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5 Pathology > L7 Wound Care > Flashcards

L7 Wound Care Flashcards

1
Q

Overlapping phases of healing in chronic wounds

A

Inflammatory (clean it up)
Proliferative (fill the void)
Maturation (remodel it)

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2
Q

Inflammatory phase steps summary

A

Vasoconstriction
Fibrin blood clot
vasodilation
neutrophils
macrophages
removal of bacteria and debris

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3
Q

Inflammatory phase

A

processes begin immediately upon tissue injury

simultaneously, several players work together to initiate and maintain this phase and the sequence of cells involved

includes coagulation cascade, AA pathways, creation/release GF, cytokines

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4
Q

Purpose of inflammation

A

clean wound of debris and stimulate fibroblast cells to produce collagen

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5
Q

Inflammation is clinically characterized by

A

redness, heat, swelling, pain, loss of function

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6
Q

Proliferative phase summary of steps

A

Macrophages release cytokines that signal endothelial cells, growth factors, epithelial cells

Causes new blood vessel growth, re-epithelization, fibroblasts–> collagen–> granulation tissue

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7
Q

Proliferative phase

A
  1. begins 2-3 days after wound, signaled by fibroblasts
  2. Fibroblasts migrate from wound margins using fibrin matrix (from inflammatory)
  3. Fibroblasts become dominant cell type, reaching peak at 7-14 days
  4. Collagen is a major component of acute wound connective tissue
  5. With cellular proliferation, angiogenesis in granulation occurs b/c of budding vessels
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8
Q

Results of proliferative phase

A

granulation tissue
contraction, epithelialization of wound

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9
Q

Granulation tissue

A

red, bumpy, doesn’t bleed easily

made of collagen, capillaries, ECM

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10
Q

Maturation phase summary steps

A

Collagen
Deposition
Remodeling
Increase tensile strength
scar reduction

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11
Q

Maturation phase

A
  1. Collagen production begins in 6 weeks
  2. Collagen is depostied randomly in acute wound granulation tissue, but remodeling into more organized structure occurs during maturation, increasing strength
  3. During scar formation, collagen 3 is replaced by type 1
  4. Wound eventually closes by migration of epithelial cells from wound edge. Once fibroblasts contact each other, causes myofibroblast formations
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12
Q

2 year post injury, tensile strength is

A

80% of normal strength
wound strength will never exceed this

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13
Q

Wound Exam

A
  1. Location
  2. Behavior of symptoms
  3. wound cultured
  4. wound type
  5. Size/depth
  6. signs of infection
  7. dry or draining
  8. swelling
  9. skin discoloration
  10. vascular exam
  11. skin nutrition
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14
Q

Hypergranulation tissue

A

also called proud flesh
extends above the surface of surrounding epithelium
has to be removed

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15
Q

Inflammatory exudates

A
  1. Hemorrhagic = surgery
  2. Seosanguinous = yellow, 2-3 days after injury
  3. Serous = watery, early stage of inflammations
  4. Purulent = cloudy pus, indicates infection
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16
Q

Wound eval steps

A
  1. hx of current wound
  2. pertinent medical history
  3. subjective and objective exam
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17
Q

Pertinent medical history

A

what impacts wound healing? what are the barriers to healing?

diabetes
PVD
hypertension
smoking
meds (glucoco, immunosupp)
last tetanus shot
allergies
nutritional status
activity level
wound culture

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18
Q

Best glucose level for best healing

A

<180 mg/dl

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19
Q

Methods to measure size/depth of wound

A
  1. plnimetry = wound tracing
  2. ruler method

no gold standard!

