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test 2 Flashcards

1
Q

causes of venous stasis wounds (7)

A
  1. venous hypertension
  2. aging
  3. trauma
  4. DVT Hx
  5. obesity/ pregnancy
  6. tumor
  7. loss of calf pump (shuffling walk)
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2
Q

pathophysiology of venous stasis

3 theories

A
  1. fibrin cuff theory- hypertension in venous system => hypertension in capillary so some molecules escape into interstitial fluid. these molecule creates fibrin which blocks nutrients and O2 from getting into vessels
  2. WBC trapping theory- hyertension in venous sytem => stagnate flow and WBC start to adhere to capillary which lead to releasing inflammatory chemicals
  3. microangiopathy- chronic hypertension damages capillaries
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3
Q

venous stasis wounds- presentation (5)

A
  1. lower leg, above malleolus (usually medial side because lots of veins there)
  2. shallow
  3. irregular border
  4. relatively painless
  5. surrounding edema and discoloration
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4
Q

venous stasis wound treatment (4)

A
  1. debride
  2. cleanse
  3. absorptive dressings
  4. compression therapy (to mobilize edema)
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5
Q

venous stasis wound treatment-
compression (4)
contraindications for this

A
  1. unna boot
  2. multilayered bandaging
  3. compression socks
  4. compression pump
  5. contraindication- severe arterial compression (ABI <0.7)
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6
Q

pt education for venous stasis wounds (6)

A
  1. encourage activity for muscle pump
  2. wear proper compression socks
  3. elevate legs regularly, avoid crossing legs
  4. skin inspection daily
  5. hygiene
  6. good nutrition (limit Na)
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7
Q

neuropathic wound (5)

A
  1. occur in plantar weight bearing locations
  2. circular punched out appearance
  3. surrounded by callous formation (must be shaved down)
  4. can be dry or moist
  5. wagner classification scale
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8
Q

diabetic neuropathic wounds

neuropathy - 3 things you lose

A
  1. first thing lost is sensory
  2. motor- lost fat pads and toe deformity- foot becomes rigid
  3. autonomic- very dry skin
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9
Q

what is charcot foot?

A

diabetic foot => oblong foot because of collapsing of tarsal bones.
occurs because of trauma to foot which causes too much blood flow into bone, which leaches out minerals and Ca of bone, weakening bone

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10
Q

how to dx a diabetic foot (6)

A
  1. dry skin
  2. pt Hx
  3. callouses
  4. deformities
  5. rigidity
  6. atrophy
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11
Q

wagner classification scale (0-5)

A

0- foot at risk (callouses/ deformities. rigid/ dry/ decreases sensation/ atrophy)
1- superficial ulcer (contained in skin)
2- deep wound (below dermis to tendon/ bone)
3- deep infected wound (osteomyelitis)
4- gangrene present on forefoot
5- extensive gangrene

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12
Q

neuropathic wound treatment (5)

A
  1. debride, cleanse and prevent infection
  2. limit WB- TCC (total contact cast) (*off- loading <0.5psi)
  3. remove surrounding callous formation
  4. appropriate dressing
  5. shoe wear and orthodics
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13
Q

venous stasis wound vs neuropathic wound… do you want pt to walk?

A

in venous stasis wound, get pt up and walking, in neuropathic wound, stop walking/ weight bearing

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14
Q

diabetic shoe necessities (6)

A
  1. extra depth
  2. pressure reducing insole
  3. breathable vamp (upper)
  4. toe rocker (see a curved sole)
  5. raised and reinforced toe box
  6. supportive shoe counter
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15
Q

pt education for diabetes (9)

+more

A
  1. daily skin inspection
  2. moisturize skin daily (humectant) - but not btwn toes
  3. do not soak feet for long periods of time
  4. be aware of signs of trauma and infection (heat/ pain)
  5. control blood sugar
  6. do not walk barefoot
  7. wear proper well fitting shoes
  8. low impact exercise
  9. go to podiatrist for removal or corn, blisters or toe nail cutting
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16
Q

una boot application (3)

A
  1. wet gauze wrap around like ace bandage (overlapping 50% of bandage). it dries and hardens
  2. 50% tension = pull wrap all the way and let go of 50% of the tension
  3. for venous stasis
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17
Q

role of dressing (4)

A
  1. maintains optimal environment? (temp, moistures, etc)
  2. removes excessive exudate (drainage)
  3. good thermal insulation
  4. protects against infection
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18
Q

qualities of a good dressing (8)

