Wound Care Flashcards
Name the three phases of wound healing
Inflammation, Proliferation, and Remodeling
What are the three types of cells that come to a wound during the three phases of wound healing? In what order do they arrive?
Platelets, fibroblasts, collagen
What are some examples of local factors that affect wound healing? (~8)
Mechanical Injury Infection Edema Ischemia Necrotic Tissue Radiation Effects Hypoxia Foreign Body
What are the effects of radiation on tissue and wound healing?
Radiation will lower the capillary network in the radiated field, leading to ischemia and hypoxia, and thus lower rate of healing
What are some examples of systemic factors that affect wound healing? (~8)
Age Nutrition Obesity Trauma Metabolic Diseases Immunosuppression Connective Tissue Diseases Smoking!!!
During a peripheral vascular exam, you will perform three different measurements/indices that will help you assess if there is adequate tissue perfusion. What three measurements/indices will you perform? What are their normal ranges?
Ankle/brachial index [ABI] (normal is 0.9 – 1.2)
Toe/brachial index [TBI] (normal is 0.65)
Transcutaneous oxygen measurement [TOM] (normal is 60 mmHg)
In compartment syndrome, the (systolic/diastolic) pressure is higher, and the (systolic/diastolic) pressure is lower.
Diastolic pressure is higher; Systolic pressure is lower
When should you refer to a vascular surgeon?
If the Ankle/brachial index is abnormal, refer
If the Toe/brachial index is abnormal, refer
If the Transcutaneous oxygen measurement is abnormal, refer
Is an ABI of > 1.2 normal or abnormal?
Abnormal
Is the right or left subclavian more affected by arterial disease?
The left subclavian is more affected
In patients with severe ischemia, is it recommended to surgically debride their wound? Explain.
Do not debride it! Instead, use autolytic or chemical debridement
If a pt’s wound is infected, what should you do? (think: labs)
Culture it
If the patient has edema present, and there is adequate tissue perfusion, what should you consider for tx?
Consider compression systems
If a pt’s wound is too dry or too wet, what should be done?
Too dry, wet it. Too wet, dry it. Proper moisture balance is key!
Adequate _____ control is essential for dressing compliance
Pain control
When considering wound healing, what are host factors that should be addressed? \_\_\_\_\_\_ in diabetics \_\_\_\_\_\_ intake in the elderly Use of \_\_\_\_\_\_ or other agents \_\_\_\_\_\_ disease in patients with edema
Glucose in diabetics
Protein intake in the elderly
Use of steroids or other agents
Cardiac disease in patients with edema
Chronic wounds are usually caused by or the result of what three conditions?
Pressure ulcers
Venous and Arterial Insufficiency
Diabetes and Neuropathy
What is a pressure ulcer?
Localized injury to the skin and/or deeper tissues as a result of constant pressure due to impaired mobility
What does the pressure result in? (in regards to a pressure ulcer)
Reduced blood flow which eventually causes cell death, skin breakdown and the development of an open wound.
What are some common sites of pressure ulcer formation?
Sacrum, back, buttocks, heel, head and elbows (bony prominences)
What are some factors, other than constant pressure, that can lead to the formation of a pressure ulcer?
Sheer force, moisture balance, preexisting atherosclerosis, nutrition and drug therapy
T/F Skin is more vulnerable than deeper soft tissue
False; Deeper soft tissue is more vulnerable than skin
What stage of ulcer is the following? (I, II, III, IV, Unstageable, Suspected Deep Tissue Injury)
Full thickness skin loss with involvement of bone, tendon, or joint, with or without infxn. Often includes undermining and tunneling.
IV.
What stage of ulcer is the following? (I, II, III, IV, Unstageable, Suspected Deep Tissue Injury)
Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.
Unstageable
What stage of ulcer is the following? (I, II, III, IV, Unstageable, Suspected Deep Tissue Injury)
Full thickness tissue loss. SubQ fat may be visible; destruction extends into muscle with or without infection. Undermining and tunneling.
III.
What stage of ulcer is the following? (I, II, III, IV, Unstageable, Suspected Deep Tissue Injury)
Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying tissue from pressure and/or shear.
