Wound Care Flashcards
Name the six describing factors of a wound
- Location
- Duration
- Size (length, width, depth)
- Exudate (odor, quality & quantity)
- Appearance of wound bed and border - (eschar, gran tissue, infection, necrosis, slough, fibrous tissue, color)
Name the 4 stages of pressure ulcer staging.
- Skin is unbroken but inflamed.
- Skin is broken to dermis or epidermis
- Ulcer extends to subcutaneous fat layer
- Ulcer extends to muscle or bone (undermining likely)
5 stages (including 0) of Wagner’s Diabetic Foot Wound Classification
- Intact skin but pressure/erythema or callus noted
- Superficial ulcer without penetration to deeper layers
- Deep ulcer which reaches to tendon, bone, or joint capsule
- Deeper ulcer with abscess, osteomyelitis, or tendonitis.
- Gangrene of some portion of the toes, and/or forefoot which may be wet or dry
- Gangrene involves the whole foot
Define superficial, partial and full thickness wounds
Superficial: Involving but not through the epidermis
Partial: epidermis and partial dermis
Full: through dermis and into subcut tissue
Five clues of wound infection
- Increased pain
- Increased or discolored drainage
- foul odor
- Periwound erythema
- failure to heal in timely fashion
6 types of etiology for wound
- Pressure ulcer
- Arterial insufficiency
- Neuropathic (diabetic) ulcer
- Venous stasis ulcer
- Wound dehiscence
- Burns
Ischemic Ulcers:
- Location:
- Pain
- Appearance:
- Pulses:
- Skin:
- Bleeding:
- Edema:
- Risk Factors:
- Key treatment:
- If delayed healing:
- Toes, heels, lateral mall
- Present, relieved w/ dependency
- Pale, irregular, dry, poor
- pulses: poor/absent
- Skin: thin, shiny, dry, hairless, thick nails
- Bleeding: poor
- Edema : none; atrophy
- Smoking, CM, age, CAD
- Revascularization
- infection, restenosis
Venous:
- Location:
- Pain
- Appearance:
- Pulses:
- Skin:
- Bleeding:
- Edema:
- Risk Factors:
- Key treatment:
- If delayed healing:
- Lower leg (gaiter), above med mall.
- Relieved with elevation
- Beefy red granulation and/or slough. Sloping edges.
- Present
- venous
- present
- varicose veins, prior DVT
- compression
- occult ischemia, inadequate compression.
Neuropathic/Diabetic Ulcer
- Location:
- Pain
- Appearance:
- Pulses:
- Skin:
- Bleeding:
- Edema:
- Risk Factors:
- Key treatment:
- If delayed healing:
- Plantar
- Absent
- Deep tract, punched out
- Normal
- Normal/callused
- Brisk
- none
- DM, Immobility
- Off loading
- Occult ischemia, osteomyelitis
6 etiologies of pressure ulcers
- Long periods of low pressure
- Short periods of high pressure
- Friction
- Moisture
- Shear
- Positioning.
Positioning affects location of ulcers:
- Supine (2)
- Lat recumbant (2)
- Upright in chair (1)
- sacrum/coccyx, heel
- Lat mall, greater troch
- Ischial tuberosity
3 ways to maximize health in wound patients
- Stop smoking
- tight control of DM and HLD
- Adequate nutrition and exercise.
Three ways to improve wound bed
- Reduce edema
- Reduce bioburden: debridement, topical abx, clean frequently
- keep bed moist.
Debridement frequency:
Do not debride if:
q1-4 weeks
a suspected arterial wound exists until you check ABI’s and doppler
Normal ABI;
Abnormal:
<______: at risk for:
> 0.95
0.6-0.9 abnormal
biphasic >monophasic > flat. Refer to vascular surgery for revascularization if abnormal first
four types of debridement
- Sharp (scalpel)
- Mechanical (wet-to-dry dressing. pulse lavage)
- Enzymatic (santyl)
- Autolytic (duoderm)
Exception to moist wound bed rule:
Do not introduce moisture into a wound that has dry gangrene until revascularization has been performed.
Four benefits of moist content
- traps endogenous enzymes
- prevents scab/eschar formation
- facilitates autolytic debridement
- moist wounds heal 3-5x faster
Three functions of wound dressing
- Controls moisture
- fills dead space
- Thermoregulation
7 types of occlusive dressings from permeable to impermeable:
- Gauze (permeable)
- Alginate
- Impregnated Gauze
- Semipermeable film
- Semipermeable foam
- Hydrogel
- Hydrocolloid (impermeable)
4 benefits of gauze dressing
- cheap
- ok to use on infected wounds
- can pack tunnels/undermining
- mechanical debridement if used wet-to-dry
4 limitations to gauze
- Higher infection rate
- requires frequent dressing changes
- may adhere to wound bed (painful)
- nonselective debridement
How do calcium alginates work?
react with wound exudate to form a hydrphilic gel, providing moist environment. Highly permeable and non-occlusive. Comes in sheets and ropes.
Limitations to calcium aginate dressing:
do not use on exposed tendon or bone.
Examples of impregnated gauze:
- xeroform
2. adaptic
3 benefits of impregnated gauze
- good for granulating tissue that does not require debridement or moisture modification.
- not painful when removed or changed.
- non-adherent
Limitations of impregnated gauze
no absorptive properties
4 benefits of semipermeable films:
- Moisture retentive
- Allow visualization of the wound
- waterproof
- reduce friction
3 Limitations of semipermeable films:
- No absorptive properties
- Cannot be used on infected wound
- Can traumatize wound w/ removal (highly adherent)
2 examples of semipermeable films
tegaderm, opsite
5 benefits of semipermeable FOAMS
- Moisture retentive
- Thermal insulation
- Cushioning
- adherent and non-adherent
- absorb moderate exudate
Limitations of semipermeable FOAMS
caution on infected wounds
two examples of semipermeable FOAMS
curafoam, mepilex
Uniqueness of semipermeable foams
hydrophilic inside and hydrophobic outside (so absorbs moisture but prevents external contamination)
3 benefits of hydrgel
reduces pressure, usually non-adherent, donates moisture to the wound.
Unique thing about hydrogel (2)
comes in sheets or gels, water or glycerin based
2 examples of hydrgel
aquasorb, curagel
2 limitations of hydrogel
- cannot use on highly exudative wounds.
2. do not use on infected wounds
3 uses of hydrocolloid dressing
- highly absorptive
- promotes autolytic debridement
- cushion
2 limitations
- May cause hypergranulation (due to excessive moisture buildup)
- May roll in areas of friction
- cannot use on infected wounds
Uniqueness of hydrocolloid dressing
impermeable to external fluid/bacteria
Example of hydrocolloid
duoderm
Name 5 examples of biosynthetic dressings and skin substitutes for chronic wounds:
Oasis, integra, dermagraft, apligraf, epifix
(contains various amounts of keratinocytes, fibroblasts, collagen, growth factors, etc)
(use to stimulate granulation in chronic wound that has minimal slough or fibrous tissue)
Name 2 growth factors:
Used for:
- regranex, promogran
2. stimulates granulation in chronic wound that has minimal slough or fibrous tissue.
What is hydrofiber
such as aquacel ag
Do not use on dry wound bed, pack into wound and it absorbs moisture
