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NeuroRehab > Wound Care > Flashcards

Wound Care Flashcards

1
Q

Name the six describing factors of a wound

A
  1. Location
  2. Duration
  3. Size (length, width, depth)
  4. Exudate (odor, quality & quantity)
  5. Appearance of wound bed and border - (eschar, gran tissue, infection, necrosis, slough, fibrous tissue, color)
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2
Q

Name the 4 stages of pressure ulcer staging.

A
  1. Skin is unbroken but inflamed.
  2. Skin is broken to dermis or epidermis
  3. Ulcer extends to subcutaneous fat layer
  4. Ulcer extends to muscle or bone (undermining likely)
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3
Q

5 stages (including 0) of Wagner’s Diabetic Foot Wound Classification

A
  1. Intact skin but pressure/erythema or callus noted
  2. Superficial ulcer without penetration to deeper layers
  3. Deep ulcer which reaches to tendon, bone, or joint capsule
  4. Deeper ulcer with abscess, osteomyelitis, or tendonitis.
  5. Gangrene of some portion of the toes, and/or forefoot which may be wet or dry
  6. Gangrene involves the whole foot
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4
Q

Define superficial, partial and full thickness wounds

A

Superficial: Involving but not through the epidermis
Partial: epidermis and partial dermis
Full: through dermis and into subcut tissue

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5
Q

Five clues of wound infection

A
  1. Increased pain
  2. Increased or discolored drainage
  3. foul odor
  4. Periwound erythema
  5. failure to heal in timely fashion
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6
Q

6 types of etiology for wound

A
  1. Pressure ulcer
  2. Arterial insufficiency
  3. Neuropathic (diabetic) ulcer
  4. Venous stasis ulcer
  5. Wound dehiscence
  6. Burns
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7
Q

Ischemic Ulcers:

  1. Location:
  2. Pain
  3. Appearance:
  4. Pulses:
  5. Skin:
  6. Bleeding:
  7. Edema:
  8. Risk Factors:
  9. Key treatment:
  10. If delayed healing:
A
  1. Toes, heels, lateral mall
  2. Present, relieved w/ dependency
  3. Pale, irregular, dry, poor
  4. pulses: poor/absent
  5. Skin: thin, shiny, dry, hairless, thick nails
  6. Bleeding: poor
  7. Edema : none; atrophy
  8. Smoking, CM, age, CAD
  9. Revascularization
  10. infection, restenosis
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8
Q

Venous:

  1. Location:
  2. Pain
  3. Appearance:
  4. Pulses:
  5. Skin:
  6. Bleeding:
  7. Edema:
  8. Risk Factors:
  9. Key treatment:
  10. If delayed healing:
A
  1. Lower leg (gaiter), above med mall.
  2. Relieved with elevation
  3. Beefy red granulation and/or slough. Sloping edges.
  4. Present
  5. venous
  6. present
  7. varicose veins, prior DVT
  8. compression
  9. occult ischemia, inadequate compression.
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9
Q

Neuropathic/Diabetic Ulcer

  1. Location:
  2. Pain
  3. Appearance:
  4. Pulses:
  5. Skin:
  6. Bleeding:
  7. Edema:
  8. Risk Factors:
  9. Key treatment:
  10. If delayed healing:
A
  1. Plantar
  2. Absent
  3. Deep tract, punched out
  4. Normal
  5. Normal/callused
  6. Brisk
  7. none
  8. DM, Immobility
  9. Off loading
  10. Occult ischemia, osteomyelitis
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10
Q

6 etiologies of pressure ulcers

A
  1. Long periods of low pressure
  2. Short periods of high pressure
  3. Friction
  4. Moisture
  5. Shear
  6. Positioning.
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11
Q

Positioning affects location of ulcers:

  1. Supine (2)
  2. Lat recumbant (2)
  3. Upright in chair (1)
A
  1. sacrum/coccyx, heel
  2. Lat mall, greater troch
  3. Ischial tuberosity
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12
Q

3 ways to maximize health in wound patients

A
  1. Stop smoking
  2. tight control of DM and HLD
  3. Adequate nutrition and exercise.
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13
Q

Three ways to improve wound bed

A
  1. Reduce edema
  2. Reduce bioburden: debridement, topical abx, clean frequently
  3. keep bed moist.
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14
Q

Debridement frequency:

Do not debride if:

A

q1-4 weeks

a suspected arterial wound exists until you check ABI’s and doppler

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15
Q

Normal ABI;
Abnormal:
<______: at risk for:

A

> 0.95
0.6-0.9 abnormal
biphasic >monophasic > flat. Refer to vascular surgery for revascularization if abnormal first

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16
Q

four types of debridement

A
  1. Sharp (scalpel)
  2. Mechanical (wet-to-dry dressing. pulse lavage)
  3. Enzymatic (santyl)
  4. Autolytic (duoderm)
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17
Q

Exception to moist wound bed rule:

A

Do not introduce moisture into a wound that has dry gangrene until revascularization has been performed.

