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Integumentary Mgmt > Test1 > Flashcards

Test1 Flashcards

1
Q

Infection-

Rubor

A

Poorly defined border, disproportionate, possible red streaks

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2
Q

Autolytic Debridement

A

Selective
Conservative
Least painful, easy
Cheaper- but takes time

Maintains favorable wound environment:
Occlusive dressings, moist, warm - “cook”
Hydrocolloid
Transparent films
Foams
Hydrogels

Typically changed at “strike thru” or spiked
Combine w/ cross hatching if appropriate

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3
Q

Compression garments

A

Farrow wrap
Foot pieces and series of Velcro bands (similar to short stretch)
Easier don on/off vs compression stockings

Circ-Aid
Custom, non-elastic, Velcro bands
For VI and lymphedema

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4
Q

Modes of Delivery- NPWT

A

Continuous

Intermittent (on/off)

Variable (up/down but not off)

Combination (continuous then intermittent)

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5
Q

Signs of healing-
Surgical-
Positive Days 1-4

A

Edges approximated
Normal inflammation
Minimum to moderate drainage (bloody progressing to serosanguineous)

Primary dressing: dry or non-adherent gauze

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6
Q

Mechanical Debridement

“Mechanical force”

A 
Nonselective:
Soft abrasion
Hydrotherapy (WP, PLWS)
Wet to dry or wet to moist
Low frequency contact ultrasound

Painful (?)
Can be effective if used correctly
Familiar to healthcare workers

Wet-to-Dry rarely used; must be 100% non-viable

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7
Q

DM monofilament testing

A

5.07 monofilament (10 gram)

Test each site 3x

> 1 absent = LOPS

(LOPS = Loss of protective sensation)

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8
Q

AI interventions-

Referrals

A

Dietician
Reduced caffeine, smoking, proper nutrition and hydration

Diabetic educator

Podiatry

Prosthetics (if having amputation)

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9
Q

Pressure injury classification-

DTPI (deep tissue pressure injury)

A

Localized area of discolored intact or non-intact skin

Purple or maroon

Damage of underlying soft tissue

Difficult to detect in dark skin tones

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10
Q

NPWT- parameters

A

Filler and protective barriers
Mode of delivery
Frequency of change
Pressure

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11
Q

NERDS

A

If 3 or more present,
Treat topically

N- nonhealing wound
E- exudative wounds
R- red and bleeding wound surface granulation tissue
D- debris (yellow or black necrotic tissue) on the wound surface
S- smell or unpleasant odor from wound

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12
Q

Surgical wound healing-

Tertiary or Delayed primary closure

A

Initially wound left open then after a short time edges are approximated

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13
Q

Irrigation -

What and why

A

Use of fluid to remove loosely adherent cellular debris, surface bacteria, wound exudate, dressing residue, and residual topical agents

Facilitate debridement
Maintain moist wound environment
Enhance wound healing

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14
Q

Enzymatic Debridement-

Adverse effects

A

Burning/Stinging, allergic reaction

Peri-Wound irritation: highly exudative wounds, contact w/ skin

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15
Q

Tube-like (Tubigrip)

A

Least compression, inexpensive, easy to apply/remove/reapply, reusable, comfortable

Generally considered light compression (can double it), stretches out with repeated use

Conservative trial to determine compression tolerance

Utilized with UE and LE issues or with at risk mild edema- sprains, wounds

Typically 10-12 mmHg
Different sizes

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16
Q

Pseudomonas

A

Blueish, green Drainage

Odor

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17
Q

AI - Wound characteristics

Location

A

commonly below ankle

Foot, heel, metatarsal heads, tips of toes, “bunion” areas

Possible superior to lateral malleolus or anterior lower leg

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18
Q

DIME-

E

A

Edge effect

Progressing, stalled/rolled, callus, clean

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19
Q

AI wounds:

Prevention

A

Recognize risk factors and encourage lifestyle changes before it progresses
Takes less O2 to maintain intact skin than to heal skin loss

Smoking cessation 
Control DM (A1c < 7%), HTN (< 130/80)
Take prescribed meds 
Healthy diet and hydration 
Exercise (30 min, 3x week), control stress 
Soft appropriate/protective shoes 
Avoid cold temps 
Offloading and positioning prn 
Bed sheets/blankets, soft “heel lift” boots for bed
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20
Q

Pressure injury classification-

Stage II

A

Partial thickness skin loss with exposed dermis

Red or pink wound without slough or granulation tissue
Usually moist

Stage II is NOT skin tears, dermatitis, maceration

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21
Q

Treatment of pressure injuries-

Cleanse

A

Cleanse the wound and periwound
Normal saline
Tap water
Antiseptics

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22
Q

Whirlpool- positives

A 
Cleanses
Agitation 
Additives 
Temperature range 
Tx large areas 
Exercise
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23
Q

Local factors

Wound healing

A
  1. Circulation
    Macro and Micro
    Sympathetic nervous system responses to: cold, fear and pain
  2. Sensation
    Decreased knowledge of pain
    Additional trauma to area
  3. Mechanical stress
    Friction, shear, weight bearing, pressure
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24
Q

Cellulitis

A

Spreading bacterial infection of skin and subcutaneous tissue

Localized or advancing:
Tenderness, induration, fever
Necrosis, blisters.
Streaks- spreading along lymphatic channel

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25
Q

Epithelialization

A

Proliferation

Keratinocytes and epidermal appendages multiply and migrate across wound bed

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26
Q

STONEES

A

If 3 or more present,
Treat systemically

S- size is bigger 
T- temperature of 3* F or more vs mirror image
O- Os (probe to or exposed bone) 
N- new or satellite areas of breakdown 
E- exudate is increased 
E- erythema and/or edema (cellulitis)
S- smell
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27
Q

AI interventions-

Supervised exercise program

A

3x wk
Short bouts of treadmill walking 40-60 min each session

Improved oxygen metabolism, collateralization, improved blood viscosity, improved walking economy

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28
Q

Enzymatic Debridement-

How does it work?

A

Denatured collagen filaments anchor debris to wound bed

Collagenase digests these collagen filaments

Do NOT use with dressings containing:
Silver 
Iodine 
Hydrogen peroxide 
Acetic acid
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29
Q

Pressure injury interventions-

Prevention: Positioning In-chair

A

Sitting in intervals
Change position in chair
Reposition frequently: WC pushups, weight shifts
Support surfaces

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30
Q

VI- Patient education

A

Compression
Chronic situations, understand etiology and intervention

Extended standing or sitting, crossing legs
Ankle pumps, kneee bends, etc when necessary

Elevation - true elevation above heart
Elevation alone not adequate, must have compression when dependent

Care and replacement of compression stockings

Healthy lifestyle- weight, smoking, diet, sleep, etc

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31
Q

Braden Risk Assessment Scale

A

15-16 mild risk
12-15 moderate risk
<12 high risk

15-18 mild risk for those >75 y/o

Sensory/Mental 
Moisture 
Activity 
Mobility 
Nutrition 
Friction/Shear

Pressure ulcer risk predictor

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32
Q

Wet gangrene

A 
Drainage 
Odor 
Fluctuance/Edema 
Erythema 
Less clear line of demarcation

Urgent referral
Vascular surgeon

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33
Q

Greatest risk for pressure injuries

A

SCI
Hospitalized patients
Long term care patients

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34
Q

In-Elastic (Unna boot)

A 
Applied only with enough tension to hold in place 
No specified technique 
2-3 layers over entire LE (or UE) 
Requires 2ndary wrap
Usually long stretch or Coban 
Kerlix May be added for padding 
Considered multi-layer

Longer wear time- up to 1 week
Telescopes as edema reduces
Can cause frequent changes during first week due to initial changes in limb size

Can rub- especially along bend at ant ankle

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35
Q

Wound- Drainage

Serous

A

Protein rich fluid with WBC

Clear-pale yellow, watery

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36
Q

Neuropathic ulcer characteristics

A

Round, punched out. May be deep/probe to bone. Tracts/Tunnels

Peri-Wound callus (surrounding skin dry/cracked)
Often on plantar aspect of foot (metatarsal heads, great toe)

Min-mod Drainage, eschar uncommon

Red-pale granulation

Typically pain free (abnormal sensation/burning)
Wound itself not painful

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37
Q

Irrigation solutions-

Tap water

A

Caution with immunocompromised

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38
Q

Wound bed

Tissue identification

A

Describe in percentages present

  1. Granulation tissue- temp scaffolding of vascularized connective tissue
    Healthy granulation is bright or beefy red
    Pale or dusky: blood supply poor or may be infected
  2. Necrotic or Non-viable
    Slough: yellow or tan, stringy or mucinous
    Eschar: black necrotic tissue, soft or hard, wet or dry, adherent or non-adherent
  3. Fascia, adipose, muscle, tendon, joint capsule, bone, new epithelium
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39
Q 
Systemic factors (wound healing)
Nutrition
A

Carbs for energy

Protein for cellular repair/regeneration

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40
Q

Stocking - mmHg levels

A

15-20 mmHg
Support
Early s/s w/o ulcer, lite prophylaxis for high risk pt; “tired legs”

20-30 mmHg
Therapeutic- Mild VI,

30-40 mmHg
Therapeutic- moderate VI, lymphedema; varicose veins

40-50 mmHg
Therapeutic- severe VI, lymphedema

60+ mmHg
Therapeutic- severe lymphedema, elephantiasis, post thrombotic disease

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41
Q 
Systemic factors (wound healing)
Medications
A

Steroids
Chemotherapy
NSAIDS (?)