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20
Q

Negatives of planimetry

A

difficult to race wound edges
doesn’t measure wound depth

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21
Q

Ruler method

A

dimensions with a ruler using clock method

12 to 6, 3 to 9

depth is done with q-tip

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22
Q

Signs of infection

A
  1. Odor
  2. Colored Drainage
  3. Fever
  4. Cellulitis

in a nonhealing wound, you must consider infection

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23
Q

Odor

A

pseudomonas smells sweet
proteus smells like urine

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24
Q

Colored drainage

A

pseudomonas is greenish
proteus is yellowish

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25
Q

Cellulitis

A

diffuse infection of subcutaneous layer of skin, usually spreads rapidly

caused by bacteria

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26
Q

Types of chronic wounds

A

pressure injuries
venous stasis ulcers
arterial insufficiency ulcers
neuropathic ulcers

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27
Q

Purpose of wound care (no matter the type)

A

remove infection
remove devitalized tissue
promote healing

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28
Q

Pressure Injuries

A

localized areas of cellular necorsis resulting from prolonged, unrelieved pressure between any bony prominence and an external obkect, injury can present as intact skin or open ulcer

the unrelieved pressure results in ischemic hypoxia and damage to underlying tissue

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29
Q

Incidence of pressure injuries

A

1.5 million a year

in long term care, regulatory agencies use development of pressure injuries as an indicator of QOC to patients

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30
Q

Tip of the iceberg effect

A

Begins with ischemia first in
tendon, then subcutaenous, dermis, epidermis

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31
Q

Contributory factors to pressure injuries

A

prolonged pressure, shear forces, friction, maceration, repetitive stress and nutritional deficiencies

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32
Q

RF for pressure injuries

A

elderly, debilitated, immobilized
sitting for long periods
inability to reposition every 20 to 30 min
sitting in commode chair >20 min
exposure to unrelieved pressure during operation

decreased blood flow from hypotension
decrease sensation
cognitive impairment
loss of bowel/bladder control

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33
Q

Maceration

A

skin changes due to excessive moisture

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34
Q

For pressure injury prevention, do not raise HOB

A

> 30°

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35
Q

CP of Pressure Injuries

A

occurs over bony prominences
most common in sacrum, buttocks, hips, heels

color: red, brown, yellow
infection
painful if sensation is intact
inflammatory response with necrotic tissue

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36
Q

Stage 1 Pressure Injuries

A

nonblanchable erythema of intact skin whose indicators as compared to an ajacent or opposite area on the body

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37
Q

Stage 1 may include changes:

A

skin temp
tissue consistency-firm or boggy
sensation
persistent redness, NOT purple or maroon

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38
Q

Stage 2 Pressure Injuries

A

partial thickness skin loss with exposed dermis,

shallow open ulcer with red or pink wound bed without slough.

may also present as intact or open serum filled blister. no bruising

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39
Q

Stage 3 pressure injury

A

full thickness skin loss
adipose is visible
granulation tissue and rolled edges are present
can include undermining and tunneling
no fascia/muscle present

slough/eschar are present

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40
Q

Stage 4 pressure injury

A

full thickness skin and tissue loss
exposed muscle, bone, tendon
includes sinus tracts or tunneling

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41
Q

Epibole

A

rolled wound edges

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42
Q

Osteomyelitis

A

inflammation that occurs in the bone

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43
Q

Undermining

A

deeper wound than surface edge depth

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44
Q

Sinus tracts

A

most common in surgical or neuropathic wounds

present in stage 4

measured with q-tip

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45
Q

Unstageable pressure ulcer

A

obscured full-thickness skin and tissue loss

covered by slough and/or eschar

the true depth cannot be determined until slough is removed

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46
Q

Stable eschar on heel

A

serves as body’s natural cover and should not be removed

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47
Q

Deep tissue pressure injury

A

persistent non-blanchable deep red, maroon, or purple localized area

intact or non intact skin or epidermal separation revealing dark wound bed or blood filled blister

damage of underlying soft tissue

often an evolution of stage 3/4 ulcer

must document color

educate about wound evolution

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48
Q

Vascular Ulcers Types

A

Venous
Arterial
Neuropathic
Mixed

not the same staging as pressure injuries

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49
Q

Venous ulcers

A

Associated with chornic venous insufficiency, valvular incompetence, venous HTN. Most common chronic wound

RF: HF, LE muscle weakness, prolonged standing, pregnancy, obesity, LE trauma, immobility, family hx, advancing age

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50
Q

Location of venous ulcers

A

can occur anywhere in leg, most common site is area over medial mallelous

usually bilateral

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51
Q

How does heart failure lead to venous ulcers?

