Wound Care Part 1 Flashcards

1
Q

what are the layers of the skin?

A

epidermis
dermis
stratum corneum
subQ fatty tissue

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2
Q

what is the largest layer of the skin?

A

the subQ fatty tissue

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3
Q

what are the 3 phases of wound healing?

A

inflammation

proliferation

remodeling/maturation

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4
Q

how long does it take for scar tissue to heal?

A

21 days to 24 months

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5
Q

t/f: epithelialized means that the scar is healed

A

false

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6
Q

what is the timeline for the inflammation phase of healing?

A

0-72 hrs

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7
Q

what is the timeline for the proliferation phase of healing?

A

10-14 days

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8
Q

what is the timeline for the remodeling/maturation phase of healing?

A

24 months

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9
Q

how does aging impact health?

A

slowed healing with age bc skin and skin fxns decrease

decreased dermal thickness

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10
Q

skin begins to decline at ___ yo for women and ___ yo for men

A

25, 35

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11
Q

what are the fxns of the skin?

A

immunity through protection against the entry of microorganisms

thermoregulation

regulation of water loss

sensor

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12
Q

why is thermoregulation impaired in aging populations?

A

bc there is a decrease in sub Q and dermal thickness which aids in thermoregulation

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13
Q

skin fxns deteriorate due to what changes?

A

morphological/structural changes

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14
Q

what are the extrinsic factors that influence aging skin?

A

genetic makeup

changes in hormone levels

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15
Q

what are the intrinsic factors that influence aging skin?

A

sun exposure

tobacco smoking

alcohol abuse

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16
Q

what are the age related skin changes?

A

epidermal changes

dermis changes

dimished sensation to light touch/pressure/temp

reduced sebum secretion

decreased capacity to produce vit D3

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17
Q

what are the epidermal changes that happen with aging?

A

decreased # of Langerhan cells and malocytes

flattening of the dermal-epidermal junction

keratinocyte proliferation is reduced and the turnover time is increased by 50%

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18
Q

what are the dermis changes that happen with aging?

A

fewer fibroblasts, macrophages, and mast cells

reduced vascularity

loss in ECM components such as collagen and glycosaminoglycan

imbalance of collagen production and degradation

odd morphology of elastin

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19
Q

what are the 3 most common types of neoplastic skin diseases?

A

basal cell carcinoma

squamous cell carcinoma

malignant melanoma

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20
Q

what are the ABCD rules with cancerous skin lesions?

A

A-asymmetry of the pigmented lesion

B-borders that are irregular

C-color varies from dark black to dark brown to dark red

D-diameter of the lesion (>6mm)

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21
Q

t/f: any alteration in the skin whether a break, bruise, or discoloration is considered a wound

A

true

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22
Q

a wound can heal in what 3 primary categories?

A

primary intention

secondary intention

tertiary intention

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23
Q

what is primary intention?

A

wound that closes essentially on its own

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24
Q

what kind of healing is characterized by no loss of tissue, well approximated edges, clean edges that can be pulled together, and usually heal within 4-14 days with a hairline scar?

A

primary intention

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25
Q

what is secondary intention?

A

when you have to force the wound into healing, and usually leaves a scar

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26
Q

what kind of healing is characterized by some degree of tissue loss, longer healing time, more scarring, higher rates of complications, edges that don’t easily approximate?

A

secondary intention

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27
Q

what is tertiary intention?

A

wounds that need help closing witch stitches, grafts, etc

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28
Q

what types of healing is characterized by a wound that may be left open, may be debrided, are closed with sutures or some other skin closure, and generally result in a wide scar?

A

tertiary intention

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29
Q

what local factors would delay wound healing?

A

bioburden (bacteria)

perfusion

dessication (bad tissue/moisture)

foreign body

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30
Q

what systemic factors would delay wound healing?

A

stress

obesity

nutrition

comorbidities

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31
Q

what are some comorbidities that could delay wound healing?

