Principles Of Wound Care Schoenwald (Exam 2) Flashcards
When assessing a wound what are you looking for?
- Tissue type
- Wound exudate
- Periwound condition
- Pain level
- Size
What are the types of granulation tissue?
- Hypergranulation tissue - overdrive = not great for wound healing
- Beefy red granulation tissue = this is what you are looking for
- Hypogranulation - hardly any possibly due to decreased blood flow to that area
What are pressure ulcers a result of and where do they often develop?
- Result from pressure or repetitive pressure at the same anatomical locatin
- Often develop at bony prominences
How would you describe a Stage 1 pressure ulcer?
Nonblanchable erythema of intact skin (heel is common)
How would you describe a Stage 2 pressure ulcer?
Partial thickness skin loss with exposed dermis
How would you describe a Stage 3 pressure ulcer?
Full thickness skin loss
How would you describe a Stage 4 pressure ulcer?
Full thickness skin and tissue loss
What does it mean for a pressure ulcer to be unstageable?
Obscured full thickness skin and tissue loss (eschar)
What is a deep tissue pressure injury?
- Persistent, non-blanchable deep red, maroon, purple injury
- (Might need imaging and close f/u)
What is the treatment for pressure ulcers?
- Relieve/remove pressure
- air beds, padded seat covers, sheep skin, boots
- Treat wound as it is assesses
- Maceration
- Eschar
- Infection
What is the function of an Alginates dressing?
- Made from seaweed - silver in it to help keep microbes at bay
- Exudate absoprtion
- Pulls wetness away from wound
What is the function of Foams dressings?
- Retain moisture
- Absoprtion
What is the function of Gauze dressings?
- Retain mositure
- Debride (wound sticks to gauze - upon removal, takes good tissue too)
What is the function of Hydrocolloid dressings?
- Occlusion
- Good for skin tears
What is the function of Wound Filler dressings?
- Obliterate dead space
- Absorb
What should you do when addressing nonhealing wounds?
- Assess the entire patient
- Systemic problems impair wound healing
- Smoking delays wound healing!
- Consider endocrinology problems
What should you be documenting for wounds?
Characterize the wound:
- Size and depth measurements
- Appearance of wound (foreign body, debris?)
- Amount of drainage (type)
- Appearance of surrounding tissue
If a wound is nonhealing what else should you consider?
- Malnutrition
- Vit C and Zinc common supplements for woundcare
- Treat infection is present
What is the protein requirement in a healthy patient? What about for wound healing?
- 1.25 - 1.5 grams of protein/kg
- More for wound healing (increase as tolerated)
What are risk factors for venous ulcerations (stasis)?
- Varicose veins
- DVT
- Chronic venous insufficiency
- Poor calf muscle function
- Ovesity
Where do 95% of venous ulcerations occur on the body?
Gaiter area of the leg (think “sock distribution” of the leg)
Common signs and sypmtoms of a venous ulcer?
- Edema often present
- Hemosiderin staining
- Hair loss of extremity
- Weeping and itchin gof skin often present
What is the treatment for a venous ulceration?
- Compression therapy (stockings)
- Appropriate for ulcers caused by edema
- Avoid if arterial flow compromised
- 40-60 mmHG of pressure (Unna boot)
- Elevation of extremity
- Woundcare and assessment
What causes arterial ulcerations and what do they result in?
- Due to decreased arterial blood supply to the LE
- PVD, DM, Sickle Cell
- Results in tissue hypoxemia and damage
- Reduced capillary refill time
What are common signs and symptoms of arterial ulcers?
- Painful
- Ulcer appeared “punched out”
- Well demarcated edges
- Pale, often necrotic base
- Surrounding skin dusky, shiny, hairless
- Usually occur over the toes, foot, and ankle
What is the treatment for arterial ulcers?
- Restore arterial function if possible
- SX usually
- Wound treatment
- Smoking cessation
Note: Medication susually not helpful
What is an ankle brachial index (ABI) helpful in determining?
The extent of peripheral vascular disease
How is an ABI performed?
- Systolic BP measure in both brachial arteries
- Systolic BP then measure in both dorsal pedis/psoterior tibial arteries
- Pt should be at rest and supine for 10 mins.
What is a normal value for an ABI?
1.0 - 1.4
What does an ABI value > 1.4 suggest?
A noncompressible calcified vessel
What does an ABI value < 0.9 indicate? What about < 0.5?
- <0.9 = moderate PAD –> Refer to vascular specialist
- < 0.5 = Severe PAD –> Refer to vascular specialist
What are the 3 main ways negative pressure wound therapy (wound vac) enhances wound healing?
- Reducing edema
- Increasing rate of granulation tissue formation
- Stimulation of circulation
What types of wounds are wound vac used for?
- Chronic and Acute wounds
- Traumatic wounds
- Partial thickness
- Dehisced wounds
- DM ulcers
- Pressure ulcers
What are contraindications for the use of wound vac therapy?
- Malignancy of wound
- Untreated osteomyelitis
- Placement of dressing in contact with exposed blood vessels, organs, or nerves
- Nonenteric or unexplored fistulas
What are the 2 types of growth factors we talked about called?
- Apligraf - human derived
- Dermagraft
What are some debridement methods?
- Enzymatic-chemical agents (most taken off market)
- Mechanical-wet to dry dressings- gauze (peroxide debridement controverial)
- Sharp-surgical removal (done by surgeon)
What is involved in the follow up care of wounds?
- Close monitoring
- Weekly visits
- Careful documentation