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42
Q

Pain pattern - Arterial Insufficiency (AI)

A

Increases with elevation and exertion (walking)
Numbness, tingling, cold, ache with exertion
Worse at night (Go to sleep, then up w/pain)
Can walk but require rest breaks (fatigue, pain)

Increasing pain is an indication for vascular consult
Pain can be masked by neuropathy in patients with DM

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43
Q

Pt education-

Self-care (surgical wound)

A

Infection: s/s and action to take

Showering/Bathing

Nutrition/social habits

Wound cleansing, dressing changes, protection

Antibiotics

Pain meds

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44
Q

Inflammation-

Dolor

A

Proportional pain

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45
Q

Tri-Neuropathy

Sensory

A

Poor awareness of trauma to feet

Occurs gradually

Paresthesias:
Burning, tingling, aching
Painful and debilitating
False sense of protective sensation

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46
Q

Proliferation

A

Angiogenesis
Granulation tissue
Wound contraction
Epithelialization

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47
Q

Irrigation solutions-

Wound cleansers

A

Shur-Clens : surfactant (oil, grease)

Vashe: hypochlorous acid- antimicrobial, R

Wound wash

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48
Q

Inflammation

Vascular response

A

Goal: control bleeding, fight infectious agents

Transudate leaks out of vessel walls: local edema

Local blood vessels reflexively constrict

Platelets aggregate and are activated: forms a plug to wall off affected area and closes off lymphatic channels creating more edema, release chemical mediators necessary for wound healing

Within 30 min of vasoconstriction, vasodilation occurs: localized redness, warmth, edema

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49
Q

Potential risk factors-

Arterial insufficiency

A

History:
Hyperlipidemia, hypertriglyceridemia (CAD, heart disease, etc)

Smoking (cessation: circulation improvements in 4 weeks, decrease CAD risk by 1/2 in 1 year)

DM (DM assoc neuropathy May prevent pain normally assoc with AI)

HTN
Trauma 
Advanced age 
PAD (occlusive, inflammatory, vasomotor) 
Obesity
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50
Q

Surgical site assessment-

Screening

A

Onset, fever, pain, last dressing change

Complicating factors

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51
Q

Infection- function

A

Malaise, May feel sick

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52
Q

Stockings

A

Not just for VI, can be for support/vein health
Replace ~6 months, buy 2 pairs: hand wash, air dry
Custom vs OTC - different colors and materials, can double layer
Can be worn during wound closure after edema resolved
Not 100% effective at prevention/maintenance

Prescribe lowest effective level for maintenance

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53
Q

Pressure ulcers

Treatment of cause

A 
Redistribute pressure (relieve heel pressure) 
Promote physical activity as tolerated 
Manage incontinence and moisture 
Reduce shear 
Enhance and optimize nutrition
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54
Q

Dry gangrene

A

Mummification
No drainage, hard
Little/No odor
Clear demarcation

Protect, off-load
Monitor for conversion to wet gangrene
Auto-amp?

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55
Q

Irrigation-
Low pressure capsules
PSI?

A

PSI 4-8

Max 10

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56
Q

Surgical wound healing-

Primary intention

A

Edges approximated during surgery

Sutures, staples, dermal glues

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57
Q

Wound- Drainage

Amount

A

None, minimal, moderate, copious

Must consider dressing used and when last changed

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58
Q

Signs of wound deterioration (NPWT)

A 
Increased peri-Wound erythema 
Repeated need for sharp or surgical Debridement 
Increased drainage, bleeding 
Newly observed infection/necrosis 
Increased pain 
Increased wound size 
Newly observed undermining or tracts
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59
Q

Cadexomer iodine

A

Broad spectrum antimicrobial
Slow release of iodine, non-cytotoxic

Absorptive- turns white w/ absorption

Various forms
Can be cheaper - depends on dressing frequency

Can stain skin
Cannot combine with collagenase

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60
Q

Exercise for patients with VI ulcers

A

Gastroc stretches to optimize ankle ROM (facilitate calf muscle)
Assess ankle ROM/flexibility- May also require ankle mobs, etc

Ankle pumps, circumduction, ABCs
Rocker board exercise

Heel-toe raises in sitting and standing

Step-overs - step 3-4 inch obstacle using heel strike in front, toe-pushoff in back
Exaggerated heel-toe sequence during walking
Walking
Biking
Aquatics (if no Wound)

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61
Q

Enzymatic Debridement-
Discontinue when?
Application?

A

“Clean”
Can promote cell migration
If not “clean” in 2 weeks, switch to another method

Application: thickness of nickel, must be kept moist
Cover w/ saline moist gauze, adaptic, hydrogel, etc

Frequently used for burns- except on face
May take longer if used alone (combo)

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62
Q

Debridement-

Sharp- Indications

A

Presence of non-viable tissue/callus

Amount of non-viable tissue rendering other methods too slow (infection or risk)

Advancing cellulitis

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63
Q

S/S of sepsis

A 
Shivering, fever or very cold 
Extreme pain or discomfort 
Clammy or sweaty skin
Confusion or disorientation 
SOB
High HR
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64
Q

Signs of healing-
Surgical-
Negative Days 5-9

A

Drainage

Little to no new pink epithelium

Absent or partial healing ridge

S/S of Infection

Dehiscence

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65
Q

Tri-Neuropathy

Autonomic

A

Altered sweating
Dry, less elastic, cracked skin

Callus formation (increased pressure)

Blood flow
AV shunting (less perfusion at skin)
Vasodilation (increase blood to bone, leaches calcium, predisposes bones of foot to fx 2ndary to osteopenia)

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66
Q

Biosurgical Debridement-

Contraindications

A

Near eyes, upper GI or upper respiratory tract
Allergy: fly larvae, brewers yeast, soy
Exposed blood vessels connecting to deep vital organs
Decreased perfusion
Malignant wounds

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67
Q

Debridement and AI

A

Caution- lack of good blood flow = decreased healing

Sharp Debridement - typically contraindicated
Collaborative decision with MD

=<0.8 ABI - NO Debridement of “stable” eschar
Goal is maintenance
Same for heel pressure wounds

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68
Q

Margination

A

Cellular response- Inflammation

Increased leakiness of vessel walls: pushes PMNs to sides of vessel walls

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69
Q

Systemic factors

Wound healing

A 
Age
Nutrition 
Comorbidities 
Medications
Behavioral risk
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70
Q

Irrigation-
Gentle and rinsing
PSI?

A

Safe and effective PSI 4-15

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71
Q

AI- Interventions

Ther Ex: Before a wound

A

Address modifiable risk factors

Positioning - avoid excessive hip/knee flexion (periodic dangle LE)

Gentle flexibility exercise- especially ankle

Aerobic exercise- graded walking program
Benefits: collateral vessel formation, weight loss, etc

Screening and monitoring- high % w/ CAD
Excessive exercise diverts blood flow to mms = pain

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72
Q

Cadexomer iodine-

Cautions

A

Allergy to iodine/shellfish
Pregnancy/breast feeding
<6 mo old
Widespread prolonged use (hyperthyroidism/cytotoxicity)

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73
Q

Irrigation solutions-

Sterile water

A

Must use with silver dressings

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74
Q

Infection-

Status

A

Plateau or changes in granulation tissue

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75
Q

Wound- Drainage

Type, color, consistency, amount

A

Serous
Sanguineous
Purulent
Amount: none, minimal, moderate, copious

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76
Q

Inflammation-

Function

A

Temporary decrease

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77
Q

ABI and compression

A

Generally (a place to start)

ABI => 0.8 compression 35-40 mmHg
MD “ok” below 0.8 (follow facility guidelines)
May see claudication start when<0.8

ABI <0.8 but >0.6 cautious light compression 17-25 mmHg

ABI < 0.5 = NO compression; rest pain

Pain/sensation, contraindications for compression
Always better to be conservative, start low

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78
Q

Dressing surgical wound-

When is moist dressing appropriate? What type?