A
  1. provides a moist environment
  2. absorbent
  3. impermeable (not w/ infection)
  4. flexible (fill in deeper wounds- a gel can be considered a dressing)
  5. easy to apply and remove (non-traumatic)
  6. non-toxic
  7. inexpensive
  8. decrease dressing changes
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19
Q

guidelines for dressing use (5)

A
  1. no pressure/ tight packing- can cause more necrosis
  2. full contact with wound bed (for cell migration)
  3. monitor for strike thru (exudate coming thru dressing, means you need more absorbent dressing)
  4. moisture retention
  5. protect surrounding tissue
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20
Q

calcium alginate dressing

(seaweed derived) (3)

A
  1. fibrous tissue that absorbs moisture and turns into gel
  2. hydrophilic
  3. comes in ropes and sheets
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21
Q

calcium alginate benefits (7)

A
  1. can use with infections
  2. helps with autolytic debridement
  3. fill in cavities
  4. comfortable dressing
  5. easy removal
  6. great for absorption
  7. maintains a moist enviroment
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22
Q

calcium alginate drawbacks (4)

A
  1. not indicated for dry wounds
  2. requires secondary dressing
  3. more expensive than gauze
  4. not for superficial wounds
    sorbsan/ kalostat
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23
Q

foam dressings (3)

A
  1. composed of open cell polyurethane
  2. comes in different thicknesses and absorbencies
  3. has adhesion on borders of dressing
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24
Q

foam dressing benefits (7)

A
  1. can be used with infected wounds
  2. good under compression for venous stasis
  3. good absorbing capabilities
  4. provide cushioning protection
  5. good thermal insulation
  6. good secondary dressing with deep wounds
  7. non-traumatic removal/ can cut to shape
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25
Q

foam dressing drawbacks (5)

A
  1. not good alone for deep wounds
  2. not good for very dry wounds
  3. not best for autolytic debridement
  4. need to monitor strike thru
  5. need to protect surrounding skin (maceration or adhesive trauma)
    hydrasorb/ curafoam
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26
Q

transparent film dressing (3)

A
  1. thin see thru; dressing made with clear polyurethane => relatively impermeable and not absorbent
  2. adhesive borders
  3. elastic and extensible
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27
Q

transparent film benefits (7)

A
  1. able to monitor wound
  2. maintains moist environment- but not absorbent
  3. good for autolytic debridement
  4. minor burns, lacerations, abrasions, post op suture line and superficial wounds
  5. good barrier to keep out bacteria
  6. used to decrease friction for “at risk” individuals with stage I pressure ulcer
  7. excellent secondary dressing
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28
Q

transparent film drawbacks (4)

A
  1. not absorbent at all so watch for surrounding skin maceration
  2. cannot use with inefections (too occlusive so anaerobic bacteria can proliferate)
  3. not good alone for deep wounds
  4. consider skin sealant for surrounding tissue
    opsite/ tegaderm
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29
Q

hydrogel dressings (4)

A
  1. moisture donator- good for deep dry wounds
  2. in tube or gauze dressing
  3. non-crosslinked polymers, water and glycerine
  4. can include additives (Ag)
    derma-gel or flexi-gel
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30
Q

hydrogel benefits (5)

A
  1. assist with autolytic debridement
  2. good for dry wounds that need moisture
  3. soothing effect in wound allows eay removal
  4. good for filling deep wounds (tube)
  5. stage IV need to be kept moist or tissue will die*
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31
Q

hydrogel drawbacks (4)

A
  1. not for mod- heavy draining wounds
  2. potential for surrounding macerations
  3. require secondary dressing for deep wounds
  4. typically dressing is changed daily
32
Q

hydrocolloid dressing (2)

A
  1. elastometric occlusive bandage (basically sterile rubber)

2. lined with carboxymethyl cellulose, pectin and gelatin

33
Q

hydrocolloid benefits (5)

A
  1. occlusion for warm moist environment
  2. good protection from outside bacteria
  3. good for autolytic debridement
  4. used to decrease friction for at risk pts
  5. secondary dressing (minimal absorptive capabilities)
34
Q

hydrocolloid drawbacks (5)

A
  1. not for infected wounds
  2. not for heavy drainage (minimal absorption)
  3. need a filler for deeper wounds
  4. tacky perimeter => periwound maceration
  5. need skin prep
35
Q

gauze (3)

A
  1. sterile cotton fibers
  2. woven and non-woven
  3. used for surgery
    cuticell/ curity
36
Q

gauze benefits (4)

