Wound Care Part 1 Flashcards
what are the layers of the skin?
epidermis
dermis
stratum corneum
subQ fatty tissue
what is the largest layer of the skin?
the subQ fatty tissue
what are the 3 phases of wound healing?
inflammation
proliferation
remodeling/maturation
how long does it take for scar tissue to heal?
21 days to 24 months
t/f: epithelialized means that the scar is healed
false
what is the timeline for the inflammation phase of healing?
0-72 hrs
what is the timeline for the proliferation phase of healing?
10-14 days
what is the timeline for the remodeling/maturation phase of healing?
24 months
how does aging impact health?
slowed healing with age bc skin and skin fxns decrease
decreased dermal thickness
skin begins to decline at ___ yo for women and ___ yo for men
25, 35
what are the fxns of the skin?
immunity through protection against the entry of microorganisms
thermoregulation
regulation of water loss
sensor
why is thermoregulation impaired in aging populations?
bc there is a decrease in sub Q and dermal thickness which aids in thermoregulation
skin fxns deteriorate due to what changes?
morphological/structural changes
what are the extrinsic factors that influence aging skin?
genetic makeup
changes in hormone levels
what are the intrinsic factors that influence aging skin?
sun exposure
tobacco smoking
alcohol abuse
what are the age related skin changes?
epidermal changes
dermis changes
dimished sensation to light touch/pressure/temp
reduced sebum secretion
decreased capacity to produce vit D3
what are the epidermal changes that happen with aging?
decreased # of Langerhan cells and malocytes
flattening of the dermal-epidermal junction
keratinocyte proliferation is reduced and the turnover time is increased by 50%
what are the dermis changes that happen with aging?
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
what are the 3 most common types of neoplastic skin diseases?
basal cell carcinoma
squamous cell carcinoma
malignant melanoma
what are the ABCD rules with cancerous skin lesions?
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)
t/f: any alteration in the skin whether a break, bruise, or discoloration is considered a wound
true
a wound can heal in what 3 primary categories?
primary intention
secondary intention
tertiary intention
what is primary intention?
wound that closes essentially on its own
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?
primary intention
what is secondary intention?
when you have to force the wound into healing, and usually leaves a scar
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?
secondary intention
what is tertiary intention?
wounds that need help closing witch stitches, grafts, etc
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?
tertiary intention
what local factors would delay wound healing?
bioburden (bacteria)
perfusion
dessication (bad tissue/moisture)
foreign body
what systemic factors would delay wound healing?
stress
obesity
nutrition
comorbidities
what are some comorbidities that could delay wound healing?
DM, COPD, CHF, arthritis
what iatrogenic factors would delay wound healing?
meds (antibiotics, anti-inflammatories)
topic agents
trauma due to inappropriate tx
if there is a bone infection, what likely needs to be done?
amputation
what is the mortality rate at 2 yrs post amputation?
50%
what is the mortality rate at 3 yrs post amputation?
an additional 50%
t/f: as long as the pt is not in medical danger, we should give pts the chance to heal b4 amputating
true
what are the signs of a wound that lacks healing?
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
what are the signs of healing failure?
red, hot skin (INFECTION)
tenderness or induration of the skin (INFECTION)
maceration
epibole
ecchymosis
what is induration?
hardness of the skin
what is maceration?
white tissue from too much fluid
a dry cell is a ____ cell
DEAD
what is epibole?
rolled wound edges that must be gotten rid of before healing can occur
what are the possible complications of wound healing?
dehisence
infection
fistulas and sinus tracts
undermining
what is a sinus tract?
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
what is a wound tunnel?
a deep, open space within defined walls that may/may not have an exit
what is undermining?
a pocket of dead space occurring around the edges of a wound
why might an arterially insufficient wound not heal well?
bc of poor blood flow
why would PT be involved in wound management?
bc we know that the best way to increase circulation needed for wound healing is to exercise and move your body
t/f: the pt assessment in wound care is more or less the same as a normal eval with some added wound considerations
true
pts with wounds need ___ times the amount of protein for good healing
3
what system impairments might contribute to wounds and healing processes
CV
neuromuscular
MSK
what personal factors might impact wound healing?
medical comorbidities
anxiety
depression
what environmental factors might impact wound healing?
meds
financial resources
family/social support
equipment available
what things do we need to gather about a pt in wound care?
age, sex, occupation
recent injury/trauma
medical/surgical hx
current meds
mobility
nutrition
wound hx
what do we need to know about the wound hx?
onset, sx, duration
what tests of blood flow do we need to do?