A

Viable tissue exposed

Impregnated gauze cut to fit over opening
Dry gauze over the rest

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79
Q

NPWT

A

Negative pressure wound therapy

Closed wound dressing system with suction

Controlled sub-atmospheric pressure across open wounds
0-125 mmHg

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80
Q

Clinician induced factors

Inappropriate wound care

A

Prolonged or inappropriate use of antiseptics
Wrong dressing selection (macerates or dries out)
Failure to detect/treat infection
Inappropriate irrigation, debridement, compression etc
Poor wound exploration
Poor temperature management

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81
Q

Alginate - Contraindications

A

Not to be used over bone, tendon, etc

Not to be used on neonates (<38 weeks gestation)

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82
Q

Impregnated gauze

A

Atraumatic removal- “contact layer”
Multiple sizes, cut to fit
Mild occlusiveness, promotes moist wound healing
Less permeable than “regular” gauze (fluid held underneath)
Can be combined with topicals
Can be primary or 2ndary
Some can be left in place several days
Typically used on wounds w/o a lot of depth (some used to protect deeper names structures)

Ex: adaptic, xeroform
Cautions: maceration, adherent if allowed to dry

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83
Q

Combo Debridement

A

Sharp- remove loosely adherent tissue: cross hatch thicker areas

Enzymatic- applied collagenase to all non-viable areas

Autolytic- warm, well insulated, thick dressing

Pt education: rest, nutrition, etc

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84
Q

Surgical Debridement-

Indications

A

Complexity of wound
Gross infection or high risk of infection
When amount of non-viable tissue is too much within acceptable timeframe
Extensive undermining
Unknown depth or abscesses
Involves fistula
Named structures
Bleeding tendency, extreme pain, or trauma

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85
Q

If think patient has AI?

A

MD referral

Pt education:
disease, progression, self-care
Skin care and protection (shoe checks, warming, etc)
Hot water bottles, “gentle warming” - heat groin, low back..
Behavior modification (smoking, diet, exercise, meds…)
Sleep (bed position)
Wound mgmt (protection, off-loading, wound care, etc)

Safe graded exercise (if cleared) - careful monitoring

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86
Q

NPWT- reducing pain at dressing change

A

Soak wound filler 3-5 min w/ saline- infuse via tubing
Protective layer-prevents adherence
Xeroform strips around edges
Pull occlusive sheeting parallel to skin
Frequent dressing changes (24 vs 48 hrs)
Granulation ingrowth less likely w/ gauze
White foam may be less painful to remove vs black
Calcium alginate under foam
At dressing change, cover tissue w/ soak to prevent dehydration

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87
Q

Signs of healing-
Surgical-
Negative Days 1-4

A

No signs of inflammation

Tension along incision line

Primary dressing: dry or non-adherent gauze

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88
Q

Surgical wound healing-

Secondary intention

A

Left open after surgery, healing with scar tissue

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89
Q

Wound edges

A

Well defined (demarcated) or Diffuse

Thick or thin

Attached to wound base or raised or rolled (epibole)

Color

Evidence of epithelialization

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90
Q

Most common visual with venous insufficiency

A

Hemosiderin staining

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91
Q

HAI

A

Healthcare-associated infections

Infections pt got while receiving treatment for medical or surgical conditions

Most common:
Central line-associated bloodstream infections 
Catheter-associated UTI 
Surgical site infections
Ventilator-associated pneumonia

Prevention key

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92
Q

Intermittent claudication

A

Arterial insufficiency

Activity specific discomfort
Discomfort goes away within 1-5 minutes of stopping activity
Repeatable and predictable

Differential diagnosis: spinal stenosis
S/S relief with change of position

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93
Q

15 common locations of pressure injuries

A
  1. Posterior heel
  2. Sacrum/Coccyx
  3. Spinous process
  4. Medial/Lateral humeral epicondyles
  5. Scapula
  6. Occiput
  7. Anterior tibia
  8. Anterior knee
  9. Iliac crest
  10. Malleolus
  11. Medial/Lateral femoral condyles
  12. Greater trochanter
  13. Ear
  14. Ischial tuberosity (WC)
  15. Greater trochanter (WC)
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94
Q

Pathophysiology of pressure injuries

A

Pressure creates increase in intracapillary blood pressure
= decreased blood flow to soft tissue and obstructed lymphatic channels

Local tissue ischemia

Increased metabolic waste and acidosis
= increased cell death

Capillary permeability and local edema increases further limiting circulation and increased tissue necrosis

Decreased fibrinolysis leading to fibrin deposits leading to microthrombi further occluding vessels and increasing necrosis

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95
Q

Signs of healing-
Surgical-
Negative Days 15 up to 1-2 years

A

Keloid or hypertrophic scarring

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96
Q

Surgical site assessment

A

Screening
Observations
Measurement of incision
Palpation (incision and surrounding area)

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97
Q

Pressure injuries-

Intrinsic factors

A 
Muscle atrophy- impaired mobility 
Medications 
Malnutrition 
Medical conditions- impaired sensation; previous pressure injury
Advanced age
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98
Q

PLWS- negatives

A

Expense

Aerosolization risk:
Confined space
Cover horizontal surfaces

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99
Q

Alcohol hand rub

A

When hands NOT visibly soiled

Enough to saturate all parts of hands
Rub hands together 15 seconds
Allow product to dry

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100
Q

Infection-

Tumor

A

Disproportionate edema, possible induration

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101
Q

Prediabetes - exercise

A

Lose 5-10% body weight
At least 150 min moderate exercise per week

Focus on overall health and importance of regular exercise
Gait, balance, fall prevention

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102
Q

Common infectious disease needing droplet precautions

A 
Ebola 
Pertussis (whooping cough) 
Influenza 
Rhinovirus 
Pneumonia: Adenovirus 
Streptococcus Group A 
Rubella
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103
Q

Wound bed preparation

A

After comprehensive exam/assessment

Determine ability of wound to heal (includes underlying cause, pt status, complicating factors, etc - broad picture)

Healable- address underlying cause
Maintenance- potential but barriers
Non-healable/palliative- irreversible causes/illnesses

Once status determined, appropriately dose care

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104
Q

Wound bed-

Tunnel

A

Entrance and exit

Document location and length

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105
Q

Common infectious diseases requiring contact precautions

A

MDROs (multi-drug resistant organisms):
MRSA; VRE

CRE (carbapenem-resistant enterbacteriaceae)
Ebola 
C.difficile 
Norovirus
RSV 
Rotavirus 
Herpes Zoster (Shingles) -in some cases 
Scabies
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106
Q

Debridement-

Sharp

A

Fast
Aggressive (high level of skill- some states require special license)
Painful (can be bc non-viable is attached to viable tissue)
Often combined w/ other forms
Selective- forceps, scissors, scalpel, curette

MUST have order from MD to perform

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107
Q

Clinical exam-

Neuropathic ulcer

A

Lab values (Fasting glucose, A1C, albumin, pre-albumin)

Inspection of skin and nails (Skin: Dry, scaly, callus; Nails: Hypertrophic, fungus)

Foot deformity (Joint subluxation, dislocation, etc)

Vascular: Noninvasive vascular screen including ABI

Motor/ROM: STR if ankle/foot mms; Flexibility (DF at least 10*; great toe, metatarsal mobility); General gait analysis and balance

Sensory testing: monofilament, vibration, etc

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108
Q

Signs of healing-
Surgical-
Positive Days 15- up to 1-2 years

A

Pale pink scar progressing to white/silver
Will be darker in darkly pigmented skin

Note: scar will always be weaker. Only up to 80% of full strength

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109
Q

Wound - Odor

A

Assessed after irrigation
Present or absent

Caused by:
Infection 
Non-viable tissue 
Old dressing 
Hot weather
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110
Q

Pressure injury classification-

Stage IV

A

Full thickness skin and tissue loss

Exposed bone, tendon or muscle
May have slough and eschar
Undermining and tracts common

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111
Q

Autolytic Debridement-

Contraindications

A

Infection
Dry gangrene
Deep cavity wounds
Other methods more appropriate

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112
Q

Clinician induced factors

Appropriate wound care

A

Initial use of antiseptics to kill everything
Maintenance care when wound healing is not priority
Use of iodine to encourage/maintain non-viable tissue desiccation

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113
Q

Droplet precautions

A

Prevent spread by close mucous or respiratory membrane contact.
Usually passed through a cough, sneeze, or talking

Private room preferred, but if not available spatial separation of >3 feet needed and curtain drawn between patients

PPE: mask on healthcare provider or on patient if transport outside of room necessary
Don upon entry; Doff before exit

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114
Q

Signs of healing-
Surgical-
Positive Days 10-14

A

Sutures/Staples removes

Pink incision site

Tiny openings post removal

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115
Q

PMNs

A

Polymorphonuclearneutrophils

1st to site of injury (12-24 hours)
Kill bacteria
Clean wound
Secrete MMPs (matrix metalloproteases) - degrade debris

(Inflammation- cellular response)

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116
Q

Visual inspection - vascular status

A

Skin:
Discoloration, hyperpigmentation (hemosiderin staining)
Dry/cracked, old scar, hair loss, thick yellow nails
Dermatitis, lipodermatosclerosis, atrophic blanche

Vein distention, varicose veins

Edema- compared to contralateral side, bilateral? Soft, hard, pitting, etc

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117
Q

Irrigation solutions-

Antiseptics

A

Use cautiously

Acetic acid: pseudomonas
Chlorhexidine gluconate (Hibiclens): intact skin, surgical scrub
Dakin’s sol’n (sodium hypochlorite, bleach): inanimate objects
Chloramine-T (chlorazene) : heavily colonized or infected wounds
Hydrogen peroxide: cleanse around pin sites and sutures
Povidone-iodine (Betadine) : surgical scrub, very short term acute