A

DM, COPD, CHF, arthritis

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32
Q

what iatrogenic factors would delay wound healing?

A

meds (antibiotics, anti-inflammatories)

topic agents

trauma due to inappropriate tx

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33
Q

if there is a bone infection, what likely needs to be done?

A

amputation

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34
Q

what is the mortality rate at 2 yrs post amputation?

A

50%

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35
Q

what is the mortality rate at 3 yrs post amputation?

A

an additional 50%

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36
Q

t/f: as long as the pt is not in medical danger, we should give pts the chance to heal b4 amputating

A

true

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37
Q

what are the signs of a wound that lacks healing?

A

the wound bed is dry

there is no change/an increase in the size/depth in 2 weeks

presence of necrotic tissue

increased in drainage or change in drainage color

tunneling/undermining/sinus tracts

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38
Q

what are the signs of healing failure?

A

red, hot skin (INFECTION)

tenderness or induration of the skin (INFECTION)

maceration

epibole

ecchymosis

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39
Q

what is induration?

A

hardness of the skin

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40
Q

what is maceration?

A

white tissue from too much fluid

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41
Q

a dry cell is a ____ cell

A

DEAD

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42
Q

what is epibole?

A

rolled wound edges that must be gotten rid of before healing can occur

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43
Q

what are the possible complications of wound healing?

A

dehisence

infection

fistulas and sinus tracts

undermining

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44
Q

what is a sinus tract?

A

course/pathway which can extend in any direction from the base of the wound

a soft cavity w/o defined edges resulting in an area larger than the visible surface of the wound

results in dead space and potential for abscesses to form

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45
Q

what is a wound tunnel?

A

a deep, open space within defined walls that may/may not have an exit

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46
Q

what is undermining?

A

a pocket of dead space occurring around the edges of a wound

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47
Q

why might an arterially insufficient wound not heal well?

A

bc of poor blood flow

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48
Q

why would PT be involved in wound management?

A

bc we know that the best way to increase circulation needed for wound healing is to exercise and move your body

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49
Q

t/f: the pt assessment in wound care is more or less the same as a normal eval with some added wound considerations

A

true

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50
Q

pts with wounds need ___ times the amount of protein for good healing

A

3

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51
Q

what system impairments might contribute to wounds and healing processes

A

CV
neuromuscular
MSK

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52
Q

what personal factors might impact wound healing?

A

medical comorbidities

anxiety

depression

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53
Q

what environmental factors might impact wound healing?

A

meds

financial resources

family/social support

equipment available

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54
Q

what things do we need to gather about a pt in wound care?

A

age, sex, occupation

recent injury/trauma

medical/surgical hx

current meds

mobility

nutrition

wound hx

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55
Q

what do we need to know about the wound hx?

A

onset, sx, duration

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56
Q

what tests of blood flow do we need to do?

A

ABI

capillary refill

pulses

rubor on dependency

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57
Q

what neuro fxn do we need to test with wound care?

A

loss of protective sensation

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58
Q

how do we classify wounds?

A

by age, color, degree of tissue loss, and etiology

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59
Q

how do we classify wounds by age?

A

acute vs chronic

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60
Q

what is an acute wound?

A

a new, healing wounds normally by primary intention

any wound <30 days

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61
Q

what is a chronic wound?

A

a wound in which the healing has stopped/slowed, typically healing by secondary intention

any wound >30 days

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62
Q

how do we classify wounds by degree of tissue loss?

A

partial thickness vs full thickness

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63
Q

what is a partial thickness wound?

A

a wound that extends through the epidermia and Amy extend into but no through the dermis

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64
Q

what is a full thickness wound?

A

a wound that extends through the dermis and into underlying structures such as adipose, muscle, and bone tissues

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65
Q

t/f: if a wound is not staged, wound care cannot be claimed as part of your care

A

true

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66
Q

all wounds can be categorized as either partial or full thickness wounds except what two types of wounds?

