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Fundamentals ATI > Wound Care > Flashcards

Wound Care Flashcards

1
Q

3 categories of chronic wounds

A

Venous disease wounds
Arterial disease wounds
Neuropathic disease wounds

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2
Q

Days 1-4 of acute wound healing

A
  • redness
  • Edema
  • Exudate
  • Epithelial closure by day 4
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3
Q

Days 5-14 of acute wound healing

A
  • Bright pink
  • Edema and exudate resolve by day 5
  • Staples/sutures removed between days 9 and 14
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4
Q

Days 15-1 year

A
  • Pale pink
  • Scar tissue forms
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5
Q

What is primary intention?

A

Wound edges are approximated, which prevents granulated tissue formation

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6
Q

What is secondary intention?

A

Wound edges are not approximated, such as in a pressure injury

Heals by granulation tissue formation and re-epitheliazation

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7
Q

What is tertiary intention?

A

Wound is left open and closed at a later time

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8
Q

Negative Pressure Wound Therapy/Vacuum Assisted Closure

A
  • Applies continuous or intermittent suction to wound
  • removes bacteria and exudate
  • Promotes granulation
  • Not for areas of poor perfusion
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9
Q

Open drainage system

A
  • Penrose drains (absorbent dressing with collapsable tube)
  • Pros: protects surrounding skin, provides drainage
  • Cons: difficult to assess the amount of drainage and to control microbes
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10
Q

Closed drainage system

A
  • Use compression/suction to remove drainage in reservoir
  • Pros: accurate measurement of drainage and prevents infection
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11
Q

Types of closed drains

A
  • Self-contained drainage system (bulb)
  • Portable wound suction device
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12
Q

Describe components of wound assessment

A
  1. Location, shape, size (width by length by depth in mm), color
  2. Erythema (blanchable or nonblanchable (structural damage))
  3. Temperature (cold indicates low perfusion vs expected warmth)
  4. Odor (helps identify certain microorganisms)
    presence of exudate, slough, or eschar
  5. Signs of impaired healing (necrosis, tunneling, undermining, edema)
  6. Signs of good healing (clean edges or granulating tissue)
  7. Condition of the area around the wound
  8. Psychosocial: body image, esteem, sex, socialization
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13
Q

What are dry dressings used for?

A

Wounds with little or no exudate
(use sterile or clean technique, self-adhered or held by gauze and tape)

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14
Q

Wet-to-dry dressings

A
  • Saline soaked gauze that is squeezed
  • Pulls healthy and necrotic tissue out of wound when it dries
  • Do not use on clean wound with granulation
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15
Q

Chemically impregnated dressings

A
  • Silver, povodine iodine, petrolatum, collagen, or antibiotics
  • Speed healing process
  • Make sure using appropriate dressing for wound/microbe type
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16
Q

Foam dressings

A
  • Absorbent and provide more support for boney prominences
  • Mild to moderate exudate
  • Self-adherent or nonadherent
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17
Q

Alginate dressings

A
  • Made from seaweed
  • Provides moist healing environment, absorbs exudate, and promotes hemostasis
  • Doesn’t adhere to wound and needs second dressing
  • Good for lots of exudate or packing deep wounds
    * Do not use on dry wounds
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18
Q

Hydrogel dressings

A
  • Promotes moist environment and absorbs exudate
  • No effect on hemostasis
  • Swells with exudate and requires secondary dressing on top
  • Good for necrosis and infection and dry wounds
    * Do not use on excessive exudate
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19
Q

Wound fillers

A
  • Gels, powders, beads
  • Soften tissue to facilitate debridement
  • Do not use on dry wounds
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20
Q

Transparent dressing

A
  • No absorption, but provides barrier, moist environment, oxygen, and visualization of wound
  • Good for necrotic tissue and superficial tears
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21
Q

Hydrofiber dressings

A
  • Moderate to high exudate wounds
  • Hemostasis and very absorptive, less maceration than alginate
  • Can stay in place for several days
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22
Q

Hydrocolloid dressings

A
  • Autolytic debridement, make moist wound bed, bacteriostatic, and stimulate cell growth
  • Can’t see through and can look like purulent drainage
  • Good for small abrasions, superficial burns, pressure injuries, postoperative wounds
    * Do not use on dry wounds, and some infected wounds
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23
Q

Types of antiseptic agents

A

Provodine iodine
Silver
Hydrogen peroxide

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24
Q

Chemical debridement gels

A

For pressure injuries with eschar or slough, or uneven edges
Use only on necrotic tissue

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25
Q

Types of wound cleansing

A

Pressurized irrigation
Passive irrigation
Mechanical cleansing

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26
Q

Pressurized irrigation

A

8 psi through syringe or catheter
Start at top edge and hold syringe 1 inch away from wound
Irrigation and packing

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27
Q

Mechanical cleansing

A

gauze and solution to clean wound

28
Q

Passive irrigation

A

0.9 % sterile saline solution and gravity
Solution runs top-to-bottom

29
Q

Types of debridement

A

Mechanical
Autolytic
Chemical
Surgical

30
Q

What is mechanical debridement

A

Either wet-to-dry dressing or pressurized irrigation

31
Q

What is autolytic debridement?

A

Dressings help wound fluids self-digest necrotic tissue

32
Q

What is chemical debridement?

A

Topical enzymes

33
Q

Examples of pressure relief devices

A

Only work in combo with turning and skin care
Heal protectors, pillows, foam surfaces, specialized beds

34
Q

What types of wounds can electrical stimulation be used for?

