test 2 Flashcards
causes of venous stasis wounds (7)
- venous hypertension
- aging
- trauma
- DVT Hx
- obesity/ pregnancy
- tumor
- loss of calf pump (shuffling walk)
pathophysiology of venous stasis
3 theories
- 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
- WBC trapping theory- hyertension in venous sytem => stagnate flow and WBC start to adhere to capillary which lead to releasing inflammatory chemicals
- microangiopathy- chronic hypertension damages capillaries
venous stasis wounds- presentation (5)
- lower leg, above malleolus (usually medial side because lots of veins there)
- shallow
- irregular border
- relatively painless
- surrounding edema and discoloration
venous stasis wound treatment (4)
- debride
- cleanse
- absorptive dressings
- compression therapy (to mobilize edema)
venous stasis wound treatment-
compression (4)
contraindications for this
- unna boot
- multilayered bandaging
- compression socks
- compression pump
- contraindication- severe arterial compression (ABI <0.7)
pt education for venous stasis wounds (6)
- encourage activity for muscle pump
- wear proper compression socks
- elevate legs regularly, avoid crossing legs
- skin inspection daily
- hygiene
- good nutrition (limit Na)
neuropathic wound (5)
- occur in plantar weight bearing locations
- circular punched out appearance
- surrounded by callous formation (must be shaved down)
- can be dry or moist
- wagner classification scale
diabetic neuropathic wounds
neuropathy - 3 things you lose
- first thing lost is sensory
- motor- lost fat pads and toe deformity- foot becomes rigid
- autonomic- very dry skin
what is charcot foot?
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
how to dx a diabetic foot (6)
- dry skin
- pt Hx
- callouses
- deformities
- rigidity
- atrophy
wagner classification scale (0-5)
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
neuropathic wound treatment (5)
- debride, cleanse and prevent infection
- limit WB- TCC (total contact cast) (*off- loading <0.5psi)
- remove surrounding callous formation
- appropriate dressing
- shoe wear and orthodics
venous stasis wound vs neuropathic wound… do you want pt to walk?
in venous stasis wound, get pt up and walking, in neuropathic wound, stop walking/ weight bearing
diabetic shoe necessities (6)
- extra depth
- pressure reducing insole
- breathable vamp (upper)
- toe rocker (see a curved sole)
- raised and reinforced toe box
- supportive shoe counter
pt education for diabetes (9)
+more
- daily skin inspection
- moisturize skin daily (humectant) - but not btwn toes
- do not soak feet for long periods of time
- be aware of signs of trauma and infection (heat/ pain)
- control blood sugar
- do not walk barefoot
- wear proper well fitting shoes
- low impact exercise
- go to podiatrist for removal or corn, blisters or toe nail cutting
una boot application (3)
- wet gauze wrap around like ace bandage (overlapping 50% of bandage). it dries and hardens
- 50% tension = pull wrap all the way and let go of 50% of the tension
- for venous stasis
role of dressing (4)
- maintains optimal environment? (temp, moistures, etc)
- removes excessive exudate (drainage)
- good thermal insulation
- protects against infection
qualities of a good dressing (8)
- provides a moist environment
- absorbent
- impermeable (not w/ infection)
- flexible (fill in deeper wounds- a gel can be considered a dressing)
- easy to apply and remove (non-traumatic)
- non-toxic
- inexpensive
- decrease dressing changes
guidelines for dressing use (5)
- no pressure/ tight packing- can cause more necrosis
- full contact with wound bed (for cell migration)
- monitor for strike thru (exudate coming thru dressing, means you need more absorbent dressing)
- moisture retention
- protect surrounding tissue
calcium alginate dressing
(seaweed derived) (3)
- fibrous tissue that absorbs moisture and turns into gel
- hydrophilic
- comes in ropes and sheets
calcium alginate benefits (7)
- can use with infections
- helps with autolytic debridement
- fill in cavities
- comfortable dressing
- easy removal
- great for absorption
- maintains a moist enviroment
calcium alginate drawbacks (4)
- not indicated for dry wounds
- requires secondary dressing
- more expensive than gauze
- not for superficial wounds
sorbsan/ kalostat
foam dressings (3)
- composed of open cell polyurethane
- comes in different thicknesses and absorbencies
- has adhesion on borders of dressing
foam dressing benefits (7)
- can be used with infected wounds
- good under compression for venous stasis
- good absorbing capabilities
- provide cushioning protection
- good thermal insulation
- good secondary dressing with deep wounds
- non-traumatic removal/ can cut to shape
foam dressing drawbacks (5)
- not good alone for deep wounds
- not good for very dry wounds
- not best for autolytic debridement
- need to monitor strike thru
- need to protect surrounding skin (maceration or adhesive trauma)
hydrasorb/ curafoam
transparent film dressing (3)
- thin see thru; dressing made with clear polyurethane => relatively impermeable and not absorbent
- adhesive borders
- elastic and extensible
transparent film benefits (7)
- able to monitor wound
- maintains moist environment- but not absorbent
- good for autolytic debridement
- minor burns, lacerations, abrasions, post op suture line and superficial wounds
- good barrier to keep out bacteria
- used to decrease friction for “at risk” individuals with stage I pressure ulcer
- excellent secondary dressing
transparent film drawbacks (4)
- not absorbent at all so watch for surrounding skin maceration
- cannot use with inefections (too occlusive so anaerobic bacteria can proliferate)
- not good alone for deep wounds
- consider skin sealant for surrounding tissue
opsite/ tegaderm
hydrogel dressings (4)
- moisture donator- good for deep dry wounds
- in tube or gauze dressing
- non-crosslinked polymers, water and glycerine
- can include additives (Ag)
derma-gel or flexi-gel
hydrogel benefits (5)
- assist with autolytic debridement
- good for dry wounds that need moisture
- soothing effect in wound allows eay removal
- good for filling deep wounds (tube)
- stage IV need to be kept moist or tissue will die*