A

pressure wounds and diabetic foot ulcers

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67
Q

what is the classification system for diabetic foot ulcers?

A

the Wagner scale

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68
Q

what is the classification system for pressure wounds?

A

a staging system

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69
Q

how do we calculate the surface area of a wound?

A

length x width

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70
Q

t/f: our wound measurements should be to the outermost edge of the periwound

A

true

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71
Q

how do we calculate the volume of a wound?

A

length x width x height

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72
Q

what is wound tracing?

A

outlining the wound edges to track progress

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73
Q

what unit of measurement is typically preferred?

A

cm

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74
Q

t/f: when measuring wounds, you should use phrases like “nickel, dime, or quarter sized”

A

false, don’t do that shit

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75
Q

t/f: you can use the clock reference to document undermining of a wound

A

true

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76
Q

how do we measure tunneling/sinus tracts?

A

with a long ass q tip looking thingy

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77
Q

what are the types of devitalized tissues?

A

fibrin

necrotic

slough

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78
Q

what is fibrin?

A

thick white dead tissue that we can’t just lift off the wound

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79
Q

what is necrotic tissue?

A

thick black or brown tissue

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80
Q

what is the name of necrotic tissue that is flat and black?

A

eschar

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81
Q

what is slough?

A

soft, yellow, or tan tissue that looks kinda like slime?

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82
Q

what is granulation tissue?

A

bumpy, shiny red tissue

beefy red tissue

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83
Q

what is epithelial tissue?

A

dry, usually skin colored tissue

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84
Q

t/f; we should describe the % of the different types of tissue in a wound

A

true

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85
Q

what exposed structures might we see in a wound?

A

bone, tendons, metal implants

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86
Q

what are the types of periwound statuses?

A

redness

swelling

epibole

well-defined

purse string effect

erythema

maceration

edema

tape injury

induration

fluctuance

warmth

pain

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87
Q

how do we document the amount of drainage/exudate?

A

none, minimal, moderate, copious

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88
Q

what is serous fluid?

A

thin, watery drainage

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89
Q

what is purulent drainage?

A

fluid containing, consisting of, or forming pus

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90
Q

what is serosanguinous drainage?

A

bloody fluid consisting primarily of red blood cells and water

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91
Q

how do we document wound odor?

A

absent, mild, moderate, foul

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92
Q

what odor and color does a wound from pseudomonas infection cause?

A

sweet smell with a greenish-blue tinge

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93
Q

what odor does a wound from anaerobic organisms cause?

A

fecal smell

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94
Q

what odor does a wound from aerobic organisms cause?

A

various smells

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95
Q

how do we document the consistency of drainage?

A

thin/watery, thick/opaque

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96
Q

what is the appearance of hemorrhagic/sanguineous fluid?

A

bright red or bloody

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97
Q

are there RBCs present in hemorrhagic/sanguineous fluid?

A

yes

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98
Q

when is hemorrhagic/sanguineous fluid expected?

A

after surgery

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99
Q

what is the appearance of serosanguinous fluid?

A

bloody-tinged yellow or link

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100
Q

are there RBCs present in serosanguinous fluid?

A

yes

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101
Q

when is serosanguineous fluid expected?

A

48-72 hrs post op

102
Q

a sudden increase in serosangineous fluid may proceed what?

A

dehiscence

103
Q

what is the appearance of serous fluid?

A

thin, clear yellow or straw colored

104
Q

does serous fluid contain RBCs?

A

no, it contains albumin and immunoglobulins

105
Q

when is serous fluid expected?

A

in the early stages of blisters, inflammation, joint effusion

up to 1 week after trauma/surgery

106
Q

what does a sudden increase in serous fluid indicate?

107
Q

what is the appearance of purulent fluid?

A

viscous, cloudy, pus with cellular debris from necrotic cells and dying neutrophils/PMN/leukocytes

108
Q

does purulent fluid contain RBCs?