ABI
capillary refill
pulses
rubor on dependency
what neuro fxn do we need to test with wound care?
loss of protective sensation
how do we classify wounds?
by age, color, degree of tissue loss, and etiology
how do we classify wounds by age?
acute vs chronic
what is an acute wound?
a new, healing wounds normally by primary intention
any wound <30 days
what is a chronic wound?
a wound in which the healing has stopped/slowed, typically healing by secondary intention
any wound >30 days
how do we classify wounds by degree of tissue loss?
partial thickness vs full thickness
what is a partial thickness wound?
a wound that extends through the epidermis and may extend into but no through the dermis
what is a full thickness wound?
a wound that extends through the dermis and into underlying structures such as adipose, muscle, and bone tissues
t/f: if a wound is not staged, wound care cannot be claimed as part of your care
true
all wounds can be categorized as either partial or full thickness wounds except what two types of wounds?
pressure wounds and diabetic foot ulcers
what is the classification system for diabetic foot ulcers?
the Wagner scale
what is the classification system for pressure wounds?
a staging system
how do we calculate the surface area of a wound?
length x width
t/f: our wound measurements should be to the outermost edge of the periwound
true
how do we calculate the volume of a wound?
length x width x height
what is wound tracing?
outlining the wound edges to track progress
what unit of measurement is typically preferred?
cm
t/f: when measuring wounds, you should use phrases like “nickel, dime, or quarter sized”
false, don’t do that shit
t/f: you can use the clock reference to document undermining of a wound
true
how do we measure tunneling/sinus tracts?
with a long ass q tip looking thingy
what are the types of devitalized tissues?
fibrin
necrotic
slough
what is fibrin?
thick white dead tissue that we can’t just lift off the wound
what is necrotic tissue?
thick black or brown tissue
what is the name of necrotic tissue that is flat and black?
eschar
what is slough?
soft, yellow, or tan tissue that looks kinda like slime?
what is granulation tissue?
bumpy, shiny red tissue
beefy red tissue
what is epithelial tissue?
dry, usually skin colored tissue
t/f; we should describe the % of the different types of tissue in a wound
true
what exposed structures might we see in a wound?
bone, tendons, metal implants
what are the types of periwound statuses?
redness
swelling
epibole
well-defined
purse string effect
erythema
maceration
edema
tape injury
induration
fluctuance
warmth
pain
how do we document the amount of drainage/exudate?
none, minimal, moderate, copious
what is serous fluid?
thin, watery drainage
what is purulent drainage?
fluid containing, consisting of, or forming pus
what is serosanguinous drainage?
bloody fluid consisting primarily of red blood cells and water
how do we document wound odor?
absent, mild, moderate, foul
what odor and color does a wound from pseudomonas infection cause?
sweet smell with a greenish-blue tinge
what odor does a wound from anaerobic organisms cause?
fecal smell
what odor does a wound from aerobic organisms cause?
various smells
how do we document the consistency of drainage?
thin/watery, thick/opaque
what is the appearance of hemorrhagic/sanguineous fluid?
bright red or bloody
are there RBCs present in hemorrhagic/sanguineous fluid?
yes
when is hemorrhagic/sanguineous fluid expected?
after surgery
what is the appearance of serosanguinous fluid?
bloody-tinged yellow or pink
are there RBCs present in serosanguinous fluid?
yes
when is serosanguineous fluid expected?
