Wound Care: Integumentary, Wound Healing, Assessment Flashcards
T or F; the epidermis is avascular
T
the dermis is composed of…
elastin and collagen
what is underneath the subcutaneous layer
fascia and muscle
normal phases of wound healing
1 - inflammation
2 - proliferation
3 - maturation/remodeling
signs of inflammation on open wounds
increased drainage, erythema around wound edges
what kind of collagen is granulation tissue
3
what color is healthy granulation tissue
beefy red
during maturation and remodeling, collagen type 1 replaces type 3 in a ratio of
4:1
why is it a good idea to do ROM during maturation and remodeling
because collagen aligns along lines of stress
T or F: scar tissue contains epidermal appendages
F
chronic inflammation and insufficient inflammation are signs of ___ healing
abnormal
wound dehiscence (hypogranulation)
scar tissue pulls apart
hypergranulation tissue
granulation tissue does not stop once it reaches the wound surface
_______ scarring is within the bounds of the original injury while ______ scarring extends outside the bounds of the original injury
hypertrophic
keloid
epiboli
premature epithelization
rolled/curled edges
wound assessment subjective history components
- demographics
- social history
- occupation
- living environment
- family hx
- fitness, nutrition
- drug/alcohol use
- current conditions
- chief complaint
- function
- meds
- lab measures
pressure ulcer risk assessments
braden
norton
gosnell
vascular wound risk assessments
doppler ultrasound, ABI
neuropathic wound risk assessments
wagner
semmes
monofilament
foot screening tools
LE pulses
dorsalis pedis or posterior tib (medial)
normal capillary refill
less than 3 seconds
ankle brachial index
systolic pressure ankle/systolic pressure brachial
is a high number or low number good for ABI?
high, if it is low you have poor healing
ABI results dictate…
healing potential
debridement options
LE compression options
normal ABI
1.0-1.3
ABI > 1.3
non-compressible vessels
*commen in diabetics
ABI < 0.3
gangrene, emergent vascular consult, may need to amputate
if the ABI > 0.8 what level of compression can they have
any level
if ABI is 0.6-0.8 what level of compression can they have
20-30 mmHg
if ABI is less than 0.6 what level of compression can they have
none
if ABI is less than ______ you should not debride
0.5
* they are at 5x greater risk of CV events
pitting edema scale
1+ = normal contour, a barely perceptible pit
2+ = fairly normal LE contours with a moderately deep pit
3+ = obvious foot and leg swelling with a deep pit
4+ = severe swelling that distorts the normal contours with a deep pit
monofilament for protective sensation
5.07 (10g)
monofilament for minimal to no sensation
6.10 (75g)
monofilament for normal sensation
4.17 (1g)
locations for vibration sense in LE
base of 5th met head
navicular
medial or lateral malleolus
what measurements of a wound should you get
length
width
longest width
depth
what method do you use to measure length and width of the wound
clock method
(length is 12-6 and width is 3-9)
how does the clock face for the foot with the clock method
toes to heel
toes = 12, heel =6
*everywhere else is head to toe
tract
tunnel that is closed on one end
what do you need to make sure is included ina. picture of a wound for documentation
measuring device
date
patient identifier
location
eschar
dry necrotic tissue
should you remove eschar
it depends
if it is stable you can leave it because it acts as a band-aid. but if it is draining or infected it needs to be removed
purulent drainage
yellow drainage
* a sign of infection
serous drainage
clear normal
serosaguineous drainage
light pink
sanginous drainage
blood
T or F: erythema around a wound is normal at the beginning
T: but if is prolonged or spreading it could be a sign of infection
induration
hardening of the skin due to inflammation
*this is normal at first, but if prolonged it could be a sign of infection
maceration
softening of tissue due to excessive moisture
hemosiderin staining
the dark purple-brown color of skin due to chronic swelling
osteomyelitis
inflammation of bone and bone marrow
** need IV antibiotics
do cultures or biopsies provide more details
-biopsies, cultures only tell you about the surface
- but biopsies are more invasive and not as quic
how to tell the difference between normal inflammation and infection
- are we in the inflammatory phase or is this prolonged?
- does it expand out past the wound edges
- is the amount/extent disproportionate to size of wound
