Wound Care Flashcards
Where are common locations of wounds?
abdomen and heels
What is the primary function of the epidermis?
protection and synthesis of Vitamin D
What layer of skin contains pigementation/melanin?
epidermis
How often does the epidermis repair and regenerate?
every 28-42 days
What are the primary cells of the dermis?
fibroblasts
What is the function of fibroblasts in the dermis?
synthesize and secrete collagen and elastin
What nerve endings does the dermis contain?
pain
temperature
pressure
What anchors the dermis to the subcutaneous layer and other structures in the body?
collagen bundles
What are the functions of the subcutaneous tissue layer?
- stores energy
- insulate the body
- move nutrients and oxygen to the dermis
What are the phases of wound healing?
- hemostasis (release of proteins)
- inflammatory (clean up)
- proliferative (re-build)
- maturation
What phase starts the process of healing? How does it achieve this?
a. hemostasis phase
b. releases proteins/growth factors
What phase of wound healing is very important? Why?
a. inflammation phase
b. removing bacteria, eschar, slough, and dead skin to prevent infection
(true/false) If a person does not remove all bacteria in the inflammation phase, they can still move onto the proliferative phase.
False (they cannot)
During the proliferative phase, the wound fills with _____ tissue.
granulation (collagen)
(true/false) The skin is no longer fragile once it gets to the maturation phase.
FALSE
What are signs of delayed/non-healing wounds?
- 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
What should granulation tissue look llike?
red, beefy, bubbly
What types of medications impede wound healing?
- 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
How does obesity impede wound healing?
decreases O2 going to the tissues
definition: the measure of microorganisms on a surface such as a wound bed
bioburden
All surfaces, including the skin, are contaminated with > _____ microorganisms.
> 100
(true/false) A surface’s bioburden does not have a predictable life/death cycle
FALSE
(true/false) Different organisms creating bioburden live dependently on each other
false (they live individually)
(true/false) controlled bioburden does NOT harm the surface of the skin
true
Growth of bioburden from one that is stable/harmonious to one that is uncontrolled and invasive/destructive to its environment ischaracterized by the__________ cycle.
bioburden cycle
What are factors that contribute to bioburden growth?
- necrotic tissue
- poor perfusion
- poor immunity
- antibiotic resistance
- external contamination
What impact does uncontrolled bioburden have on healing?
- 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
(true/false) If a microorganisms progresses from the wound bed to invade the surrounding tissues, system infection is possible.
true
What are the phases of the bioburden cycle?
- contamination
- colonization
- critical colonization/biofilm
- infection
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
contamination
phase of bioburden cycle:
- organisms multiply on the wound surface
- organisms begin to attach to the wound surface
- no s/s of infection
colonization
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
critical colonization/biofilm
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
infection
What are the goals of managing bioburden?
- maximize host resistance
- prevent accidental environmental contamination
- dislodge surface contamination from the wound bed
- disrupt or destroy contaminants and colonies in wound beds
What are active management techniques to treat biofilm?
- cleanse wound with surfactants and/or microbials
- cleanse surrounding skin
- antimicrobial dressings
- antiseptics
- negative pressure wound therapy
- debridement
What active management of biofilm can stop the healing process if used too long (> 2 weeks)?
antiseptics
definition: channel extending from the wound bed through the subcutaneous tissue and muscle
tunneling
definition: tissue deconstruction under intact skin along the edges
undermining
What do tunneling and undermining result in?
dead space
What primarily causes tunneling and undermining?
- shearing forces
- infection
What does epithelial tissue look like?
Light pink or pearly pink with a closed wound bed
What are the viable tissue types?
epithelial, granulation, clear/non-granular
What does clean, non-granular tissue look like?
pink or red w/o signs of granular tissue
definition: clear, think, watery exudate
serous exudate
(true/false) small amounts of serous fluid is indicative of a high bioburden.
false (small amount of exudate is considered normal… moderate to heavy exudate may indicate high bioburden)
definition: bloody drainage
sanguinous
What type of exudate is normal in the inflammatory phase? What does it indicate?
a. sanguinous
b. indicates that there is circulation to the wound
definition: pale red/pink, thin/watery exudate
serosanguinous
definition: thick, opaque, tan/yellow/green/brown exudate
can have an odor indicating infection
purulent
amount of exudate: wound bed is moist/glistening w/ no measurable drainage
scant
amount of exudate: minimal amount of exudate in the wound bed but can be visible on <25% of the dressing
small
amount of exudate: wound bed is wet and is visible on 50-75% of the dressing.
moderate
amount of exudate: wound bed is filled with exudate and may be draining out in copious amounts
large
What is commonly used as a driving factor when choosing a type of dressing?
amount of drainage present
definition: clear definition of when the wound begins/ends
defined wound edges
definition: edges that are unclear/difficult to assess
undefined wound edges
definition: wound edges that are flushed with the wound bed
attached
definition: wound edges that have undermining beneath the intact skin
unattached
definition: wound edges indicating excessive moisture
maceration
definition: wound edges that appear white and fragile
soft
definition: wound edges that are rolled/curled under due to epithelial tissue growing on the underside of the wound instead of across
epibole
definition: the area of tissue that immediately surrounds the open wound for up to 4 cm
periwound
type of wound:
- does not contain necrotic tissue, slough, or eschar
- never granulates
- only epithelializes to close wound margins
- no tunneling or undermining
partial thickness wound
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
full thickness wound
(true/false) full thickness wounds remain full thickness wounds until closure
true
What stage(s) of pressure injuries are always full thickness wounds?
stages 3 and 4
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
pressure injury
(true/false) you can backstage wounds.
false
(true/false) you can stage all wounds.