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118
Q

Sepsis

A

Systemic inflammatory response to infection

Combination of virulent infection and body’s strong response
Bacteria in blood, may travel to other areas (UTI, pneumonia…)

Fever, tachycardia, tachypnea, inadequate blood flow to internal organs
Shock, organ failure
~50% mortality rate

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119
Q

Biosurgical Debridement-

Precautions

A

Drown in heavy exudate, squished by pressure

Patients with breathing disorders

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120
Q

Neuropathic wound =

A

Diabetic foot ulcers

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121
Q

Moist wound healing

A

Enhance wound healing and promote new tissue growth

Low moisture levels lead to necrosis and eschar formation, hindering wound re-epithelialization and closure

Moisture balance of the wound bed is critical for wound healing

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122
Q

Purposes of debridement

A

Decrease bioburden and risk of infection
Increase effectiveness of topicals
Improve bactericidal activity of leukocytes
Shorten inflammatory phase
Decrease energy required by body to heal
Eliminate physical barriers
Decrease wound odor

123
Q

Treatment of pressure injuries-

Dressing selection

A

Moisture balance
Amount of exudate

Bacterial bioburden 
Tissue condition in wound bed 
Peri-Wound skin 
Size, depth, location 
Tunneling, Undermining 
Goals
124
Q

Neuropathic-

Physical agents

A

Careful with heat application
Faster insulin absorption from injection site ; Hypoglycemia
More likely to burn (blood flow; sensation)
Ex- abnormal cardiac responses, vitals, glucose levels, etc

Careful with cold application
Slower absorption from injection site; Hyperglycemia
Cold tissue injury (blood flow; sensation)

125
Q

ABI interpretation

A

> 1.2 Unreliable (vessel calcification)

  1. 0-1.2 Normal
  2. 8-1.0 Mild PAD, compression for edema with caution/monitoring

0.5-0.8 Moderate PAD, intermittent claudication <0.8
0.6-0.8 cautious modified compression (contraindication <0.6), night pain
Refer to vascular specialist

<0.5 severe ischemia, rest pain (“critical limb ischemia”) - compression and Debridement absolutely contraindicated

<0.2 tissue death

126
Q

Pressure injury interventions-

Prevention: Mobility

A

Encourage
Lengthen lines and tubes as able
Avoid polypharmacy
Adequate pain control

127
Q

NPWT- Contraindications (11)

A
  1. > 30% slough/necrotic tissue OR over dry wounds
  2. Untreated osteomyelitis
  3. Gross infection or sepsis
  4. Malignancy (except in palliative care)
  5. Lack of hemostasis
  6. Blood dyscrasia (leukemia/hemophilia)
  7. Directly over exposed vessels/by-pass grafts/organs/named structures
  8. Ischemic wounds w/ significant proximal occlusion
  9. No intermittent over grafts due to high potential for disruption
  10. No suction devices/pumps in MRI, HBOT, or close to flammable anesthesics
  11. Any wound showing negative response to initial tx
128
Q

“Regular” gauze offers

A

Readily available, various sizes, inexpensive
Non-occlusive and absorptive (dry)
Mechanical Debridement
Padding, primary (w/ hydrogel) or 2ndary dressing (wet to dry)
Cut to size

Telfa- non-adherent, little absorption

Changed daily as primary dressing

Cautions: drying, can absorb topicals quickly, fibers, roll gauze applied at an angle

129
Q

NPWT- AI

A

Precautions

NOT for moderate/severe AI

Compression at wound edges causes 1-2.5 cm area of hypoperfusion

Not good idea in AI where surrounding tissue is already compromised
Use lower pressures
Intermittent mode- if appropriate

130
Q

Foam

A

Absorptive - can be used with most thicker topicals (ointments)
Flexible, variety of sizes, cut to size
Non-adherent, thick and thin
Primary or 2ndary dressing (padding, additional absorption; can be combined with other dressings)
Insulating (promote autolytic Debridement)
Can be left in place up to 7 days

Cautions: maceration, can roll with friction

131
Q

Autolytic Debridement-

Disadvantages

A

Odor upon removal
Time
Infrequent visualization

132
Q

NPWT- equipment

A

Pump provides suction

Wound filler or cover transfer pressure across wound bed and allow fluid to move through and into canister

Tubing- delivers suction, transports fluid
Canister- hold evacuated fluids
Occlusive sheeting provides air-tight seal
Application- simple to complicated

133
Q

Phases of wound healing

A

Inflammation
Proliferation
Maturation/Remodeling

134
Q

Mast cells

A

Produce histamine and secrete enzymes to accelerate riddance of damaged cells

(Inflammation- cellular response)

135
Q

Macrophages

A

Kill pathogens
Direct the repair process

(Inflammation- cellular response)

136
Q

Dressing surgical wounds-

Most common

A

Dry or non-adherent gauze

Bordered foam

May see beta-dine dabs along incision line as well

137
Q

Common infectious diseases requiring airborne precautions

A

TB
Measles
Chickenpox
Smallpox

138
Q

Irrigation solutions-

Normal saline

A

0.9% sodium chloride

Can be made at home

Refrigerate but warm before use.
Wounds heal best when kept under warm conditions.

139
Q

Inflammation

Cellular response

A

Increased leakiness of vessel walls: pushes PMNs (polymorphonuclearneutrophils) to sides of vessel walls (Margination)

PMNs- 1st to site of injury (12-24 hours), kill bacteria, clean wound, secrete MMPs (matrix metalloproteases) degrade debris

Macrophages arrive: kill pathogens, direct repair process

Mast cells: produce histamine and secrete enzymes to accelerate riddance of damaged cells

140
Q

Basic incision care

A

Keep dry (dry gauze, Telford; abx ointment and impregnated gauze if tissue exposed)

Protection (reduce tension -edema; steristrips)

Cleansing and Debridement (clean water; wipe toward incision line; remove loose debris/scab)

Monitor

141
Q

Biosurgical debridement

A

Biologic

Maggot therapy (MT) 
Larval Debridement therapy (LDT)

Used since 1500s
Selective, quick, painless
Invest non-viable tissue and decrease odor
Release enzymes that degrade non-viable tissue and biofilm

Antimicrobial- MRSA, strep, pseudomonas, biofilm
Change in pH
Killing (secreted enzymes) and ingestion of bacteria
Excretions and mvmt stimulate granulation tissue

142
Q

Sharp Debridement-

Technique

A

Forceps in non-dominant hand; scalpel/curette/scissors in dominant hand

Parallel to wound surface
Lift necrotic tissue with forceps
Avoid sawing

Cut parallel to plane of wound tissue
Remove in thin layers
Can sometimes use a “scrape” technique

Bleeding s/b minimal bc non-viable tissue doesn’t bleed

Good to take before and after pictures

Warn patient wound will be deeper/bigger

143
Q

Tri-Neuropathy

Motor

A

Paralysis of foot intrinsics
Increased plantar forces

Hallux VALGUS

Claw toe

144
Q

Debridement- methods

A
  1. Sharp (MDs, PTs, PTAs, Nursing)
  2. Mechanical
  3. Enzymatic
  4. Autolytic
  5. Biological
  6. Surgical (MDs): named structures, large stage III and IV pressure injuries, significant undermining, tunneling, sinus tracts, epibole)
145
Q

SSI: surgical site infection

A

Most common nosocomial infection

Majority related to incision
To avoid->
IV abx 1 hr prior to first cut: good infusion to tissue, continued throughout surgical procedure

Preoperative hair removal (clipped not shaved)

146
Q

NPWT- patient education

A 
Basic operation, alarms, how to patch 
Benefits 
Device “on” 24 hrs day 
Keep tubing on, no kinks
24 hr troubleshooting assistance line 
Keep battery charged 
What to do: bleeding, increased pain, etc
147
Q

Total contact cast

A

Gold standard
For forefoot ulceration and Charcot foot

Requires special training

Forced off loading
Changed 1-2 weeks
Decreases activity level, stride length, cadence
Hot, heavy, difficult self-care

148
Q

Discontinue NPWT

A
  1. Goals met
  2. Good granular bed achieved, even w/ skin surface
  3. No appreciable benefit post 48 hrs
  4. S/S deterioration
  5. Development of new infection post NPWT
  6. Pt discomfort/intolerance
  7. Other dressings better suited to current phase of healing
  8. Progression too little/no drainage
  9. Anticoagulants
  10. Sanguineous Drainage, fills canister in 1 hr or >2 canisters in 24 hrs
149
Q

Infection/

Drainage

A

Disproportionate, thick consistency, purulent, May be copious,white, yellow, green or blue, May have odor

150
Q

Surgical wound-

When to contact MD

A 
Early increased bloody drainage 
Change to purulent drainage
Drainage after 5-6 days 
Absence of healing ridge by day 9 
Infection: local s/s post day 4; systemic s/s anytime 
Dehiscence 
Increased pain 
Consider contributions of increased mobility
151
Q

NPWT- intermittent pressure

A

125 mmHg: 5 min on/2 min off

40-75 mmHg for mild arterial wounds (and lower pressures)