A

no, it contains cellular debris from necrotic cells and dying neutrophils/PMN/leukocytes

109
Q

what causes purulent fluid?

A

pus forming bacteria

110
Q

what does purulent drainage indicate?

A

possible infection

111
Q

t/f: purulent fluid may drain suddenly from an abscess

112
Q

what is the appearance of catarrhal fluid?

A

thin clear mucus

113
Q

when would we see catarrhal fluid?

A

with a respiratory infection

114
Q

would we need to implement pain control measures prior to treatment of a full thickness wound? why or why not?

A

no bc there aren’t any exposed nerve endings

115
Q

what are pressure injuries?

A

localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device that can present as intact skin or an open ulcer and may be painful

the injury results from intense and/or prolonged pressure or pressure in combo with shear

116
Q

what are common locations of pressure injuries?

A

sacrum

heels

greater trochanter

ischial tuberosity

117
Q

what are the risk factors for pressure injuries?

A

immobility

incontinence

advanced age

malnutrition

low BP

infection

118
Q

what are the top two risk factors for pressure injuries?

A

immobility and incontinence

119
Q

t/f: a pt is guaranteed to get a wound if they are incontinent and left alone without getting cleaned up bc the urine is so acidic and hard on the epidermis

120
Q

what is a stage 1 pressure injury?

A

Intact skin with localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin

Presence of blanchable erythema or changes in sensation, temp, or firmness may precede visual changes

121
Q

what is a stage 2 pressure injury?

A

Partial thickness loss of skin with exposed dermis

The wound bed is viable, pink/red, moist, and may present as an intact or ruptured serum-filled blister

122
Q

what is a stage 3 pressure injury?

A

Full thickness loss of skin, in which adipose tissue is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are present

123
Q

what is a stage 4 pressure injury?

A

Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer

124
Q

what is an unstageable pressure injury?

A

Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer can’t be confirmed bc it is obscured by slough or eschar (dead tissue in the way of measuring it)

125
Q

what is a deep tissue injury?

A

Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blister filled (72 hrs after operation)

126
Q

what pressure injuries are low pressure, long time?

A

superficial pressure ulcers

127
Q

what are the extrinsic contributing factors to superficial pressure ulcers?

A

moisture

heat

friction

extended time

128
Q

what are the extrinsic contributing factors to deep tissue injuries?

A

positioning

firmness of surface

time

129
Q

what are the intrinsic contributing factors to superficial pressure ulcers?

A

decreased sensory/motor

decreased nutrition

130
Q

what are the intrinsic contributing factors to deep tissue injuries?

A

decreased sensory/motor

atrophy

131
Q

what is a deep tissue injury (DTI)?

A

a tissue injury that occurs from the inside out and rapidly progresses to a stage 4 pressure injury/unstageable

132
Q

what are the phases of a deep tissue injury?

A

early presentation

blister phase

necrotic phase

133
Q

what are medical device related pressure injuries?

A

pressure injuries that result from the use of devices designed and applied for diagnostic or therapeutic purposes

134
Q

t/f: with medical device related pressure injuries, the resultant pressure injury generally conforms to the pattern/shape of the device

135
Q

what are the contributing factors that can help us ID poor nutrition?

A

impaired nutritional intake

low body weight/unintentional weight loss

136
Q

albumin measures levels over the past ___ days

137
Q

what is the normal albumin level?

138
Q

t/f: serum albumin and pre-albumin are not components of the currently accepted definition of malnutrition and do not serve as valid proxy measures of total body protein or total muscles mass

139
Q

should albumin or pre-albumin be used as nutrition markers?

140
Q

t/f: the serum concentrations of albumin and pre-albumin decline in the presence of inflammation, regardless of the underlying nutritional status

141
Q

is there an association bw visceral protein levels and malnutrition?

A

no, the association is bw malnutrition and inflammation

142
Q

pre-albumin measures levels over the past ___ days

143
Q

what is normal hemoglobin?

