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Selected Topics > Wound Care > Flashcards

Wound Care Flashcards

1
Q

Where are common locations of wounds?

A

abdomen and heels

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2
Q

What is the primary function of the epidermis?

A

protection and synthesis of Vitamin D

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3
Q

What layer of skin contains pigementation/melanin?

A

epidermis

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4
Q

How often does the epidermis repair and regenerate?

A

every 28-42 days

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5
Q

What are the primary cells of the dermis?

A

fibroblasts

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6
Q

What is the function of fibroblasts in the dermis?

A

synthesize and secrete collagen and elastin

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7
Q

What nerve endings does the dermis contain?

A

pain
temperature
pressure

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8
Q

What anchors the dermis to the subcutaneous layer and other structures in the body?

A

collagen bundles

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9
Q

What are the functions of the subcutaneous tissue layer?

A
  • stores energy
  • insulate the body
  • move nutrients and oxygen to the dermis
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10
Q

What are the phases of wound healing?

A
  1. hemostasis (release of proteins)
  2. inflammatory (clean up)
  3. proliferative (re-build)
  4. maturation
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11
Q

What phase starts the process of healing? How does it achieve this?

A

a. hemostasis phase
b. releases proteins/growth factors

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12
Q

What phase of wound healing is very important? Why?

A

a. inflammation phase

b. removing bacteria, eschar, slough, and dead skin to prevent infection

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13
Q

(true/false) If a person does not remove all bacteria in the inflammation phase, they can still move onto the proliferative phase.

A

False (they cannot)

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14
Q

During the proliferative phase, the wound fills with _____ tissue.

A

granulation (collagen)

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15
Q

(true/false) The skin is no longer fragile once it gets to the maturation phase.

A

FALSE

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16
Q

What are signs of delayed/non-healing wounds?

A
  • wound becoming larger
  • new or increasing pain
  • exudate
  • discoloration of granulation tissue
  • increased necrotic tissue
  • bad odor
  • fever
  • erythema
  • induration
  • no improvement w/in 2 weeks
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17
Q

What should granulation tissue look llike?

A

red, beefy, bubbly

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18
Q

What types of medications impede wound healing?

A
  • Anti-inflammatories (corticosteroids and NSAIDS) –> interfere with regeneration of epidermis and collagen synthesis
  • antineoplastic agents (chemo) –> destroy normal cells/tissues
  • anti-coagulants –> inhibits growth of fibrin
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19
Q

How does obesity impede wound healing?

A

decreases O2 going to the tissues

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20
Q

definition: the measure of microorganisms on a surface such as a wound bed​

A

bioburden

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21
Q

All surfaces, including the skin, are contaminated with > _____ microorganisms.

A

> 100

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22
Q

(true/false) A surface’s bioburden does not have a predictable life/death cycle

A

FALSE

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23
Q

(true/false) Different organisms creating bioburden live dependently on each other

A

false (they live individually)

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24
Q

(true/false) controlled bioburden does NOT harm the surface of the skin

A

true

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25
Q

Growth of bioburden from one that is stable/harmonious to one that is uncontrolled and invasive/destructive to its environment ischaracterized by the__________ cycle.

A

bioburden cycle

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26
Q

What are factors that contribute to bioburden growth?

A
  • necrotic tissue
  • poor perfusion
  • poor immunity
  • antibiotic resistance
  • external contamination
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27
Q

What impact does uncontrolled bioburden have on healing?

A
  • The microbes compete with healing tissues for nutrients and O2 in the wound bed
  • disrupt granulation and epithelialization
  • can lead to chronic inflammation, necrotic tissue, exudate, and odor
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28
Q

(true/false) If a microorganisms progresses from the wound bed to invade the surrounding tissues, system infection is possible.

A

true

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29
Q

What are the phases of the bioburden cycle?

