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Acute Care > Wound Care Modules > Flashcards

Wound Care Modules Flashcards

1
Q

Components of Braden Scale

A
  1. Sensory Perception
  2. Moisture
  3. Activity
  4. Mobility
  5. Nutrition
  6. Friction and Shear
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2
Q

Braden scale scoring

A

High: 28

18 or lower: risk of pressure ulcers

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3
Q

Repositioning in bed

A

change position every 2 hours

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4
Q

Repositioning in chair

A

change position every hour

shift weight every 15 min if possible

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5
Q

Pressure reduction surfaces

A
  1. Redistribute
  2. Inner spring mattress
  3. foam core mattress
  4. thick foam overlay (eggcrate)
  5. low air loss overly
  6. low air loss replacement
  7. alternating air cell
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6
Q

Goal for offloading diabetic foot ulcers

A

control, limit or remove all intrinsic and extrinsic factors that increase plantar pressures.

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7
Q

Diabetic foot ulcers:

Non-surgical trx

A

contact casting, orthotics, cast walkers, therapeutic footwear

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8
Q

Diabetic foot ulcers:

curative surgery

A
  1. exostectomy
  2. digital arthroplasty
  3. bone and joint resection
  4. partial calcanectomy
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9
Q

Venous stasis ulcer treatment

A
  1. elevate the leg

2. compression therapy (rigid or elastic) when you can’t elevate

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10
Q

Benefits of compression therapy

A
  1. improves rate as ulcer healing
  2. reduces incidences of recurrence
  3. prolongs the time to the first recurrence
  4. improves lymphatic drainage
  5. reduces superficial venous pressure
  6. improves blood flow velocity through unoccluded deep and superficial veins
  7. reduces reflux in the deep veins
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11
Q

Arterial Ulcers:

Goal of treatment

A

revascularization procedures

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12
Q

Arterial Ulcers:

Revascularization procedures

A
  1. arterial bypass
  2. angioplasty
  3. stents
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13
Q

Arterial Ulcers:

Arterial bypass

A

most common

graft may be autogenous or synthetic

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14
Q

Arterial Ulcers:

Angioplasty

A

catheter with balloon inserted into artery portion with plaque.
balloon crushes plaque against arterial wall

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15
Q

Arterial Ulcers:

Stents

A

holds the artery open

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16
Q

Perfusion:

effects of impaired blood flow and tissue perfusion

A
  1. ischemia

2. affects scarring, and can lead to increased risk of infection

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17
Q

Nutritional Assessment components

A
  1. Nutrition
  2. Hydration
  3. Education
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18
Q

Nutritional Assessment:

Protein

A
  1. Initial assessment provides baseline data about a patient’s nutritional status
  2. Subsequent assessments reflect changes in status and effects of interventions
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19
Q

Nutritional Assessment:

Nitrogen-balance study

A
  1. Nitrogen input determined by eval of 24 hour intake of nitrogen
  2. Nitrogen output from 24 hr urine collection
  3. Nitrogen input minus output (want=0)
  4. Retained nitrogen available for protein synthesis
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20
Q

Nutritional Assessment:

physical signs of dehydration

A
  1. dry skin
  2. cracked lips
  3. thirst
  4. poor skin turgor
  5. fever
  6. appetite loss
  7. nausea
  8. dizziness
  9. increased confusion
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21
Q

Nutritional Assessment:

clinical signs of dehydration

A
  1. Increased lab values for serum creatinine, HCT, BUN, K+, Cl-, osmolarity, and Na+
  2. Decreased BP
  3. increased pulse rate
  4. constipation
  5. concentrated urine
22
Q

Pressure ulcer Do’s and Don’ts

A

Do:

  1. change position every 2 hours
  2. check skin for signs of pressure ulcers 2/day
  3. use mirror to check difficult areas
  4. follow HEP
  5. well balanced diet, hydrate, maintain recommended weight

Don’ts:

  1. use commercial soaps that dry skin
  2. sleep on wrinkled bed sheet or tuck corners tight into EOB
23
Q

Colonization:

A

Group of organisms living together in or on the body prior to tissue invasion not causing infection

24
Q

Infection:

A

invasion of tissues by microorganisms resulting in systemic reaction

25
Q

Local signs of infection

A
  1. edema
  2. erythema
  3. drainage
  4. warmth
  5. tenderness
  6. crepitus
26
Q

Systemic signs of infection

A
  1. fever
  2. leukocytosis
  3. confusion
  4. tachycardia
  5. HTN
  6. malaise
27
Q

autolytic debridement

A

allows body to lysis necrotic tissue using its own moisture to dissolve tissue.