A

12-17 g/dL

144
Q

what is normal hematocrit?

145
Q

how can we check hydration levels?

A

by pinching the skin on the dorsum of the hand and seeing how fast it returns to its normal shape

146
Q

t/f: obese pts usually have poor nutrition

147
Q

what are the warning signs for poor nutrition? (long ass list, just know a few)

A

Disease

Eating properly

Tooth loss/mouth pain

Economic hardship

Reduced social contact

Multiple meds

Involuntary weight loss/gain

Needs assistance in self-care

Elder years above age 80

148
Q

what are better overall assessments of health than nutrition?

A

BMI

weight changes

disease severity

GI sx

physical exam

mobility

fxnal capacity

cognitive fxn

aged >70 yo

149
Q

if someone is at high risk for developing a pressure wound, what do they NEED?

A

a support surface bc a mattress won’t work

150
Q

what is involved in the etiology of pressure ulcers?

A

tissue anoxia

accumulation of waste

more permeable capillaries (edema)

slowed perfusion

cell death

increased metabolic waste release

increased tissue inflammation

151
Q

what is the minimal pressure it takes to collapse capillaries?

A

32 mmHg (not a lot of pressure)

152
Q

just sitting for ___ minutes could cause a pressure injury

153
Q

t/f: friction injuries involve superficial skin layers when moving across coarse surfaces

154
Q

what are high risk persons for friction/shear injuries?

A

those who are immobile

those with sensory loss

those with altered consciousness

155
Q

what can we do to minimize friction/shear injury?

A

use positioning, transferring, and turning techniques

156
Q

how can we prevent friction/shear injury?

A

with heel protectors, stockings, elevation of heels, skill protectants

157
Q

how often should bed bound individuals be repositioned?

A

every 2 hours

158
Q

how often should chair bound individuals be repositioned?

A

every hour

159
Q

for chair bound individuals, we should encourage weight shifts every ____ minutes

160
Q

what position to we have to put someone in to remove pressure from the sacrum?

A

turned 40 deg (not quite to SL) using foam wedges to keep them in this position

161
Q

why would we not put someone in SL to remove pressure from the sacrum?

A

bc it puts the ear, hip, and shoulder at risk

162
Q

what is autolytic debridement?

A

the use of a semi-occlusive dressing to keep eschar moist until it liquifies

163
Q

is autolytic debridement painful?

164
Q

how long does it take for autolytic debridement to work?

A

weeks to months

165
Q

what types of wounds would we use autolytic debridement on?

A

a well perfused wound with minimal necrotic tissue

166
Q

what are the indications for use of autolytic debridement?

A

use in wounds where there is light to moderate drainage

167
Q

t/f: autolytic debridement is NOT indicated when infection is present or suspected

168
Q

what are the advantages of autolytic debridement?

A

painless (sometimes??)

169
Q

what are the disadvantages of autolytic debridement?

A

slow acting

risk of infection

170
Q

what is biologic debridement?

A

the use of sterile maggots to ingest necrotic tissue from a wound

171
Q

how long does it take biologic debridement to work?

172
Q

what types of wounds would we use biologic debridement on?

A

wounds where sharp debridement is contraindicated

173
Q

what are the advantages of biologic debridement?

A

relatively fast acting (but not really bc it takes weeks)

174
Q

what are the disadvantages of biologic debridement?

A

psychologically challenging

short term use

175
Q

what are the indications for use of biologic debridement?

A

used with minimal to large amounts of necrotic tissue when surgical debridement isn’t possible

to avoid damage to viable tissue

176
Q

what is enzymatic (chemical) debridement?

A

topical application of enzymes to digest proteins

177
Q

is enzymatic (chemical) debridement painful?

178
Q

how long does it take enzymatic (chemical) debridement to work?

A

days to weeks

179
Q

what types of wounds would we use enzymatic (chemical) debridement on?

A

exudation and necrotic wounds

180
Q

what are the advantages of enzymatic (chemical) debridement?

