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Special Clientele > Wound Care 3 > Flashcards

Wound Care 3 Flashcards

1
Q

3 types of wound drainage

A

serous
sanguineous
purulent

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2
Q

serous wound drainage

A

pale yellow or transparent fluid from body cavities

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3
Q

sanguineous wound drainage

A

color of blood or containing blood

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4
Q

purulent

A

possible infection

production of pus

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5
Q

When should odor be assessed?

A

after debridgement and rinsing

should be described as present of not present

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6
Q

What is Turgor?

A

sign of dehydration

you pull up skin on back of hand for few seconds and see how quickly it returns to normal

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7
Q

Color-hyperpigmentation

A

long standing venous insufficiency

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8
Q

color-blue

A

prolonged ischemia

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9
Q

Color-lighter/paler

A

means decreased blood supply or newly formed scar tissue

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10
Q

What does it mean if wound is nonblanchable?

A

ischemic damage due to unrelieved pressure

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11
Q

What is induration?

A

firm edema

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12
Q

Measuring Temperature

A

measure with dorsum of hand after pt has rested in supine for 5 min.
compare to proximal body segments
Increased temp=inflammation or infection

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13
Q

Purposes of debridement

A

decrease bacterial concentraion/infection risk
increase effectiveness of topical antimicrobials
improve bactericidal activity of leukocytes
shorten the inflammatory phase of wound healing
decrease energy required by body for wound healing

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14
Q

What does black wound bed indicate?

A

covered in eschar
indicates full thickness wound probably
should be debrided

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15
Q

Yellow wound means what?

A

draining wound covered with slough
may result from partially removed eschar of black wound or may represent more superficial wound.
moisture=bacteria growth and maceration

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16
Q

Red wound means what?

A

granular wound (red and ready to heal)
should not be debrided
should be protected in a warm, moist environment

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17
Q

Should calluses be debrided?

A

yes possibly

if large fluid filled blisters, over joint, or burn blisters, they may need to be debrided.

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18
Q

Contraindications for PT debridement

A 
red, granular wounds
surgical debridement (deep tissues, undermining stage 4, electrical burns, and gangrenous tissue
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19
Q

Two types of debridement

A

selective

non selective

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20
Q

4 methods of debridement

A

sharp (selective)
autolytic (selective)
enzymatic (selective)
mechanical (non selective)

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21
Q

Sharp debridment

A

selective
fastest, most aggressive method outside of surgery
may be done by PTs but not PTAs

22
Q

When is sharp debridement indicated?

A

large amount of necrosis
advancing cellulitis
advancing sepsis
wounds w/necrotic tissue

23
Q

When is sharp debridement contraindicated?

A

area can’t be seen because of tunneling/undermining
material to be debrided can’t be identified
on uninfected ischemic ulcers

24
Q

Definition of Autolytic debridement (selective)

A

uses body’s own enzymes, including collagenase to digest necrotic tissue by applying moisture retentive dressing and leaving it in place several days

25
Q

Facts about autolytic debridement

A

most conservative, least invasive, least painful
takes min. time
reduces cost over long term
easy to teach pts/clinicians
doesn’t allow frequent visual of wound bed and you have to wait a few days for it to work

26
Q

Indications for autolytic debridement

A

wound that contains necrotic tissue

pt who can’t tolerate other forms of tx

27
Q

Contraindications for autolytic debridement

A

infected wounds

wounds needing sharp or surgical debridment

28
Q

What is enzymatic debridment? (selective)

A

use of topical exogenous enzyme to remove devitalized tissue

can be done by PTA

29
Q

About enzymatic debridement

A 
need physicians prescription
don't need as much skill
less painful than others (beside autolytic)
can be expensive/time consuming
less effective
30
Q

Types of enzymatic debridement

A

proteolytics-family of proteins that degrade necrotic debris
fibrinolytics=breaks down blood clot
collagenases-promote cellular response to injury

31
Q

Indications for enzymatic debridement

A

infected and uninfected wounds w/necrotic tissue
pts who can’t tolerate sharp debridement
adjunct to sharp or mechanical debridement between sessions
home care or LTC settings

32
Q

Contraindications

A 
wounds w/exposed deep tissues
when sharp or surgical debridement is required
facial burns
wounds with no necrotic tissue
wounds being autolytically debrided
33
Q

What is mechanical debridement?