(don’t do if infected)

28
Q

chemical debridement

A

enzymes applied topically to necrotic tissue. digests.

allows for moist wound healing

29
Q

mechanical debridement

A

use of physical forces to remove necrotic tissue

wet-to-dry dressings
wound irrigation
whirlpool

30
Q

sharp debridement

A

removing necrotic tissue with cutting tool

31
Q

sharp debridement:

conservative vs surgical

A

conservative: removes necrotic tissue only
surgical: removes necrotic and healthy tissue

32
Q

Cleansing:

normal saline

A
  • provides a moist environment
  • promotes granulation tissue formation
  • causes minimal fluid shifts in healthy cells
33
Q

Cleansing:

commercial wound cleansers

A

used to remove containments, foreign debris, and exudate from wound surface

or

used to irrigate deep cavity wound

34
Q

Cleansing:

antiseptic solutions

A

may damage tissue and delay healing

35
Q

Wound environment:

Moist wound bed provides

A
  1. communication amongst cells
  2. communication with growth factors
  3. construction of collagen
  4. migration of new epithelium
36
Q

Wound environment:

Benefit for moist wound bed

A
  1. enhances epidermal migration
  2. promotes new blood vessel growth
  3. promotes development of collagen/CT
37
Q

Wound environment:

Dry wound bed effects

A
  1. WBCs can’t fight infection
  2. enzymes can’t break down dead material
  3. macrophages can’t carry away debris
  4. epithelial cells burrow underneath wound bed preventing re-epitheliazation
38
Q

Components of a wound environment

A

Moist environment

protection from heat and cold

39
Q

Wound environment:

heat

A
  • some benefit, too much detriment.
  • excessive heat can cause increase in bacteria
  • increase of temp combined with pressure =susceptibility to injury
40
Q

Wound environment:

Cold

A
  • may cause hypoxia
  • may have AE on immune function
  • decreased subcut O2
41
Q

Considerations for packing

A
  1. wound size
  2. depth
  3. drainage
  4. type of dressing
  5. solution to maintain moist environment
42
Q

Impact of frequency of dressing changes:

A
  1. prevent washing away of growth factors and other beneficial proteins
  2. protect fragile wound bed from damage
43
Q

Most susceptible areas for pressure ulcers

A

sacrum and coccyx (65%)
trochanter (9%)
heel and ankle (15%)

44
Q

Most common areas for venous ulcers

A

anywhere between ankle and midcalf. medial aspect above malleolus most common

45
Q

Venous ulcer appearance

A

shaggy, irregular borders. usually shallow

46
Q

Venous ulcer pathophysiology

A
  1. vein becomes dilated
  2. blood vessel congestion
  3. fluid leaks out and congests immediate tissue area
  4. tissue becomes poorly perfused, dies, ulcer results
47
Q

Arterial ulcer pathophysiology

A

caused by damaged arteries that decrease blood flow to tissue

leads to cell death

PVD, DM, smoking

48
Q

Arterial ulcer assessment

A
  • weak or absent pulse
  • absence of leg hair
  • thickened nails
  • pain
  • cold feet
49
Q

Ulcers:

minimal drainage, often occurs on the toes or dorsum of the foot, and is accompanied by a weak or absent pulse?

A

arterial

50
Q

Ulcers:

heavy drainage, irregular wound borders, and often results in hemosiderin stains around the lower leg/ankle?

A

venous ulcers

51
Q

Microscopic biochemical environment

A

metabolic control, nutritional status, immune status, presence of inflammation, and tissue perfusion

52
Q

Macroscopic biochemical environment

A

levels of tissue proteases, high levels of cytokines, low levels of growth factors,
tissue hypoxia,
decreased proliferative capacity of the key cells,
increased levels and types of bacteria.

Acute Care (6 decks)

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