152
Q

Trophic changes

A

Skin: dry, withered, shiny, thin, taut

Comparatively cool: recommend 5 min without socks/shoes before checking temp

Loss of hair

Limb/surrounding area pale/dusky
Pallor with elevation, Rubor with dependency

Decreased sensation

Muscle atrophy and weakness (MMT, girth)
Claw toes w/ mm atrophy of foot intrinsics

Nails: yellow, hard, brittle, thick (fungus)

Edema: not usually (dependent possible, CHF, VI)

153
Q

Charcot foot

A

Fx and dislocation = foot deformity and abnormal pressure/shear forces

Suspect if:
Inflammation, edema, warm, bounding pulse, may have an open wound (or may come after)
Temp 4-15* higher w/o ulcer- May indicate Charcot foot

Dx: X-ray, MRI
Tx: casting 6-12 mo- TCC, boots (CROW)

154
Q

Wound closure

Secondary intention

A

Wound edges unable to be approximated

Granulation tissue fills in wound bed

PT more likely to be involved

155
Q

Infection-

Calor

A

Greater amount of increase, wider surface, may be febrile

156
Q 
Systemic factors (wound healing)
Comorbidities
A

Those affecting O2 perfusion
PVD, anemia, COPD, heart conditions

Immunocompromised
HIV/AIDS, diabetes

Activity limitations

157
Q

Steri-Strips (3M)

A

PT placement
Post suture/staple removal
Sometimes placed over sutures/staples

Removal post closure:
When they fall off
Ok to shower

For ~2 weeks after suture/staple removal

158
Q

Incision lines- scar management

A

Minimize inflammation

Encourage quick closure

Functional mobility during healing
Upright posture, ROM, etc
Moisturize lightly
STM

159
Q

Diabetic foot ulcers-

Exercise

A

Avoid if glucose >250 with ketosis or >300 without
No exercise if glucose <70
Stress = increased insulin requirements

Hydrate before: ~17 oz
Eat 2 hrs before exercise, or 1 hr after food intake

Snacks: quick vs slower absorption 
Eat quick (fruit) every 30 min; Eat slow (bread) after exercise

Avoid heavy exercise late at night and do not exercise alone. (Delayed hypoglycemic event during sleep)
Don’t inject insulin over mm that will be heavily exercised that day

Type 2- no more than 2 days between bouts of exercise for best control

160
Q

Dressings-

Purpose

A

Provide optimal environment
Moisture, neutral warmth, protection/barrier, odor, delivery of topicals, reduce pain m
NOT static - applied in response to changing wound status/needs
Changes with drainage amount/type, healing phase, activity, temp, tissue, bioburden, etc

Re-evaluate dressing every visit

161
Q

General factors

Wound healing

A 
Mechanism of onset 
Time since onset (Acute vs Chronic) 
Location- consider blood supply, bony prominences, typical skin thickness 
Wound dimensions- circular is slower than square or rectangle is slower than linear 
Temperature (37-38* C is best) 
Wound hydration 
Necrotic tissue 
Infection
162
Q

Inflammation-

Tumor

A

Slight proportionate edema

163
Q

Capillary refill - vascular status

A

Microvascular exam

Press end of toe/proximal to wound

Normal: <3 seconds

164
Q

Inflammation-

Calor

A

Local increase in temperature

165
Q

ABI

A

Ankle brachial index

Ratio of ankle systolic to brachial systolic pressure

BP cuff proximal to ankle, inflated
Doppler: Dorsalis pedis and Posterior Tib pulses, use higher pressure
Obtain L and R brachial pressure, use higher pressure

Contraindications for test: ulcer near ankle
Considerations: calcified, noncompressible vessels will skew results (Diabetes, renal insufficiency, edema, obesity, poor cardiac output, etc)

166
Q

Irrigation Solutions

A

Normal saline (0.9% sodium chloride)

Sterile water

Tap water

Wound cleaners

Other: antiseptics (use cautiously)

167
Q

Pressure injury evaluation-

Specific tools

A

BWAT: bates-Jensen assessment tool
15 items describing wound and peri-wound
Correlated with severity of wound
Higher number = more severe

PUSH : pressure ulcer scale for healing
Developed to monitor healing of ulcers

168
Q

Debridement-
Sharp-
Contraindications

A 
PT comfort/skill level
Cannot see (tracts etc) or identify tissue 
Consent, or not consistent with POC 
Ischemic ulcers (AI) 
Hypergranulation - live tissue 
Pyoderma gangrenosum
169
Q

AI intervention- with a wound

Plan?

A

Treat, wait for auto-amp, surgical intervention?
Conservative approach

Gangrene: monitor for conversion
Protection: dry, padded, NWB on affected limb

Moisturize surrounding skin 
Monitor for infection 
ROM for joint mobility and muscle flexibility 
Exercise/walking program as appropriate 
Foot care guidelines
170
Q

Inflammation

Cardinal signs

A 
Edema
Redness 
Warmth 
Pain 
Decreased function
171
Q

AI- Wound characteristics

Presentation

A

Start shallow then deepen
“Punched out” appearance
Usually round

172
Q

Proliferation

Key cells

A

Angioblasts
Fibroblasts
Myofibroblasts
Keratinocytes

173
Q

Why not close via primary intention?

A

Risk on infection

Too much tissue removed- deep cavity

Closure would result in too much tension (edema)

174
Q

Wound - size

A

Multi methods…

Direct measurement
Length (longest)
Width (perpendicular to length)
Depth (deepest)

Clock method
12 o-clock in area closest to head, but can be assigned differently by clinician 
Length (12-6)
Width (9-3) 
Depth (various: 2,4,8,10 or other)

Other methods: tracing, photos, volumetric, total body surface area

175
Q

VI Wound characteristics

A

Uneven edges (can be diffuse or rolled)

Shallow

Highly exudative (especially at initiation of tx), primarily serous - 
If little to no drainage-consider AI component

Pain- usually not too bad, if severe consider AI or vasculitis (or mixed)

176
Q

Sharp Debridement-

Controlling bleeding

A

Elevate, pressure x 10 min, silver nitrate (if have MD order for silver)

If structure pulsates- do not cut it!

Contact MD when:
Bleeding has a pulse, won’t stop, hear it
Fever/chills, downhill course, no improvement, impending exposure of named structures, unexpected abscesses or gross purulence

177
Q

DIME-

I

A

Inflammation/Infection

What stage of healing, immunocompromised, activity, s/s of infection, s/s out of proportion for phase of healing

178
Q

MMPs

A

Matrix metalloproteases

Degrade debris
Secreted by PMNs

(Inflammation- cellular response)

179
Q

Pressure injury classification-

Unstageable

A

Obscured full thickness skin and tissue loss

Base covered by slough/eschar

True depth can’t be determined

(Eschar and slough have to be removed to stage the wound)

180
Q

Enzymatic Debridement

A

Selective
Physician prescription
Pain free- some day it stings
Easy to apply - once daily
Can be used on infected wounds (combo): polymyxin b powder added
Do NOT use with silver or iodine products

Collagenase Santyl

181
Q

PLWS- positives

A 
Cleaning 
Known PSI
Sterile, no additives 
Temperature range
Site specific 
Portable 
Disposable (easy cleanup) 
Few contraindications
182
Q

Inflammation-

Drainage

A

Proportionate, thin consistency, serous or serosanguinous

183
Q

Wound bed-

Undermining

A

Tissue under wound edge is gone, similar to cave under skin, “waggle room”

Documentation example:
Undermining of 4 cm from 10-12 o’clock

184
Q

VI Peri-Wound

A 
Maceration common 
(Initially or with inadequate dressings or change schedule)

Diffuse edges

Irritation

185
Q

DIME-

M

A

Moisture balance

Tissue type/quality, maceration, activity, infection, dressing schedule, out of proportion, add or absorb moisture

186
Q

Etiology and progression of arterial insufficiency

A

Decreased arterial blood flow ->
Intermittent claudication->

Ischemic rest pain 
Burning pain with elevation or at night 
Relieved by dependency 
-> 
Ischemic ulcer or gangrene
187
Q

Neuropathic wound exam

A

Thoroughly explore wound bed
Depth, tunnels, tracts, named structures
Callus

Classification: Wagner grading scale

188
Q

What causes pressure injuries

A

Pressure (force/area)

Pathophysiology
Intrinsic factors
Extrinsic factors

189
Q

Debridement-
Sharp-
Precautions

A

Anticoagulants/Clotting issues, pain
Immunosuppression
Unable to be still

190
Q

Hyperglycemia impairs __ phases of healing

A

All phases of healing

Bacteria proliferate rapidly in high glucose environment

Impaired: 
Production and migration of neutrophils 
Chemotaxis, migration and mobility of macrophages 
Function of fibroblasts 
Epithelial cell migration

Deficient blocking of “normal” enzymes that degrade tissue
Endothelial cell dysfunction

Further complicated by underlying decreased blood flow

191
Q

Surgical site assessment-

Observations

A

Epithelialization/Wound closure, exudate

Wound tissue, periwound, surrounding skin
S/S of infection (clinical and critical colonization)

