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Modalities > Wound Care: Integumentary, Wound Healing, Assessment > Flashcards

Wound Care: Integumentary, Wound Healing, Assessment Flashcards

1
Q

T or F; the epidermis is avascular

A

T

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2
Q

the dermis is composed of…

A

elastin and collagen

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3
Q

what is underneath the subcutaneous layer

A

fascia and muscle

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4
Q

normal phases of wound healing

A

1 - inflammation
2 - proliferation
3 - maturation/remodeling

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5
Q

signs of inflammation on open wounds

A

increased drainage, erythema around wound edges

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6
Q

what kind of collagen is granulation tissue

A

3

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7
Q

what color is healthy granulation tissue

A

beefy red

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8
Q

during maturation and remodeling, collagen type 1 replaces type 3 in a ratio of

A

4:1

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9
Q

why is it a good idea to do ROM during maturation and remodeling

A

because collagen aligns along lines of stress

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10
Q

T or F: scar tissue contains epidermal appendages

A

F

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11
Q

chronic inflammation and insufficient inflammation are signs of ___ healing

A

abnormal

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12
Q

wound dehiscence (hypogranulation)

A

scar tissue pulls apart

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13
Q

hypergranulation tissue

A

granulation tissue does not stop once it reaches the wound surface

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14
Q

_______ scarring is within the bounds of the original injury while ______ scarring extends outside the bounds of the original injury

A

hypertrophic
keloid

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15
Q

epiboli

A

premature epithelization
rolled/curled edges

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16
Q

wound assessment subjective history components

A
  • demographics
  • social history
  • occupation
  • living environment
  • family hx
  • fitness, nutrition
  • drug/alcohol use
  • current conditions
  • chief complaint
  • function
  • meds
  • lab measures
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17
Q

pressure ulcer risk assessments

A

braden
norton
gosnell

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18
Q

vascular wound risk assessments

A

doppler ultrasound, ABI

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19
Q

neuropathic wound risk assessments

A

wagner
semmes
monofilament
foot screening tools

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20
Q

LE pulses

A

dorsalis pedis or posterior tib (medial)

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21
Q

normal capillary refill

A

less than 3 seconds

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22
Q

ankle brachial index

A

systolic pressure ankle/systolic pressure brachial

23
Q

is a high number or low number good for ABI?

A

high, if it is low you have poor healing

24
Q

ABI results dictate…

A

healing potential
debridement options
LE compression options

25
Q

normal ABI

A

1.0-1.3

26
Q

ABI > 1.3

A

non-compressible vessels
*commen in diabetics

27
Q

ABI < 0.3

A

gangrene, emergent vascular consult, may need to amputate

28
Q

if the ABI > 0.8 what level of compression can they have

A

any level

29
Q

if ABI is 0.6-0.8 what level of compression can they have

A

20-30 mmHg

30
Q

if ABI is less than 0.6 what level of compression can they have

A

none

31
Q

if ABI is less than ______ you should not debride

A

0.5
* they are at 5x greater risk of CV events

32
Q

pitting edema scale

A

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

33
Q

monofilament for protective sensation

A

5.07 (10g)

34
Q

monofilament for minimal to no sensation

A

6.10 (75g)

35
Q

monofilament for normal sensation

A

4.17 (1g)

36
Q

locations for vibration sense in LE

A

base of 5th met head
navicular
medial or lateral malleolus

37
Q

what measurements of a wound should you get

A

length
width
longest width
depth

38
Q

what method do you use to measure length and width of the wound

A

clock method
(length is 12-6 and width is 3-9)

39
Q

how does the clock face for the foot with the clock method

A

toes to heel
toes = 12, heel =6
*everywhere else is head to toe

40
Q

tract

A

tunnel that is closed on one end

41
Q

what do you need to make sure is included ina. picture of a wound for documentation

A

measuring device
date
patient identifier
location

42
Q

eschar

A

dry necrotic tissue

43
Q

should you remove eschar

A

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

44
Q

purulent drainage

A

yellow drainage
* a sign of infection

45
Q

serous drainage

A

clear normal

46
Q

serosaguineous drainage

A

light pink

47
Q

sanginous drainage

A

blood

48
Q

T or F: erythema around a wound is normal at the beginning

A

T: but if is prolonged or spreading it could be a sign of infection

49
Q

induration

A

hardening of the skin due to inflammation
*this is normal at first, but if prolonged it could be a sign of infection

50
Q

maceration

A

softening of tissue due to excessive moisture

51
Q

hemosiderin staining

A

the dark purple-brown color of skin due to chronic swelling

52
Q

osteomyelitis

A

inflammation of bone and bone marrow
** need IV antibiotics

53
Q

do cultures or biopsies provide more details

A

-biopsies, cultures only tell you about the surface
- but biopsies are more invasive and not as quic

54
Q

how to tell the difference between normal inflammation and infection

A
  • 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

Modalities (7 decks)

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