Suspected Deep Tissue Injury.
What stage of ulcer is the following? (I, II, III, IV, Unstageable, Suspected Deep Tissue Injury)
Skin intact but with non-blanchable redness for >1 hour after relief of pressure
I.
What stage of ulcer is the following? (I, II, III, IV, Unstageable, Suspected Deep Tissue Injury)
Blister or other break in the dermis with partial thickness loss of dermis, with or without infxn
II.
To prevent pressure ulcers, a pt should be repositioned every ____ hours
every 2 hours
In pts with pressure ulcers, you should keep the skin______ but avoid prolonged contact with _____
Moisturized; fluids
About ___% of all Americans will suffer from a venous stasis ulcer at some time
1%
Venous ulcers account for ____% of all lower extremity ulcers
80%
Venous ulcers are more common in _____ and the _____
women and the elderly
Risk factors for developing venous ulcers include…
Previous leg injuries, DVT, phlebitis, obesity and older age
T/F Venous ulcers tend to be isolated occurrences with ulcers lasting weeks to months
False; Although they do last for weeks to months, they are usually recurrent
What is the mechanism for the development of venous ulcers?
Venous incompetence and venous HTN
In a pt with a venous ulcer, accompanying peripheral edema may contribute to localized ______
ischemia
Venous ulcers often occur in the _____ area, though any area is possible
gaiter area (medial malleolus)
What are some characteristics of venous ulcers? (describe them!)
Edema, weeping wound, irregular shape, hemosideran deposition
Pain, swelling and varicosities with an open wound that is generally irregular and shallow
What is the standard of care for a venous ulcer?
Compression therapy
With compression therapy, the external pressure on the leg will be increased ____ mmHg - ____ mmHg
20 - 60 mmHg
T/F If a pt has venous insufficiency, surgery is recommended
True
T/F Arterial ulcers are typically associated with moderate to severe pain which is made better with leg elevation
False; Typically associated with moderate to severe pain which is made WORSE with leg elevation
How would an arterial ulcer be described?
Present with “punched out” ulcer
A pt with arterial ulcers typically has underlying risk factors for _______, such as ….
Typical patient has underlying risk factors for atherosclerosis such as smoking, HTN, HLD, DM, etc…
Diagnosis of arterial ulcer is suggested by an abnormal ______
ABI
Treatment of arterial ulcers is with ______ care and ______ surgery, if possible
wound care; vascular surgery
Should you compress an arterial ulcer?
NO
An ABI < 0.5 is associated with ____ ____ and < 0.3 with ____ ____
rest pain
tissue necrosis
A pt with an arterial ulcer typically has an ABI of ____
> 1.2
The primary underlying problem of ulcer development in DM pts is dysfunction of the _______
PNS (peripheral nervous system)
T/F Diabetic neuropathy can be motor, sensory, and autonomic
True
DM neuropathy is likely due to microvascular blood supply to the ______, thickening of the _____ membrane which impairs diffusion of oxygen and nutrients and to intracellular ______ as the ______ levels increase.
Nerve
Basement
Dehydration
Glucose
Define sensory neuropathy
Loss of sensation results in unrecognized trauma. Loss of proprioception leads to additional trauma and joint deformity with time
Define autonomic neuropathy
Increased blood flow causing osteolysis and osteopenia with resultant bone fractures
Loss of sweating (anhydrosis) leads to dry, cracked skin (portal for bacteria)
What is the single biggest cause of diabetic foot ulcers?
Peripheral sensory neuropathy
What is Charcot foot the end result of? Describe Charcot Foot?
End result of various metabolic and neuropathic processes
The foot becomes grossly deformed with loss of the normal foot arches and the development of a “rocker bottom” plantar surface prone to repeated episodes of ulcer formation
What occurs in the acute phase of Charcot foot?
Joint effusion, soft tissue edema, formation of bone and cartilage debris and bone fractures
What condition can Charcot Foot mimic?
Cellulitis
Does the following description match with a Wagner Grade 1, 2, 3, 4, or 5?
