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Medical Conditions 3 > wound care > Flashcards

wound care Flashcards

1
Q

Layers of epidermis

A

Stratum corneum
Stratum lucidum
Stratum granulosum
Stratum spinosum
Stratum basale
Basement membrane

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2
Q

Stratum corneum

A

o Tough outer layer – acts as primary barrier
o Promotes protection from mechanical and chemical injury
o Constantly sloughing
o Consists of dead keratinized cells (15-20 layers)
o Can indicate hydration

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3
Q

Stratum lucidum

A

o Transparent, thin, transitional layer
o Present only at “stress points” (palms, soles of feet)

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4
Q

Stratum granulosum

A

o Metabolically active
o Contain keratinocytes & Langerhans cells
 Develops keratin
 Important for immune function/macrophage activity

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5
Q

Stratum spinosum

A

o Contains desmosomes that function as a cell to cell junction
o “spiky” or “spiny” projections
o Also contains Langerhans immune cells

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6
Q

Stratum basale (basal layer)

A

o Innermost, most continuous layer of epidermis
o 1-3 layers of active keritanocytes (regenerates the epidermis)
o Merkel cells (touch receptors)
o Melanocytes (pigment production)
o Cells take 2-3 weeks to migrate from basal layer
o Rete ridges/rete pegs protrude downward into dermis
 Anchor epidermis to dermis

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7
Q

Dermis contents

A

o Blood vessels
o Lymphatic vessels
o Nerve endings
o Appendages
 Hair
 Sebaceous glands
 Sudoriferous glands
 Nails

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8
Q

Dermis primary functions

A

o Thermoregulation
o Storage of water/maintaining hydration
o Provides nutrients and waste removal
o Houses epidermal appendages
o Assists with infection control
o Provides sensation

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9
Q

Dermis

A

thickest layer
papillary region
reticular region

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10
Q

Hypodermis

A
  • Subcutaneous tissue
  • Attaches skin to underlying bone and muscles
  • Contains loose connective tissue, adipose, elastin
    o Contains 50% of body fat
  • Insulation and shock absorption
  • Pacinian cells and free nerve endings for cold and pressure
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11
Q

Keratinocytes

A

develop keratin

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12
Q

Langerhans cells

A

immune cells, fight infection, macrophage activity

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13
Q

Melanocytes

A

produce melanin, protects from UV radiation

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14
Q

Merkel cells

A

mechanoreceptors for light touch sensation

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15
Q

Phases of wound healing

A

inflammatory
proliferative
maturation

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16
Q

inflammatory phase

A
  • Begins when the wound develops
  • 4-6 days
  • Edema, erythema, inflammation, pain
  • Healing process triggering
  • Immune system works to prevent microbial colonization
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17
Q

proliferative phase

A
  • 2-24 days
  • Angiogenesis: capillaries form buds and grow
  • Granulation tissue fills in the wound
  • Fibroblasts lay collagen in the wound bed, strengthening new granulation tissue
  • Wound edges begin to contract (myofibroblasts)
  • Epithelial cells migrate from the wound margins (epithelialization)
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18
Q

maturation phase

A
  • 21 days to 2 years
    o Greatest change in 6-12 months
  • Collagen fibers transform from immature type 3 to mature type 1 and reorient along lines of stress
  • Length of time depends on patient and wound related complicating factors
  • Filled-in wound is covered and strengthened
  • Scar tissue forms
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19
Q

Primary intention

A
  • Clean, straight line
  • Edges well approximated with sutures
  • Rapid healing
  • Usually best cosmetic outcome
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20
Q

secondary intention

A
  • Larger wounds with tissue loss
  • Edges not approximated
  • Heals from the inside out
  • Granulation tissue fills in the wound
  • Longer healing time
  • Larger scars
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21
Q

tertiary intention

A

(delayed primary)
- 3-5 day delay before injury is sutured
- Used to manage infected or unhealthy wounds
- Larger scars

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22
Q

local factors affecting wound healing

A

circulation
sensation
mechanical stress

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23
Q

red skin color indicates

A

o Infection
o Inflammation
o Cellulitis
 Flat texture, shiny
o Dermatitis
 Raised bumps
o Erythema
o Stage 1 pressure injury
o 1st degree burn

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24
Q

localized edema indicates

A

sign of infection
inflammatory response in immediate wound area

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25
Q

unilateral edema indicates

A

dvt
venous insufficiency
poor IV placement

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26
Q

bilateral edema indicates

A

renal insufficiency
heart failure

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27
Q

induration

A

extreme edema
starts to feel hard/firm
tissue changes
chronic edema

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28
Q

signs of infection

A

disproportionate edema
broad area that is hot to touch
fever
large amounts of drainage
broad, blistering erythema
severe pain, disproportionate to wound

29
Q

wound measurement methods

A

perpendicular
clock (most common)
volumetric
tracing
photography

length x width x depth

30
Q

granulation tissue

A

o Red, “beefy” looking
o Result of angiogenesis
o Composed of new capillaries and extracellular matrix
o Carefully protected in good wound management