A

the heart fails, right ventricle backs up into the body, leading to a lot of edema, and tehn venous stasis ulcers

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52
Q

Dynamic insufficiency

A

problems with:

capillary filtration
osmotic uptake of fluid

53
Q

Mechanical insufficiency

A

problems with lymphatic drainage

54
Q

CP of venous stasis ulcers

A
  1. normal pulses b/c arterial system is intact
  2. no pain to aching/throbbing, especially when body part is below heart
  3. Color is normal or bluish
  4. Temperature is normal
  5. Edema is usually marked
  6. Many skin changes like pigmentation from dying hemoglobin, drying skin, thickening of skin
  7. Ulceration: especially over medial ankle, WET
  8. Gangrene is absent
55
Q

Common looks of venous ulcers

A

usually present as shallow, irregular, or oval in shape, with macerated borders. Wet/moist skin

color is red, brown, purple. Edema and scally

56
Q

Treatment of venous insufficiency ulcers

A
  1. CONTROL EDEMA with leg elevation and compression therapy
  2. Topical therapy
57
Q

Prevention of venous ulcers

A

no smoking, adequate nutrition, skin care, optimize venous return , compliance with meds like digitalis and diuretics

58
Q

Topical therapy for venous ulcers

A

bandages, pressure garments, unna boot, mechanical pump

helps to promote favorable healing environment by removing exudate, infection, necrosis. also protects surrounding skin to avoid maceration

59
Q

Whenis a Wound culture required?

A

required after 2-4 weeks of failing to respond to therapy or if it appears infected

60
Q

Unna Boot

A

medication-impregnated dressing containing zinc oxide paste, calamine lotion, glycerin, gelatin

purpose is edema control, skin care, protection

less effective in non-ambulatory patients, espeically uncomfortable in hot weather

changed every 7-10 days

can help stop scratching and itching

61
Q

Unna boot technique

A

Reduce local edema
apply unna boot with 4 layers w/overlapping spiral technique
last ace bandage layer applied firmly from foot to knee

62
Q

Compression pump

A

goal to decrease edema, ideally would do this prior to unna boot

intermittent compression unit designed to reduce swelling in lower extremity

63
Q

Arterial insufficiency ulcers

A

associated with chronic arterial insufficiency, arteriosclerosis obliterans, atheroembolism, hx of minor non healing trauma

most worrisome because of threat of limb loss

64
Q

RF for Arterial ulcers

A

smoking, HTN, hyperlipidemia, diabetes, advanced age

65
Q

Location of arterial ulcers

A

can occur anywhere in leg, most common in small toes, feet, on boney areas of trauma

66
Q

CP of arterial ulcers

A
  1. Poor/absent pulses
  2. Severe pain; intermittent claudication that often progresses to pain at rest
  3. Color is pale on elevation, dusky rubor on dependency
  4. Cool temperature
  5. Trophic skin changes, loss of hair in feet/toes, thickened toenails
  6. Gangrene may be present adjacent to ulcer
67
Q

Dusky rubor

A

redness below heart
due to increases in vasodilation

68
Q

Arterial ulcers treatment

A

Patient ed
Control underlying medical problem of BP, A1c, diet, and weight
topical therapy

69
Q

Prevention for Arterial ulcers

A

no smoking
diabetes control
compliance w/meds
proper fitting footwear

70
Q

Patient ed for arterial

A

neutral or dependent position for legs
avoid sitting w/crossed legs, exposure to cold/friction/tight clothing, stop moisture between toes, don’t walk barefoot

