Wound Flashcards

1
Q

Site of wounds in arterial insufficiency

A

lat malleolus
dorsum of foot
toes

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2
Q

Trophic changes in arterial insufficiency

A

Abnormal hair growth
Decreased LE hair
Dry skin

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2
Q

Clinical presentation of a pt c venous insufficiency

A

Swelling of U/L or bilat LE
LE pain that is relieved by elevation

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2
Q

Early S/Sx of Arterial insufficiency

A

Decreased hair on toes

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2
Q

Characteristics of arterial wounds

A

(-) granulation
necrotic
pale

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2
Q

Temperature of extremity upon palpation in pts c Arterial insufficiency

A

Cool

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2
Q

Late S/Sx of Arterial insufficiency

A

Gangrene

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2
Q

Treatment for Lymphatic dse

A

Complete Decongestive Therapy (Phase 1 and 2)

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2
Q

Trophic changes in a pt c venous dse

A

Hemosiderin staining
Lipodermatosclerosis

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2
Q

Primary areas of pressure ulcers

A

Sacrum
Coccyx
GT
OT
Calcaneus
Lateral Malleolus

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2
Q

The temperature of extremity upon palpation in a pt c venous dse

A

Warm

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2
Q

Status of LE upon elevation in a pt c Arterial dse

A

Pallor

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2
Q

Steps for MLD

A

Decongest first
Milk distal to proximal

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2
Q

S/Sx of venous insufficiency

A

itching, aching, heavy limb

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2
Q

Status of LE upon dependency in a pt c Arterial dse

A

Rubor

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2
Q

Treatment for Arterial wounds

A

Debridement
Skin grafts
Amputation

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2
Q

Site of wounds in venous dse

A

Proximal to medial malleolus

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2
Q

Stages of pressure ulcers

A

Blanchable Erythema
Superficial abrasion, blisters, and shallow craters
Full thickness loss

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2
Q

Dyvascular S/Sx of neuropathies

A

Ischemia resulting to impaired healing time
Impaired O2 transportation
Poor wound healing

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2
Q

Cause of Pressure/Decubitus Ulcers

A

Unrelieved pressure to the dermis

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2
Q

Pressure sores/ulcers are common among

A

Immobilized individuals

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3
Q

Clinical presentation of a pt c lymphatic impairment

A

Swelling distal to or adjacent to the area c impaired lymphatic drainage

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3
Q

Gold standard intervention for venous dse

A

Compression therapy

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3
Q

Tissue under the wound edge becomes eroded, resulting in a pocket beneath the skin

A

Undermining

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3
Q

Clinical presentation of neuropathies

A

Ulcers in WB surfaces of the foot
Anesthetic, round, over bony prominences

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3
Q

Pathogenesis of pressure ulcers

A

Pressure occludes blood vessels leading to decreased blood flow towards it and resulting in cell death and necrosis

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3
Q

Motor S/Sx of neuropathies

A

Loss of intrinsic muscles
Hammer claw toes
Foot drop d/t loss of nerve supply

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3
Q

Characteristics of an Exudate

A

Creamy, yellowish
Moderate to very thick

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3
Q

Sensory S/Sx of neuropathies

A

No pain pressure and temperature sense
Increased risk for skin breakdown
Wound formation d/t

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3
Q

Any dse involving peripheral, cranial, and/or autonomic nerves

A

Neurpathies

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3
Q

Passageways underneath the skin surface that extend from a wound and can take twists and turns

A

Tunneling

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3
Q

Autonomic S/Sx of neuropathies

A

decreased or absent sweat and oil production resulting to dry and inelasstic skin
Heavy callus formation

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3
Q

Characteristics of a Transudate

A

Clear
Thin
Watery

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3
Q

Characteristics of a Pus

A

Yellow, brown
Moderate to very thick

3
Q

Characteristics of a Serosanguineous

A

Clear or tinge of red/brown
Thin
Watery

3
Q

Intact skin with a localized area of non-blanchable erythema
No color changes

A

Stage 1: Non-blanchable erythema

3
Q

Wound bed is viable; pink or red in color, moist and may present as an intact or ruptured blister

A

Stage 2: Partial-thickness skin loss

3
Q

S/Sx of Diabetic neuropathy

A

Foot insenstivity
Ulceration

3
Q

NPUAP stages pressure ulcers

A

Non-blanchable erythema of intact skin
Partial-thickness skin loss with exposed dermis
Full-thickness skin loss
Full-thickness skin loss and tissue loss
Unstageable
Deep Tissue Pressure Injury

3
Q

Characteristics of an infected Pus

A

Hues of yellow, blue, and green
Thick
May have a foul drainage

4
Q

Adipose is visible in the ulcer and granulation tissue and epibole are often present
Slough or eschar may be visible