31
Q

slough

A

o Soft, lighter necrotic debris
 Difficult to grasp with forceps
o Byproduct of autolysis
o Usually seen beneath eschar
o Inflammatory phase of healing

32
Q

necrotic tissue

A

o Composed of dead cells and fibrin
o May be dry and hard or soft and rubbery/leathery
o Dry or wet gangrene

33
Q

muscle

A

o Striated
o Reddish when healthy
o Brown/gray or black when devitalized
o Sensate when healthy, painful when exposed

34
Q

tendons

A

o Shiny/stringy when healthy
o Dull/dry/leathery when devitalized
o Covered with fibrous sheath of connective tissue containing synovial flid or fatty fluid

35
Q

bone

A

o Dark brown when necrotic
o Can soften/appear moth eaten
o Covered with periosteum when healthy

36
Q

adipose

A

o Shiny, yellow-white globules when healthy
o Shriveled/dry when devitalized
o Frequent source of abscess formation

37
Q

even border wound edge

A

o Typical of arterial wounds
o Typically around ankle/foot

38
Q

irregular wound edge

A

o Typical of venous wounds
o May occur as the wound epithelializes

39
Q

epibole

A

rolled
o Signs of a halted healing process
o Cells are termed senescent (unable to reproduce)

40
Q

hyperkeratosis

A

o Overdevelopment of stratum corneum (outermost layer of epidermis)
o Appears as thickened skin around the edge of a wound or as a callus

41
Q

maceration

A

o Softening of skin due to prolonged/excessive moisture

42
Q

arterial ulcer

A

impaired arterial blood flow
muscle atrophy
shiny skin
reduced hair growth
cold skin
absent/weak pulse
brittle nails
punched out wound

43
Q

venous ulcer

A

chronic venous insufficiency
brownish discoloration and scaling of the skin
warm skin
edema
varicose veins

44
Q

neuropathic ulcer

A

diabetic neuropathy
dry, scaly skin
sensory loss
cracked calluses
charcot foot

45
Q

cause of arterial wounds

A

ischemia
micro/macro vascular disease
artery obstruction

46
Q

causes of venous insufficiency wounds

A

DVT
recent surgery
prolonged standing
pregnancy
congestive heart failure

47
Q

causes of neuropathic/diabetic wounds

A

diabetes
peripheral vascular disease
hansen’s disease
spina bifida
lupus
CMT

48
Q

Stage 3 wound

A
  • Tunneling/undermining
  • Fat tissue exposed
  • No muscle or bone
49
Q

Stage 4 wound

A
  • Muscle/tendon/bone visible
  • Slough/eschar
  • Tunneling/undermining
50
Q

sanguineous exudate

A

thin, bright red

51
Q

serosanguinous exudate

A

Thin, watery, pale red to pink

52
Q

serous exudate

A

Thin, watery, clear

53
Q

purulent exudate

A

 Thick or thin
 Opaque tan to yellow

54
Q

foul purulent exudate

A

 Thick opaque yellow to green with offensive odor

55
Q

penrose drain

A

passive

soft, flexible tube that drains fluid from a surgical site

56
Q

pigtail catheter

A

passive

 Smaller, less invasive alternative to a chest tube
 Drainage for pleural effusion

57
Q

gastrostomy

A

passive

 “g-tube”
 Delivers nutrition directly to the stomach
 Type of enteral nutrition

58
Q

Active drains

A

o Negative pressure
o Connected to collection device

Jackson-pratt (JP)
Hemovac

59
Q

purpose of debridement

A

o Remove necrotic tissue/bacteria
o Shorten inflammatory phase
o Decrease energy required by the body for healing
o Increase ability to assess wound bed

60
Q

indications for debridement

A

o Necrotic tissue
o Foreign material
o Debris
o Residual topical agents
o Blisters
o Callus

61
Q

contraindications for debridement

A

o Granular tissue
o Viable tissue
o Stable, hard, dry eschar in ischemic limbs
o Need for surgical debridement (gangrene, osteomyelitis)
o Electrical burns
o Deeper tissue

62
Q

non-selective/mechanical debridement

A

 Wet to dry (like waxing a wound)
 Irrigation
 Hydrotherapy
 Abraded technique

63
Q

selective - autolytic

A
  • Occlusive (hydrocolloid)
  • Transparent (non-occlusive)
  • Hydrogel
  • Medihoney
64
Q

selective - enzymatic

A

topical application that breaks down proteins in necrotic tissue

65
Q

types of selective debridement

A

autolytic
biosurgical (maggots)
enzymatic
sharp/surgical

66
Q

excoriation

A

 Chafing, raw irritated lesion
 Linear erosion of the skin by mechanical means

67
Q

denuded

A

 Loss of epidermis due to exposure to urine, feces, body fluids, exudate, or friction

68
Q

what wounds would benefit from compression?

A

venous
arterial

Medical Conditions 3 (5 decks)

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