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18
Q

Four benefits of moist content

A
  1. traps endogenous enzymes
  2. prevents scab/eschar formation
  3. facilitates autolytic debridement
  4. moist wounds heal 3-5x faster
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19
Q

Three functions of wound dressing

A
  1. Controls moisture
  2. fills dead space
  3. Thermoregulation
20
Q

7 types of occlusive dressings from permeable to impermeable:

A
  1. Gauze (permeable)
  2. Alginate
  3. Impregnated Gauze
  4. Semipermeable film
  5. Semipermeable foam
  6. Hydrogel
  7. Hydrocolloid (impermeable)
21
Q

4 benefits of gauze dressing

A
  1. cheap
  2. ok to use on infected wounds
  3. can pack tunnels/undermining
  4. mechanical debridement if used wet-to-dry
22
Q

4 limitations to gauze

A
  1. Higher infection rate
  2. requires frequent dressing changes
  3. may adhere to wound bed (painful)
  4. nonselective debridement
23
Q

How do calcium alginates work?

A

react with wound exudate to form a hydrphilic gel, providing moist environment. Highly permeable and non-occlusive. Comes in sheets and ropes.

24
Q

Limitations to calcium aginate dressing:

A

do not use on exposed tendon or bone.

25
Q

Examples of impregnated gauze:

A
  1. xeroform

2. adaptic

26
Q

3 benefits of impregnated gauze

A
  1. good for granulating tissue that does not require debridement or moisture modification.
  2. not painful when removed or changed.
  3. non-adherent
27
Q

Limitations of impregnated gauze

A

no absorptive properties

28
Q

4 benefits of semipermeable films:

A
  1. Moisture retentive
  2. Allow visualization of the wound
  3. waterproof
  4. reduce friction
29
Q

3 Limitations of semipermeable films:

A
  1. No absorptive properties
  2. Cannot be used on infected wound
  3. Can traumatize wound w/ removal (highly adherent)
30
Q

2 examples of semipermeable films

A

tegaderm, opsite

31
Q

5 benefits of semipermeable FOAMS

A
  1. Moisture retentive
  2. Thermal insulation
  3. Cushioning
  4. adherent and non-adherent
  5. absorb moderate exudate
32
Q

Limitations of semipermeable FOAMS

A

caution on infected wounds

33
Q

two examples of semipermeable FOAMS

A

curafoam, mepilex

34
Q

Uniqueness of semipermeable foams

A

hydrophilic inside and hydrophobic outside (so absorbs moisture but prevents external contamination)

35
Q

3 benefits of hydrgel

A

reduces pressure, usually non-adherent, donates moisture to the wound.

36
Q

Unique thing about hydrogel (2)

A

comes in sheets or gels, water or glycerin based

37
Q

2 examples of hydrgel

A

aquasorb, curagel

38
Q

2 limitations of hydrogel

A
  1. cannot use on highly exudative wounds.

2. do not use on infected wounds

39
Q

3 uses of hydrocolloid dressing

A
  1. highly absorptive
  2. promotes autolytic debridement
  3. cushion
40
Q

2 limitations

A
  1. May cause hypergranulation (due to excessive moisture buildup)
  2. May roll in areas of friction
  3. cannot use on infected wounds
41
Q

Uniqueness of hydrocolloid dressing

A

impermeable to external fluid/bacteria

42
Q

Example of hydrocolloid

A

duoderm

43
Q

Name 5 examples of biosynthetic dressings and skin substitutes for chronic wounds:

A

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)

44
Q

Name 2 growth factors:

Used for:

A
  1. regranex, promogran

2. stimulates granulation in chronic wound that has minimal slough or fibrous tissue.

45
Q

What is hydrofiber

A

such as aquacel ag

Do not use on dry wound bed, pack into wound and it absorbs moisture

NeuroRehab (12 decks)

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