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N232 > Module 2: Acute and Chronic Wounds > Flashcards

Module 2: Acute and Chronic Wounds Flashcards

1
Q

What is a WOUND?

A

Any disruption to the layers of the skin and underlying tissues

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2
Q

What are the types of WOUND healing?

A
  • Primary Intention
  • Secondary Intention
  • Tertiary Intention
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3
Q

What are the steps in the trajectory of wound healing? (4)

A

1) HEMOSTASIS
2) INFLM
3) PROLIFERATION
4) REMODELLING

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4
Q

What is HEMOSTASIS and when does it happen during wound healing?

A

The stoppage of bleeding, takes place immediately after wound is created and begins to bleed

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5
Q

What is INFLM and when does it happen during wound healing?

A

A localized, vascular response to injury, happens for up to 4 days after wound is created

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6
Q

What is PROLIFERATION and when does it happen during wound healing?

A

New tissues and cells are created to “rebuild” the damaged tissue, takes 4-21 days

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7
Q

What is REMODELLING and when does it happen during wound healing?

A

This is when the new tissue matures (the stage is sometimes referred to as the “maturation” phase) and this can take up to 2 years

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8
Q

What factors may impact HEMOSTASIS?

A
  • B thinners
  • Ca imbalance
  • Certain meds (eg ASA)
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9
Q

What factors may impact INFLM?

A
  • IMMUNODEFICIENCY

- Infct

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10
Q

What factors may impact PROLIF?

A
  • Nutrition

- Ability of cells to reproduce

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11
Q

What factors may impact REMOD?

A
  • The same as PROLIF
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12
Q

T or F:

Not all wounds start as ACUTE

A

F, all wounds do start as ACUTE

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13
Q

What is an ACUTE wound?

A

Any wound that heals w/in its expected time frame (usually 21 days)

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14
Q

What is a CHRONIC wound?

A

A wound that’s normal process of healing is disrupted at one or more points in the phases of wound healing (stalling in the healing process)

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15
Q

Examples of CHRONIC wounds are…

A

…Pressure ulcers ,Venous ulcers ,Arterial ulcers, Diabetic foot ulcers

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16
Q

Who is at the most risk for CHRONIC wounds? Why?

A

The elderly because they are generally less mobile

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17
Q

What is a PRESSURE ULCER? Why do they occur?

A

An localized areas of infarcted soft tissue that occur when pressure applied to the skin over time is greater than normal capillary closure pressure

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18
Q

What is the normal CAPILLARY CLOSURE PRESSURE?

A

25-32 mm Hg

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19
Q

What are risk factors for PRESSURE ULCERS?

know at least 5

A
  • Prolonged pressure on tissue
  • Immobility, compromised mobility
  • Loss of protective reflexes, sensory deficit/loss
  • Poor skin perfusion, edema
  • Malnutrition, hypoproteinemia, anemia, vitamin deficiency; overweight/underweight
  • Friction, shearing, forces, trauma
  • Incontinence of urine or feces
  • Altered skin moisture: excessively dry, excessively moist
  • Advanced age
  • Equipment
  • Critically ill pts
20
Q

How often should the nurse assess skin condition?

A

At least BID

21
Q

If ERYTHEMA is found, what response should the nurse test for?

22
Q

What scale do nurses need to use on admission to evaluate skin-integrity?

A

The Braden Scale

23
Q

How often should pts be turned in their beds?

A

a minimum of every 2 hours

24
Q

Characteristics of a STAGE 1 PRESS UL:

A
  • ERYTHEMA

- Skin still intact

25
Characteristics of a STAGE 2 PRESS UL:
- Skin breakdow - Entering DERMIS - Shallow, cracked - Possible EDEMA and/or discharge - Pt at risk for infct
26
Characteristics of a STAGE 3 PRESS UL:
- "Full thickness" - Wound enters subQ tissue - Drainage (note the color) - Affects the surrounding skin - bigger perimeters
27
Characteristics of a STAGE 4 PRESS UL:
- All the way through the skin layers - Underlying structures visible (bone, tendons, etc) - Lots of drainage
28
Characteristics of a UNSTAGEABLE PRESS UL:
- UL is covered by SLOUGH or ESCHAR - Requires advanced Tx - Depth is unknown (hence *UN*stageable)
29
How can nurses help prevent PRESS ULs?
- Encouraging mobility - Making sure pts are not lying in the same position for ever - Assessing skintegrity - Ensuring proper hygiene - Making sure the pts is getting adeq nutrition
30
What are some medical management options for Tx of PRESS ULs? (probs only need to know the first 5)
- Antibiotics - Compression socks or machines - Debridment (removal of dead tissue) - Topical Tx - Wound dressing (can prevent water evaporation and retain warmth - promotes healing) - Stimulated healing (Tissue-engineered human skin equivalent is applied to wound, this promotes production of growth factor and new cells) - Hyperbaric Oxygenation (pt in environment breathing 100% O2) - Negative pressure wound therapy
31
What causes lower limb ULs? (3)
1) DIABETES 2) VENOUS INSUFFICIENCY 3) ARTERIAL INSUFFICIENCY
32
What equipment is used to assess lower limb ULs?
A Doppler Ultrasound
33
What cause 75% of leg ULs?
Chronic VENOUS INSUFF
34
Characteristics of VENOUS ULs: | know at least 4
- Dull aching or heavy - Edema - Typically large, superficial - Highly exudative - Irregular ulcer border - Pulses present - Bleeds easily - Location: Gaiter area, especially medial malleolus
35
Major goals of VENOUS UL Tx?
Restoration of skin integrity, improved physical mobility, adequate nutrition, and absence of complications
36
Prevention techniques for VENOUS ULs:
- Compression of the extremity - Elevation - Protect from trauma - Skin kept clean, dry, and soft
37
20% of leg ULs is d/t
ARTERIAL INSUFF
38
Modifiable risk factors of ARTERIAL ULs:
- Smoking - Unhealthy diet - Hypertension - Diabetes mellitus - Obesity - Stress - Sedentary lifestyle - Elevated C-reactive protein - Hyperhomocysteinemia
39
Non-modifiable risk factors
- Age - Ethnicity/genetics - Gender
40
What is claudication?
Cramping pain in leg induced by exercise, typically caused by obstruction of the arteries
41
Characteristics of ARTERIAL ULs: | know at least 4
- Digital or forefoot pain at rest - Smooth/regular shaped borders - Typically small, circular, deep - Minimal drainage - Non bleeding - Pulse weak or not palpable - Pale or black
42
Where are ARTERIAL ULs usually found?
On or between toes, heel, shin, medial side of hallux
43
ARTERIAL UL interventions?
- No restrictive clothing - Avoid limb exposure to cold/trauma - Warmth to promote B flow - Exercise as tolerated (consult PT)
44
With ARTERIAL ULs, would you prefer the legs elevated or lower than the heart?
Lower than the heart
45
What might cause a DIABETIC FOOT UL?
- Hyperglycaemia - Motor neuropathy - Sensory neuropathy - Peripheral Vascular Disease
46
Are DIAB ULs preventable?
Yes! Protect, inspect, relieve pressure, appropriate skin care, lifestyle factors

N232 (9 decks)

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