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PTRS 705 > Wound Care Day 1 > Flashcards

Wound Care Day 1 Flashcards

1
Q

Functions of Skin

A

thermoregulation, sensation, metabolism of Vit. D, protection from shear, protection from water loss

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2
Q

aging effects on skin

A

decreases: thickness, fatty layer, collagen/elastin, sensation, metabolism, sweat glands, circulation, epidermal regeneration

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3
Q

Epidermis

  • regenerates in ____
  • prevents ____
  • synthesizes ___
  • provides ____
  • protection from ____
A
  • 45-75 days
  • water loss (90% keratinocytes)
  • vit. D
  • pigmentation
  • shear, friction, toxic irritants
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4
Q

Dermis

  • houses ____
  • ___ layer of skin
  • provides _____ and ____
A
  • sensory organs and vasculature
  • thickest (2-4 cm
  • structure (collagen) and elasticity (elastin)
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5
Q

Hypodermis

  • contains ___
  • provides ____
  • also called
A
  • deep blood vessels and nerve endings
  • insulation, energy reserve, cushion
  • superficial fascia
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6
Q

4 phases of wound healing

A

hemostasis, inflammatory, proliferation, remodeling

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7
Q

components of hemostasis

A

immediate, vasoconstriction, platelet aggregation, fibrin deposition- clot is end product

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8
Q

components of inflammatory phase

A

clean wound site for tissue restoration, vasodilation, phagocytosis

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9
Q

signs of inflammatory phase

A

red, blue or purple skin, warm, pain, 3-7 days

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10
Q

components of proliferation

A

skin integrity restored, 3-5 days to 3 weeks, angiogenesis, granulation, collagen synthesis, wound contraction

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11
Q

components of remodeling phase

A

will not exceed 70-80% tensile strength of original (only 15% at closure), 21-28 days post injury up to 2 years,

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12
Q

chronic remodeling

A

imbalance in collagen synthesis and lysis, dehiscence, keloids

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13
Q

acute wounds

A

healing sequence continuous and within expected time frame, little complications, can get overreaction in healing (hypertrophic scars/keloids)

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14
Q

chronic wounds

A

delay/failure of healing component, associated with repeated trauma, poor oxygenation, dormant, secescent cells

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15
Q

when should a wound be assessed?

A

each time it is observed, and documentation should happen at least weekly

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16
Q

How to measure wounds

A

length x width x height
in centimeters always
length- 12-6
width- 9-3

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17
Q

depth

A

measure deepest area of wound bed, document clock time of undermining, tunneling, straight depth

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18
Q

tunneling/sinus tract

A

tissue loss into the depths of the wound, dead space, measure pathway and document on clock time

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19
Q

undermining

A

tissue loss parallel to wound surface

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20
Q

Stages for all wounds except pressure ulcers

A

partial thickness- into but not through dermis

-full thickness- through dermis into subcutaneous tissue & muscle may be exposed

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21
Q

Periwound inspection and palpation must be at least within ____

A

4cm of wound edge

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22
Q

edema measurement

A

0-1/4 inch: 1+ mild
1/4-1/2 inch: 2+ moderate
1/2-1 inch: 3+ severe
>1 inch: 4+ very severe

23
Q

arterial occlusion

A

if capillary refill is longer than 2-3 seconds

24
Q

pulse grading

A 
0= absent
1+= barely palpable
2+= palpable, but diminished
3+= normal
4+=prominent, suggestive of aneurysm
25
Q

ABI

A

ankle systolic/ brachial systolic

measures quality of blood flow to area

26
Q

Transcutaneous Oxygen measurement

A

30 mmHg will heal/debridement safe

27
Q

ABI results
>1
<.3

A 
calcified vessels
arterial disease
mild disease
claudication
debridement contraindicated
compression contraindicated
tissue loss
28
Q

