 seconds), PLTs <30K
132
Why are wet to moist dressings preferred over wet to dry dressings?
Wet to moist dressings help prevent removal of healthy granulation tissue with subsequent wound dressing changes that would not occur with wet to dry dressings
133
Why is autolytic debridement alone not indicated for infected wounds?
Autolytic debridement amplifies effect/use of the body's natural enzymes to destroy bioburden; this effect may not be amplified greatly enough in the face of active infection to clear bioburden
134
When using biologic debridement, the outer layer dressing must be __ in order to work effectively
semi-permeable
135
MIST therapy MOA
MIST therapy utilizes water filtered infrared light to cause an increase in local temperature at the wound bed --> local vasodilation --> increased oxygenation at the wound bed
136
ABI >1.4
Indicative of calcified arteries
**requires follow-up with TBI for a true read
137
ABI 0.9-1.3
normal value
138
ABI 0.7-0.9
mild PAD
139
ABI 0.5-0.7
moderate PAD
140
ABI <0.5
severe PAD; potential (or likely) critical limb ischemia
141
TBI >0.70
normal value
142
TBI 0.5-0.7
mild PAD
143
TBI 0.35-0.5
Moderate PAD
144
TBI <0.35
Severe PAD
145
Why are TBIs indicated/more accurate for patients with DM?
ABIs are usually artificially elevated in patients with DM due to significant arterial stiffening, leading to artifically higher ABI values for these patients
146
TCOM >40mm Hg
recognized as adequate oxygenation/sufficient for wound healing
147
TCOM 20-40mmHg
Indeterminant oxygenation status for wound healing
148
TCOM <20mmHg
Indicative of tissue ischemia/not sufficient for wound healing
149
What is the gold standard scoring tool/test to diagnose malnutrition?
ASPEN criteria
150
Adequate hydration necessary for wound healing
1600 mL/24 hours
151
Clinical manifestations of PAD
dry/leathery skin, atrophic skin, cool extremity, absence of hair below the knee, "punched out" ulcer appearance
152
What angle must the doppler be held when determining ABI?
45 degree angle
153
What TCOM value is incompatible with wound healing?
<30mmHg
154
What is the primary function of fibroblasts?
epidermal re-surfacing
155
MC post-operative complication of flap placement
Hematoma
156
What is the optimal PSI for wound cleaning?
10mmHg
157
Function of keratinocytes
GF/MMP release, protection against infection, assists with thermoregulation
158
What direct effect does glycemic control have on the body/immune system?
improves neutrophil function
159
What is the most common organism found in DFUs?
S. aureus
160
Braden score of 9 or less
very high risk for PI
161
Braden score of 10-12
High risk for PI
162
Braden score of 13-14
Moderate risk for PI
163
Braden score of 15-18
Mild risk of PI
164
Braden score of 19+
No risk for PI
165
What does the Braden score measure/what is it used for
Screening tool used to evaluate the risk of developing a PI
166
Criteria used for Braden score
Sensory perception; moisture; activity; mobility; nutrition; friction & shear
167
Steps to the Levine Technique
Cleanse wound with sterile water; rotate cotton swab over clean area of tissue for 5 seconds; apply enough pressure to express exudate from the wound bed; break off tip into a sterile medium
168
6 criteria to diagnose malnutrition (ASPEN guidelines)
energy intake, weight loss, loss of SQ fat, muscle loss, fluid accumulation, grip strength
169
How many of the ASPEN criteria must be satisfied to make a diagnosis of malnutrition?
2
170
3 etiologies of malnutrition (per ASPEN criteria)
Acute injury/illness; Chronic disease; Social & environmental factors
171
Examples of acute injury/illness (ASPEN)
infection, burns, trauma
172
Examples of chronic disease (ASPEN)
ESRD/COPD/HIV, advanced liver disease
173
Examples of environmental/social causes of malnutrition (ASPEN)
food insecurity, drug/alcohol abuse, eating disorders
174
What is the Parkland formula used for?
an estimate of the volume of fluid resuscitation required for a burn victim within the first 24 hours of injury
175
The Parkland formula
4mL * %BSA * weight(kg) = volume in 24 hours
176
Fluid distribution with the Parkland formula
1/2 given within the first 8 hours; the remainder given over the next 16 hours
177
How quickly can a pressure injury develop?
Within 2 hours
178
Stage 0 Lymphedema
No visible edema nor pitting evident
179
Stage 1 Lymphedema
considered mild disease; pitting is present, however stage is reversible and improves with elevation
180
Stage 2 Lymphedema
considered moderate disease; pitting edema that does not resolve with elevation
181
Stage 3 Lymphedema
considered severe disease; characterized by fibroadipose deposition & skin changes present
182
Percentage of volume increase in Stage 3 Lymphedema
>40%
183
Percentage of volume increase in Stage 2 Lymphedema
20-40%
184
Percentage of volume increase in Stage 1 Lymphedema
<20%
185
Stemmer's sign
involves pinching the dorsum of the 2nd toe with thumb & index finger; if unable to do so, the test is positive for lymphedema
186
The most abundant form of collagen in the body
Type 1 Collagen
187
Gold standard diagnostic tool for lymphedema
Lymphoscintigraphy
188
Stratum basale
composed of a single layer of keratinocytes; rapidly dividing
189
Stratum spinosum
composed of several layers of cells with web-like filaments & desmosomes; also contact dendritic cells
190
Stratum granulosum
4-6 cell layers thick; keratinization begins here
191
Stratum lucidum
2-3 cell layers thick; composed of dead & clear keratinocytes (found primarily in palms of hands & soles of feet)
192
Stratum corneum
20-30 cell layers thick; composed of dead & anucleated cells
193
Papillary dermis
superficial dermis; composed of areolar connective tissue with a network of collagen and elastic fibers
-allows for easy maneuverability of defensive cells to identify & neutralize bacteria
194
Reticular dermis
~80% of the dermis (deeper dermis) composed of dense, fibrous connective tissue
195
WiFi components
Wound, Ischemia, Foot infection
196
Etiologies of malnutrition (per ASPEN criteria)
acute injury/illness; chronic disease; social/environmental factors
197
Acute injury/illness (ASPEN criteria)
burns, infection, trauma
198
Chronic disease (ASPEN criteria)
CKD, advanced liver disease, HIV
199
Social/Environmental factors (ASPEN criteria)
eating disorders, religion, etc
200
What are the 6 markers of malnutrition (ASPEN criteria)?
weight loss, energy intake, body fat, muscle mass, fluid accumulation, grip strength
201
Albumin half-life
14-20 days
202
Pre-albumin half life
2 days
203
What leads to decrease in albumin & prealbumin
stress, trauma, infection, malnutrition
204
Normal TBI value
>0.7
205
Low (mild PAD) TBI value
0.5-0.7
206
Moderate (moderate PAD) TBI value
0.35-0.5
207
Severe (severe PAD) TBI value
<0.35