71
Q

Topical therapy for arterial ulcer

A

promote favorable healing environment by removing excessive exudate, infection, necrosis

wound cleansing with saline

some debridement may be contraindicated for necrotic

non-necrotic require topical dressings

protect surrounding skin

72
Q

When peripheral pulses are present (with alterial ulcers)

A

hydrogels, collagens, alginates, medicated creams

occlusive dressings should be used with caution

73
Q

When should you get a vascular consult?

A

ABI <.5
pain is increasing
ulcer fails to respond to treatment in 2-4 weeks

74
Q

Complications of arterial ulcer treatment

A

infection, gangrene, osteomyelitis, amputation

clinical manifestations of infection are likely to be subtle, due to reduced blood flow

75
Q

Tests for vascular ulcers

A

PTs must use tests to detect and quantify peripheral arterial disease (PAD)

  1. LE pulses: palpate or doppler
  2. Dependent rubor
  3. ABI
76
Q

Dependent Rubor/redness

A
  1. position patient supine with lower extremity elevate 45° for 1 min or until foot blanches
  2. Observe color of foot
  3. Instruct patient to sit up and dangle leg
  4. Record time for color to return to foot
77
Q

Capillary filling time

A

normal = 10-15 s
mod ischemia = 15-25 s
Severe ischemia = 25-40 s
Very severe ischemia = 40s+

78
Q

ABI Method

A
  1. position patient supine w/hips in slight ER, knees slightly flexed and lateral borders of foot in contact with table/bed
  2. Record brachial SBP
  3. Place BP cuff around leg just above malleoli and record SBP
  4. Calculate ABI: Ankle SBP (higher value)/ Arm SBP (higher value). Choose the smaller ratio for the ABI
79
Q

> 1.4 ABI

A

vessel calcification/hardening
refer to vascular specialist/surgeon

80
Q

1.0-1.4 ABI

A

normal

81
Q

.9-1.0 ABI

A

acceptable

82
Q

.8-.9 ABI

A

some arterial disease/occlusion
treat risk factors

83
Q

.5-.8 ABI

A

moderate arterial disease/occlusion

refer to vascular specialist

84
Q

<.8 ABI

A

No LE compression for wound healing
refer out

85
Q

<.5 ABI

A

severe arterial disease/occlusion. usually pain at rest, wounds may need to be revascularized heal
refer out

86
Q

Neuropathic ulcers

A

caused by diabetes, associated with arterial disease and peripheral neuropathy, caused by repetitive trauma on insensitive skin

87
Q

Location of neuropathic ulcers

A

occurs where arterial ulcers usually appear, or where peripheral neuropahty appears (plantar aspect of foot)

88
Q

CP of Neuropathic ulcers

A
  1. typically not painful due to sensory loss
  2. pulses may be present or dimished
  3. absent ankle jerks common
  4. sepsis common, gangrene may develop
  5. surrounding calluses are typical
89
Q

Prevention of neuropathic ulcers

A

no smoking
control A1C ,7%
diabetic foot screen
routine professional foot care
compliance with meds
proper-fitting footwear

control underlying medical problem

90
Q

Patient ed for neuropathic ulcers

A

exposure to cold, friction, moisture between toes, walking barefoot, external use of heat

91
Q

Topical therapy for neuropathic ulcers

A
  1. promote favorable healing
  2. WOund cleansing with saline
  3. Necrotic tissue–surgical consul, autolysis, mechanical
  4. Non-necrotic ulcers–absorptive dressings
  5. Shallow ulcers–hydrocolloid, moist gauze
  6. Protect surrounding skin to avoid maceration
92
Q