A

moderately acting

generally no effect on viable tissue

181
Q

what are the disadvantages of enzymatic (chemical) debridement?

A

it is expensive and requires a prescription

182
Q

what are the indications for use of enzymatic (chemical) debridement?

A

used with any amount of necrotic tissue when surgical or mechanical debridement may not be indicated or in combo with other forms of debridement

183
Q

what is mechanical debridement?

A

hydrotherapy irrigation using a syringe or high power

wound scrubbing

wet to dry dressings

184
Q

is mechanical debridement painful?

185
Q

how long does mechanical debridement take to work?

A

days to weeks

186
Q

what wounds would we use mechanical debridement for?

A

exudation and necrotic wounds

187
Q

what are the disadvantages of mechanical debridement?

A

slow acting

painful

may damage viable tissue

may cause maceration and infection

188
Q

what are the advantages of mechanical debridement?

A

it is inexpensive

189
Q

what are the indications for use of mechanical debridement?

A

wounds with moderate amounts of exudate

to remove loose debris

to soften eschar, callus, and other necrotic tissue

190
Q

what is surgical debridement?

A

surgical excision (scalpel, curette, scissors, foreceps) to remove tissue

191
Q

what type of surgical debridement do surgeons have to do?

A

sharp excisional

192
Q

what types of surgical debridement can PTs do?

A

sharp selective

193
Q

is surgical debridement painful?

194
Q

how long does it take surgical debridement to work?

A

it works immediately

195
Q

what are the advantages of surgical debridement?

A

it is fast acting

196
Q

what is the gold standard for debridement?

A

surgical debridement

197
Q

what are the disadvantages of surgical debridement?

A

it may require local or general anesthesia for the pain

198
Q

what is ultrasonic debridement?

A

using a 20-30 kHz low frequency US device with a debridement wands to longitudinally scrape the wound bed

199
Q

is ultrasonic debridement painful?

200
Q

how long does it take ultrasonic debridement to work?

A

days to weeks

201
Q

what wounds would we use surgical debridement for?

A

all types of wounds

202
Q

what wounds would we use ultrasonic debridement for?

A

all types of wounds

wounds with fibrin and slough

203
Q

what are the advantages of ultrasonic debridement?

A

it quickly removes tissue (2-4 min)

it neutralizes acidic environments

it is less painfully than sharp-excisional debridement

204
Q

what are the disadvantages of ultrasonic debridement?

A

it is expensive

it requires tops to be autoclaved and sterilized

it is not reimbursed well

205
Q

what are the indications for use of ultrasonic debridement?

A

adherent necrotic tissue, fibrin, and slough

to flush encapsulated bacteria

when not a candidate for surgical debridement

206
Q

what is debridement?

A

removal of devitalized tissue (necrotic) and foreign matter, which supports the growth of pathological organisms

207
Q

what is the goal of debridement?

A

to improve the healing potential of the remaining viable tissue

208
Q

why is debridement necessary?

A

to decrease bacterial burden and risk of infection

to facilitate healing

to eliminate edema

to maximize moist wound environment

to manage local and systemic factors

for prevention of cancer and other skin conditions

209
Q

if a wound has been there longer than 6 months, what should we do? why?

A

have them go for a biopsy bc it may be cancer

210
Q

what is eschar?

A

thick, leathery necrotic tissue

flat black necrotic tissue

211
Q

what is slough?

A

loose stringy tissue that is yellow, green, or gray

212
Q

what is necrotic tissue?

A

dead, avascular tissue that is green, gray, or yellow

213
Q

what is fibrin?

A

insoluble protein that cannot be wiped off and often cannot be scraped off

white tissue

214
Q

will regular debridement work on fibrin?

215
Q

what is biofilm?

A

bacteria that grow EVERYWHERE and impair healing ability

216
Q

why would antibiotics not help with biofilm?

A

bc the bacteria in biofilm become metabolically inactive and only metabolically active bacteria respond to antibiotics

217
Q

what is the only way to get rid of biofilm?

