Wound Care Module 1 Flashcards
PART 1: REDUCE OF ELIMINATION CAUSE
PART 1: REDUCE OF ELIMINATION CAUSE
What are the 5 parts of a wound care assessment?
- Assess patient risk using the Braden Scale
- Make adjustments for correct bed and chair positions
- Determine appropriate surfaces for pressure reduction
- Reduce the effects of gravity
- Understand the importance of oxygenation and blood flow
What is used to assess risk for pressure ulcer risk?
Braden Scale
What 6 factors are scored with the Braden Scale?
- Sensory Perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and Shear
- What is the highest Braden Scale score?
- A score lower than ____ puts patients at risk for pressure ulcers.
- 28
- 18
What is the correct bed positioning?
knees and hips slightly flexed
Pressure Reduction Surfaces are categorized as _________ Pressure or _________ Pressure.
localized or distributed
- If the patient is in bed, change position at least every ___ hours.
- If the patient is in a chair, change position at least every ____. Instruct your patient to shift their weight every ___ minutes if they are able.
- 2 hours
- hour, 15 minutes
What causes a diabetic foot ulcer?
- Neuropathy leading to decrease/loss of sensation.
- Difficulty discovering an ulcer.
- Cant feel pressure being exerted on foot.
- May go unnoticed until ulcer already present.
- What is off-loading?
- Why is it important?
- Off-loading is the act of relieving pressure from plantar tissues. It is the key to pressure ulcer treatment and prevention.
- The goal of off-loading is to control, limit, or remove all intrinsic and extrinsic factors that increase plantar pressures.
What non-surgical methods can be used for treatment of ulcers?
- Contact Casting
- Orthotics
- Cast Walkers
- Therapeutic Footwear
- Dressings
What is the most effective method of reducing edema?
Elevate the leg and allow gravity to drain fluid from the limb.
- ___________ bandages are useful when a patient can’t elevate their affected limbs. They’re also helpful for times when a patient is on his feet.
- What must be taken before application of this?
- Compression
- ABI Index
What are the benefits of compression therapy?
- Improves rate of ulcer healing
- Reduces the incidences of recurrence
- Prolongs the time to the first recurrence
- Improves lymphatic drainage
- Reduces superficial venous pressure
- Improves blood flow velocity through unoccludeddeep and superficial veins
- Reduces reflux in the deep veins
What 2 things are used for compression therapy?
Rigid and Elastic Compression
What is the first goal in the treatment of an ulcer?
Reestablish arterial flow (revascularization)
What are 3 surgical methods for revascularization?
- Arterial bypass
- Angioplasty
- Stents
What are the causes of poor blood flow?
- Pressure
- Arterial occlusion
- Vasoconstriction
- Peripheral vascular disease
- Atherosclerosis
What causes lower oxygenation levels?
- Inadequate oxygen intake
- Hypothermia or hyperthermia
- Anemia
- Alkalemia
- Chronic obstructive pulmonary disease
PART 2: NUTRITION AND PATIENT SUPPORT
PART 2: NUTRITION AND PATIENT SUPPORT
Thorough nutrition therapy should include what 3 things?
- A nutritional assessment
- Design of an individualized treatment plan
- Periodic monitoring to evaluate the plan’s effectiveness
A treatment plan should always begin with the least _______/_______ approach and should incorporate what 2 things?
-invasive/costly
- Adequate calories and proteins to promote anabolism and the growth of new tissue.
- A diet that fits the individual patient needs.
A complete nutritional assessment includes what 5 things?
- body measurements
- evaluation of lab results
- physical examination
- dietary interview
The outcome of a nutritional assessment provides the ability to do what?
- Determine pt nutrient needs.
- Evaluate adequacy/appropriateness of current diet.
- Recommend changes.
- Malnutrition occurs in ___% of non-surgical patients.
- Malnutrition occurs in ___-___% of surgical patients.
- Malnutrition occurs in ___-___% of older patients.
- 30%
- 45%-57%
- 53%-74%
What are the physical signs of dehydration?
- Dry skin
- Cracked lips
- Thirst
- Poor skin turgor
- Fever
- Appetite loss
- Nausea
- Dizziness
- Increased confusion
What are the clinical signs of dehydration?
- Increased laboratory values for the following: serum creatinine, hematocrit, blood urea nitrogen, potassium, chloride, osmolarity, sodium
- Decreased blood pressure
- Increased pulse rate
- Constipation
- Concentrated urine
What are 3 ways to prevent dehydration?
- Keep water or other beverages at the bedside so that they are easily accessible.
- Offer water at least every two hours if the patient doesn’t consume fluids on his or her own.
- Intravenous therapy when necessary.
PART 3: PREPARE FOR WOUND HEALING
PART 3: PREPARE FOR WOUND HEALING
________ = A group of organisms living together in or on the body prior to tissue invasion not causing infection.
Colonization
_________ = Invasion of tissues by microorganisms resulting in systemic reaction
(fever, edema, erythema, etc.).
Infection
What are the 3 things used in the detection of infection?
- Local and systemic symptoms
- Contamination and bacterial balance
- Clinical abnormalities
What are the local symptoms of infection?
- Erythema
- Edema
- Drainage
- Tissue around wound with induration
- Tenderness
- Warmth
- Crepitus
What are the systemic symptoms of infection?
- Fever
- Leukocytosis
- Confusion
- Tachycardia
- Hypotension
- Malaise
Wounds with bacterial counts of ___k organisms per gram of tissue or less are considered contaminated.
100k
What are 3 culturing methods?
- Surface Swab Culturing
- Needle Aspiration
- Tissue Biopsy
What is debridement?
Debridement is the removal of necrotic tissue from the wound area.
What are some types of debridement?
- Sharp Debridement
- Chemical/Enzymatic
- Autolytic
- Mechanical
What are the goals of wound cleansing?
- To remove debris that support bacterial growth and delay healing.
- To use as little chemical or mechanical force as possible.
- To protect healthy granulation tissue.
- To balance pH and moisture.
- To minimize odor and pain.
- To separate necrotic tissue from healthy tissue.
What 3 types of solutions are used for wound cleaning?
- Saline Solution
- Commercial Wound Cleaners
- Antiseptic Solution
You must limit the use of antiseptic solutions to between __-__ days.
3-7