A

Stage 2, 3, or 4 pressure injuries
Stimulates granulation and decreases pain

35
Q

What types of wounds are negative pressure wound therapy used for?

A

Stage 3 or 4 pressure injury
Drains removed when drainiage is 30–100 mL within 24 hr

36
Q

Hyperbaric oxygen therapy

A

100% oxygen stimulates cell growth for burns and necrosis

37
Q

Growth factors

A

Plasma rich in platelets stimulates fibroblasts to activate cell growth

38
Q

How does ultrasound therapy work to heal wounds?

A

Stimulates granulation, decreases pain, and decreases infection rate

39
Q

Describe eschar

A

Black/brown
Firmly attached
Can be soft

40
Q

Describe slough

A

Tan, yellow, white
Stringy and soft
Firmly attached

41
Q

Describe fibrin

A

Yellow, white
Stringy and soft
Loosly attached clumps

42
Q

Describe hyperkeratosis

A

White, grey
Hard or soft
Firmly attached surrounding edges

43
Q

Describe gangrene

A

Black, brown
Hard
Firmly attached

44
Q

Braden scale components

A

Braden Scale (score 6–23 where lower is bad)
Perception
Moisture
Activity
Mobility
Nutrition
Friction/shearing

45
Q

Why do chronic wounds heal slowly?

A

They have more cytokines, which slow new cell proliferation

46
Q

How should shearing be prevented?

A

Raise HOB to 30 degrees maximum

47
Q

4 stages of healing

A

Hemostasis (vasoconstriction)
Inflammatory phase
Proliferative phase
Maturation/remodeling phase

48
Q

Describe components of the inflammatory phase

A
  • **Begins after the skin is injured and lasts 3–6 days
  • Heat, swelling, color changes, pain, loss of function, fever
  • Presence of neutrophils, lymphocytes, macrophages, mast cells, plasma proteins, complement system **
    Neutrophils: first to arrive, phagocytosis
    Macrophages: phagocytosis, release of nitric oxide, autolytic debridement, and secretion of growth factors (attract collagen-synthesizing fibroblasts)
    Mast cells secrete histamine (vasodilation=edema, and collagen formation)
49
Q

Describe components of the proliferative phase

A
  • Begins 3 days after injury and lasts 24 hours
  • **Fills in the wound with new tissue
  • Angiogenesis=creation of new blood vessels
  • Bleeding and edema due granulation tissue (fragile capillaries and tissue)**
    Epitheliazation: temporary protection, keratinocytes move inward from edges
    Begins at the edges and moves upward
    Fibroblasts synthesize collagen to form scaffolding for scar formation
    Myofibroblasts cause contraction of wound edges
    Risk of evisceration because scar is immature
50
Q

Components of maturation/remodeling phase

A
  • Completion of wound healing can take more than 1 year
  • Collagen is replaced with stroger collagen
  • Myofibroblasts continue to secrete proteins to cause contraction and wound closure
  • Color of scar changes from pink/red to white, or be more pigmented in melanated skin
  • Thinner and reduced need for blood
51
Q

Skin problems in children

A

maceration and dermatitis
Skin tears, pressure injuries, diaper rash

52
Q

Skin problems in elderly

A

thinning of skin, collagen loss, decreased blood supply and hydration
Skin tears, pressure injuries, dryness, infections

53
Q

Skin problems with chronic illness

A

(reduced immune system, decreased oxygenation)
Skin tears, pressure injuries, infection, lesions caused by moisture

54
Q

Skin problems with reduced sensation

A

Skin tears, pressure injury, infection, incontinence related dermatitis

55
Q

Extrinsic factors related to wound formation

A

Medications
Radiation and chemo
Inflammation and decreased blood supply
(Delayed wound healing, dermatitis, infections, pressure iinjuries)
Nutrition
Stress reduces immune response
Damage, repeat trauma, illness can lengthen healing

56
Q

Moisture associated skin damage

A
  • dermatitis develops when skin is exposed to urine, feces, sweat, stoma effluent, wound drainage
  • sweating, skin folds, abnormal skin pH are risk factors
57
Q

Types of Biological Debridement

A

Collegenase (targets necrotic tissue only)
Bromelain and papain
Fly larvae secrete enzymes that liquifies necrotic tissue, which larvae eat

58
Q

When are sterile dressings applied to a wound?

A

After surgery and kept in place for 24-48 hrs

59
Q

Open dressings

A
  • gauze
  • Used to pack wounds with saline (wet to dry)
60
Q

Semi-open dressings

A
  • 3 layers: fine knit gauze with therapeutic ointment, middle absorptive layer, and adhesive layer
  • Do not control drainage well and can cause poor wound healing
61
Q

Semi-occlusive dressings

A

Most diverse in options:
Hydrocolloid
Hydrogel
Alginate
Foam
Hydrofiber
Polymeric membranes
Films

62
Q

Signs of wound infection

A

cellulitis
warm skin
redness around the wound
exudate
foul odor

63
Q

Define Surgical Site Infection (SSI)

A

infections that occur near a surgical site incision in the 30 days after surgery (superficial) or 30-90 days after surgery (deep)

64
Q

How should a wound culture be taken?

A

Apply saline top to bottom of wound to prevent contamination of culture with skin microflora
Use cotton tipped applicator to swab wound without touching edges

65
Q

Dehiscence

A

The complete or partial separation of the suture line and underlying tissues that occurs when a wound fails to heal properly from poor surgical technique, foreign material in the wound, or infection.

Fundamentals ATI (13 decks)

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