A
  1. contamination
  2. colonization
  3. critical colonization/biofilm
  4. infection
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30
Q

Phase of bioburden cycle:
- organisms are present on the wound surface but are NOT multiplying

  • all bacteria are in balance with environment
  • no s/s of infection
A

contamination

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31
Q

phase of bioburden cycle:
- organisms multiply on the wound surface

  • organisms begin to attach to the wound surface
  • no s/s of infection
A

colonization

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32
Q

phase of bioburden cycle:
- organisms cause tissue damage

  • biofilm forms and is ATTACHED to the wound bed
  • 1 to 2 classic s/s of infection
  • IMPAIRED HEALING
A

critical colonization/biofilm

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33
Q

phase of bioburden cycle:
- organisms invade the surrounding tissues of the wound bed and continue to multiply

  • host immune response is triggered
  • 3+ classic s/s of infection
A

infection

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34
Q

What are the goals of managing bioburden?

A
  • maximize host resistance
  • prevent accidental environmental contamination
  • dislodge surface contamination from the wound bed
  • disrupt or destroy contaminants and colonies in wound beds
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35
Q

What are active management techniques to treat biofilm?

A
  • cleanse wound with surfactants and/or microbials
  • cleanse surrounding skin
  • antimicrobial dressings
  • antiseptics
  • negative pressure wound therapy
  • debridement
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36
Q

What active management of biofilm can stop the healing process if used too long (> 2 weeks)?

A

antiseptics

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37
Q

definition: channel extending from the wound bed through the subcutaneous tissue and muscle

A

tunneling

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38
Q

definition: tissue deconstruction under intact skin along the edges

A

undermining

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39
Q

What do tunneling and undermining result in?

A

dead space

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40
Q

What primarily causes tunneling and undermining?

A
  • shearing forces
  • infection
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41
Q

What does epithelial tissue look like?

A

Light pink or pearly pink with a closed wound bed

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42
Q

What are the viable tissue types?

A

epithelial, granulation, clear/non-granular

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43
Q

What does clean, non-granular tissue look like?

A

pink or red w/o signs of granular tissue

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44
Q

definition: clear, think, watery exudate

A

serous exudate

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45
Q

(true/false) small amounts of serous fluid is indicative of a high bioburden.

A

false (small amount of exudate is considered normal… moderate to heavy exudate may indicate high bioburden)

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46
Q

definition: bloody drainage

A

sanguinous

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47
Q

What type of exudate is normal in the inflammatory phase? What does it indicate?

A

a. sanguinous
b. indicates that there is circulation to the wound

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48
Q

definition: pale red/pink, thin/watery exudate

A

serosanguinous

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49
Q

definition: thick, opaque, tan/yellow/green/brown exudate

can have an odor indicating infection

A

purulent

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50
Q

amount of exudate: wound bed is moist/glistening w/ no measurable drainage

A

scant

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51
Q

amount of exudate: minimal amount of exudate in the wound bed but can be visible on <25% of the dressing

A

small

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52
Q

amount of exudate: wound bed is wet and is visible on 50-75% of the dressing.

A

moderate

53
Q

amount of exudate: wound bed is filled with exudate and may be draining out in copious amounts

A

large

54
Q

What is commonly used as a driving factor when choosing a type of dressing?

A

amount of drainage present

55
Q

definition: clear definition of when the wound begins/ends

A

defined wound edges

56
Q

definition: edges that are unclear/difficult to assess

A

undefined wound edges

57
Q

definition: wound edges that are flushed with the wound bed

A

attached

58
Q

definition: wound edges that have undermining beneath the intact skin

A

unattached

59
Q

definition: wound edges indicating excessive moisture

A

maceration

60
Q

definition: wound edges that appear white and fragile

A

soft

61
Q

definition: wound edges that are rolled/curled under due to epithelial tissue growing on the underside of the wound instead of across

A

epibole

62
Q

definition: the area of tissue that immediately surrounds the open wound for up to 4 cm

A

periwound

63
Q

type of wound:

  • does not contain necrotic tissue, slough, or eschar
  • never granulates
  • only epithelializes to close wound margins
  • no tunneling or undermining
A

partial thickness wound

64
Q

type of wound:

  • may contain adipose and/or necrotic tissue
  • will fill with granulation tissue and close with epithelial tissue (IF HEALTHY)
  • may have tunneling and undermining
A

full thickness wound

65
Q

(true/false) full thickness wounds remain full thickness wounds until closure

A

true

66
Q

What stage(s) of pressure injuries are always full thickness wounds?