Superficial ulcer without subcutaneous tissue involvement
Grade 1
Does the following description match with a Wagner Grade 1, 2, 3, 4, or 5?
Extensive ulceration with exposed bone
Grade 3
Does the following description match with a Wagner Grade 1, 2, 3, 4, or 5?
Gangrene of the whole foot
Grade 5
Does the following description match with a Wagner Grade 1, 2, 3, 4, or 5?
Gangrene of toes or forefoot
Grade 4
Does the following description match with a Wagner Grade 1, 2, 3, 4, or 5?
Penetrates through the subcutaneous tissue; may expose bone, tendon, ligament or joint capsule
Grade 2
Diabetics have a ____ fold higher risk of an amputation compared to nondiabetics
10 fold
The five year survival following a diabetic amputation is ___% and there is a ___-___% incidence of contralateral amputation w/in the same time frame
30%
25-50%
T/F Early amputation allows for quicker rehabilitation
True
T/F The vast majority of chronic wounds are due to abnormal pressure, venous or arterial insufficiency or diabetic neuropathy
True
“Unusual causes” of skin ulceration include…
Raynauds, Pyoderma gangrenosum, Calciphylaxis, Necrobiosis lipoidica, Basal cell carcinoma, Squamous Cell carcinoma, Marjolin’s ulcer,
______ _______ is an ulcerative skin disease of uncertain etiology.
Histopathology from a skin biopsy usually shows vasculitis but later on is nonspecific with skin infarction with abscess formation
Treatment is with immunosuppression
Pyoderma gangrenosum
______ _______ is an ulcerative skin disease of uncertain etiology. Histopathology from a skin biopsy usually shows vasculitis, but later on is nonspecific with skin infarction and abscess formation
Pyoderma gangrenosum
_______ is characterized by medial calcification of the arterioles that leads to ischemia and ulceration. Histology shows small vessel calcification with thrombosis leading to ulcers as well as soft tissue calcification.
Calciphylaxis
How do you treat pyoderma gangrenosum?
Immunosuppression
Calciphylaxis is not ______, but seems to be related to calcium metabolism
Autoimmune
What is the recommended tx for calciphylaxis?
Supportive with wound care
Necrobiosis lipoidica diabeticorum (NLD) occurs in patients with ______ and necrobiosis lipoidica occurs in what type of pt?
DM; non-diabetic
What is the cause of Necrobiosis lipoidica?
Unknown, but is most likely an inflammatory disorder with collagen degeneration, granulomata formation in the dermis, and microangiopathy
What is the recommended tx of Necrobiosis lipoidica?
Wound care
The most common tumor is (basal/squamous/melanoma), followed by (basal/squamous/melanoma) and then (basal/squamous/melanoma)
The most common tumor is basal cell carcinoma (face) followed by squamous cell carcinoma and melanoma (sun exposure)
(Basal/Squamous) cell carcinomas do NOT metastasize but (basal/squamous) cell carcinomas CAN and do
Basal cell carcinomas do not metastasize but squamous cell carcinomas can and do
A _______ is a squamous cell carcinoma that arises in an area of previously traumatized, chronically inflamed or scarred skin
Marjolin’s ulcer
T/F A Marjolin’s ulcer is usually diagnosed late with poor prognosis
True :(
Wound care is a generalized term that refers to the processes associated with the (primary/secondary/tertiary) closure of (acute/chronic) wounds
Secondary; chronic
All wound care begins with a thorough ________
history and physical
Choice of wound care products is based upon the _____ and _____ of the wound.
nature; etiology
Describe a few components of “the ideal wound care product”. (~10)
Maintain moist wound environment Conformability Painless Odor control Nonallergenic and nonirritating Permeability to gas Non-traumatic removal Cost effective Convenience Thermal isolation (35-37 C)
What is usually the most inexpensive dressing?
Gauze
What are some advantages of using gauze as a wound dressing?
Absorption Packing Ease of use Inexpensive Mechanical debridement Can be used with solutions
What are some disadvantages of using gauze as a wound dressing?
Traumatic removal
May dry out
Requires a secondary dressing
May leave lint or fiber in the wound
Do transparent films usually have an adhesive layer?
