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Acute Care > Positioning and Wound Care > Flashcards

Positioning and Wound Care Flashcards

1
Q

what are the 3 goals of patient positioning?

A
  • pt comfort
  • skin hygiene
  • joint mobility
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2
Q

what are the 4 “dos” of pillows?

A

float heels, elevate UE, use for S/L, prevent hip ER in supine

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3
Q

what are the 2 “don’ts” of pillows?

A

place under knees, keep neck flexed

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4
Q

what is the gold standard for offloading with diabetic ulcers, and what does it allow the pt to do?

A
  • total contact cast

- allows pt to be ambulatory

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5
Q

define eschar

A

black and crusty stuff

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6
Q

define desiccated

A

dried out

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7
Q

define epibole

A

rolled or curled under wound edges

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8
Q

what are the 3 main characteristics of skin?

A

waterproof, protective, adaptive

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9
Q

arterial insufficiency is associated with a(n) ____ pedal pulse (increased/decreased)

A

decreased (might be absent)

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10
Q

describe intermittent claudication

A

O2 not meeting muscle demand → ischemia → pain

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11
Q

what body parts are most affected by arterial insufficiency?

A
  • Anterolateral foot/ankle and toes

- Dorsum of the foot

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12
Q

how will wounds due to arterial insufficiency appear?

A
  • full thickness with well-defined borders
  • minimal drainage
  • often with eschar
  • shiny, anhydrous, pale to cyanotic skin
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13
Q

what causes venous insufficiency?

A

vales aren’t working and there is backflow of fluid

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14
Q

is the pedal pulse present with venous insufficiency?

A

yes, unless there is a concomitant arterial disease

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15
Q

what makes the lower limb discomfort and edema with venous insufficiency worse?

A

being in a dependent position

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16
Q

what makes the lower limb discomfort and edema with venous insufficiency better?

A

being more raised up

17
Q

what part of the foot is most affected by venous insufficiency?

A

anteromedial

18
Q

how will wounds due to venous insufficiency appear?

A
  • Irregularly shaped, shallow wound
  • Typically located on the medial lower leg and malleolus
  • Moderate to copious drainage
19
Q

is the pedal pulse present with diabetic foot ulcers?

A

not usually, it is often absent with arterial disease (but it may be present)

20
Q

diabetic foot ulcers are often ____ with decreased ____

A

painless; temperature

21
Q

what body part is most commonly affected by diabetic foot ulcers?

A

plantar surface of foot/toes

22
Q

what are some other body parts impacted by diabetic foot ulcers?

A
  • dorsum of foot/toes
  • ends of toes
  • metatarsals
23
Q

how do diabetic foot ulcers appear?

A

pale wound bed often with nonviable tissue and minimal drainage

24
Q

what kinds of changes happen to the skin/hair/nails in pts with diabetic foot ulcers?

A
  • trophic changes

- skin will be shiny and hairless

25
Q

are pulses intact with pressure injuries?

A

yes, unless there is vascular compromise

26
Q

where are pressure injuries typically found?

A

pressure areas/bony prominences

27
Q

pressure injuries are ____ if sensation is still intact

A

painful

28
Q

describe a superficial wound

A
  • damage to epithelium

- heals rapidly through regeneration of epithelial cells

29
Q

describe a partial thickness wound

A
  • involves the dermal layers

- vessel damage

30
Q

describe a full thickness wound

A
  • involves subcutaneous fat and deeper
  • takes longest time to heal bc new CT needs to regenerate
  • contraction occurs during healing
31
Q

describe a stage 1 pressure injury

A

Intact, reddened skin that does not lighten when palpated

32
Q

describe a stage 2 pressure injury

A
  • Partial thickness w exposed, viable dermis

- No slough or eschar

33
Q

describe a stage 3 pressure injury

A
  • Full-thickness w exposed subcutaneous layer
  • May include epibole, tunneling, undermining
  • Slough and eschar can be present
34
Q

describe a stage 4 pressure injury

A
  • Full-thickness with exposed muscle, tendon, ligament, fascia, cartilage, and/or bone
  • Often with epibole, tunneling, undermining
  • Slough and eschar may be present
35
Q

what does it mean for a pressure injury to be “unstageable”?

A
  • slough/eschar covers full-thickness wound

- unable to detect depth

36
Q

what is a deep tissue pressure injury (DTPI)?

A

intact or non-intact skin appearing as non-blanchable red, maroon, or purple in color

37
Q

what is the most common type of chronic wound?

A

diabetic ulcer

38
Q

what factors can delay wound healing (VAL NM MBA)?

A
  • vascular status
  • age
  • lifestyle
  • nutrition
  • medical status
  • medications
  • bioburden and infections
  • appropriate care and pt compliance
39
Q

what are 4 PT considerations with wound healing?

A
  • prevention
  • pain management
  • ROM, strength, functional mobility
  • edema management

Acute Care (7 decks)

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