192
Q

Diabetic (neurotrophic) foot ulcers

A

Vascular: ensure adequate vascular supply
Infection: control superficial critical colonization/deep + surrounding infection
Redistribute plantar pressure

Callus= pressure
Blister = friction and shear
193
Q

Wound- Drainage

Purulent

A

Indicator of infection

White-pale yellow, viscous or creamy consistency

194
Q

LaPlace’s Law

A

Compression =

Tension X number of layers X 4630
%
(Limb girth X bandage width)

195
Q

Biosurgical Debridement -

Patient population

A

Maggot therapy

Osteo, Inf around hardware, etc
Poor candidate for sx
Unable to tolerate other forms of Debridement

196
Q

Tri-Neuropathy

A

Diabetic neuropathy

Sensory - Motor - Autonomic

Usually symmetrical

Affects distal nerves first - feet/hands

Severity increases with: age, disease duration (~10 years), glucose control

197
Q

___ dressings are important for healable wounds, with ___ often more appropriate for non-healable or maintenance wounds

A

Moisture balance dressings for healable

Moisture reduction for non-healable and maintenance

198
Q

Pressure injuries-

Extrinsic factors

A 
Amount of pressure 
Duration of pressure 
Friction 
Shear 
Moisture 
Temperature
199
Q

NPWT- Tissue protection

A

Can apply over any body tissue-w/protection
Cannot put over named structures directly- must be protected (so don’t dry out)

Adaptic
Sometimes3-4 layers

White foam
Less aggressive compared to black/green

200
Q

Debriding blisters

A 
Remove:
Larger than nickel 
Area likely to rupture or tear 
Worried about possible tissue injuries- burns 
Great medium for bacterial growth

Secure with forceps
Release tension carefully
Skin/blister line
Clean away residue (can appear like jelly)

201
Q

Dehiscence

A 
Tension, edema 
Smoking 
Infection/osteomyelitis 
Trauma (pressure) 
HTN 
Stress 
Malnutrition 
Decreased healing potential (DM, etc)
202
Q

Wound bed preparation -

Maintenance and Non-Healable/Palliative

A

Conservative approach-

Limited debridement, bacterial reduction through antiseptics, moisture reduction

203
Q

Autolytic Debridement-

Indications

A

Pain
Palliative tx
Can’t be still

204
Q

Whirlpool- negatives

A

Risk of infection (sterility; aerosolization)

Risk of tissue injury (PSI; maceration)

Additives

Expense (cleaning, space, water)

(They suck- not ideal- not recommended period- unless nothing else available)

205
Q

Colonization

A

Microflora replicate and form colonies

No adverse affect
Does not cause host response

206
Q

NPWT- continuous pressure

A

80-125 mmHg for most acute wounds and pressure injuries

100-125 over grafts first 3-5 days

80 mmHg = max effects on blood flow

50-75: if pain issue; most chronic wounds

40-50 M: wounds w/ decreased circulation

75 mmHg for abdominal wounds due to pressure receptors in abdomen

207
Q

PLWS- Contraindications

A 
Exposed named tissues
Body cavities 
Facial wounds 
Recent grafts or surgical procedures
Actively bleeding
208
Q

Pressure injury interventions-

Prevention: Positioning In-bed

A

Avoid side positioning- 30* lateral instead
Pillows or foam pads between bony prominences
HOB lowest degree of elevation (prevent shear)
Clean and wrinkle free bed linens
Pillows/Wedges to prop heels and head
Support surfaces

209
Q

Opportunities for hand washing

A

Before and After…

Patient contact
Any patient procedure
Wearing gloves
Environmental or Equipment contact

210
Q

Signs of healing-
Surgical-
Positive Days 5-9

A

No inflammation

No drainage

New epithelium along entire incision line

Healing ridge present
Firmness along incision line from collagen deposition - Feels like a pencil under incision line

211
Q

Biosurgical Debridement- specifics, application

A

Sterile, non-reproducing
Medicinal maggots order from Irvine, CA (250-300 ~$98)
10 for 1 cm2 wound surface area

“Free range” or “contained”
Need air so don’t seal off- nylon mesh cover
Covered w/ dry gauze to absorb drainage and allow air flow
Change ~3 days

Don’t travel around body

212
Q

Contact precautions

A

Also used when environmental contamination from excessive wound drainage, fecal incontinence, and other bodily discharges

Private room s/b utilized if available or at minimum >3 feet separation b/w beds to avoid sharing of equipment and touching of surfaces

Most common mode of transmission

PPE: gloves and gown

Wash hands before entry. Don after entry into room and Doff before exiting. Wash hands after exiting.

213
Q

VI- Goals of PT

A

Prevention
Referrals

Tx- set stage for body to heal
Relieve pressure and congestion- resolve/manage edema
Care for open wounds- manage drainage, protection, etc
Compression- determine level/method

Help pt adjust to lifelong issue:
Educate- condition, expectation for other rounds w/o intervention
Longterm compression needs

214
Q

Debridement-
Sharp-
When to stop and warning signs

A 
Patient request, pain control issues 
Wound is clean 
You get nervous, tired, unsure
Impending exposure of named structures 
Holes you cannot are bottom of
Unexpected infection/purulence 
Extensive undermining 
Excessive bleeding

(May have slight bleeding- connected to live tissue)

215
Q

Signs of healing-
Surgical-
Negative Days 10-14

A

Signs of inflammation or infection

Drainage

Dehiscence

Absent or partial healing ridge

216
Q

Ultrasound based Debridement

A 
Low-frequency contact US (kilohertz) 
Tissue vibration (unstable cavitation)

Sonoca 180 (spring medical technology)
Qoustic Wnd Therapy System (Arabella medical LLCArobella)
SonicOne (misonix inc)

Antimicrobial effects as well

217
Q

Mechanisms of Action and Benefits of NPWT

A 
Removal of exudate 
Moist wound environment 
Decrease bacterial burden 
Reduce edema and excess interstitial fluid- increases blood flow 
Increase in microvascular blood flow 
Stimulation of granulation tissue- mechanical deformation 
Promotes wound contraction 
Reduced dressing change frequency
218
Q

Inflammation

Key cells in cellular response

A

Platelets
PMNs
Macrophages
Mast cells

219
Q

Rubor of dependency- vascular status

A

Supine, LE elevated 30-60*
1 minute

Observe for pallor/blanching
Normal = little to no color change
Mild-Moderate insufficiency = 45-60 and 30 seconds respectively
Severe insufficiency = <=25 seconds

LE dependency - Observe color
Normal = < 15 seconds, return of pink
Reactive hyperemia = >=30 seconds and dark red/rubor (+ for severe ischemic disease)

Venous filling

220
Q

VI - compression

Considerations for decision making

A

Comfort, cosmetics, tolerance
Some compression is better than none
Frequency of dressing change
Ok to compress over most wound dressings

Change at home or only in clinic 
Condition of skin 
Vascular status- varying amts of compression 
Ambulation- calf muscle pump working? 
CHF?
Cost 
What has/hasn’t worked before? 
For wound healing or longterm maintenance/prevention?
221
Q

Clinical vascular exam

A

Palpation
Skin temp, pulses (can use Doppler)

Capillary refill

Rubor of dependency (loss of vasomotor control)

Claudication time

ABI

Venous filling time

222
Q

Long stretch

A

Stretches a long way (ACE wrap)
Wants to return to its resting state

Delivers constant compression-can feel tight at rest
Increased compression during calf contraction
Good for ambulatory and non-ambulatory

Apply with figure 8 or spiral technique- requires skill, difficult to self apply
Consistent tension and layering
Can telescope (injury/restricted blood flow)

Caution with use in AI
Reusable but stretches out quickly
Issues with inconsistent tension (self application at home)

223
Q

Low pressure lavage

A

Irrigation without suction

Jetox :
4-12 PSI
Uses wall O2 as pressure
Jet stream tip

224
Q

Bioburden

A

Number of organisms with which an object is contaminated

Possible high levels if:
Friable granulation
“Clean” wounds without improvement in 2 wks
MOI: laceration from trauma, war injury, torn wound…

225
Q

Standard precautions

A

Primary strategy for prevention of HAI

Combo of universal precautions and body substance

All blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes contain transmissible infectious agents

Hand hygiene, gloves, gowns, face shield/masks, eye protection

226
Q

MRSA

A

Methicillin-Resistant Staphylococcus Aureus

May result in abscess, osteomyelitis, cellulitis

Can result in death (young and healthy)
Rise in CA-MRSA

Can live on surfaces for a long time:
Polyester 40 days, 3-9 months on dental chairs in high humidity
Grocery cart handles, skin-to-skin contact
Personal items- plinths

227
Q

VI

Methods of compression

A 
Tubigrip 
Long stretch 
Short stretch 
In-Elastic 
Multilayer 
Stockings 
Garments
228
Q

Transmission precautions

A

Used when route of transmission is not covered by standard precautions alone

Used in addition to standard precautions

229
Q

Bite wounds

A

Can lead to serious infections (can develop rapidly)
Inoculation of oral (and skin) flora into body
Local infection, abscess, pain, loss of function