A
  1. can be used to fill cavities (keep moist via occlusive secondary dressing)
  2. can be used to deliver topical meds/ enzymes (autolytic debridement)
  3. some minimal absorptive capabilties
  4. inexpensive and readily available
37
Q

gauze drawbacks (5)

A
  1. not imperemeable or occlusive (so not great for maintaining moist environment)
  2. not best barrier against outside microorganisms, or thermal regulation
  3. not good for heavy drainage (strikethru)
  4. can traumatize wound bed with removal
  5. leave fibers in wound => impeded healing
38
Q

impregnated gauze (3)

A
  1. more occlusive so less absorptive than regular gel
  2. lined with petroleum or other agents
  3. saline, iodine, zinc, hydrogel, silver, honey (these are antimicrobial)
    kendall/ xeroform
39
Q

impregnated gauze benefits (5)

A
  1. good for small superficial burns
  2. over skin donor sites
  3. move occlusive than regular gauze
  4. great secondary dressing\
  5. relatively inexpensive
40
Q

impregnated gauze drawbacks (3)

A
  1. not primary for deep wounds
  2. not absorbent
  3. can leave residue in wound
41
Q

other dressings
hydrofibers (aquacell) (3)
biological (apligraf) (4)

A

these come last, need to rid wound of necrotic tissue
hydrofibers
1. pure carboxymethylcellulose
2. more absorptive dressing
3. ropes and sheets
biological
1. contain dermal or epidermal cells
2. have collagen and hyaluronan supported in a biodegradable matrix
3. allogenic (harvested foreskin cells), xenogenic (harvested from animals)
4. need prepped wound bed and good pressure relief

42
Q

wound infection

A
  1. bacterial count (culture or biopsy)
  2. bacterial type
  3. immune system status
  4. contaminated vs. colonization
  5. colonization vs. critical colonization (CC)
  6. CC vs. local infection (topical antimicrobial)
  7. local can result in systemic infection
43
Q

contaminated vs. colonization vs. critical colonization (CC)

A
  1. contaminated- all wounds are contaminated- just means there is bacterial there
  2. colonization - bacteria is multiplying
  3. CC- bacteria reached critical level = infected
44
Q

local vs. systemic infection treatment

A
  1. local- topical meds are generally okay

2. systemic- need oral antibiotics

45
Q

4 signs and symptoms of local infection

A
  1. pain/edema/redness/ heat
  2. purulent/ thick discharge (not all infected wounds have discharge)
  3. foul odor
  4. arrested healing* (wound not progressing)
46
Q

5 signs and symptoms of systemic infection

A
  1. change in vitals- drop in BP and increase HR
  2. increase in ESR
  3. elevated WBC count
  4. fever
  5. lethargy/ cognitive change
47
Q

wound culturing (5)

A
  1. rinse wound initially
  2. do not use discharge
  3. never swab over hard eschar
  4. rotate in “z” motion
  5. consider biopsies if needed
48
Q

management of infection (5)

A
  1. wound cleansing
  2. debridement
  3. proper dressing
  4. topical antimicrobials
  5. rule out osteomyletis
49
Q

4 examples of topical antimicrobials

A
  1. antiseptic
  2. antibacterial
  3. antifungal
  4. antibiotic
50
Q

5 causes pressure ulcers

A
  1. pressure (external pressure > 30mmHg/ capillary closing pressure)
  2. shearing
  3. friction
  4. epidermal stripping
  5. constant mositure
51
Q

shearing vs. friction

A

shearing- superficial layers of skin rubbing against deeper layers
friction- skin rubbing against protective surface

52
Q

risk factors for pressure ulcers (6)

A
  1. decreased activity and mobility
  2. decreased sensation
  3. diminished mental status
  4. poor nutrition
  5. medical problems
  6. incontinence
53
Q

common areas for pressure ulcers (8)

A
  1. sacrum
  2. heels
  3. greater trochanter
  4. lateral malleoli
  5. elbow
  6. occiput
  7. ear
  8. spinous processes
54
Q

prevention of pressure ulcers (6)

A
  1. repositioning
  2. frequent skin inspection
  3. proper support surface
  4. management of incontinence
  5. nutrition
  6. mobility training
55
Q

positioning principles (6)

A
  1. reposition every 2 hours
  2. supine > left > right
  3. use quarter turn for side ly
  4. make sure heels float in supine
  5. relieve at risk areas w/ pillows
  6. remember support surface is key
56
Q 
PRD (pressure relieving devices) factors
 envelopment
 immersion
 redirection
 capillary closing pressure
 pressure formula
A
  1. envelopment - can surface contour around body parts
  2. immersion- will body part sink down
  3. redirection- redistributing the pressure
  4. capillary closing pressure is 32mmHg , so this needs to be below that
  5. P= F/A
57
Q

support surface requirements (6)

