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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?

A

Blanching

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
Q

Characteristics of a STAGE 2 PRESS UL:

A
  • Skin breakdow
  • Entering DERMIS
  • Shallow, cracked
  • Possible EDEMA and/or discharge
  • Pt at risk for infct
26
Q

Characteristics of a STAGE 3 PRESS UL:

A
  • “Full thickness”
  • Wound enters subQ tissue
  • Drainage (note the color)
  • Affects the surrounding skin
  • bigger perimeters
27
Q

Characteristics of a STAGE 4 PRESS UL:

A
  • All the way through the skin layers
  • Underlying structures visible (bone, tendons, etc)
  • Lots of drainage
28
Q

Characteristics of a UNSTAGEABLE PRESS UL:

A
  • UL is covered by SLOUGH or ESCHAR
  • Requires advanced Tx
  • Depth is unknown (hence UNstageable)
29
Q

How can nurses help prevent PRESS ULs?

A
  • 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
Q

What are some medical management options for Tx of PRESS ULs?
(probs only need to know the first 5)

A
  • 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
Q

What causes lower limb ULs? (3)

A

1) DIABETES
2) VENOUS INSUFFICIENCY
3) ARTERIAL INSUFFICIENCY

32
Q

What equipment is used to assess lower limb ULs?

A

A Doppler Ultrasound

33
Q

What cause 75% of leg ULs?

A

Chronic VENOUS INSUFF

34
Q

Characteristics of VENOUS ULs:

know at least 4

A
  • Dull aching or heavy
  • Edema
  • Typically large, superficial
  • Highly exudative
  • Irregular ulcer border
  • Pulses present
  • Bleeds easily
  • Location: Gaiter area, especially medial malleolus
35
Q

Major goals of VENOUS UL Tx?

A

Restoration of skin integrity, improved physical mobility, adequate nutrition, and absence of complications

36
Q

Prevention techniques for VENOUS ULs:

A
  • Compression of the extremity
  • Elevation
  • Protect from trauma
  • Skin kept clean, dry, and soft
37
Q

20% of leg ULs is d/t

A

ARTERIAL INSUFF

38
Q

Modifiable risk factors of ARTERIAL ULs:

A
  • Smoking
  • Unhealthy diet
  • Hypertension
  • Diabetes mellitus
  • Obesity
  • Stress
  • Sedentary lifestyle
  • Elevated C-reactive protein
  • Hyperhomocysteinemia
39
Q

Non-modifiable risk factors

A
  • Age
  • Ethnicity/genetics
  • Gender
40
Q

What is claudication?

A

Cramping pain in leg induced by exercise, typically caused by obstruction of the arteries

41
Q

Characteristics of ARTERIAL ULs:

know at least 4

A
  • 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
Q

Where are ARTERIAL ULs usually found?

A

On or between toes, heel, shin, medial side of hallux

43
Q

ARTERIAL UL interventions?

A
  • No restrictive clothing
  • Avoid limb exposure to cold/trauma
  • Warmth to promote B flow
  • Exercise as tolerated (consult PT)
44
Q

With ARTERIAL ULs, would you prefer the legs elevated or lower than the heart?

A

Lower than the heart

45
Q

What might cause a DIABETIC FOOT UL?

A
  • Hyperglycaemia
  • Motor neuropathy
  • Sensory neuropathy
  • Peripheral Vascular Disease
46
Q

Are DIAB ULs preventable?

A

Yes! Protect, inspect, relieve pressure, appropriate skin care, lifestyle factors

N232 (9 decks)

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