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Integumentary > Wound Basics > Flashcards

Wound Basics Flashcards

1
Q

Wound Documentation

A

-give location
-measurement
-shape
-appearance
-drainage

cheese on pizza

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2
Q

Systems Review

A

Cardio: vitals, edema
MSK: posture, ROM, Strength
NeuroMSK: transfers, gaits ensation
GI: nutrition
Urogenital: continence and fre
Integ: color, scars, hair, nails

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3
Q

Wound Edges Documentation

A

-describe with terms, include viability

pizza crust

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4
Q

Periwound

A

-space around the wound
-describe its health

pizza box

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5
Q

Wound Location

A

-describe body part its located on and orientation
-number the wounds if multiple

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6
Q

Wound Measurement

A

Test longest and widest and calculate area
-support by lit, but might be inacurate

Clock Method
-12 relative to head and 6 relative to butt
-consistent
- L 12-6, W 9-3

Tracing Methods
-paper to trace the wound
-count boxes

Volumetric
-contamination

Photo
-HIPPA

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7
Q

Sinus Tract

A

-extends under skin surface but doesn not lead to anything
-drainage

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8
Q

Tunnel

A

-caused by destructtion of fascia
-has a destination (organ, joint, wound)

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9
Q

Undermining

A

-erosion under the wound edges

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10
Q

Granulation Tissue

A

-good, shows healing/blood supply
-bright red

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11
Q

Friable Tissue

A

-pink
-poor circulation/infection
-will not heal

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12
Q

Slough

A

-not viable tissue
-snot like
-yellow or brown
-WBC and bacteria

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13
Q

Eschar

A

-black or brown and leathery
-tissue death
-soft or hard
-usually on full thickness injuries

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14
Q

Drainage Color

A

Serous: clean/yellow/watery

Serosanguinous: pink

Sanguinous: red/blood

Purluent: yellow/tan/creamy
-infection

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15
Q

Drainage Amount

A

-None, min, mod, max

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16
Q

Epibole

A

-curved in wound edges
-signs of chronic wound

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17
Q

Hyperkeratosis

A

-build up of keratin on edge of wound and periwound

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18
Q

Maceration

A

-whiteness of wound edges and periwound
-skin has too much fluid
-waterlogged and is weaker

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19
Q

Turgor

A

-skin with less hydration
-will stay elevated after pinch

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20
Q

Erythema

A

-redness
-inflammation

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21
Q

Hemosiderin Stain

A

-blood stains skin
-chronic wound

22
Q

Pitting Edema Grading

A

+1 to +4
1. small depression
2. identifiable, rebound in <15s
3. repoinds in 15-30s
4. >30s

23
Q

Pulses

A

0-4+
-normal is 2+

24
Q

Skin

A

-largest organ
-1/3 of cardiac output

Epidermis: 5 layers
-avascular with hair, gland, nails
-barrier, regulates fluid, sensation, thermoreg, excretion, vit d
-renew in 45-75 days

Dermis: 2 layers
-vascular, lymphatics and epidermal appendages
-supports and nourishes epi, infection control, sensation

Subcutaneous:
-fat and fascia
-highly vascular

25
Q

Epidermal Cells

A

Keratinocytes: re-eithepithekialization

Melanocytes

Merkel Cells: mechanoreceptors, light touch

Langerhan’s: immune from bone marrow

26
Q

Dermal Cells

A

Fibroblasts: main cells of dermis, produce elastic and collagen, responsible for graulation tissue

Macrophages

WBC

Mast Cells: mediators of inflammation, histamines

27
Q

Superficial Wound

A

-epidermis only
-abrasion, 1st degree burn

28
Q

Partial Thickness Wound

A

-epidermis and dermis
-blister, 2nd degree burn, stage II PI

29
Q

Full Thickness Wound

A

-all 3 layers
-full thickness burn, stage III or IV PI

30
Q

Inflammatory Phase Cells

A

Platelets

Cytokines: signal protein

Growth Factors

Polymorphonuclear Neutrophils

Macrohages

Mast Cells

31
Q

Maturatiton of Remodeling

A

-new collagen (type 1) is put down for strength
-old collagen (type III) is broken down

-scar is only 80% as strong, 2nd gen scar is 64%

32
Q

pH

A

4-6.5
-damage to corneum increases pH
-washing often increases pH
-urine or sweat decreases pH

33
Q

Wound Closure

A

Primary: wound is cleana nd physically closes

Secondary: wound left open and closes on its own

Delayed Primary Closure: wound is initially left open but after is closed

Abnormal:
-scarring
-Dehiscence: wound closes is opened
-Hypogranulation: fails to granulate and fill in
-Hypergranulation: granulation outside of wound

34
Q

Chronic Wound

A

-stuck in inflammatory healing phase
-have senescent cells
-lower tissue inhibitors
-dont respond to growth facots

35
Q

Factors Affecting Healing

A

-wound dimensions, temp (decrease temp= decrease healing), hydration (want it hydrated), infection, circulation, stress, comorbidities, meds, nutrition, MOI, location, age, pt adherence

36
Q

Protein for Wound Healing

A

-increase risk of PI
-impaires collagen, granulation, angiogenesis, poor o2 perfusion

37
Q

Carbs for Wound Healing

A

-energy for repair
-energy needs increase with a wound

38
Q

Fats for Wound Healing

A

-backup energy source
-caries vitamins
-thermoreg and cell membranes

39
Q

Vitamin A

A

-collagen syn, granulation tissue, epithelization
-can reverse damage of long term corticosteriod
-can put in wound bed

40
Q

Vitamin C

A

-build and maintain tissues, absorb iron, synthesize collagen
-anttioxidant

Deficiency:
-altered capillaries, decreased wound strength
-increased dehiscence

41
Q

Vitamin K

A

-blood clotting

Deficiency:
-lengthen inflammatory phase

42
Q

Zinc

A

-collagen and protein synth
-epithelization
-immune

43
Q

Iron

A

-hemoglobinn binding o2
-antibody

44
Q

Copper

A

-hemoglobin synthesis
-iron absorption

45
Q

Magnesium

A

Deficiency
-HTN and vasoconstriction

46
Q

Calcium

A

-fibrin synth for blood clotting

47
Q

Lean Body Mass

A

10% loss: impaired immunity
20% loss: impaired healing and skin
30% loss: no healing, new wounds
40% loss: death

48
Q

Labs

A

Creatine: kidney function

Albumin: protein deficiency

Prealbumin: recent changes in protein

Serum Transferrin: protein status

C-Reactive: inflammation

BUN: decreased healing

Glucose: risk of ulcer, infection, imapired healing

49
Q

Measuring Depth

A

-dont average measurements
-eschar may give misconception of debth

50
Q

Myofibroblasts

A

-wound contraction

Integumentary (9 decks)

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