Yes, to allow it to stay in place
What are some advantages of using transparent film as a wound dressing?
Wound visualization Impermeable to fluids and bacteria Conformable Can stay in place for days Allows for autolytic debridement
What are some disadvantages of using transparent film as a wound dressing?
Does not absorb
Adheres to skin
May cause maceration
Hydrophilic colloid particles will form a _____ with wound fluid
gel
What are some advantages of using hydrocolloids as a wound dressing?
Maintain moist wound environment
Impermeable
Self adhering and conforming to wound surfaces
May last for 7 days
What are some disadvantages of using hydrocolloids as a wound dressing?
Most are opaque
Not absorptive
Can be difficult to remove
Leaves a sticky residue
T/F Hydrogel most often has gold added to it
False, silver is added to it most often
What are some advantages of using hydrogel as a wound dressing?
Hydrates the wound Promotes autolytic debridement Easily rinses from wound Can fill spaces Relatively painless
What are some disadvantages of using hydrogel as a wound dressing?
Potential for maceration
Minimal absorption
Requires a secondary dressing
At least daily dressing changes needed
_______ are heteropolysaccharides derived from the cell walls of brown algae, and is often combined with silver
Alginates
What are some advantages of using alginates as a wound dressing?
Highly absorptive Has some hemostatic properties Can fill in spaces Unlimited choice of shapes Usually comes with silver Usually changed every 3 days
What are some disadvantages of using alginates as a wound dressing?
Requires a secondary dressing
Can adhere to wound bed and leave behind fibers when removed
Can make wound too dry
What are some advantages of using foam as a wound dressing?
Highly absorptive and protective
Available with or without border
Available in sheets and composites
Can fill spaces
What are some disadvantages of using foam as a wound dressing?
May macerate if hydration extends beyond border of wound
Thickness of foam may impair conformability
Calcium alginate is the calcium salt of alginic acid which is used in (wound care/ textiles and food) and sodium salt is used in (wound care/textiles and food)
wounds care; textiles and food
What is the primary purpose of foam in wound care/dressing? What can foam be used with for malodorous wounds?
To absorb wound exudate though it also provide a “cushion”
Charcoal
____________ appears to exert greatest influence on wound healing by stimulating fibroblasts and by absorbing matrix metalloprotesases (inhibit wound healing)
Exogenous collagen
Both _____ and _____ compounds have been known to have antiseptic properties for years, as they inhibit bacterial replication (see reference if interested)
iodine and silver
Santyl is the brand name of topically applied collagenase enzyme made by _______, which is reported to digest collagen in necrotic tissue allowing the wound to close faster
Clostridium histolyticum
________ uses the sterile larvae of the green bottle fly, and their secretions contain ________ that chemically debride the wound.
Maggot therapy; proteolytic enzymes
The physiologic effects of hyperbaric oxygen therapy include: Increases \_\_\_\_\_\_ oxygenation Causes \_\_\_\_\_\_ with resultant decrease in tissue \_\_\_\_\_ Bacterio\_\_\_\_\_ Increases \_\_\_\_\_\_\_ Increases \_\_\_\_\_\_ proliferation Improves \_\_\_\_\_\_ toxicity Improves function of \_\_\_\_\_\_
Increases tissue oxygenation Causes vasoconstriction with resultant decrease in tissue edema Bacteriocidal Increases neovascularization Increases fibroblast proliferation Improves neutrophil toxicity Improves function of osteoclasts
Hyperbaric oxygen therapy increases the amount of O2 dissolved in _______
Plasma
Most hyperbaric oxygen therapy sessions are ____ hours in length, _____ days per week, for ___-___ treatments. Each session lasts _____ minutes not including pressurization and decompression.
2 hours; 5 days; 20 to 40 treatments; ~90 minutes
Hyperbaric oxygen therapy is most often between __-__ atmospheres
2-3 atm
What are potential complications of hyperbaric oxygen therapy?
Barotrauma – significant ear pain with potential for TM rupture, or PTX
Air embolism
Oxygen toxicity and sz
Fire risk