Use antiseptics and antimicrobial topicals

Check lymph nodes adjacent to injury

Follow up 24-48 hrs post injury

230
Q

Offloading

A

Reduce pressure, promote slow ambulation, facilitate “normal” gait as possible

TCC: total contact cast 
CROW: Charcot restraint orthotic walker 
Boots 
Half shoes and AFOs 
AD: FWW, SPC, crutches ok for some; WC as last resort
231
Q

Prerequisites for NPWT with Infection

A
  1. Pt. free of most systemic s/s of gross infection
  2. Necrotic tissue debrided
  3. Abscesses drained
  4. Adequate perfusion
  5. Can be combined with silver (Ag)
  6. Instillation (VAC) - Wound wash w/o removal of dressing (antibiotics, saline…)
232
Q

Wound fillers - NPWT

A

Black, white, green foam

Gauze and JP “Type” drain

Flat, simple, disposable “stick on” dressings

233
Q

VI wounds-

Surrounding skin

A

Hyperpigmentation
Hemosiderin staining

Lipodermatosclerosis
Scarring of skin/fat (fibrin deposition)
Results in hard, thickened, immobile skin
Can cause “champagne-bottle leg” : scarring can restrict fluid flow

Hypertrophic changes- thick/scaly epidermis
Breaks in skin = openings for bacteria = risk of cellulitis

Irritation from chronic : exposure to large amounts of drainage; dressings and constant compression

Varicose veins- common due to overloaded, backed-up system

234
Q

Contamination-Infection Continuum

A

Contamination->
Colonized ->
Critically colonized->
LocalSystemic (Infection)

235
Q

AI:

Wound care precautions and contraindications

A
  1. Moist dressings-
    NEVER on dry gangrene/eschar, careful at other times, depends on surgical candidacy

Unhealable AI Ulcers: tx all AI wounds this way until proven healable
Healable AI Ulcers: must have objective evidence of vascular status (ABI > 0.5)- consult with vascular MD
Expect slower progression

  1. Avoid adhesives - no tape to injure fragile skin
  2. PT role: identify, refer, protect, monitor, educate
    Wound care, exercise
    Treatment after re-vascularization/amp, team effort
236
Q

Common interventions for Diabetic Foot Ulcers (DFUs)

A

Aggressive Debridement and callus saucerization
Depends on vascular status
No debridement for stable heel ulcers

Moist wound environment

Offloading is key
Monitor closely for infection
Patient education is key
Glucose control is key

Silver (antimicrobial) dressings common
Growth factors

237
Q

Risk factors for abdominal dehiscence

A 
Advanced age 
Anemia 
Chronic pulmonary disease 
Infection 
Increased intra-abdominal pressure (obesity, ascites, coughing, etc)

Drains
Continuous draining of fluids to reduce edema/tension
Can be located anywhere
Different types- negative pressure bulb, tubing

238
Q

Whirlpool-

Contraindications

A 
Clean and granulating
Edematous, draining, macerated 
Active bleeding 
VI
Multi-wounds same area 
Uncontrolled seizures 
B and B issues
239
Q

Debridement- goals

A 
Conversion from chronic to acute 
Reduction in bacteria 
Improved environment for closure 
Prep for grafting or sx closure 
Tissue protection or exam (callus, blisters)

Check state practice act for debridement guidelines

240
Q

Wound - Location

A

Correct terminology to describe location
Be specific and consistent
Medial/Lateral, Left/Right, Proximal/Distal…

Body chart or drawings

Photos

Multiple wounds : assign numbers

241
Q

Infection

A

Microorganisms multiply and invade viable body tissues

242
Q

Alginate- cautions

A

Maceration if placed outside wound margins
For highly draining wounds
Wounds desiccation
Look “bad” when wet

243
Q

Wound bed preparation -

Healable

A

Address underlying cause

Move to “local wound care” or DIME

(Debridement, Inflammation/Infection, Moisture balance, Edge effect)

244
Q

Neuropathic ulcers :

Risk factors

A 
DM
Impaired healing 
Vascular disease 
Tri-neuropathy (sensory, motor, autonomic) 
Mechanical stress 
Impaired ROM
Foot deformities 
Previous ulcer or amputation
245
Q

Wound contraction

A

Proliferation

Myofibroblasts pull wound margins together

246
Q

Wound closure

Primary intention

A

Wound edges are approximated without/little formation of granulation tissue

Not typically seen by PT unless preparing for delayed primary closure

247
Q

Multi-layer

A

2-4 layers
More layers = higher levels of compression 30-40 mmHg
“On” during work or rest
If long stretch layer- can feel tight at rest

Specific layering technique and sequence
Allows for some adjustment
Profore, Profore Lite, 3M, etc

More expensive, more time for application
Adds padding/bulk for fragile skin, bony prominences, shoes, heat…

Long wear time- up to 1 week
Requires skilled application
Disposable single use

248
Q

Pressure injury interventions-

Prevention: Education

A

Patients, caregivers and healthcare workers

Daily skin checks (mirrors) 
Transfer techniques 
Position changes 
Incontinence mgmt :
Mild soap, pat dry, moisture barriers 
No diapers, talc based powders
249
Q

Inflammation-

Rubor

A

Well defined border, proportionate to size of wound

250
Q

VI wounds -

Location

A

Above malleoli in the Distal 1/3 of the lower leg (medial and lateral)

If outside this area, may not have VI etiology (unless mixed etiology)

251
Q

Critical colonization

A

Increasing number of bacteria becomes a bioburden

Adverse affects

252
Q

DIME-

D

A

Debridement

What tissues are present, safe to debride, type, frequency

253
Q

Inflammation-

Status

A

Normal phases of wound healing

254
Q

Debridement- indications

A

Red-Yellow-Black system

Red: typically granular wound - NO debridement bc want to protect it
Yellow: indicates non-viable tissue- MAY want to debride
Black: eschar- USUALLY want to debride

PT: non-viable tissue, callus, blister

(MD only: live tissue; large amounts of non-viable; infected tissue)

255
Q

AI - Wound characteristics

Tissue

A

Black/Brown eschar
Pale granulation tissue
Mixed

256
Q

Hydrocolloids

A

Highly occlusive
Promote autolytic Debridement

Highly adhesive

Sheets: various sizes, cut to fit, thick and thin
Paste: can be used for deeper wounds

Primary or 2ndary- usually primary

Cautions: maceration, skin damage w/ removal, edges can roll with friction,
Linked with hypergranulation

257
Q

7 tests for examining vascular status

A
  1. Visual inspection
  2. Palpation
  3. Capillary refill
  4. Rubor of dependency
  5. Venous filling time
  6. ABI (ankle brachial index)
  7. Claudication onset time
258
Q

Critically colonized wounds (___ criteria) require ___ dressings.

With deep and surrounding infections (___ criteria) most appropriately treated with ___.

A

> =3 NERDS : antimicrobial dressings

> = 3 STONEES criteria : systemic antimicrobial agents

259
Q

Enzymatic Debridement-

Contraindications

A

Timeframe- take too long

Not for deeper wounds:
Tracts, body cavities
Named tissues (organs, nn, vessels, tendons, bone, ligs)

Facial burns

260
Q

Airborne precautions

A

Prevent spread of disease that remain infectious over long distances

If possible patient s/b in airborne infection isolation room (aiir)
If not possible- private room, door closed until patient can be transferred to an aiir

N95 Respirator

261
Q

Bites: treatment

A

Short term use of antiseptics- if at risk for infection

Thorough irrigation- PLWS, syringe, catheter etc

Aggressive Debridement

Test sensation, monitor for s/s of infection- educate . 24 hr follow up

Medical mgmt - systemic complications: antibiotics, steroids, anti-inflammatories, anti-histamines

262
Q 
Systemic factors (wound healing)
Behavioral risk
A

Smoking

ETOH

263
Q

Treatment of pressure injuries-

Debridement

A

If needed, appropriate and consistent with goals

For LE, ensure adequate vascular supply for healing prior to Debridement

Do NOT debride dry stable eschar in ischemic limbs

264
Q

PLWS

A

Pulsed lavage with suction

Irrigation and suction
Creates negative pressure

265
Q

Cadexomer iodine-

Contraindications

A

Thyroid disease

Deep cavity wounds

266
Q

Pressure injury interventions-

Prevention: Incontinence

A 
Moisture barriers
Speedy gentle hygiene 
Incontinence pads 
Voiding/defacating schedule
NM re-re-education
Call light in reach
267
Q

4 factors affecting wound healing

A

General
Local
Systematic
Clinician

268
Q

AI interventions-

Prescriptive exercise

A

Walking or biking until onset of pain-rest-repeat. (Monitor vitals)

Better utilization of oxygen
Increased ability for work
Can encourage collateralization
Ischemia triggers collateralization

Progressive conditioning program
Walk until pain - rest - walk again
Progress to max tolerable pain before rest
Progress to 30-45 min w/o pain in 6-8 wks
(Patients typically won’t do on own bc pain)