A

Stage 3: Full-thickness skin loss

4
Q

Exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone

A

Stage 4: Full-thickness skin and tissue loss

4
Q

Staging cannot be confirmed d/t slough or eschar

A

Unstageable: Obscure full-thickness skin and tissue loss

5
Q

Purpose of doing whirlpool for wounds

A

Softens adherent necrotic tissue

5
Q

Intact or non-intact skin with localized area of persistent non-blanchable erythema
Deep red, marron, or purple in color revealing a dark wound bed or blood-filled blister

A

Deep Tissue Injury

6
Q

Sensory assessment used for wounds

A

Semmes-Weinstein Monofilament test

6
Q

What type of debridement does whirlpool fall under?

A

Non-selective

7
Q

Disadvantages of using whirlpool

A

Increased risk for infection
May delay wound healing

8
Q

Removal of foreign material and dead or damaged tissues

A

Debridement

8
Q

Types of non-selective debridement

A

Wet-to-dry
Surgical debridement
Pulsatile lavage with suction
Whirlpool

8
Q

Purpose of doing debridement

A

Prevents bacterial overgrowth
Encourages normal cell activity
Better tissue repair

8
Q

Tool used in sharp debridement

A

Scalpel

8
Q

Disadvantages of doing wet-to-dry dressing

A

Removes endogenous fluids, fibrin, and other cells needed for healing
Increased risk for trauma and bleeding

8
Q

Another name for maggot debridement

A

larval therapy

8
Q

Characteristics of Alginates

A

calcium alginate
absorbs 20-30 times its weight
biocompatible c wound bed
needs secondary dressing
permeable to bacteria

8
Q

Duration of maggot over the wound

A

2-5 days

8
Q

Types of selective debridement

A

Sharp
Chemical/Enzymatic
Biosurgery

8
Q

Advantages of maggot debridement

A

removal of devitalized tissues resulting in improved wound healing
reduced risk for infections

8
Q

Advantages of chemical/enzymatic debridement

A

Simple, selective, and minimal discomfort

8
Q

Most common type of non-selective debridement

A

Wet-to-dry dressing

8
Q

A dressing applied over the primary for anchoring

A

Secondary

8
Q

What is applied in a chemical/enzymatic debridement

A

topical agent containing enzymes that dissolve necrotic tissue

8
Q

Contraindication of sharp debridement

A

Vascular wounds c limited blood flow
Eschar-covered wound

8
Q

Ideal dressing

A

Preserves wound hydration
Limits fluid loss

9
Q

Characteristics of an Impregnated Gauze dressing

A

Synthetic gauze; less adherent
Impregnated c Vaseline or Petroleum emulsion
Minimally absorptive

9
Q

Disadvantages of chemical/enzymatic debridement

A

requires frequent dressing changes
requires removal of eschar to improve penetration

9
Q

Characteristics of Foam dressing

A

Highly absorbent pads
Highly occlusive and assists in moist wound healing
Not used in dry wounds

9
Q

Use of endogenous enzymes to digest devitalized tissue

A

Autolytic debridement

9
Q

Characteristics of a Fiber gauze dressing

A

Cost-effective
Synthetic gauze; less adherent

9
Q

A dressing applied in direct contact to the wound

A

Primary

9
Q

Most occlusive dressing

A

Hydrocolloids

9
Q

Indication of Hydrocolloid

A

Mild to moderate exudate

9
Q

Characteristics of Hydrofibers

A

Selective absorptive capacity
Combined positive effects of alginate, foam, and gel dressing
Absorbs exudate
Fibers align perpendicular

9
Q

Characteristics of a Transparent Film Dressing

A

Transparent membranes c acrylic adhesive layer
Prevents bacteria and moisture from entering the wound
Keeps moisture, traps endogenous fluid and allows for autolytic debridement

10
Q

What type of dressing used as covering maggot debridement

A

Hydrocolloid

10
Q

Contraindication of Antiseptics

A

Non-infected wounds

11
Q

Recommended for wounds c Staph Aureus

A

Povidone-Iodine

12
Q

Used for wounds with purulent exudates

A

Sodium Hypochlorite

13
Q

Examples of Sodium Hypochlorite

A

Dakin’s solution
Bleach

14
Q

Used to manage Pseudomonas Aeruginosa

A

Acetic Acid Solution

15
Q

Example of Oxidizing agents

A

Hydrogen peroxide

15
Q

Non-selective debridement reaction of Oxidizing agents

A

Bubbling reaction

16
Q

Examples of antibacterials

A

Mupirocin ointments