A

stages 3 and 4

67
Q

definition: localized damage to the skin and/or underlying tissue, as a result of pressure or pressure in combination with shear. Pressure injuries usually occur over a bony prominence but may also be related to a device or other object

A

pressure injury

68
Q

(true/false) you can backstage wounds.

A

false

69
Q

(true/false) you can stage all wounds.

A

FALSE (only pressure injuries)

70
Q

Stage 2 pressure injury is an example of a ___ thickness wound.

A

partial

71
Q

stage of pressure injury:
- Intact skin with non-blanching redness of a localized area due to prolonged pressure

  • Usually over a bony prominence
  • May be painful, firm, soft, warmer, or cooler compared to other tissue
A

stage 1

72
Q

stage of pressure injury:
- Partial thickness skin loss of the dermis

  • May present as a shallow pen ulcer intact/ruptured serum-filled blister due to pressure
  • Does NOT contain necrotic tissue, granulation tissue, undermining/tunneling
A

stage 2

73
Q

stage of pressure injury:
- Full thickness tissue loss into the subcutaneous layer

  • May see subcutaneous fat
  • muscle, tendon, bone NOT exposed
  • May have necrotic tissue, but does not obscure base of wound bed
  • May have tunneling and undermining
A

stage 3

74
Q

stage of pressure injury:
- Full thickness tissue loss with exposed bone, tendon or muscle

  • slough or eschar may be present
  • Often includes undermining and tunneling
  • Depth varies by anatomical location
  • Can extend into muscle &/or supporting structures
A

stage 4

75
Q

stage of pressure injury: Full thickness tissue loss in which the base of the ulcer is covered by slough &/or eschar

A

unstageable pressure injury

76
Q

Can you stage a unstageable pressure injury once the base of the wound is visible?

A

yes

77
Q

stage of pressure injury:
Purple or maroon area of discolored intact but non-blanchable skin
OR
Blood-filled blister related to damage of underlying soft tissue from pressure/shear

A

deep tissue injury (unstageable)

78
Q

What is the goal for deep pressure injury treatment?

A

keep the wound closed

79
Q

To reduce pressure/shearing forces, lower the HOB to < ___ degrees if not eating.

A

30 degrees

80
Q

Have a patient reposition themselves on non-pressure-reducing support surfaces at least every __ hour(s).

A

2 hours

81
Q

Reposition chair-bound patients every ___ hour(s) if the patient is unable to redistribute their own weight

A

1 hour

82
Q

Encourage chair-bound patients to shift their weight every ___ minutes.

A

15 minutes

83
Q

Encourage patients to stand for at least _______ during every waking hour.

A

> 60 seconds

84
Q

What are the causes of diabetic ulcers?

A

peripheral neuropathy and PAD

85
Q

What are the classifications of diabetic ulcers?

A
  • neuropathic
  • ischemic
  • neuro-ischemic
86
Q

What does the appearance of a diabetic ulcer look like?

A
  • even wound margins with a deep wound bed
  • low to moderate drainage
  • calloused periwound
87
Q

ulcer grade:
- Pre-ulcer Lesion
- Healed Ulcer
- Presence of bony deformity

A

grade 0 ulcer

88
Q

ulcer grade: Superficial Ulcer of skin

A

grade 1

89
Q

ulcer grade: Penetration through subcutaneous tissue into bone, tendon, ligament, or joint capsule

A

grade 2

90
Q

ulcer grade: Deep Ulcer with osteomyelitis or abscess

A

grade 3

91
Q

ulcer grade: Partial foot gangrene

A

grade 4

92
Q

ulcer grade: Whole foot gangrene requiring amputation

A

grade 5

93
Q

What is the optimal blood sugar level for wound healing?

A

below 160

94
Q

What is the optimal A1C level for wound healing?

A

< 7

95
Q

(true/false) part of diabetic ulcer prevention is to apply lotion between toes.

A

false

96
Q

What treatment for diabetic ulcers is the gold standard for off-loading the foot and increasing weight-bearing over entire lower leg?

A

total contact cast (TCC)

97
Q

What are the causes/risk factors of venous stasis ulcers?

