Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Integ/Lymph > Ulcers/wound Dressings > Flashcards

Ulcers/wound Dressings Flashcards

1
Q

What is the presentation of an arterial ulcer?

A

-Anywhere on legs or dorsum of foot, toes, LATERAL MALLEOLOUS
-round, punched out, WELL DEFINED
-Color: white, pale, not granulating
-Appearance: shallow in early stages, skin thin, smooth, later has hair loss, dry, trophic changes, brittle nails
-Exudate: minimal, dry
-Pain: relieved in dependent position / very painful
-Pulse/temp: pulse indistinguishabintermittent claudication, cold to touch

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Presentation of a venous ulcer?

A

-ABOVE medial malleolus, distal LE
-size: shallow, large and irregular , dark pigmentation
-Color: ruddy red with granular tissue, discolored with yellow slogh, if its chronic it has hemosiderian stain, SCALY AND SHINY
-exudate: moderate to heavy/ wet
-pain: dull ache pain more related to venous HTN, comfortable with legs elevated
-Normal arterial pulses, warm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is stage 0 of the Wagner Scale?

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is stage 1 of the Wagner Scale?

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is stage 2 of the Wagner Scale?

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is stage 3 of the Wagner Scale?

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is 4 of the Wagner Scale?

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is stage 5 injury of the Wagner Scale?

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Diabetic ulcer presentation?

A

-Caused by loss of protective sensation, coordination
-associated with peripheral artery disease and peripheral neuropathy
-Occurs where arterial ulcers appear or neuropathy areas (Plantar aspect of foot - usually big toe)
-typically not painful 2’ sensory loss
-pulse may or may not be present
-infection, sepsis, gangrene may present

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What do we use transparent films for?

A

-Stage 1 and II pressure ulcer
-Is an adhesive
-For autolytic debridement
-Visual evaluation of wound without removal*****
-Impermeable to external fluids and bacteria

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What do we use hydrocolloid dressings for?

A

-Protection of partial thickness wounds
-Also used for autolytic debridement*** of necrosis or slough
-Used for MILD EXUDATE
-They are adhesive wafers containing absorptive particles that interact with wound fluid to make gelatinous mass over wound bed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are hydrogel dressings used for?

A

-Partial and full thickness, wounds with necrosis and slough, BURNS AND TISSUE DAMAGE BY RADIATION
(Remember colloids are used AFTER autolytic debridement of slough and necrosis)
-These are water or glycerine based gels
-Rehydrate dry wound beds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are foam dressings used for?

A

-Partial and full thickness wounds with MINIMAL TO MOD EXUDATE
-Secondary dressing for wounds with packing to provide absorption
-Made of semipermeable membranes that are hydrophobic
-Insulate wounds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are alginate dressings used for?

A

-Wounds with mod- large amounts of exudate
-Wounds with combination exudate and necrosis, that require packing and absorption
-Infected and noninfected exuding wounds
-Soft, absorbent, nonwoven dressings from seaweed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

When is gauze used for dressing?

A

-Exudateive wounds, wounds with dead space, tunneling or sinus tracts, exudate or necrotic tissue
-Wet to dry: mechanical debridement of necrotic tissue and slough
-Continuous dry: heavily exudating wounds
-Continuous moist: protection of clean wounds, autolytic debridement of slough or eschar, delivery of topical needs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is stage I pressure ulcer?

A

-Non-blancheable erythema of intact skin (redness, irritation) EPIDERMIS
-May include changes in skin temperature, tissue consistency and sensation
-Redness may not be visible in darker skin (dark blue/purple print)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is stage II pressure injury?

A

-Partial-thickness skin loss
-Epidermis, dermis or both
-Ulcer is superficial and presents as an abrasion, blister, or shallow crater

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Stage III pressure injury?

A

-Full-thickness skin loss
-Involves damage to or necrosis of subcutaneous tissue
-May extend to underlying fascia but not through
-Presents as a deep crater

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is a stage IV pressure injury?

A

-Full thickness skin loss (MUSCLE, BONE, TENDONS)
-Undermining and sinus tracts may be present

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What is an unstageable ulcer?

A

Tissue depth is obscured due to slough or eschar and extent of damage cannot be determined

21
Q

What is the stage of “deep tissue injury” for a pressure ulcer?

A

Discolored area of tissue that is not reversible and will likely progress to a full thickness injury

22
Q

What is autolytic debridement?