218
Q

what factors do we need to consider b4 debridement?

A

overall pt health status

etiology of the wound

types of necrotic tissue

potential for wound to heal

pain control

clinical skills and expertise

219
Q

what is the mechanism of action of enzymatic/chemical debridement?

A

commercially applied enzymes that aggressively digest devitalized tissue by proteolytic and other enzymes

220
Q

when using enzymatic/chemical with eschar, what do we have to do b4?

A

cross hatch the tissue with a blade for it to work and get through the tissue

221
Q

t/f: enzymatic/chemical debridement must be applied DIRECTLY to the wound

222
Q

what debridement would we use when there is granulation tissue present? why?

A

enzymatic/chemical or biological debridement bc they are the least destructive

223
Q

what is the mechanism of action of mechanical debridement?

A

use of external force or manipulation to remove devitalized tissue

224
Q

what is selective sharp debridement?

A

used when a plane of non-viable tissue has separated from intact skin

225
Q

what is excisional debridement?

A

removal of tissue at the wound/wound margin until viable tissue is removed (done by a surgeon)

226
Q

would we use surgical debridement if the pt has poor blood flow like in arterial insufficiency?

227
Q

when is surgical debridement done?

A

when the devitalized tissue needs to come out FAST and when a wound is unstageable

228
Q

what is the mechanism of action of ultrasonic debridement?

A

the vibration of 38 kHz is applied longitudinally along the wound bed fragments and removes the adherent necrotic tissue

saline comes out to keep the wound cool

229
Q

when there is black, dry, and shriveled up tissue, should we debride it?

A

no, this is dead tissue and will autoamputate

230
Q

if the wound bed consists of beefy red tissue, what does it need?

A

a dressing, not debridement

231
Q

what is the normal ABI range?

232
Q

what does an ABI of >1.2 mean?

A

abnormal vessel hardening from PVD

233
Q

what does an ABI of 0.90-0.99 mean?

A

acceptable range

234
Q

what does an ABI of 0.80-0.89 mean?

A

some arterial disease

235
Q

what does an ABI of 0.50-0.79 mean?

A

moderate arterial disease

236
Q

what does an ABI of <0.50 mean?

A

severe arterial disease

237
Q

if someone has an ABI >1.2, what should we do?

A

refer routinely

238
Q

if someone has an ABI 0.80-0.89, what should we do?

A

manage risk factors

239
Q

if someone has an ABI 0.50-0.79, what should we do?

A

routine specialist referral

240
Q

if someone has an ABI <0.50, what should we do?

A

urgent specialist referral

241
Q

what is the nature of the ulcers, if present with ABI bw 0.80-1.2?

A

venous ulcers

242
Q

what is the nature of the ulcers, if present with ABI 0.50-0.79?

A

mixed ulcers

243
Q

what is the nature of the ulcers, if present with ABI <0.50?

A

arterial ulcer

244
Q

what is the ABI calculation?

A

higher ankle #/higher arm #

245
Q

what are the arterial tests?

A

capillary refill

rubor of dependency

246
Q

t/f: capillary refill indicates the adequacy of peripheral perfusion

247
Q

how do we test capillary refill?

A

firmly pinch the great for 5 sec to blanch skin then release the pressure and measure how quickly normal color returns

248
Q

what is a normal capillary refill test? abnormal?

A

normal= </=2 sec to return to normal color

abnormal=>2 sec to return to normal color

249
Q

how do we test rubor of dependency?

A

lie the pt in supine and elevate the foot to a 30 deg angle to see if the skin turns pale within 30 sec(pallor elevation)

then have the pt sit upright with the foot in a dependent position to see if there is a dramatic reddening of the foot within 30 sec (rubor of dependency)

250
Q

what does pallor of elevation suggest?

A

arterial insufficiency

251
Q

what does rubor of dependency suggest?

A

severe ischemia