Tissue types that could be present in a wound bed

A

eschar, slough, fibrin, granulation tissue, epithelium

29
Q

exudate

  • what is it?
  • what to document
A
  • drainage

- amount, color, character (serous, serosanguinous, purulent, dressing residue)

30
Q

types of wounds

A

burns, arterial insufficiency, diabetic/neuropathic, pressure ulcers

31
Q

Superficial burns

A

epidermal involvement, erythema, tenderness, pain

-sunburn, hot liquid

32
Q

superficial partial thickness burns

A

dermal involvement, large blisters, pain, edema, weeping

-hot liquid, flame injury, flash injury

33
Q

deep partial thickness burns

A

small amount of dermis remains, white or charred, blood flow compromised, less pain
-flame, chemical, electrical

34
Q

full thickness burn

A

into or through subcutaneous tissue

-flame, chemical, electrical injury

35
Q

arterial wound

A

result of complete or partial arterial blockage limiting perfusion causing tissue necrosis/ulceration

36
Q

illnesses associated with arterial wounds

A

coronary disease, CHF, COPD, hypertension, DM, ESRD, hypercholesterolemia

37
Q

arterial wounds

  • locations
  • surrounding skin
  • pulses
A

between toes and tips of toes, dorsal aspect of foot and over phalangeal heads, lateral malleolus, tibia

  • thin dry skin, absence of hair, shiny, smooth, cool to touch
  • absent or diminished
38
Q

arterial wounds

  • characteristics
  • symptoms
A
  • dry gangrene, punched out, smooth edges, erythematous halo, black/gray necrotic tissue
  • wound is painful, decreased pain and increased redness in dependent position, claudication
39
Q

Chronic venous insufficiency ulcers

  • pathology
  • associated symptoms
A
  • caused by valvular incompetence, obstruction of deep venous system, or congenital absence or malformation of venous valves
  • dull ache or heaviness, c/o pain in dependent position, decreased pain with elevation
40
Q

venous ulcers

  • location
  • wound characteristics
  • surrounding skin
  • pulses
A
  • superior to malleoli, usually medial
  • eschar/slough, wet, yellow, exudate, irregular and shallow wound edges
  • dry and scaly, varicose veins, hemosiderin staining
  • present
41
Q

diabetic ulcers

  • location
  • causes
A
  • tips of toes, lateral foot, dorsum, metatarsal heads, heels, deformities
  • neuropathic (60-70%), PVD, if to bone 90% have osteomyelitis
42
Q

diabetic ulcers

  • symptoms
  • surrounding skin
  • effect on healing
A
  • delayed
  • cracking, callous formation
  • decreased collagen deposition, delayed everything
43
Q

diabetic neuropathies

A

sensory- most common
autonomic
motor

44
Q

contributing factors to pressure ulcers

A

pressure, shear, friction, moisture

45
Q

pressure ulcer risk factors

A

age, nutrition, smoking, low BP, poor O2 perfusion

46
Q

Pressure ulcers stage 1

A

intact skin, non-blanchable redness

47
Q

pressure ulcer stage 2

A

partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. may present as an intact or serum filled blister

48
Q

pressure ulcer stage 3

A

Full thickness tissue loss, subcutaneous fat may be visible, but not bone, tendon or muscle. May include undermining/tunneling

49
Q

pressure ulcer stage 4

A

full thickness loss with exposed bone, tendon or muscle. often include undermining and tunneling

50
Q

pressure ulcer-unstageable

A

full thickness tissue loss when base is covered and you can’t see depth

51
Q

deep tissue injury

A

purple or maroon area of discolored intact skin or blood filled blister from pressure and/or shear.

52
Q 
bruises
0-2 days
2-5
5-7
7-10
10-14
2-4 weeks
A
  • red
  • blue
  • green
  • yellow
  • brown
  • clear
53
Q

Skin tear categories

A

1- no tissue loss
2- partial tissue loss
3- complete tissue loss

PTRS 705 (1 decks)

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