Week 6 Flashcards
what information should be obtained in a wound examination?
-general demographics
-lifestyle and functional status
-past and current medical histories (medical conditions, meds affecting healing, allergies)
-past and current wound history (etiology, POC, prognosis, past or currently successful/unsuccessful treatments)
what is a systems review
series of questions for the PT to identify symptoms that may be attributed to medical conditions that require a referral for further investigation
what special systems should be included in a wound systems review?
gastrointestinal (nutrition intake, continence (could affect sacral wound dressing), body mass index) and urogenital (incontinence affects dressings, poorly controlled diabetes, UTI)
what is included in a cardio/pulmonary system review?
heart rate, blood pressure, respiratory rate, edema, and pulse oximetry
what is included in a musculoskeletal system review?
structure, posture, range of motion, strength
what is included in a neuromuscular system review?
mobility, transfers, gait, and balance
what is included in an integumentary system review?
brief screen, skin integrity, skin color, scar formation, hair and nail growth
what is the clock method?
-method for measuring wound size
-3:00-9:00 and 12:00-6:00
-if on the foot 12:00 if towards the heel
what is undermining?
-usually involved subcutaneous tissues and follows fascial planes
-erosion of tissue close to the wound edge (cave)
-result in a large wound with small openings
what is tunneling?
-narrow passageway within a wound bed (subway)
-usually will form when a wound has been infected
-common in all types of wound except venous ulcers
what is a sinus tract?
-tunnel
-elongated cavity or abscess that drains to the body surface
-common in neuropathic wounds
what is a fistula?
tunnel that connects with a body cavity or organ
what is granulation?
temporary scaffolding of vascularized tissue that fills the hole
what does it mean if granulation tissue is pale?
doesn’t have a good bloody supply or it is infected and will heal more slowly or not at all
what is the difference between eschar and slough?
eschar: black, soft or hard
slough: yellow or tan, stringy like snot
what is occurring when a wound is red?
ready to heal appearance with definite borders; granulation tissue is present and revascularization is apparent
what is occurring when a wound is yellow?
pus, debris, fibrin, slough, and yellow exudate present which may require cleansing and minor debridement to promote healing; may require use of a topical antimicrobial if wound is unusually contaminated
what is occurring when a wound is black?
necrotic tissue/eschar may be present; may include pus, fibrin, and other cellular components that inhibit granulation tissue
what is the difference between slough and fibrin?
slough: produced by autolysis, soft and mushy, product of inflammatory phase, snot like consistency, yellow or white
fibrin: yellow but more fibrous in appearance, can be mistaken as connective tissue, yellow or white
what are the 4 things included in a drainage examination?
-type: serous, sanguineous, serosanguinous, purulent, seropurulent
-color
-consistency/viscosity: thin, watery, thick
-amount: none, minimal, moderate, copious
Describe the scoring of pitting edema
1+ = barely perceptible depression; < 2mm
2+ = easily identifiable depression, rebounds < 15 seconds; 2-4mm
3+ = depression rebounds 15-30 seconds; 5-7mm
4+ = depression last > 30 seconds; >7mm
what are the signs of infection?
-erythema disproportionate to the size of the wound
-poorly defined erythema boarder
-fever
-warmth disproportionate to the size of the wound
-could have induration
what are the stages of healing?
-inflammatory
-proliferation
-maturation and remodeling
what are the positive indicators of wound prognosis?
-A1C, ABI, previous healing, compliance with compression
-20-40% decrease in wound surface area within 2-4 weeks
what are the negative indicators of wound prognosis?
-A1C, smoking, ABI
-no decrease in size or signs of improvement within 2 weeks
what are some interventions for wound care?
education, debridement, dressing selection and modification, biophysical agents, mobility training, referrals
what can a PTA not do?
-certain interventions which require immediate and continuous examination and evaluation throughout the intervention
-sharp debridement
