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Musculoskeletal > Wound Care II > Flashcards

Wound Care II Flashcards

1
Q

What is granulation tissue?

A

New connective tissue and tiny vessels that form on the surface of wounds during the early healing process

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2
Q

What is epithelialization?

A

Epithelium is a membranous tissue made up of one or more layers of cells that contains very little intercellular substance. The process is the closing or sealing of a wound

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3
Q

What is necrosis?

A

Death of tissue usually from lack of blood supply

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4
Q

What is eschar?

A

A dry tough scab or slough. Often seen with burns or cauterization of the skin

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5
Q

What is exudate?

A

A fluid that has moved out of tissue or its capillaries due to injury or inflammation

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6
Q

What is dehiscence?

A

A surgical complication where the edges of a wound no longer meet. It is also known as wound separation. There may be drainage noted

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7
Q

What are the different types of exudate?

A
  • Serous drainage
  • Sanguineous
  • Serosanguineous
  • Seropurulent
  • Purulent
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8
Q

What is serous drainage?

A

Clear, thin, watery plasma. It’s normal during the inflammatory stage of wound healing

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9
Q

What is sanguineous exudate?

A

Fresh bleeding, seen in deep partial-thickness and full-thickness wounds. A small amount may be normal during the inflammatory stage

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10
Q

What is serosanguineous exudate?

A

Thin, watery, and pale red to pink in color. The pink tinge, which comes from red blood cells, indicates damage to the capillaries with dressing changes

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11
Q

What is seropurulent exudate?

A

Thin, watery, cloudy, and yellow to tan in color

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12
Q

What is purulent exudate?

A

Thick and opaque. It can be tan, yellow, green, or brown in color. It’s never normal in a wound bed

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13
Q

What is phagocytosis?

A

The process of white blood cells that ingest smaller cells or cell fragments

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14
Q

What is slough?

A

The layer of dead tissue that separates tissue from sound flesh

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15
Q

What is angiogenesis?

A

The growth of blood vessels to increase or return circulation to a healing tissue (1 mm a day)

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16
Q

What does a red wound signify?

A

Uninfected, granulation tissue, revascularization

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17
Q

What does a yellow wound signify?

A

Drainage, slough, delayed epithelialization

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18
Q

What does a black wound signify?

A

Eschar, necrotic tissue

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19
Q

What is debridement?

A
  • Manual removal of dead tissue, eschar, slough, and fibrin
  • Sharp debridement: scissors, scalpel
  • Tweezers
  • Chemical debridement
  • Surgical debridement
20
Q

What are examples of acute and open wounds?

A
  • Abrasion: scrapes, road rash, superficial wounds
  • Laceration or incision: knife, glass, razor blade
  • Avulsion: body structure is pulled or forcibly detached
  • Animal bites
  • Traumatic injuries: motor vehicle accidents, farming and factory accidents
21
Q

What are examples of acute closed wounds?

A
  • Contusions
  • Crush injuries
  • Repetitive strain or cumulative trauma
  • Sprains
22
Q

What are other types of wounds?

A
  • Rashes
  • Bacterial infections
  • Arterial or venous stasis ulcers
  • Diabetic ulcers
  • Skin tears
  • Burns
  • Cellulitis
  • Folliculitis
  • Bug bites
23
Q

What are chronic wounds?

A
  • Wounds that fall outside the 3 phases of wound healing due to complications or severity
  • Treatment is based on treating the underlying pathological condition
  • A chronic wound can be converted to an acute wound with debridement
  • Chronic wounds do not proceed through an orderly or timely repair process
24
Q

What do OTs need to understand about wound care?

A
  • Healing process
  • Roles of members on rehab team
  • Solutions in prevention, positioning, providing activities to increase engagement in activities (circulatory and psychological)
  • Patient education on avoiding pressure when performing occupations, good hygiene, and skin inspection
25
Q

What are wound care principles?

A
  • Practice universal precautions!
  • Be aware of allergies to adhesives and latex in order to avoid development of secondary rash, burn, or severe allergic reaction
26
Q

What is a primary dressing?

A
  • The dressing that goes directly on top or inside of the wound.
  • May have specific chemical properties to provide or absorb moisture, prevent infection through anti-microbial intervention (silver, honey) or prevent the secondary dressing from sticking to the wound or sutures
27
Q

What is a secondary dressing?

A
  • Usually used to secure the primary dressing

- Gauze, Tegaderm, coban, etc.

28
Q

What are examples of post-surgical dressings and materials used post-surgery?

A
  • Adaptic or petroleum impregnated gauze
  • Xeroform
  • Silver dressings
  • 4x4 and 2x2 dressings
  • Semi-occlusive dressings
  • Gloves
  • Cotton tipped applicators
  • 1 or 2” gauze dressing wrap
  • Coban, digisleeve, or compression garment
  • Tweezers
  • Suture removal kits
  • Debriding agents
29
Q

What are decubitus ulcers?

