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PT 854 Integument > Principles of Wound Healing > Flashcards

Principles of Wound Healing Flashcards

1
Q

Explain what the head to toe measurement is and used for?

A
  • (12-6 clock method) where 12 o’clock is in the direction of the head and 6 o’clock in the direction towards the feet.
  • used for measuring the length of a wound.
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2
Q

Explain what the side to side measurement is and used for?

A
  • (3-9 clock method) where the measurement is from side to side.
  • used for measuring the width of a wound.
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3
Q

If a wound has undermining or tunneling how do you measure and document the size and shape of the wound?

A
  • use the clock method

- drawing a picture is sometimes helpful

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4
Q

How can you distinguish between granulation tissue and epithelium tissue in a wound bed?

A
  • granulation will be shiny

- epithelium will be matte

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5
Q

When should the odor of your patients wound be assessed?

A

after you clean the wound

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6
Q

What is the primary treating option of a DFU?

A
  • Offloading

- Pressure Redistribution

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7
Q

What is pressure redistribution?

A

Taking pressure off the foot with another part of the FOOT

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8
Q

What are (4) ways to redistribute pressure in the foot?

A
  • Building up the arch
  • Increasing the padding just proximal to a Met-heads
  • Using a rocker bottom shoe to decrease pressure on metatarsals as heel comes off the floor
  • Removing a section of boot’s insert under the wound
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9
Q

What is offloading?

A

Taking pressure off the foot with another part of the BODY

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10
Q

What are (3) ways to offload the foot?

A
  • A brace that straps to the calf
  • A walking boot
  • CROW (Charcot Restraint Orthotic Walker) Boot
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11
Q

What is the gold standard for healing DFU?

A
  • Total Contact Cast

- (Provides offloading AND pressure redistribution)

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12
Q

What is correct sequence for casting the foot for DFU?

A

1st - foot/leg protected with foam, felt, to negative spaces
2nd - the protection is custom molded to patients foot with plaster and hardened with fiberglass
3rd - a variety of walking surfaces can be used

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13
Q

What (2) is important to considered for keeping the pt functional when selecting an offloading device?

A
  • You want to take as much pressure off wound as possible

- Are you going to redistribute or offload the pressure

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14
Q

What (3) things are considered when selecting a dressing for your patients DFU?

A
  • Amount of drainage
  • Moisture level of wound
  • Level (if any) of infection in wound
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15
Q

What are the (8) DFU treatment options?

A
  • Wash foot/wound
  • Debridement
  • Dressing
  • Treat infection
  • Revascularize limb if necessary – refer to surgeon
  • Optimize glycemic control
  • Stop smoking
  • Hyperbaric oxygen for Wagner 3 and 4
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16
Q

What is the sequence for cleaning a foot and a wound during your treatment session?

A
  • First clean the foot
  • Second clean the wound (use saline/gauze for actual wound)
  • You don’t want to mix bugs etc from the foot in with the wound.
17
Q

If cleaning a wound and periwound during your treatment session how are are you going to do it?

A
  • First clean up (debride) wound,

- Second, clean periwound

18
Q

What are the (8) periwound tissue observations/description that need to be documented?

A
  • Rash/Dermatitis
  • Epithelium (new=pink)
  • Fungal
  • Callus
  • Macerated (wet, white color)
  • Erythema
  • Hemosiderin staining
  • Rolled edges
19
Q

What (7) items are you going to document/inspect when performing a wound bed assessment?

A
  • Necrotic tissue
  • Fibrin/Slough
  • Granulation tissue
  • Epithelium
  • Estimate percentage of wound with granulation vs. slough, etc.
  • Exudate
  • Odor
20
Q

What is the sequence of assessing and treating a DFU?

A

Assess pre debridement – clean – assess post debridement

21
Q

How should you measure the depth of a wound?

A

measure the deepest part of the wound, from the wound bed up to the skin edge.

22
Q

If assessing your pt DFU and you notice it is infected do you clean the wound or wait till the infection is gone?

A

wait till the infection is gone

23
Q

What does autolytic mean?

A

Its use of the body’s own enzymes to break down and debride a wound.

24
Q

When debriding a DFU what (2 things) are you doing?

A
  • cleaning up any callus around the wound

- cleaning any fibrin/slough from the base of the wound

25
Q

When assessing a DFU’s exudate, what are you looking for?

A
  • amount (scant, moderate, large)

- type (serous, serosanguanous, bloody, yellow, green, brown, etc)

26
Q

If epithelium grows in over/around the wound the edges will be rolled over and there will be cavernous undermining, how are you going to clean/treat this wound?

A
  • therapist needs to shave off rolled edges to give the wound a new wound base
  • this promotes (the body) healing and closure of the wound.

PT 854 Integument (11 decks)

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