A

Venous Hypertension/Incompetent Valves
Obesity
Previous DVT
Varicose veins
Lymphedema
CHF
Muscle weakness
Decreased activity
Age
Family History
Poor nutrition

98
Q

What are the causes/risks for arterial ulcers?

A

PVD (Peripheral Vascular Disease)
Atherosclerosis
Diabetes
Smoking
HTN
Age
Obesity
Cardiovascular Disease
Sickle Cell Disease
Renal Failure
Hyperlipidemia
Trauma
Limited joint mobility

99
Q

What is the typical location of venous stasis ulcers?

A

medial lower leg and ankle on the malleolar area

100
Q

What does a venous stasis ulcer look like?

A
  • irregular, superficial shape
  • pink/red granulation tissue
  • NO pain
  • moderate to heavy drainage
  • firm edema
  • hemosiderin staining
101
Q

What is the key to healing venous stasis ulcers?

A

compression

102
Q

When in a static position, elevate the legs (above/below) the heart if a patient has a venous stasis ulcer.

A

above the heart

103
Q

What are the common locations of arterial ulcers?

A

between the toes, tips of toes, and lateral malleolus

104
Q

what do arterial ulcers look like?

A
  • Appear “punched out”
  • Deep, pale wound bed
  • Pain
  • Minimal exudate
  • Thin shiny skin with hair loss on ankle and foot
  • Thickened toenails
  • Absent or diminished pulses
  • Decreased limb temperature
105
Q

When treating arterial insufficiency, if ___ is not corrected, wound healing will not occur.

A

ischemia

106
Q

What is the gold standard of care for arterial insufficiency treatment?

A

revascularization

107
Q

Unstable gangrene needs ___ to treat it.

A

debridement

108
Q

venous/artial insufficiency diagnostic tests:
combination of Doppler US and blood pressures at various locations on arms and legs

A

segmental pressures

109
Q

venous/artial insufficiency diagnostic tests: doppler probe over femoral popliteal, dosalis pedis, and posterior tibial arteries

A

doppler waveform analysis

110
Q

venous/artial insufficiency diagnostic tests: Ultrasound provides data via transducer held over vessels to evaluate changes in systolic velocity: Long exam

A

color duplex scanning

111
Q

venous/arterial insufficiency diagnostic tests: contrast dye injected into blood vessels and x-ray is used to identify blockages gold standard for identifying arterial occlusion

A

angiography/arteriogram

112
Q

When should ABI be used?

A
  • Foot pulses (PT and DP) are not clearly palpable
  • Any patient that has a LE ulcer
  • When LE ulcer is not healing
  • When you have order for compression therapy
113
Q

When measuring ABI, be aware that diabetics may need toe _____ pressure due to calcification of arteries.

A

brachial

114
Q

What is normal ABI range?

A

> /= 1.0

115
Q

What is the ABI range that indicates a threatened limb?

A

< 0.4

116
Q

What is the ABI range that indicates severe ischemia?

A

</= 0.5

117
Q

What is the ABI range that indicates LE arterial disease?

A

</= 0.9

118
Q

What is the ABI range that indicates a moderate occlusion?

A

0.6-0.8

119
Q

What are the most common diagnoses that use compression dressings?

A

venous insufficiency
lymphedema

120
Q

What are contraindications for compression dressings?

A
  • DVT
  • Active CHF
  • arterial insufficiency
121
Q

It is important for patients using (short/long) stretch bandages to complete LE ROM/strengthening exercises and to ambulate. This causes the calf to pump fluid

A

short stretch bandages

122
Q

Ace wraps are an example of (short/long) stretch bandages.

A

long stretch bandages

123
Q

For compression therapy, recommend putting a dressing on for ___-___ days and then removing it to check the skin.

A

3-4 days

124
Q

What pressure provides low support with compression garments?

A

18-24

125
Q

What pressure provides low to moderate support with compression garments?

A

25-35

126
Q

What pressure provides moderate support with compression garments?

A

30-40

127
Q

What pressure provides high support with compression garments?

A

40-50

128
Q

What is the ABI requirement for moderate and high support compression garments?

A

> 0.8

129
Q

What is the ABI requirement for low support compression garments?

A

0.5

Selected Topics (8 decks)

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