A
  • Pressure ulcers, pressure sores, bed sores
  • Injuries to skin and underlying tissue resulting from prolonged pressure on skin. Bed sores most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips, and tailbone
30
Q

Who is most at risk of developing bed sores?

A
  • Medical conditions that limit ability to change positions, requires them to use a wheelchair, confines them to a bed for a long period of time, or who have impaired sensation
  • People who do not perceive normal sensory cues from the body to shift weight
  • Bed sores develop quickly and are difficult to treat
31
Q

Where can decubitus ulcers occur?

A
  • Nursing, homes, hospitals, assisted living, home health
32
Q

Who can issue citations for neglect?

A
  • Can be issued by governing agencies if a pressure sore was developed in-house
  • Extensive documentation is required
33
Q

Who is on a wound care team?

A
  • Anyone who provide care for the patient and the patient themselves
  • Physician/surgeon: prescribe care and medication
  • Nursing: usually perform the dressing changes and call the shots with wound care
  • Physical Therapy: perform modalities such as e-stim, ultrasound, diathermy, as well as wound care. In some settings, PTs irrigate the wound. Assist with positioning and improving mobility
  • Occupational Therapy: patient and family education regarding prevention, skin care, pressure prevention positioning, safety when performing ADLs, encourage more participation in occupation. In some settings, wound care
  • Dietician: ensures proper nutrition
  • Psychologist or social worker might be involved: depending on cause, for proper discharge planning, and to determine if there is any depression
  • Family members and caregivers: for follow through in prevention and healing
34
Q

What are the governing wound care entities?

A
  • National Pressure Ulcer Advisory Panel (NPUAP)
  • Minimum Data Set 3 (MDS is used in nursing homes and skilled nursing units)
  • The Agency for Health Care Policy and Research Guidelines (AHCPR)
  • The Omnibus Budget Reconciliation Act (OBRA)
35
Q

What are the four stages and unstageable categories of decubitus ulcers?

A
  • Stage 1: an area of localized redness that does not blanch when pressed. Skin is intact
  • Stage 2: a shallow ulcer affecting only the epidermis. May be blistered or fluid filled. There is no slough present. Skin tears do not fall in this category
  • Stage 3: deeper wound that extends into the subcutaneous tissue but does not go all the way through. May include tunneling and undermining
  • Stage 4: full thickness tissue loss affecting the epidermis, dermis, and subcutaneous tissue. May include muscle and bone. Tunneling and undermining are common at this stage
  • Unstageable: the extent of the wound cannot be measured or visualized. Usually blocked by eschar, necrosis, or blister. DTI (deep tissue injury)
36
Q

What is the Braden Scale?

A

It is used to identify risk of pressure sores. The scale looks at sensory perception, moisture, activity, mobility, nutrition, and friction and shear

37
Q

What is the PUSH Scale?

A

It is used by nurses to help further define Extent of Pressure Sore

38
Q

What is undermining?

A

When the depth of the wound extends past the original opening. You can lift the lip of the wound off the wound border

39
Q

What is tunneling?

A

Caused by destruction of the fascial planes which results in a narrow passageway. Tunneling results in dead space that has the potential for abscess formation

40
Q

What is the difference between NPAUAP and MDS 3.0?

A

There is no reverse back staging of wounds. A stage 4 pressure ulcer is always stage 4, even when fully healed

41
Q

What are other measuring techniques for wounds?

A
  • Computer software programs
  • Photographs
  • Zip-lock baggy tracing technique
42
Q

What are the different types of wound dressings?

A
  • Moist wound healing
  • Interactive dressings
  • Alginate wound dressings (processed seaweed)
  • Hydrocolloid dressings
  • Composite dressings
  • Foam wound dressings
  • Gauze dressing (sterile and non-sterile, 2x2, 4x4, wrap dressings)
  • Hydrogel dressings
43
Q

What is a wound vacuum assisted closure?

A
  • Application of controlled levels of negative pressure to accelerate debridement and promote healing
  • Decreases bacterial level
44
Q

What is hyperbaric oxygen therapy?

A

Oxygen significantly increases the oxygen saturation of plasma available to the tissues

45
Q

How can decubitus ulcers be prevented?

A
  • Turning schedules (times vary: every hour, every 30 minutes, etc.)
  • Proper pressure reducing wheelchair cushions
  • Hill-Rom or similar air bed
  • Other pressure reducing devices for bed
  • Patient and family education: skin inspection, pressure reduction, use of pressure relieving devices. Monitoring tubes, cords, dressings, shoes, clothing, etc. that can produce pressure and limit blood flow to and area
  • Good nutrition
  • Monitor and control sugars if diabetic
  • Dressing changes if at home
46
Q

What are pressure reducing devices?

A
  • Typically use of foam, gel, air, or a negative space to relieve pressure
  • Memory foam was developed by NASA
47
Q

What are other sources of pressure that may not be thought of as being culprits?

A
  • Wires and tubes

- IVs, vents, catheters, bedding tucked in too tightly

Musculoskeletal (17 decks)

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