Wound care, hydrotherapy, lymphedema Flashcards
Key functions of the integumentary system
- Protection
- Sensation
- Thermoregulation
- Excretion of sweat
- Vitamin D synthesis
Inflammatory phase characteristics
-Days 1 to 6
-Heat, redness, swelling, pain, loss of function
- Vasoconstriction then vasodilation (histamine)
-Blood clot formed
-Fibrin lattice formed
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
Maturation phase characteristics
-Day 9 onward
-“return to normal”
-Restoration of prior function of tissue
- Healing process decreases and returns to normal
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
Standard precaution
Includes hand hygiene, the use of PPE, safe injections procedures, safe management of contaminated equipment
Transmission based precaution
Based on type of disease. More specific. Contact, droplet, and air-bone dictate which type of SP is used.
Aseptic technique
Method to prevent contamination of microorganisms. Everything used is sterile
Clean technique
Free from visible marks/stains. Is not as in-depth as aseptic
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
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
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
Stage I pressure ulcer
-Skin intact
-Redness
-Usually over bony prominence
Stage II pressure ulcer
-Partial thickness loss
-Epidermis lost/ some dermis
-Pink/red wound
-No slough
Stage III pressure ulcer
-Full thickness loss
-Subcutaneous tissue may be showing
-Tendon, bone, muscle not showing
-Slough/eschar present
Stage IV pressure ulcer
-Full thickness loss
-Epidermis, dermis, subcutaneous gone
-Muscle, bone, tendon exposed
-tunneling/ mining present
-Slough/eschar present
Deep tissue injury
Localized area of discoloration
skin intact but feels “boggy”
Unstageable pressure ulcer
-Ulcer covered by necrotic tissue
-Needs removed to see damage
-Usually III/IV
Eschar
black necrotic tissue
Slough
white, byproduct of inflammation process