Wound care, hydrotherapy, lymphedema Flashcards by Ashtin .Eslick

Key functions of the integumentary system

Protection
Sensation
Thermoregulation
Excretion of sweat
Vitamin D synthesis

How well did you know this?

Not at all

Perfectly

Inflammatory phase characteristics

-Days 1 to 6
-Heat, redness, swelling, pain, loss of function
- Vasoconstriction then vasodilation (histamine)
-Blood clot formed
-Fibrin lattice formed

How well did you know this?

Not at all

Perfectly

Proliferative phase characteristics

-Days 3 to 20
-wound is covered, injury site regains initial strength
-Collagen made by fibroblast enters wound
-Neovascularization- new blood supply to bring oxygen/nutrients

How well did you know this?

Not at all

Perfectly

Maturation phase characteristics

-Day 9 onward
-“return to normal”
-Restoration of prior function of tissue
- Healing process decreases and returns to normal

How well did you know this?

Not at all

Perfectly

Universal precaution

An approach to infection control in which all human blood and human fluids are treated as if the are known to be infectious

How well did you know this?

Not at all

Perfectly

Standard precaution

Includes hand hygiene, the use of PPE, safe injections procedures, safe management of contaminated equipment

How well did you know this?

Not at all

Perfectly

Transmission based precaution

Based on type of disease. More specific. Contact, droplet, and air-bone dictate which type of SP is used.

How well did you know this?

Not at all

Perfectly

Aseptic technique

Method to prevent contamination of microorganisms. Everything used is sterile

How well did you know this?

Not at all

Perfectly

Clean technique

Free from visible marks/stains. Is not as in-depth as aseptic

How well did you know this?

Not at all

Perfectly

Wagner diabetic foot classification

0- Foot at risk
1- Superficial ulcers
2- Deep ulcers
3- Abscessed deep ulcers
4- Limited gangrene
5- Extensive gangrene

-Points based off of wound depth and presence of infection

How well did you know this?

Not at all

Perfectly

Braden Scale for pressure ulcers

9 or less- Very high risk
10-12- High risk
13-14- Moderate risk
15-18 Mild risk
19-23- No risk

-Points based off moisture, sensory perception, activity, mobility, nutrition, friction/shear

How well did you know this?

Not at all

Perfectly

Ankle brachial index

-Compares blood pressure in UE/LE
-Divide BP in ankle by BP in arm
-If the result is less than 0.9 then it may indicate person has peripheral artery disease (PAD)

0.9 or above- normal
0.71- 0.9 Mild obstruction
0.41- 0.70 Moderate obstruction
0.00- 0.40 Severe obstruction

How well did you know this?

Not at all

Perfectly

Stage I pressure ulcer

-Skin intact
-Redness
-Usually over bony prominence

How well did you know this?

Not at all

Perfectly

Stage II pressure ulcer

-Partial thickness loss
-Epidermis lost/ some dermis
-Pink/red wound
-No slough

How well did you know this?

Not at all

Perfectly

Stage III pressure ulcer

-Full thickness loss
-Subcutaneous tissue may be showing
-Tendon, bone, muscle not showing
-Slough/eschar present

How well did you know this?

Not at all

Perfectly

Stage IV pressure ulcer

-Full thickness loss
-Epidermis, dermis, subcutaneous gone
-Muscle, bone, tendon exposed
-tunneling/ mining present
-Slough/eschar present

How well did you know this?

Not at all

Perfectly

Deep tissue injury

Localized area of discoloration
skin intact but feels “boggy”

How well did you know this?

Not at all

Perfectly

Unstageable pressure ulcer

-Ulcer covered by necrotic tissue
-Needs removed to see damage
-Usually III/IV

How well did you know this?

Not at all

Perfectly

Eschar

black necrotic tissue

How well did you know this?

Not at all

Perfectly

Slough

white, byproduct of inflammation process

How well did you know this?

Not at all

Perfectly

Gangerene

tissue necrosis, loss of blood supply

Masceration

skin in moisture too long. Ex: fingers after bath

Exudate

fluid leaking from wound

Non-blanchable erythema

pigmented skin around wound

Arterial insufficiency ulcers characteristics

Location- lower leg, lateral malleolus Appearance- smooth edges, well defined, lack of granulation tissue, hemosiderine staining, deep Exudate- Minimal Pain- Severe Pedal pulses- Diminished/absent Edema- Normal Skin temp- Decreased Tissue changes- Thin and shiny, hair loss, yellow nails Miscellaneous- leg elevation increases pain. Compression is contraindicated

Venous insufficiency characteristics

Location- proximal medial malleolus Appearance- irregular shape, shallow Exudate- Moderate/heavy Pain- Mild to moderate Pedal pulses- Normal Edema- Increased Skin temp- Normal Tissue changes- Flaking, dry skin, brownish discoloration Miscellaneous- leg elevation decreases pain. Compression would help

Neuropathic ulcers

Usually on areas of foot, usually due to peripheral neuropathy caused by diabetes

Gaiter

below the knee and above ankle

Hemosiderine staining

appearance of brownish patches above the ankles that usually occur when red blood cells break down and begin to leak iron

Pressure wound

caused by unrelieved pressure, usually over bony prominence

Burns

Injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals

Scars

body's natural way of healing and replacing lost or damaged skin. A scar is usually composed of fibrous tissue

Abrasion

Superficial rub or wearing off of the skin, usually caused by a scrape or a brush burn.

Avulsion

Any time layers of skin have been torn off to expose muscles, tendons and tissue, it is called an avulsion.

Incisional

A cut made in the body to perform surgery

Laceration

wound that is produced by the tearing of soft body tissue. This type of wound is often irregular and jagged.

Penetrating

To pierce; to pass into the deeper tissues or into a cavity.

Puncture

An injury that is caused by a pointed object that pierces or penetrates the skin.

Skin tear

a wound caused by shear, friction, and/or blunt force resulting in separation of skin layers.

Skin layers

-Epidermis -Dermis -Subcutaneous

Primary intention wound closure

- surgical -Preferred option - Usually glue, staples, stiches, grafts - Skin heals faster

Secondary intention wound closure

-Closure of wound by itself -Not perferred -Takes longer to heal

Tertiary intention wound closure

-delayed wound closure by surgery -wound closed by secondary but need to go back in and do primary -Usually because of infection/contamination

Factors that affect wound healing

age, morbidities, edema, harsh/inappropriate wound care, infection, lifestyle, medications, obesity, bacteria

Red-yellow-black wound classificaiton

red- healthy "good steak" yellow- infection black- death, necrotic tissue

Red tissue goals

Protect wound, maintain mositure

Yellow tissue goals

Remove exudate and debris, absorb drainage

Black tissue goals

debride necrotic tissue

Selective debridement

choose which part of wound is debrided

Non-selective debridement

Not specific on which part of wound is debrided