A

nonselective

use of force to remove devitalized tissue, foreign material, and debris.

34
Q

What is Wet-to-dry mechanical debridement

A

applying single layer of fluffed saline moistened gauze to necrotic wound, covering w/more gauze, then allowing to dry 8-24 hours.
When it’s dry, it’s torn away at right angle.

35
Q

About wet to dry mechanical debridement

A

removes viable AND nonviable tissue
risk of perwound maceration and fungal infection
less effective than enzymatic and autolytic
only indicated in wounds with 100% devitalized wound beds.

36
Q

What is mechanical “scrubbing” debridement?

A

use of sponge, brush, or gauze along with a fluid to break the adherence of devitalized tissue and debris from wound bed.

37
Q

About “scrubbing” debridement

A

can remove or traumatize viable tissues as well
contraindicated for granulating wounds
high porosity sponge and LITTLE force is recommended.
begin at wound center and work out to avoid contaminating cleansed areas.

38
Q

What is wound cleansing?

A

delivery of wound cleanser to wound surface using mechanical force to remove lightly adhered necrotic tissue, debris, and bacteria.

39
Q

Facts about wound “cleanser”

A

cleansers often contain antiseptic and have antimicrobial properties.
They aren’t FDA approved
they have been found to contain cytotoxic agents that delay wound healing.

40
Q

7 main purposes of whirlpool

A

debride loosely adherent devitalized tissues
soften necrotic tissue and eschar
hydrate the wound bed/ promote healing
promote circulation
reduce pt pain complaints during wound care
ease ROM
can soak off adherent dressings

41
Q

Indications for whirlpool

A

infected wound
nondraining wound
wound with thick eschar
wound with loosely adherent necrotic tissue

42
Q

Contraindications for whirlpool

A

clean, granulating wounds
tunneling wounds or wounds w/undermining
wounds in areas of skin folds

43
Q

What is pulsed lavage w/concurrent suction?

A

delivery of wound irrigant under pressure by an electrically powered device and removal of irrigant with negative pressure.

44
Q

Advantages of pulsed lavage

A 
removal of irrigant
decreased tx cleanup
portable
shorter tx time
lower cost
less risk of cross contamination
less physiological stress
less painful than whirlpool
better ergonomics for clinician
45
Q

Disadvantages of pulsed lavage

A

one time use tubing and wound tips=increased cost

not appropriate for extensive wounds

46
Q

Indications for pulsed lavage

A

cleansing or debriding wounds due to arterial insufficiency, venous insufficiency, diabetes, pressure, small burns, surgery, or trauma

47
Q

contraindications for pulsed lavage

A 
near exposed arteries, nerves, tendons, bones
in body cavities
facial wounds
recent grafts or surgical procedures
wounds that are actively bleeding
48
Q

What is Negative pressure wound therapy?

A

subatmospheric pressure to wound using electrical pump to intermittently or continuously convey pressure through connecting tubing to a specialized wound dressing to promote healing.

49
Q

Advantages of negative pressure wound therapy

A 
moist wound environment
establish fluid balance
removal of slough
reduction in edema and 3rd space fluids
potential decrease in wound bacteria
increase blood to wound
increase growth factors by approximation
promotion of white cells and fibroblasts in wound
50
Q

Disadvantages of negative pressure wound therapy

A

one time use for tubes and supplies

not ideal for all pts

51
Q

Indications for negative pressure wound therapy

A 
pressure ulcers stage 3 &4
ortho trauma wounds
diabetic ulcers
post op flaps
open abdominal and surgical dehisced wounds
partial thickness wounds
52
Q

Contraindications for negative pressure wound therapy

A 
malignancy
untreated osteomyelitis
exposed blood vessels
necrotic tissue with eschar or slough
nonenteric or unexplored fistula
bleeding disorder
untreated malnutrition

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