FALSE (only pressure injuries)
Stage 2 pressure injury is an example of a ___ thickness wound.
partial
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
stage 1
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
stage 2
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
stage 3
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
stage 4
stage of pressure injury: Full thickness tissue loss in which the base of the ulcer is covered by slough &/or eschar
unstageable pressure injury
Can you stage a unstageable pressure injury once the base of the wound is visible?
yes
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
deep tissue injury (unstageable)
What is the goal for deep pressure injury treatment?
keep the wound closed
To reduce pressure/shearing forces, lower the HOB to < ___ degrees if not eating.
30 degrees
Have a patient reposition themselves on non-pressure-reducing support surfaces at least every __ hour(s).
2 hours
Reposition chair-bound patients every ___ hour(s) if the patient is unable to redistribute their own weight
1 hour
Encourage chair-bound patients to shift their weight every ___ minutes.
15 minutes
Encourage patients to stand for at least _______ during every waking hour.
> 60 seconds
What are the causes of diabetic ulcers?
peripheral neuropathy and PAD
What are the classifications of diabetic ulcers?
- neuropathic
- ischemic
- neuro-ischemic
What does the appearance of a diabetic ulcer look like?
- even wound margins with a deep wound bed
- low to moderate drainage
- calloused periwound
ulcer grade:
- Pre-ulcer Lesion
- Healed Ulcer
- Presence of bony deformity
grade 0 ulcer
ulcer grade: Superficial Ulcer of skin
grade 1
ulcer grade: Penetration through subcutaneous tissue into bone, tendon, ligament, or joint capsule
grade 2
ulcer grade: Deep Ulcer with osteomyelitis or abscess
grade 3
ulcer grade: Partial foot gangrene
grade 4
ulcer grade: Whole foot gangrene requiring amputation
grade 5
What is the optimal blood sugar level for wound healing?
below 160
What is the optimal A1C level for wound healing?
< 7
(true/false) part of diabetic ulcer prevention is to apply lotion between toes.
false
What treatment for diabetic ulcers is the gold standard for off-loading the foot and increasing weight-bearing over entire lower leg?
total contact cast (TCC)
What are the causes/risk factors of venous stasis ulcers?
Venous Hypertension/Incompetent Valves
Obesity
Previous DVT
Varicose veins
Lymphedema
CHF
Muscle weakness
Decreased activity
Age
Family History
Poor nutrition
What are the causes/risks for arterial ulcers?
PVD (Peripheral Vascular Disease)
Atherosclerosis
Diabetes
Smoking
HTN
Age
Obesity
Cardiovascular Disease
Sickle Cell Disease
Renal Failure
Hyperlipidemia
Trauma
Limited joint mobility
What is the typical location of venous stasis ulcers?
medial lower leg and ankle on the malleolar area
What does a venous stasis ulcer look like?
- irregular, superficial shape
- pink/red granulation tissue
- NO pain
- moderate to heavy drainage
- firm edema
- hemosiderin staining
What is the key to healing venous stasis ulcers?
compression
When in a static position, elevate the legs (above/below) the heart if a patient has a venous stasis ulcer.
above the heart
What are the common locations of arterial ulcers?
between the toes, tips of toes, and lateral malleolus
what do arterial ulcers look like?
- 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
When treating arterial insufficiency, if ___ is not corrected, wound healing will not occur.
ischemia
What is the gold standard of care for arterial insufficiency treatment?
revascularization
Unstable gangrene needs ___ to treat it.
debridement
venous/artial insufficiency diagnostic tests:
combination of Doppler US and blood pressures at various locations on arms and legs
segmental pressures
venous/artial insufficiency diagnostic tests: doppler probe over femoral popliteal, dosalis pedis, and posterior tibial arteries
doppler waveform analysis
venous/artial insufficiency diagnostic tests: Ultrasound provides data via transducer held over vessels to evaluate changes in systolic velocity: Long exam
color duplex scanning
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
angiography/arteriogram
When should ABI be used?
- 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
When measuring ABI, be aware that diabetics may need toe _____ pressure due to calcification of arteries.
brachial
What is normal ABI range?
> /= 1.0
What is the ABI range that indicates a threatened limb?
< 0.4
What is the ABI range that indicates severe ischemia?
</= 0.5
What is the ABI range that indicates LE arterial disease?
</= 0.9
What is the ABI range that indicates a moderate occlusion?
0.6-0.8
What are the most common diagnoses that use compression dressings?
venous insufficiency
lymphedema
What are contraindications for compression dressings?
- DVT
- Active CHF
- arterial insufficiency
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
short stretch bandages
Ace wraps are an example of (short/long) stretch bandages.
long stretch bandages
For compression therapy, recommend putting a dressing on for ___-___ days and then removing it to check the skin.
3-4 days
What pressure provides low support with compression garments?
18-24
What pressure provides low to moderate support with compression garments?
25-35
What pressure provides moderate support with compression garments?
30-40
What pressure provides high support with compression garments?
40-50
What is the ABI requirement for moderate and high support compression garments?
> 0.8
What is the ABI requirement for low support compression garments?
0.5