48-72 hrs post op
a sudden increase in serosangineous fluid may proceed what?
dehiscence
what is the appearance of serous fluid?
thin, clear yellow or straw colored
does serous fluid contain RBCs?
no, it contains albumin and immunoglobulins
when is serous fluid expected?
in the early stages of blisters, inflammation, joint effusion
up to 1 week after trauma/surgery
what does a sudden increase in serous fluid indicate?
seroma
what is the appearance of purulent fluid?
viscous, cloudy, pus with cellular debris from necrotic cells and dying neutrophils/PMN/leukocytes
does purulent fluid contain RBCs?
no, it contains cellular debris from necrotic cells and dying neutrophils/PMN/leukocytes
what causes purulent fluid?
pus forming bacteria
what does purulent drainage indicate?
possible infection
t/f: purulent fluid may drain suddenly from an abscess
true
what is the appearance of catarrhal fluid?
thin clear mucus
when would we see catarrhal fluid?
with a respiratory infection
would we need to implement pain control measures prior to treatment of a full thickness wound? why or why not?
no bc there aren’t any exposed nerve endings
what are pressure injuries?
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
what are common locations of pressure injuries?
sacrum
heels
greater trochanter
ischial tuberosity
what are the risk factors for pressure injuries?
immobility
incontinence
advanced age
malnutrition
low BP
infection
what are the top two risk factors for pressure injuries?
immobility and incontinence
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
true
what is a stage 1 pressure injury?
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
what is a stage 2 pressure injury?
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
what is a stage 3 pressure injury?
Full thickness loss of skin, in which adipose tissue is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are present
what is a stage 4 pressure injury?
Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer
what is an unstageable pressure injury?
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)
what is a deep tissue injury?
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)
what pressure injuries are low pressure, long time?
superficial pressure ulcers
what are the extrinsic contributing factors to superficial pressure ulcers?
moisture
heat
friction
extended time
what are the extrinsic contributing factors to deep tissue injuries?
positioning
firmness of surface
time
what are the intrinsic contributing factors to superficial pressure ulcers?
decreased sensory/motor
decreased nutrition
what are the intrinsic contributing factors to deep tissue injuries?
decreased sensory/motor
atrophy
what is a deep tissue injury (DTI)?
a tissue injury that occurs from the inside out and rapidly progresses to a stage 4 pressure injury/unstageable
what are the phases of a deep tissue injury?
early presentation
blister phase
necrotic phase
what are medical device related pressure injuries?
pressure injuries that result from the use of devices designed and applied for diagnostic or therapeutic purposes
t/f: with medical device related pressure injuries, the resultant pressure injury generally conforms to the pattern/shape of the device
true
what are the contributing factors that can help us ID poor nutrition?
impaired nutritional intake
low body weight/unintentional weight loss
albumin measures levels over the past ___ days
90
what is the normal albumin level?
3.5 g/dL
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
true
should albumin or pre-albumin be used as nutrition markers?
no
t/f: the serum concentrations of albumin and pre-albumin decline in the presence of inflammation, regardless of the underlying nutritional status
true
is there an association bw visceral protein levels and malnutrition?
no, the association is bw malnutrition and inflammation
pre-albumin measures levels over the past ___ days
7
what is normal hemoglobin?
12-17 g/dL
what is normal hematocrit?
37-52%
how can we check hydration levels?
by pinching the skin on the dorsum of the hand and seeing how fast it returns to its normal shape
t/f: obese pts usually have poor nutrition
true
what are the warning signs for poor nutrition? (long ass list, just know a few)
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
what are better overall assessments of health than nutrition?
BMI
weight changes
disease severity
GI sx
physical exam
mobility
fxnal capacity
cognitive fxn
aged >70 yo
if someone is at high risk for developing a pressure wound, what do they NEED?
a support surface bc a mattress won’t work
what is involved in the etiology of pressure ulcers?
tissue anoxia
accumulation of waste
more permeable capillaries (edema)
slowed perfusion
cell death
increased metabolic waste release
increased tissue inflammation
what is the minimal pressure it takes to collapse capillaries?