Complications of neuropathic ulcers

A

infection, gangrene, osteomyelitis

93
Q

Infection control

A

ABX tx is prescribed if indicated

oral meds: antimicrobials, anti-inflammatories, analegesics

Topic meds: NSAIDs, lidocaine, silver nitrate (anti-inflamm, anesthetics, antimicrobials)

VAC

94
Q

Vacuum assisted closure

A

open-cell foam dressing placed into wound

also called negative pressure wound therapy
provides controlled subatmospheric pressure

helps control edema, increase local blood flow, remove infectious material

you can mobilize with the patient

95
Q

Surgical intervention for chronic wound care

A

indicated for excising an ulcer, enhancing vascularity and for resurfacing wounds, preventing sepsis and osteomyelitis

may be indicated for Stage 3 and stage 4 pressure ulcers

revascularization procedures may be done for neuropathic and arterial ulcers

96
Q

Hyperbaric Oxygen Therapy

A

patient breathes 100% O2 in seated, full body chamber with elevated atmospheric pressure

helps reverse tissue hypoxia and facilitates wound healing due to enhacned solubility of O2 in blood

Used for nonhealing wounds that do not have adequate oxygenation

should NOT be used for untreated pneumothorax, some antineoplastic medications

97
Q

Is HBOT effective for chronic wounds?

A

-Ulcer healing and rate of minor amputation were not affected HBOT
-significant reduction in risk of major amputation with HBOT
-HBOT improved healing rate short term in diabetic foot ulcers
-helps with mixed ulcers
-possible decrease in venous ulcers

98
Q

Wound cleansing

A

removal of loose cellular debris, metabolic wastes, bacteria and topical agents that may slow healing

goal = obtain clean wound without trauma to new granulation tissue

wound should be cleaned initially and at each dressing change

99
Q

Do not use the following on chronic wounds

A

some common topical cleansing agents are cytotoxic to healing tissues

1.iodine
2. hydrogen peroxide
3. weak bleach solution
4. dakin’s
5. acetic acid

100
Q

You should NOT use ____ for wound cleaning

A

harsh soaps
alcohol based products
harsh antiseptics

101
Q

Use ____ for most ulcers

A

saline

102
Q

Even if a wound does not look dirty, it needs regular cleaning because

A

bacteria can form a biofilm

biofilm = layer of bacteria bound together by compounds they secrete that protect the colony and help it grow

bacteria are more resistant to antibiotics when living in a biofilm

103
Q

Methods of wound cleansing

A
  1. minimal mechanical force
  2. irrigation
  3. Hydrotherapy
104
Q

Minimal mechanical force

A

cleanse with gauze, cloth, or sponge
clean wound enough to enhance healing w/out causing trauma

105
Q

Irrigation

A

can use a syringe, squeezable bottle with tip or battery powered irrigation device (pulsatile lavage)

Pulsatile lavage is usually with suction; Safe and effective pressures are 4-15 psi. goal is to loosen wound debris and remove it by suction

106
Q

Hydrotherapy

A

not gold standard
indications: wounds/ulcers with large amounts of exudate, slough, and necrotic tissue

increases circulation, assists in wound debridement, and/or removal dressings

must be discontinued when ulcer is clean

107
Q

Wound Debridement

A

removal of necrotic or infected tissue that interferes with wound healing

allows exam of ulcer and determination of wound extent. Decreases bacterial contamination in wound. Decreases spread of infection

5 methods

108
Q

Autolytic

A

selective method of natural debridement that occurs under occlusive or semiocclusive moisture retentive dressings

Indications = all necrotic wounds in medically stable people

Contraindications: infected wounds

109
Q

Enzymatic debridement

A

selective method of chemical debridement that promotes liquefication of necrotic tissue by applying topical preparations of proteolytic/collagenolytic enzymes to tissues