A

-SELECTIVE method of natural debridement promoted under occlusive or semi occlusive moisture retentive dressing that results in solubilization of necrotic tissue -Uses the body’s own enzymes and moisture beneath dressing
-Hydrocolloids, hydrogels and transparent films
-Promotes fast healing time with less pain **

23
Q

What are the indications for autolytic debridement?

A

-Individuals on anticoagulant therapy
-Individuals who cannot tolerate other foams
-ALL NECROTIC WOUNDS in people medically stable

24
Q

What are the contraindications for autolytic debridement?

A

-infection
-immunosuppressed individuals
-Dry gangrene or dry ischemic wounds

25
Q

What is enzymatic debridement?

A

A SELECTIVE method of chemical debridement that promotes liquefaction of necrotic tissue by applying topical preparation of collagenolytic enzymes to those tissues
-Involves the application of a topical agent that liquefies necrotic tissue

26
Q

What are the indications for enzymatic debridement?

A

-All moist necrotic wounds
-Eschar after cross-hatching
-homebound individuals
-People who cannot tolerate surgical debridement

27
Q

What are the contraindications of enzymatic debridement?

A

-Ischemic wounds unless adequate vascular status has been determined
- Dry gangrene
-Clean granulated wounds

28
Q

What is mechanical debridement?

A

NONSELECTIVE method of debridement that removes foreign material and devitalized or contaminated tissue by physical forces (Wet to dry gauze, dextranomers, pulsation lavage with suction)
-involves irrigation/wet to dry dressings

29
Q

What are the indications for mechanical debridement?

A

Wounds with moist necrotic tissue or foreign material present

30
Q

What are the contraindications for mechanical debridement?

A

Clean, granulated wounds

31
Q

What is sharp debridement?

A

-SELECTIVE method of debridement using sterile instruments (scissors, scalpel, forces, silver nitrate stick) that removes the necrotic wound without anesthesia and little bleeding

32
Q

What are the indications for sharp debridement?

A

-Scoring/excision of leathery eschar
-Excision of moist necrotic tissue
-Biofilm removal

33
Q

What are the contraindications for sharp debridement?

A

-Clean wounds
-Advancing cellulitis with sepsis
-Individuals on anticoagulants

34
Q

What is surgical debridement?

A

For deep (stage III or IV) or complicated pressure ulcer
-most efficient method of debridement
-SELECTIVE and performed by physician or surgeon with sterile instruments (scissors, scalpel, forceps, etc…)
-The individual may require anesthesia for pain

35
Q

What are the indications for surgical debridement?

A

-Advancing cellulitis with sepsis
-Immunocompromised individuals
-When infection threatens the individuals life
-Granulation and scar tissue may be excised
-Biofilm removal

36
Q

What are the contraindications for surgical debridement?

A

Cardiac disease, pulmonary disease, diabetes, severe spasticity, individuals who cannot tolerate surgery, individuals with a short life expectancy, QOL cannot be improved

37
Q

What is biological debridement?

A

-use of maggots grown in a sterile environment to debridement nonviable tissue. They produce enzymes and phagocytize necrotic tissue and bacteria (MRSA). They may stimulate granulation formation and epithelialization

38
Q

What are the indications for biological debridement?

A

-rarely used
-Individuals who cannot tolerate other forms of debridement
-All non-healing necrotic wounds in people who are medically stable

39
Q

What are the contraindications for biological debridement?

A

-Psychological stress arises from having living creatures in wounds
-Reports of pain increasing
-poor perfusion or exposed blood vessels

40
Q

What does >1.2 indicate for ABI?

A

Falsely elevated, calcified

41
Q

What does 0.95-1.19 indicate for ABI?

A

NORMAL

42
Q

What does 0.75-0.94 indicate for ABI?

A

Mild, intermittent claudication

43
Q

What does 0.50-0.74 indicate on the ABI scale?

A

Mod, pain at rest

44
Q

What does <0.5 indicate for ABI?

A

Severe arterial disease

45
Q

What is a grade I on the subjective ratings of p! With intermittent claudication?

A

Minimal discomfort or pain

46
Q

What is a grade II on the subjective ratings of p! With intermittent claudication?

A

Moderate discomfort or pain; patients attention can be diverted

47
Q

What is a grade III on the subjective ratings of p! With intermittent claudication?

A

Intense pain; patients attention cannot be diverted

48
Q

What is a grade IV on the subjective ratings of p! With intermittent claudication?

A

Excruciating or unbearable pain

Integ/Lymph (3 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions