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Integumentary > Week 1 > Flashcards

Week 1 Flashcards

1
Q

What are the phases of wound healing?

A
  • Inflammation
  • Proliferation
  • Maturation/re-modeling
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2
Q

What are the types of responses we get in the inflammation phase of healing?

A
  • Vascular response

- Cellular response

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3
Q

What is the goal of the vascular response of the inflammation phase of healing?

A

Control bleeding, fight infectious agents

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4
Q

What are the events that occur during the vascular response of the inflammation phase of healing?

A
  • 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 minutes of vasoconstriction, vasodilation occurs: localized redness, warmth, edema
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5
Q

What are the cardinal signs of the vascular response of the inflammation phase of healing?

A

Edema, redness, warmth, pain, decreased function

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6
Q

What are the events that occur during the cellular response of the inflammation phase of healing?

A

• Increased leakiness of vessel walls: pushes polymorphonuclearneutrophils (PMNs) to sides of vessel walls
(Margination)
- PMNs: 1st to site of injury (12-24 hours), kill bacteria, clean
wound, secrete matrix metalloproteases (MMPs)- degrade debris
• Macrophages arrive: kill pathogens, direct the repair process
• Mast cells: produce histamine and secrete enzymes to accelerate
riddance of damaged cells

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7
Q

What are the key cells present in the cellular response of the inflammation phase of healing?

A
  • Platelets
  • PMNs
  • Macrophages
  • Mast cells
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8
Q

What are the events that occur during the proliferation phase of healing?

A

• Angiogenesis- formation of new blood vessels
• Granulation tissue- Fibroblasts lay down extracellular matrix
(eventually replaced by scar tissue)
• Wound Contraction – myofibroblasts pull wound margins
together
• Epithelialization- keratinocytes and epidermal appendages
multiply and migrate across wound bed

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9
Q

What are the key cells present in the proliferation phase of healing?

A
  • Angioblast
  • Fibroblast
  • Myofibroblast
  • Keratinocyte
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10
Q

What are the events that occur during the maturation phase of healing?

A

• Granulation tissue must be strengthened and reorganized
• Rapid collagen synthesis
• Up to 2 years following wound closure
- Greatest change in first 6-12 months
• 80% of full tissue strength
• Unable to sweat- loss of sweat glands
• Less sensitive to touch and temperature

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11
Q

What are the type of factors that can affect wound healing?

A
  • General
  • Local
  • Clinician
  • Systemic
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12
Q

What are the general factors that can affect 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 degrees C is best)
• Wound Hydration
• Necrotic tissue
• Infection
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13
Q

What are the local factors that can affect wound healing?

A
  • Circulation
  • Sensation
  • Mechanical Stress
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14
Q

What are the circulation local factors that can affect wound healing?

A
  • Macro(checking pulses) and Micro

* Sympathetic nervous system responses to: cold, fear, and pain

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15
Q

What are the sensation local factors that can affect wound healing?

A
  • Decreased knowledge of pain

* Additional trauma to area

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16
Q

What are the mechanical stress local factors that can affect wound healing?

A
  • Friction
  • Shear
  • Weight bearing
  • Pressure
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17
Q

What are the systemic factors that can affect wound healing?

A
  • Age: normal physiologic changes
  • Nutrition
  • Comorbidities
  • Medications
  • Behavioral Risk Taking
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18
Q

What are the “age” systemic factors that can affect wound healing?

A
  • Slowed immune response
  • Decreased collagen synthesis
  • Epidermal and dermal atrophy (thinner skin)
  • Less sweat and oil glands (dryer skin)
  • Decreased pain perception
  • Decreased inflammatory response
  • More co-morbidities
  • More susceptible to infection
  • More medications
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19
Q

What are the “nutrition” systemic factors that can affect wound healing?

A
  • Carbohydrates for energy

* Protein for cellular repair/regeneration (most imp)

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20
Q

What are the “comorbidities” systemic factors that can affect wound healing?

A 
• Those affecting O2 perfusion
  - PVD, anemia, COPD, heart conditions
• Immunocompromised
  - HIV/AIDS, diabetes
• Activity limitations
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21
Q

What are the “medications” systemic factors that can affect wound healing?

A
  • Steroids
  • Chemotherapy
  • NSAIDS
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22
Q

What are the “behavioral risk taking” systemic factors that can affect wound healing?

A
  • Smoking

* ETOH

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23
Q

What are the clinician induced factors that can affect wound healing?

A
  • Inappropriate Wound Care

* Appropriate Wound Care

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24
Q

What are the “inappropriate wound care” clinician induced factors that can affect wound healing?

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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25
Q

What are the “appropriate wound care” clinician induced factors that can affect wound healing?

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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26
Q

What are the types of wound closure?

A
  • Primary (Primary Intention)

* Secondary (Secondary Intention)

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27
Q

What are the events of primary wound closure?

A
  • Wound edges are approximated without/little formation of granulation tissue.
  • Not typically seen by PT unless preparing for delayed primary closure
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28
Q

What are the events of secondary wound closure?

A
  • Wound edges unable to be approximated
  • Granulation tissue fills in wound bed
  • PT more likely to be involved
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29
Q

What are the benefits of 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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30
Q

What is one of the major roles of the PT in wound healing?

A

Wound Bed Preparation

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31
Q

When does the PT perform wound bed preparation?

A

After comprehensive examination : Assessment

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32
Q

What are the events that occur in the assessment of a wound?

A

• Determine the ability of the 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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33
Q

What should be done if a wound falls into the “healable” assessment of a wound?

A 
• Address underlying cause
• Move to “local wound care” or DIME
 - Debridement
 - Inflammation/infection
 - Moisture balance
 - Edge effect
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34
Q

What is DIME used for?

A

Use to determine approach to local wound care & wound assessment
– If you have no idea where to start, start here!

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35
Q

What are the components of “debridement” in DIME?

A

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

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36
Q

What are the components of “inflammation/infection” in DIME?

A

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

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37
Q

What are the components of “moisture balance” in DIME?

A

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

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38
Q

What are the components of “edge effect” in DIME?

A

Progressing, stalled/rolled, callus, clean

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39
Q

Where is patient history gathered from?

A

From patient, medical record, family, caregivers etc.

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40
Q

What are the components included in the patient history?

A
  • General Demographics
  • Lifestyle and Functional Status
  • Past and Current Medical History
  • Past and Current Wound History
  • Systems Review
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41
Q

What is included in the general demographics portion of the patient history?

A
  • Age
  • Sex
  • Ethnicity
  • Primary language
  • Education
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42
Q

What is included in the lifestyle and functional status portion of the patient history?

A
  • Living environment
  • Prior and current level of function
  • Employment
  • Health habits (smoking, ETOH, nutrition, sleep, stress)
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43
Q

What is included in the past and current medical history portion of the patient history?

A
  • All the usual information collected (Review of systems)
  • Medications
  • Allergies
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44
Q

What is included in the past and current wound history portion of the patient history?

A
  • Acute or Chronic (How long has the wound been present? When and how did you get the wound?)
  • Has the patient had any tests run (labs, wound cultures, vascular studies, radiologic studies)?
  • Has the wound improved or is it getting worse?
  • Pain
  • Other wounds in the past
  • Dressing being used and when last changed
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45
Q

What are the wound specific tests and measures?

A
  • Location
  • Size
  • Wound bed (Tissues)
  • Wound edges
  • Drainage
  • Odor
  • Periwound
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46
Q

How do we use the location of a wound as a test and measure for the wound?

A

• Correct terminology to describe location
- Be specific & consistent
- Medial/lateral, left/right, proximal/distal, etc.
• Body chart or drawings
• Photos
• Multiple wounds
- Assign numbers

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47
Q

How do we use the size of a wound as a test and measure for the wound?

A

Direct measurement (in cm)
• Length (longest)
• Width (perpendicular to length)
• Depth (deepest)
Clock Method: 12-o’clock in area of wound closest to head, but
can be assigned a different position by clinician
• Length (12-6)
• Width (9-3)
• Depth (various clock positions, 2,4,8,10, or others)

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48
Q

How do we use the wound bed as a test and measure for the wound?

A

Tissue Identification- Describe in percentages present

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49
Q

What are the types of tissue that can be present in a wound bed?

A

• Granulation tissue
• Necrotic or non-viable
• Fascia, adipose, muscle, tendon, joint capsule, bone, new
epithelium

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50
Q

What is the granulation tissue that can be present in a wound bed?

A

Temporary scaffolding of vascularized connective tissue; healthy granulation is bright beefy red; if pale or dusky, blood supply may be poor or may be infected.

This is the type of tissue we want

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51
Q

What is the necrotic or non-viable tissue that can be present in a wound bed?

A
  • Slough- yellow or tan, stringy or mucinous

* Eschar- black necrotic tissue, soft or hard, wet or dry, adherent or nonadherent to the wound bed

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52
Q

What is undermining?

A

When the - tissue under wound edge is gone, similar to a cave under the skin, “waggle room”
• Documentation example: undermining of 4 cm from 10-12 o’clock

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53
Q

What is a tract?

A

Narrow passageway, tube like extension of wound

• Documentation example: Tract at 5 o’clock 7 cm.

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54
Q

What is a tunnel?

A

Entrance and exit

• Document location and length

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55
Q

What are the ways that a wound edge can be?

A
  • Well defined (demarcated) or defuse
  • Thick or thin
  • Attached to wound base(preferred) or raised or rolled (epibole: new epithelium is rolling over itself, requires surgery to correct)
  • Color
  • Evidence of epithelialization
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56
Q

How is the drainage of a wound described?

A

Type, Color, Consistency, Amount

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57
Q

What are the characteristics of serous drainage seen on a wound?

A
  • Protein rich fluid with white blood cells

* Clear-pale yellow, watery

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58
Q

What are the characteristics of sanguineous drainage seen on a wound?

A
  • Blood or drying blood

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

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59
Q

What are the characteristics of purulent drainage seen on a wound?

A
  • Indicator of infection

* White-pale yellow, viscous or creamy consistency

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60
Q

What are the characteristics of the amount drainage seen on a wound?

A

None, minimal, moderate, copious

• Must consider dressing used and when last changed

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61
Q

When is the odor of a wound assessed?

A

Assessed after irrigation

• Present or absent

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62
Q

What causes the odor of a wound?

A
  • Wound infection
  • Non-viable tissue
  • Old dressing
  • Hot weather
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63
Q

What are the components that needs to be assessed in a periwound?

A

• Palpation - induration, fluctuance, general edema, increased
temp, etc.
• Maceration (macerated), healthy, intact, dry/peeling, etc.
• Skin: color, texture, dryness, hair, etc.
• Callus
• Local signs & symptoms of infection
• Sensation
• Circulation

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64
Q

What are healthcare-associated Infections (HAI)?

A

Infections patient get while receiving treatment for medical or surgical conditions

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65
Q

What are the most common healthcare-associated Infections (HAI)?

A
  • Central line-associated bloodstream infections
  • Catheter-associated urinary tract infections
  • Surgical site infections
  • Ventilator-associated pneumonia
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66
Q

_____ is key towards healthcare-associated Infections (HAI)

A

Prevention is key towards healthcare-associated Infections (HAI)

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67
Q

What are the ways to prevent healthcare-associated Infections (HAI)?

A
  • Wash hands

* Prevent contamination from one patient to the next

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68
Q

The opportunities for handwashing are before and after what…?

A
  • Wearing Gloves
  • Patient Contact
  • Any Patient Procedure
  • Environmental or equipment contact
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69
Q

What is the procedure for washing with soap and water?

A

• Thoroughly wet hands with warm water
• Apply soap and rub hands together using friction for at least 15 seconds
• Be sure to wash backs of hands, between fingers, fingertips, and around
jewelry
• Rinse hands with warm water being sure to avoid splashing and with your hands pointed in a downward direction
• Dry with paper towel and then use paper towel to turn water faucet off

70
Q

When must the hands be washed with soap and water?

A
  • Hands are visibly dirty
  • After using the restroom
  • Leaving a patient/environment with Clostridium difficile (C. diff) infection
71
Q

When can alcohol hand rub be used?

A

Use when hands are NOT visibly soiled

72
Q

What is the procedure for washing with alcohol?

A
  • Get enough product to saturate all parts of your hands
  • Rub hands together for 15 seconds
  • Allow product to dry
73
Q

What are the items included in a Personal Protective Equipment (PPE)?

A
  • Gloves
  • Gown
  • Mask
  • Glasses
  • Face shield
  • Shoe Covers
74
Q

Who provides PPE for employees?

A

OSHA requires employers

to provide PPE for employees

75
Q

What are standard precautions used for?

A
  • All patients, all settings
  • Primary strategy for prevention of HAI
  • Protect you and the patient
76
Q

What are transmission precautions used for?

A
  • Contact
  • Airborne
  • Droplet
77
Q

What is a standard precaution?

A

A combination of universal precautions and body substance isolation

78
Q

What do all standard precautions assume?

A

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

79
Q

What does a standard precaution include based on anticipated exposure?

A
  • Hand hygiene
  • Gloves
  • Gowns
  • Face shields/masks
  • Eye protection
80
Q

When are transmission precautions used?

A
  • Used when route of transmission is not covered by standard precautions alone
  • Always used in addition to standard precautions
  • More than one can be combined for those agents that have multiple modes of transmission
81
Q

What are contact precautions used for?

A

• Prevent transmission of infectious agents that are spread by direct or indirect contact with the patient, equipment, patient’s
belongings, or patient’s surface environment
• Also used when environmental contamination from excessive
wound drainage, fecal incontinence, and other body discharges may be present
• Private rooms should be utilized if available or at minimum >/ 3 feet of separation b/w beds to avoid sharing of equipment and touching of surfaces

82
Q

What is the common mode of infection transmission?

A

Contact

83
Q

What are the PPEs used during a contact precaution?

A
  • Gloves

* Gown

84
Q

What are the contact precautions?

A
  • Wash hand before entry
  • Don after entry into the room
  • Doff before exiting the room
  • Wash hands after exiting room
85
Q

What are the common infectious diseases requiring contact precautions?

A

• MDROs (Multi-drug resistant organisms)
- MRSA- Methicillian-resistant Staphylococcus Aureus
- VRE- Vancomycin-resistant Enterococci
• CRE – Carbapenem-resistant Enterbacteriaceae
• Ebola
• C. difficile
• Norovirus
• RSV
• Rotavirus
• Herpes Zoster (Shingles)- in some cases
• Scabies

86
Q

What are droplet precautions used for?

A

• Prevent spread of infectious agents 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

87
Q

What are the PPEs used in a droplet precaution?

A

Mask on healthcare provider or on patient if transport
outside of the room necessary
• Don upon entry , Doff before exit

88
Q

What are the common infectious disease needing droplet precautions?

A 
• Ebola
• Pertussis (Whooping Cough)
• Influenza
• Rhinovirus
• Pneumonia
  - Adenovirus
• Streptococcus Group A
• Rubella
89
Q

What are airborne precautions used for?

A

Prevent spread of disease that remain infectious over long

distances

90
Q

What are the room precaution used for airborne precautions?

A

If possible pt. should be placed in an airborne infection isolation room (air)
• Negative pressure relative to the surrounding area
- Patient room with an ante room. Both doors are kept closed . When pt. room door is opened the air is sucked into the room rather than escaping out of the patient room.
• If not possible, private room, door closed until patient can be
transferred to an air

91
Q

What are the PPEs used in a airborne precaution?

A

Respirator (N95)
• Must be fit tested
• Don in ante room prior to entering patient room
• Doff in ante room after patient door is closed

92
Q

What are the common infectious disease needing airborne precautions?

A
  • Tuberculosis
  • Measles
  • Chickenpox
  • Smallpox
93
Q

OSHA requires ____ or all chemicals and substances used in work facilities

A

OSHA requires Safety Data Sheets (SDS) for all chemicals and substances used in work facilities

These were formerly known as Material Safety Data Sheets
(MSDS)

94
Q

What information is included in the Safety Data Sheets (SDS)?

A
  • Product, manufacturer, distributor
  • Hazards of the chemical
  • Ingredients
  • First aid measures
  • Handling and storage
  • Protection required
  • And more!
95
Q

What are some additional safety tips used for infection control?

A

• Always dispose of sharps in a sharps container
- Never recap a needle or scalpel
- Never take a sharp out of a sharps container
• Do not blind sweep bed linens
• Protect breaks in the skin
• Do not eat, drink, handle contact lenses, apply cosmetics or lip balm in patient care areas
• Use mouthpieces, resuscitation bags, and ventilation devices for CPR

96
Q

What is wound irrigation?

A

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

97
Q

What are the functions of wound irrigation?

A
  • Facilitate debridement
  • Maintain moist wound environment
  • Enhance wound healing
98
Q

What are the indications for wound irrigation?

A
  • All types of wounds with a few exceptions

* Perfect treatment for a healing granular wound

99
Q

What are the contraindications for wound irrigation?

A 
• Do not immerse/soak
  - Recent skin grafts
  - Recent surgical incision sites
  - Diabetic feet
• Active profuse bleeding wounds
• Dry Gangrene
100
Q

What are the different types of irrigation solutions used?

A
  • Normal saline (0.9% sodium chloride)
  • Sterile water
  • Tap water
  • Wound Cleansers
101
Q

What are the characteristics of normal saline irrigation solution?

A

• Can be made at home
• Refrigerate but warm before use
- Wounds heal best when kept under warm conditions

102
Q

What are the characteristics of sterile water irrigation solution?

A

Must use with silver dressings

103
Q

What are the characteristics of tap water irrigation solution?

A

Caution with the immunocompromised

104
Q

What are the characteristics of wound cleansers irrigation solution?

A
  • Shur-Clens® - surfactant (oil, grease)
  • Vashe® - hypochlorous acid – antimicrobial, Rx
  • Wound Wash
105
Q

What are the characteristics of other irrigation solutions?

A

Antiseptics- use cautiously
• Acetic Acid: Pseudomonas
• Chlorhexidine gluconate (Hibiclens): intact skin, surgical scrub
• Dakin’s solution (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

106
Q

What are the different types of irrigation?

A
  • Gentle irrigation and rinsing
  • Safe and effective psi
  • Low pressure capsules
  • psi 4-8 max 10
107
Q

What are the types of debridement, deep cleaning, tissue stimulation used for irrigation?

A 
• Low pressure lavage
• Whirlpool (WP)
• Pulsed lavage with suction
  - PLWS
  - “Pulsatile lavage”
108
Q

What are the characteristics of low pressure lavage?

A 
• Irrigation without suction
• Jetox
  - 4-12 psi
  - Uses Wall O2 as pressure
  - Jet stream tip
109
Q

What are the positives of a whirlpool?

A
  • Cleanses
  • Agitation
  • Additives
  • Temperature range
  • Tx large areas
  • Exercise
110
Q

What are the negatives of a whirlpool?

A 
• Risk of infection
  - Sterility
  - Aerosolization
• Risk of tissue injury
  - psi?
  - maceration
• Additives
• Expense
  - Cleaning, space, water
111
Q

What are the contraindication of a whirlpool?

A
  • Clean & granulating
  • Edematous, draining, macerated
  • Active bleeding
  • VI
  • Multi-wounds same area
  • Uncontrolled seizures
  • B&B issues
112
Q

What is a Pulsed Lavage with Suction (PLWS)?

A

Irrigation with Suction
• Pulsed jets of irrigation with suction
• Creates a negative pressure

113
Q

What are the positives of a Pulsed Lavage with Suction (PLWS)?

A 
• Cleaning
• Known psi
• Sterile, no additives
• Temperature range
• Site specific
• Portable
• Disposable – easy
cleanup
• Few contraindications
114
Q

What are the negatives of a Pulsed Lavage with Suction (PLWS)?

A

• Expense
• Aerosolization risk
- Confined space
- Cover horizontal surfaces

115
Q

What are the contraindications of a Pulsed Lavage with Suction (PLWS)?

A
  • Exposed named tissues
  • Body Cavities
  • Facial wounds
  • Recent grafts or surgical procedures
  • Actively bleeding
116
Q

What are the purposes of wound debridement?

A
  • Decrease bioburden & risk of infection
  • Increase effectiveness of topicals
  • Improve bactericidal activity of leukocytes
  • Shorten inflammatory phase
  • Decrease energy required by the body to heal
  • Eliminate physical barriers
  • Decrease wound odor
117
Q

What are the goals of debridement?

A 
• Conversion from chronic to acute
• Reduction in bacteria
• Improved environment for closure
• Prep for grafting or surgical closure
• Tissue protection or exam
  - Callus, blisters
118
Q

What are the contraindications for debridement?

A 
• Arterial compromise
  - Stable, dry, hard eschar
• Others:
  - Viable tissue
  - Granular tissue
  - Electrical burns
  - Deeper tissues
119
Q

What are the indications for debridement?

A

The color of the wound:
• Red (granulation, do not debride)
• Yellow (likely pus- debride)
• Black (debride, depending on location and other factors)

120
Q

What kind of tissue can the PT debride?

A

Non-viable tissue, callus, blister

121
Q

What are the type of tissues that a PT can NOT debride and has to be done by a physician?

A

Live Tissue

  • Large amount of non-viable
  • Infection
122
Q

What are the things to consider when deciding whether or not to debride a wound?

A 
• Urgency
• Resources
• Skill
• Wound etiology
• Health status of pt
  - Medications
  - Mobility
  - Nutrition
• Consistent with pt goals
123
Q

What are the methods of debridement?

A 
• Sharp (MDs, PTs, PTAs, Nrsg)
• Mechanical
• Enzymatic
• Autolytic
• Biologic
• Surgical (MDs)
  - Named structures, large stage III and IV pressure injuries, significant undermining, tunneling, or sinus tracts, epibole
124
Q

What are the characteristics of the sharp method of debridement?

A 
• Fast
• Aggressive
  - high level of skill
• Painful occasionally
• Often combined w/other forms
• We need specific MD order 
• Selective(targeting non viable tissue) - forceps, scissors, scalpel, curette
125
Q

What are the different instruments used for the sharp method of debridement?

A
  • Forceps (held in non dominant hand)
  • Scissors: Blunt mayo, or iris scissors (held in dominant hand)
  • Common scapels (#10 blade, #11 blade, #15 blade)
  • Curettes (3mm & 7mm)
126
Q

What are the indications for sharp debridement?

A

Presence of nonviable tissue/callus
• Amount of nonviable tissue rendering other methods too slow (infection or risk)
• Advancing cellulitis

127
Q

What are the precautions to take for sharp debridement?

A
  • Anticoagulants/clotting issues, pain
  • Immunosuppression
  • Unable to be still
128
Q

What are the contraindications sharp debridement?

A
  • PT comfort/skill level
  • Cannot see (tracts, etc.) or identify tissue
  • Consent, not consistent w/POC
  • Ischemic ulcers (AI)
  • Hypergranulation – live tissue
  • Pyoderma gangrenosum
129
Q

What are the warning signs to stop sharp debridement?

A
  • Pt request, pain control issues
  • Wound is clean
  • You get nervous, tired, unsure
  • Impending exposure of named structures
  • Holes you cannot see the bottom of
  • Unexpected infection/purulence
  • Extensive undermining
  • Excessive bleeding
130
Q

True or False

When you see slight bleeding during sharp debridement, stop immediately

A

False

May have slight bleeding – connected to live tissue

131
Q

How do you control bleeding during sharp debridement?

A
  • Elevate, pressure x 10 min, silver nitrate (MD)

* If structure pulsates, do not cut it!

132
Q

What can you do to help monitor pain control during sharp debridement?

A

Meds 30 min prior, topicals, deep breathing, music, distraction, etc

133
Q

When do we contact the MD during sharp debridement?

A
  • 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
134
Q

What is the technique for sharp debridement?

A
  • Hold scalpel/scissors in the dominant hand and forceps in non dominant hand
  • Cut parallel to plane of wound tissue
  • Remove tissue in thin layers (small slices)
  • Can sometimes use a “scrape” technique Take your time, if unsure/tired, etc.
  • Lift necrotic tissue w/forceps
  • Avoid sawing
135
Q

What are some tips to do when doing sharp debridement?

A
  • Nonviable tissue doesn’t bleed, but is attached to viable
  • Opens direct pathway to pt’s vascular system = Increased risk of infection
  • Good to take pics before & after
  • Warn pts wound will be deeper/bigger
136
Q

What are the indications to debride a blister?

A
  • Larger than nickel
  • Area likely to rupture or tear
  • Worried about possible tissue injury – burns
  • Common sense
  • Great medium for bacterial growth
137
Q

What is the technique to debride a blister?

A
  • Secure w/forceps
  • Release tension carefully – can be high
  • Skin/blister line
  • Clean away residue, can appear like jelly
138
Q

What are the criterias used to determine the form of debridement to chose for a patient?

A
  • Use common sense
  • What will work best for this patient?
  • What can they tolerate?
  • Will they need to do this at home?
  • Safety concerns
  • Cost
  • Risks? (speed of removal, etc.)
  • Combo?
  • Is this something I can handle?
139
Q

What are the characteristics of ultrasound based debridement?

A

Low-frequency contact US (kilohertz)
• Tissue vibration (unstable cavitation)
• Sonoca 180® (Soring Medical Technology)
• Qoustic Wnd Therapy System™ (Arobella Medical
LLCArobella)
• SonicOne® (Misonix, Inc)
• Antimicrobial effects as well

140
Q

What are the indications for surgical debridement?

A
  • Complexity of wound
  • Gross infection or high risk of infection
  • When amount of nonviable tissue is too much within acceptable timeframe
  • Extensive undermining
  • Unknown depth or abscess
  • Involves fistula
  • Named structures
  • Bleeding tendency, extreme pain, or trauma
141
Q

What are the contraindications for biosurgical debridement?

A
  • Near the eyes, upper GI or upper respiratory tract
  • Allergy: fly larvae, brewer’s yeast, soy
  • Exposed blood vessels connecting to deep vital organs
  • Decreased perfusion
  • Malignant wounds
142
Q

What are the precautions for biosurgical debridement?

A
  • Drown in heavy exudate, squished by pressure

* Pts with bleeding disorders

143
Q

What type of debridement is mechanical debridement?

A

Nonselective: meaning that it doesn’t discriminate between non-viable or viable tissue

144
Q

What are the types of mechanical debridement?

A
  • Soft abrasion
  • Hydrotherapy (WP: whirlpool, PLWS)
  • Wet to dry or wet to moist (only indicated for 100% nonviable wound)
  • Low frequency contact ultrasound
145
Q

What are the characteristics of mechanical debridement?

A
  • Can be painful
  • Can be effective if used correctly
  • Familiar to health care workers
146
Q

What type of debridement is enzymatic debridement?

A

Selective: targets only nonviable wounds

147
Q

What enzyme is used for enzymatic debridement?

A

Collagenase Santyl

148
Q

What are the characteristics of enzymatic debridement?

A 
• Physician prescription
• Pain free – some say 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
149
Q

How does enzymatic debridement work?

A
  • Denatured collagen filaments anchor debris to the wound bed.
  • Collagenase digests these collagen filaments
150
Q

Do not use enzymatic debridement with dressing containing ___?

A
  • Silver
  • Iodine
  • Hydrogen Peroxide
  • Acetic Acid
151
Q

What are the parameters to the use of enzymatic debridement?

A

• Discontinue when “clean”
- Can promote cell migration
• Application: thickness of a nickel, must be kept moist
• cover w/saline moist gauze, Adaptic, hydrogel, etc.
• If not “clean” in 2 wks, switch to other method
• Frequently used for burns, except on face
• May take longer if used alone (combo)

152
Q

What are the adverse effects that may bee seen in enzymatic debridement?

A

• Burning/stinging, allergic reaction
• Peri-wound irritation
- Highly exudative wounds, contact w/skin

153
Q

What are the contraindications of enzymatic debridement?

A 
• Timeframe – take too long
• Not for deeper wounds:
  - Tracts, body cavities
  - Named tissues (organs, nn, vessels, tendon, bone, ligs)
• Facial burns
154
Q

What type of debridement is autolytic debridement?

A

Selective: allows the body to get rid of non viable tissue

155
Q

What are the characteristics of autolytic debridement?

A
  • Conservative
  • Least painful, easy
  • Cheaper – but takes time
156
Q

How does autolytic debridement work?

A

Maintains favorable wound environment

157
Q

What are the indications for autolytic debridement?

A

Pain, palliative tx, can’t be still

158
Q

What are the most common forms of dressing for autolytic debridement?

A
  • Occlusive dressings, moist, warm - “cook” (most common)
  • Hydrocolloid
  • Transparent films
  • Foams
  • Hydrogels
159
Q

What are the contraindications for autolytic debridement?

A
  • Infection, dry gangrene, deep cavity wounds

* Other methods more appropriate

160
Q

What are the disadvantages for autolytic debridement?

A
  • Odor upon removal
  • Time
  • Infrequent visualization
161
Q

When is an autolytic debridement changed?

A

At “strike thru” or soiled

162
Q

When is an autolytic debridement combined with cross hatching?

A

When there is thick non viable tissue

163
Q

What are the most commonly used combo debridement methods?

A 
Sharp – removed loosely adherent tiss
• Cross hatched thicker areas
Enzymatic
• Applied Collagenase to all nonviable areas
Autolytic
• Warm, well insulated, thick dressing
164
Q

Biosurgical debridement utilizes what?

A 
Maggot Therapy (MT)
• larval debridement therapy (LDT)
165
Q

What type of debridement is biosurgical debridement?

A

Selective

166
Q

How does biosurgical debridement work?

A

Maggots ingest nonviable tissue & decrease odor and release enzymes that degrade nonviable tissue & biofilm!

167
Q

What are the characteristics of biosurgical debridement?

A

The maggots are antimicrobial - MRSA, Strep, Pseudomonas, biofilm
• Changes in pH
• Killing (secreted enzymes) & ingestion of bacteria
• Excretions & mvmt stimulate granulation tissue

168
Q

What are the characteristics of the maggots used for biosurgical debridement?

A
  • Sterile, non-reproducing
  • 10 maggots for 1cm2 wound surface area
  • “Free range” or “contained”
  • Don’t travel around in body
169
Q

What are the key to biosurgical debridement?

A
  • Need air – so don’t seal off – nylon mesh cover
  • Covered w/dry gauze to absorb drainage & allow air flow
  • Change ~ 3 days
170
Q

What is the patient population that are good for biosurgical debridement?

A
  • Osteo, inf around hardware, etc.
  • Poor candidate for surgery
  • Unable to tolerate other forms of debridement
171
Q

What is the percentage of tissue oxidation increase after 46 hours of not smoking?

A

10%

Integumentary (3 decks)

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