Indications: all moist necrotic wounds, eschar after cross-hatching

Contraindications = ischemic wounds

110
Q

Eschar scoring

A

diagonal lines

111
Q

Eschar cross-hatching

A

creating squares with opposite lines from the scoring

enzymatic debrider is placed on top

112
Q

Mechanical Debridement

A

nonselective method that removes foreign material and dead or contaminated tissue by physical means. May also remove healthy tissue

includes wet to dry gauze dressings, wound vac, whirlpool

indications: moist necrotic tissue
contraindications = clean, granulated wounds

113
Q

Conservative sharp wound debridement

A

selective method using sterile instruments that sequentially removes only necrotic tissue without anesthesia, resulting in little/no bleeding induced in viable tissue

includes: scalpel, scissors, forceps, silver nitrate stick

indications: scoring, cross-hatching, excision of eschar
contraindications: clean wounds, patients with clotting disorder, sepsis

114
Q

Silver nitrate uses

A

regenerative effect (growth of good cells)
cauterization (stop growth of bad cells)

115
Q

Surgical/sharp wound debridement

A

more efficient method, nonselective and performed by surgeon using sterile instruments in operative procedure in which pt is usually under anesthesia, removes most/all of necrotic tissue, and some healthy

indications = advancing cellulitis with sepsis, immunocompromised, infection

Contraindications = when OWL cannot be improved, underlying systemic disorders

116
Q

Wound Dressings

A

topical products that protect wound from trauma and contamination, absorb drainage, may debride necrotic tissue and enhance healing

GOAL is to provide warm, moist healing environment

117
Q

Simple Principles for wound dressings

A

if wound is dry = apply a moistening dressing

if wound is too wet = apply an absorptive dressing

118
Q

Transparent films

A

Tegaderm, opsite

minimal exudate
skin donor sites, IV sites
non absorptive
secondary dressings are not required

119
Q

Hydrocolloid Dressings

A

Duoderm, Curaderm

-not transparent, can’t see wound
-there’s characteristic odor w/yellow exudate that looks similar to pus when removing bandage
-causes smell when removed
-maintains moist environment
-comfortable, reduces pain, easy to apply, conformable

-for partial thickness, pressure injuries
-for mild exudate

120
Q

Hydrogel dressings

A

minimal to moderate exudate
partial and full thickness wounds
most require a secondary dressing

121
Q

Foam dressings

A

moderate exudate
provides padding, protection, insulation
-stops maceration of wound
-sometimes has antimicrobial
-non transparent

122
Q

Alginate dressings

A

absorbs 20x its weight in exudate
expensive
mod to large amounts of exudate
easy to apply
requires secondary dressing

123
Q

Black wound

A

Clean = minimal mechanical force or irrigation

Debride = yes, cross hatching and forceps, enzymatic solution, or biological, mechanical methods

Dress = hydrocolloid or hydrogel. Wet to dry gauze after enzymatic solution

124
Q

Yellow wound

A

Clean = pulsed lavage w/suction or minimal mechanical

Debride = yes, conservative sharp, mecahnical

Dress = calcium alginate, gauze, wt to dry

125
Q

Red Wound

A

Clean = very light mechanical, low pulsed lavage

Debride = no

Dress = hydrocolloid/hydrogel, foam

126
Q

Edema management

A

leg elevation and exercise
compression therapy w/wraps, bandages, stockings, pump therapy

127
Q

Nutrition

A

malnutrition and dehydration impede wound healing

nutritional assessment should be performed every 3 months to ensure adequate protein and caloric intake

patients need aggressive nutritional support

some vitamin deficiencies impede wound healing (C, A, zinc)

128
Q

Patients at high risk for poor wound healing

A

weight loss >15-25% of body weight
protein depletion = based on albumin

129
Q

Injury/wound prevention and reduction

A
  1. Daily skin inspection
  2. Positioning to relieve pressure and allow tissue reperfusion
  3. skin protection techniques
  4. pressure-relieving devices
  5. avoid maceration damage
  6. patient/caregiver educaiton

5 Pathology (9 decks)

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