Principles of Wound Healing Flashcards
Explain what the head to toe measurement is and used for?
- (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.
Explain what the side to side measurement is and used for?
- (3-9 clock method) where the measurement is from side to side.
- used for measuring the width of a wound.
If a wound has undermining or tunneling how do you measure and document the size and shape of the wound?
- use the clock method
- drawing a picture is sometimes helpful
How can you distinguish between granulation tissue and epithelium tissue in a wound bed?
- granulation will be shiny
- epithelium will be matte
When should the odor of your patients wound be assessed?
after you clean the wound
What is the primary treating option of a DFU?
- Offloading
- Pressure Redistribution
What is pressure redistribution?
Taking pressure off the foot with another part of the FOOT
What are (4) ways to redistribute pressure in the foot?
- 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
What is offloading?
Taking pressure off the foot with another part of the BODY
What are (3) ways to offload the foot?
- A brace that straps to the calf
- A walking boot
- CROW (Charcot Restraint Orthotic Walker) Boot
What is the gold standard for healing DFU?
- Total Contact Cast
- (Provides offloading AND pressure redistribution)
What is correct sequence for casting the foot for DFU?
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
What (2) is important to considered for keeping the pt functional when selecting an offloading device?
- You want to take as much pressure off wound as possible
- Are you going to redistribute or offload the pressure
What (3) things are considered when selecting a dressing for your patients DFU?
- Amount of drainage
- Moisture level of wound
- Level (if any) of infection in wound
What are the (8) DFU treatment options?
- 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
What is the sequence for cleaning a foot and a wound during your treatment session?
- 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.
If cleaning a wound and periwound during your treatment session how are are you going to do it?
- First clean up (debride) wound,
- Second, clean periwound
What are the (8) periwound tissue observations/description that need to be documented?
- Rash/Dermatitis
- Epithelium (new=pink)
- Fungal
- Callus
- Macerated (wet, white color)
- Erythema
- Hemosiderin staining
- Rolled edges
What (7) items are you going to document/inspect when performing a wound bed assessment?
- Necrotic tissue
- Fibrin/Slough
- Granulation tissue
- Epithelium
- Estimate percentage of wound with granulation vs. slough, etc.
- Exudate
- Odor
What is the sequence of assessing and treating a DFU?
Assess pre debridement – clean – assess post debridement
How should you measure the depth of a wound?
measure the deepest part of the wound, from the wound bed up to the skin edge.
If assessing your pt DFU and you notice it is infected do you clean the wound or wait till the infection is gone?
wait till the infection is gone
What does autolytic mean?
Its use of the body’s own enzymes to break down and debride a wound.
When debriding a DFU what (2 things) are you doing?
- cleaning up any callus around the wound
- cleaning any fibrin/slough from the base of the wound
When assessing a DFU’s exudate, what are you looking for?
- amount (scant, moderate, large)
- type (serous, serosanguanous, bloody, yellow, green, brown, etc)
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?
- 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.