32 mmHg (not a lot of pressure)
just sitting for ___ minutes could cause a pressure injury
15
t/f: friction injuries involve superficial skin layers when moving across coarse surfaces
true
what are high risk persons for friction/shear injuries?
those who are immobile
those with sensory loss
those with altered consciousness
what can we do to minimize friction/shear injury?
use positioning, transferring, and turning techniques
how can we prevent friction/shear injury?
with heel protectors, stockings, elevation of heels, skill protectants
how often should bed bound individuals be repositioned?
every 2 hours
how often should chair bound individuals be repositioned?
every hour
for chair bound individuals, we should encourage weight shifts every ____ minutes
15
what position do we have to put someone in to remove pressure from the sacrum?
turned 40 deg (not quite to SL) using foam wedges to keep them in this position
why would we not put someone in SL to remove pressure from the sacrum?
bc it puts the ear, hip, and shoulder at risk
what is autolytic debridement?
the use of a semi-occlusive dressing to keep eschar moist until it liquifies
is autolytic debridement painful?
sometimes
how long does it take for autolytic debridement to work?
weeks to months
what types of wounds would we use autolytic debridement on?
a well perfused wound with minimal necrotic tissue
what are the indications for use of autolytic debridement?
use in wounds where there is light to moderate drainage
t/f: autolytic debridement is NOT indicated when infection is present or suspected
true
what are the advantages of autolytic debridement?
painless (sometimes??)
what are the disadvantages of autolytic debridement?
slow acting
risk of infection
what is biologic debridement?
the use of sterile maggots to ingest necrotic tissue from a wound
how long does it take biologic debridement to work?
weeks
what types of wounds would we use biologic debridement on?
wounds where sharp debridement is contraindicated
what are the advantages of biologic debridement?
relatively fast acting (but not really bc it takes weeks)
what are the disadvantages of biologic debridement?
psychologically challenging
short term use
what are the indications for use of biologic debridement?
used with minimal to large amounts of necrotic tissue when surgical debridement isn’t possible
to avoid damage to viable tissue
what is enzymatic (chemical) debridement?
topical application of enzymes to digest proteins
is enzymatic (chemical) debridement painful?
yes
how long does it take enzymatic (chemical) debridement to work?
days to weeks
what types of wounds would we use enzymatic (chemical) debridement on?
exudation and necrotic wounds
what are the advantages of enzymatic (chemical) debridement?
moderately acting
generally no effect on viable tissue
what are the disadvantages of enzymatic (chemical) debridement?
it is expensive and requires a prescription
what are the indications for use of enzymatic (chemical) debridement?
used with any amount of necrotic tissue when surgical or mechanical debridement may not be indicated or in combo with other forms of debridement
what is mechanical debridement?
hydrotherapy irrigation using a syringe or high power
wound scrubbing
wet to dry dressings
is mechanical debridement painful?
yes!!!
how long does mechanical debridement take to work?
days to weeks
what wounds would we use mechanical debridement for?
exudation and necrotic wounds
what are the disadvantages of mechanical debridement?
slow acting
painful
may damage viable tissue
may cause maceration and infection
what are the advantages of mechanical debridement?
it is inexpensive
what are the indications for use of mechanical debridement?
wounds with moderate amounts of exudate
to remove loose debris
to soften eschar, callus, and other necrotic tissue
what is surgical debridement?
surgical excision (scalpel, curette, scissors, foreceps) to remove tissue
what type of surgical debridement do surgeons have to do?
sharp excisional
what types of surgical debridement can PTs do?
sharp selective
is surgical debridement painful?
yes!!!
how long does it take surgical debridement to work?
it works immediately
what are the advantages of surgical debridement?
it is fast acting
what is the gold standard for debridement?
surgical debridement
what are the disadvantages of surgical debridement?
it may require local or general anesthesia for the pain
what is ultrasonic debridement?
using a 20-30 kHz low frequency US device with a debridement wands to longitudinally scrape the wound bed
is ultrasonic debridement painful?
yes!!!
how long does it take ultrasonic debridement to work?
days to weeks
what wounds would we use surgical debridement for?
all types of wounds
what wounds would we use ultrasonic debridement for?
all types of wounds
wounds with fibrin and slough
what are the advantages of ultrasonic debridement?
it quickly removes tissue (2-4 min)
it neutralizes acidic environments
it is less painfully than sharp-excisional debridement
what are the disadvantages of ultrasonic debridement?
it is expensive
it requires tops to be autoclaved and sterilized
it is not reimbursed well
what are the indications for use of ultrasonic debridement?
adherent necrotic tissue, fibrin, and slough
to flush encapsulated bacteria
when not a candidate for surgical debridement
what is debridement?
removal of devitalized tissue (necrotic) and foreign matter, which supports the growth of pathological organisms
what is the goal of debridement?
to improve the healing potential of the remaining viable tissue
why is debridement necessary?