A
  1. conform to boney prominences
  2. reduce pressures by better distribution
  3. eliminate bottoming out
  4. reduce shearing forces
  5. skin maceration
  6. provide comfort
58
Q

classifications of PRD (9)

A
  1. foam
  2. high density foams
  3. water filled
  4. gel filled
  5. static air
  6. reactive response air
  7. dynamic air
  8. low air loss
  9. air fluidization
59
Q

foam considerations (5)

A
  1. only used for comfort
  2. for individuals w/o risk
  3. retains moisture and heat
  4. enhances bacterial growth
  5. bottoms out
60
Q

high density foam (3)

A
  1. prevention purposes and for individuals with minimal risk
  2. wheelchair and transfer training
  3. possible stage I and II PU
61
Q

water filled (2)

A
  1. cold, heavy, leakage

2. stage I and II pressure ulcers and individuals w/ min risk

62
Q

gel filled PRD (3)

A
  1. decrease shear force
  2. heavier
  3. for individuals with min -> risk (stronger intervention than foam)
63
Q

static air PRD (3)

A
  1. individual cells that are inflated with air
  2. goof for poor mobility and min risk
  3. stage I and II PU
64
Q

reactive response air (4)

A
  1. multiple small synthetic air pillows with communicating channels
  2. redistributes air based on pts change in position
  3. stage II and III
  4. brand name is rojo
65
Q

dynamic air (5)

A
  1. motorized air pump
  2. rhythmically redistributes pressure
  3. for mod -> max risk
  4. individuals with poor mobility
  5. stage III/IV PUs
66
Q

low air loss (6)

A
  1. adjustable air flow for each compartment
  2. low inflation pressure maintained following slow air loss
  3. used w/ more involved individuals
  4. poor bed mobility
  5. mod -> max risk
  6. stage III and IV PU
67
Q

air fluidized bed (7)

A
  1. ceramic beads set in motion by airflow
  2. lowest contact pressures (11-15 mmHg)
  3. clinitron bed
  4. totally dependent
  5. most at risk/ hard to manage PUs
  6. stage IV PU
  7. monitor dehydration
68
Q

nutrition and hydration (3)

A
  1. increases risk for PI
  2. impedes normal healing
  3. immune system health
69
Q

dehydration

Who is at risk? (9)

A
  1. output of fluids exceeds input
  2. risk in comatose or neurologically involved
  3. chronic diarrhea
  4. persistent fever/ vomiting/ hyperglycemia
  5. fluid restriction
  6. dysphagia (easier for them to handle thicker liquids)
  7. dementia/depression
  8. medications (diuretics)
  9. GI problems
70
Q

clinical signs of dehydration (7)

A
  1. dry skin and mucous membranes
  2. cracked lips
  3. poor skin turgor
  4. thirst
  5. fever
  6. elevated Hb and Hc
  7. elevated Na and K
71
Q

calculating fluid need

A
  1. bdy wt * 0.5 = required oz of liquid
72
Q

red flags for wt loss (3)

A
  1. 5% in 1 month
  2. 7.5% in 3 months
  3. 10% in 6 months
73
Q

indicators of malnutrition (6)

A
  1. cachexia
  2. pale skin
  3. swollen lips and gums
  4. swollen and dry tongue (scarlet and magenta)
  5. poor skin turgor
  6. extremity and abdominal edema (because of lack of proteins)
74
Q 
Vit A
Vit C
Vit K
Copper
Iron
Zinc
A

vit A- collagen synthesis and epithelization
Vit C- new tissue integrity
Vit K - coagulation
copper - collagen cross linkage
Iron - collagen synthesis and WBC activity
zinc- enhanced new cell proliferation

75
Q

negative pressure therapy (VAC) (8)

A
  1. assist wound contraction
  2. evacuates excessive wound fluid and bacteria
  3. reduces edema
  4. increases cellular activity
  5. dehisced/ flaps
  6. wound must be cleaned and debrided
  7. foam dressing/ film cover
  8. 25-125mmHg
76
Q

contraI for neg pressure therapy

A
  1. osteomyletis
  2. active cancerous tissue
  3. exposed BV, nerves, organs (fistula)
  4. lots of eschar (wound needs to be debrided)
  5. bleeding sores (cant coagulate)

integument (2 decks)

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