Wound care, hydrotherapy, lymphedema Flashcards

1
Q

Key functions of the integumentary system

A
  1. Protection
  2. Sensation
  3. Thermoregulation
  4. Excretion of sweat
  5. Vitamin D synthesis
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2
Q

Inflammatory phase characteristics

A

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

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3
Q

Proliferative phase characteristics

A

-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

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4
Q

Maturation phase characteristics

A

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

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5
Q

Universal precaution

A

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

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6
Q

Standard precaution

A

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

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7
Q

Transmission based precaution

A

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

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8
Q

Aseptic technique

A

Method to prevent contamination of microorganisms. Everything used is sterile

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9
Q

Clean technique

A

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

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10
Q

Wagner diabetic foot classification

A

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

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11
Q

Braden Scale for pressure ulcers

A

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

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12
Q

Ankle brachial index

A

-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

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13
Q

Stage I pressure ulcer

A

-Skin intact
-Redness
-Usually over bony prominence

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14
Q

Stage II pressure ulcer

A

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

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15
Q

Stage III pressure ulcer

A

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

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16
Q

Stage IV pressure ulcer

A

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

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17
Q

Deep tissue injury

A

Localized area of discoloration
skin intact but feels “boggy”

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18
Q

Unstageable pressure ulcer

A

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

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19
Q

Eschar

A

black necrotic tissue

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20
Q

Slough

A

white, byproduct of inflammation process

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21
Q

Gangerene

A

tissue necrosis, loss of blood supply

22
Q

Masceration

A

skin in moisture too long. Ex: fingers after bath

23
Q

Exudate

A

fluid leaking from wound

24
Q

Non-blanchable erythema

A

pigmented skin around wound

25
Q

Arterial insufficiency ulcers characteristics

A

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

26
Q

Venous insufficiency characteristics

A

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

27
Q

Neuropathic ulcers

A

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

28
Q

Gaiter

A

below the knee and above ankle

29
Q

Hemosiderine staining

A

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

30
Q

Pressure wound

A

caused by unrelieved pressure, usually over bony prominence

31
Q

Burns

A

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

32
Q

Scars

A

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

33
Q

Abrasion

A

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

34
Q

Avulsion

A

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

35
Q

Incisional

A

A cut made in the body to perform surgery

36
Q

Laceration

A

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

37
Q

Penetrating

A

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

38
Q

Puncture

A

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

39
Q

Skin tear

A

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

40
Q

Skin layers

A

-Epidermis
-Dermis
-Subcutaneous

41
Q

Primary intention wound closure

A
  • surgical
    -Preferred option
  • Usually glue, staples, stiches, grafts
  • Skin heals faster
42
Q

Secondary intention wound closure

A

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

43
Q

Tertiary intention wound closure

A

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

44
Q

Factors that affect wound healing

A

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

45
Q

Red-yellow-black wound classificaiton

A

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

46
Q

Red tissue goals

A

Protect wound, maintain mositure

47
Q

Yellow tissue goals

A

Remove exudate and debris, absorb drainage

48
Q

Black tissue goals

A

debride necrotic tissue

49
Q

Selective debridement

A

choose which part of wound is debrided

50
Q

Non-selective debridement

A

Not specific on which part of wound is debrided