269
Q

Cat bites

A

Tiny sharp teeth
Deep puncture wounds difficult to irrigate- higher rate of infection with puncture wounds

Consider opening with scalpel for easier cleaning- surgical consult

270
Q

Granulation tissue

A

Proliferation -> Maturation

Fibroblasts lay down extracellular matrix (eventually replaced by scar tissue)
->
Strengthened and reorganized (maturation)

271
Q

Pressure injury classification-

Stage III

A

Full thickness skin loss

Adipose is visible
Slough May be present
Undermining, tracts, and epibole possible

272
Q

Wagner grading scale

A

0 - No open lesions, May have deformity or cellulitis

1- superficial ulcer

2- deep ulcer to tendon, capsule or bone

3- deep ulcer with abscess, osteomyelitis or joint sepsis

4- localized gangrene
5- gangrene of entire foot

273
Q

Pressure injury classification-

Stage 1

A

Non-Blanchable erythema
Localized
Typically over bony prominence
Difficult to detect with dark pigmented skin

274
Q

Semipermeable film

A

Thin, flexible, multiple sizes, cut to size
Transparent, occlusive (promotes autolytic Debridement)
Barrier to outside world, can stay in place up to 7 days
Little absorption of used alone, can be combined with other dressings
Primary or 2ndary dressing
Usually for more superficial wounds- requires primary dressing for cavity/deep wounds
Highly conformable, adherent to periwound/surrounding skin

Cautions: limit wrinkles, applied w/o tension, difficult to apply, not waterproof, specific removal technique, damage skin w/ removal

275
Q

Infection-

Dolor

A

New onset or increased

276
Q

Must wash hands with soap and water when:

A

Hands visibly dirty
After using restroom
Leaving a pt/environment with C.diff infection

Rub soapy hands using friction at least 15 sec

277
Q

Spiral and figure 8

A

50% overlap
50% tension

Base of toes to just over gastroc (2 fingers at posterior knee)

Smooth, Minimize wrinkles

Graded/graduated compression
Ex: ankle ~30-40 mmHg, proximal calf ~18 mmHg

278
Q

Hydrogels

A

Donate moisture
Can absorb small amts of drainage
Decrease pain
Promote autolytic Debridement

Gel and sheet forms

Can be combined with other dressings
Silver power + hydrogel = silver gel
Regular gauze + saline + hydrogel = moist dressing
Mush into nu-gauze for easy wound filling- but adds moisture

Cautions: maceration, sheets not used on infected wounds

279
Q

Maturation

A

Granulation tissue must be strengthened and reorganized
Rapid collagen synthesis
Up to 2 years following wound closure (greatest in first 6-12 months)

80% full tissue strength
Unable to sweat- loss of sweat glands
Less sensitive to touch and temperature

280
Q

Venous ulcers

Treatment of cause

A

Bandages for healing

Stockings to prevent reoccurrence

281
Q

Periwound

A

Palpation: induration, fluctuance, general edema, increased temp…

Maceration (macerated), healthy, intact, Dey/peeling…

Skin: color, texture, dryness, hair, etc

Callus
Local s/s of Infection
Sensation
Circulation

282
Q

AI:

After Re-Vascularization/Amp

A

Ensure vascular status and monitor

Go after it- moist wound environment, Debridement

Amp: stump wrapping/shaping/prosthetics
ROM, positioning, STR, mobility, balance, offloading
Work with podiatrist for shoes etc

Edema control

283
Q

NPWT Indications

A

Acute and chronic
VI, pressure injuries, traumatic, surgical, burns
Mass casualty and high energy injuries (military)
Bone or tendon exposure - w/. Protection

Over grafts- w/ protection
Removes fluid, compresses, stabilizes/splints
Intermittent mode contraindicated

Over sutures- w/ protection; intermittent mode contraindicated

284
Q

Wound specific

Tests/Measures

A 
Location 
Size 
Wound bed (tissues) 
Wound edges 
Drainage 
Odor 
Periwound
285
Q

Palpation- vascular status

A

Temperature

Pulses- macrovascular exam:
BUE and BLE
Compare intensity (spot to spot)
Warm room, in supine (Posterior tib; Dorsalis Pedis absent up to 15%)

Edema- soft, pitting, fibrous, etc

286
Q

Wound bed-

Tract

A

Narrow passageway, tube like extension of wound

Documentation example:
Tract at 5 o’clock 7 cm

287
Q

Osteomyelitis

A

Infection of bone

Possible causes:
Should suspect when bone is “open to air”
DM- have it until proven otherwise

Sepsis- bacteria introduced into bone
Traumatic injury- increased bacteria
Chronic wound/infection- bacteria extends to bone

X-rat, bone scan….
Tx: removal, OV/oral antibiotics for weeks

288
Q

Irrigation-

Indications and contraindications

A

Indications: All types of wounds (unless contraindicated)
Perfect treatment for healing granular wound

Contraindications: 
1. Do NOT immerse soak: 
recent skin grafts, 
recent surgical incision sites, 
diabetic feet
  1. Active profuse bleeding wounds
  2. Dry gangrene
289
Q

Typical suture removal times

A 
Face 3-5
Scalp 7 
Chest, abdomen, extremities 7-10
Ear 10-14 
Back, foot 12-14

7-10 days is typical

290
Q

3 initial local wound care components that should be addressed in healable wounds

A

Debridement
Inflammation/Infection
Moisture balance

291
Q

Debridement- contraindications

A

Arterial comprise: stable, dry, hard eschar (remember “the heel is hard to heal”)

Viable tissue
Granular tissue
Electrical burns
Deeper tissues

292
Q

All chronic wounds should be classified as?

A

Healable
Non-healable
Or
Maintenance

293
Q

Adjustments to overall amount of graduated or graded compression:

A

Increase/Decrease tension
Change number of layers

Will change automatically based on girth
Ankle typically smaller than calf- so normally achieve graded compression with simple change in leg circumference
(Pad oddly shaped lower legs for “normal” conical shape)

Bandage width:
Smaller = Higher compression

Figure 8 wrap = 2x compression of spiral wrap

294
Q

Wound- Drainage

Sanguineous

A

Blood or drying blood

Red-dark brown, consistency of blood or slightly thickened water

295
Q

Short stretch

A

Stretches a short distance

Applied with consistent tension/spiral layering- sometimes >50% overlap
Can telescope- frequently rewarded 1-2x day

Can be used for most pt with AI unless compression contraindicated
Utilize ABI to determine safe levels
Good for mixed VI/AI ulcers

Delivers high compression during muscle contraction
Low compression during rest

296
Q

Proper shoe fit - without ulceration

A

Shape of shoe conforms to shape of foot

3/8 - 1/2 inch space between longest toe and end of shoe

Deep toe box allows toes to spread and toe clearance

Adjustable laces or straps for snug fit over instep

Fit snuggly around heel- ALWAYS wear socks

Closed toe.

297
Q

Venous filling time- vascular status

A

Supine, LE elevated 30-60*

Observe the veins drain out on top of foot (60 seconds)

Return to dependent position
Normal = 5-15 seconds
>=20 seconds indicates arterial disease

298
Q

Human bite wounds

A

3rd most common bite
(Dog, Cat are 1,2)
Can be worse than animal bites

Antibiotics and tetanus typical
High risk of infection: 10-20%
S/P 72 hrs and no s/s : hold antibiotics

Determine health of other person:
Hepatitis (higher transmission rate than HIV) 75% have detectable antigen in saliva
HIV (1 in 250 in US; 1 in 5 unaware) - not saliva alone

299
Q

Dog bites

A

Lacerations, punctures and crush
Rabies status, behavior, known dog, etc
Very low infection rate with tx 6-13%
Need to involve local health authorities

300
Q

NPWT- precautions (9)

A
  1. Anticoagulants, low platelet count
  2. Non-enteric and unexplored fistulas
  3. Over named structures- requires several layers of barrier dressing or white foam
  4. Monitor for bleeding
  5. Avoid circumferential occlusive sheeting application due to increased risk of ischemia
  6. Monitor skin condition when placed over bony prominences or hardware due to compression
  7. Sharp edges of bone s/b debrided prior to application to protect soft tissue
  8. MD notified of drainage in canister is sanguineous, fills w/in 1 hour, or if >2 canisters w/in 24 hrs
  9. AI (NOT for moderate/severe AI)
301
Q

Claudication onset time

A

Walk on treadmill, 1 mph, level grade

Record time to onset

Used for:
Developing a supervised progressive walking program
Tracking improved ambulatory endurance

302
Q

Angiogenesis

A

Proliferation

Formation of new blood vessels

303
Q 
Systemic factors (wound healing)
Age
A 
Slowed immune response 
Decreased collagen synthesis 
Epidermal and dermal atrophy (thinner skin) 
Less sweat and oil glands (drier skin)
Decreased pain perception 
Decreased inflammatory response

More comorbidities, susceptibility to infection, and more medications

304
Q

AI- Wound characteristics

Drainage

A

Minimal to none

Usually dry and hard

Integumentary Mgmt (1 decks)

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