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
if a wound has been there longer than 6 months, what should we do? why?
have them go for a biopsy bc it may be cancer
what is eschar?
thick, leathery necrotic tissue
flat black necrotic tissue
what is slough?
loose stringy tissue that is yellow, green, or gray
what is necrotic tissue?
dead, avascular tissue that is green, gray, or yellow
what is fibrin?
insoluble protein that cannot be wiped off and often cannot be scraped off
white tissue
will regular debridement work on fibrin?
nope
what is biofilm?
bacteria that grow EVERYWHERE and impair healing ability
why would antibiotics not help with biofilm?
bc the bacteria in biofilm become metabolically inactive and only metabolically active bacteria respond to antibiotics
what is the only way to get rid of biofilm?
mist US
what factors do we need to consider b4 debridement?
overall pt health status
etiology of the wound
types of necrotic tissue
potential for wound to heal
pain control
clinical skills and expertise
what is the mechanism of action of enzymatic/chemical debridement?
commercially applied enzymes that aggressively digest devitalized tissue by proteolytic and other enzymes
when using enzymatic/chemical debridement with eschar, what do we have to do b4?
cross hatch the tissue with a blade for it to work and get through the tissue
t/f: enzymatic/chemical debridement must be applied DIRECTLY to the wound
true
what debridement would we use when there is granulation tissue present? why?
enzymatic/chemical or biological debridement bc they are the least destructive
what is the mechanism of action of mechanical debridement?
use of external force or manipulation to remove devitalized tissue
what is selective sharp debridement?
used when a plane of non-viable tissue has separated from intact skin
what is excisional debridement?
removal of tissue at the wound/wound margin until viable tissue is removed (done by a surgeon)
would we use surgical debridement if the pt has poor blood flow like in arterial insufficiency?
NO!
when is surgical debridement done?
when the devitalized tissue needs to come out FAST and when a wound is unstageable
what is the mechanism of action of ultrasonic debridement?
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
when there is black, dry, and shriveled up tissue, should we debride it?
no, this is dead tissue and will autoamputate
if the wound bed consists of beefy red tissue, what does it need?
a dressing, not debridement
what is the normal ABI range?
1.0-1.2
what does an ABI of >1.2 mean?
abnormal vessel hardening from PVD
what does an ABI of 0.90-0.99 mean?
acceptable range
what does an ABI of 0.80-0.89 mean?
some arterial disease
what does an ABI of 0.50-0.79 mean?
moderate arterial disease
what does an ABI of <0.50 mean?
severe arterial disease
if someone has an ABI >1.2, what should we do?
refer routinely
if someone has an ABI 0.80-0.89, what should we do?
manage risk factors
if someone has an ABI 0.50-0.79, what should we do?
routine specialist referral
if someone has an ABI <0.50, what should we do?
urgent specialist referral
what is the nature of the ulcers, if present with ABI bw 0.80-1.2?
venous ulcers
what is the nature of the ulcers, if present with ABI 0.50-0.79?
mixed ulcers
what is the nature of the ulcers, if present with ABI <0.50?
arterial ulcer
what is the ABI calculation?
higher ankle #/higher arm #
what are the arterial tests?
capillary refill
rubor of dependency
t/f: capillary refill indicates the adequacy of peripheral perfusion
true
how do we test capillary refill?
firmly pinch the great for 5 sec to blanch skin then release the pressure and measure how quickly normal color returns
what is a normal capillary refill test? abnormal?
normal= </=2 sec to return to normal color
abnormal=>2 sec to return to normal color
how do we test rubor of dependency?
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)
what does pallor of elevation suggest?
arterial insufficiency
what does rubor of dependency suggest?
severe ischemia
