Wound Care Part 2

Question 1

what is HVPC?

Answer 1

twin peaked monophasic waveform with 2 single pulses having a short phase duration and long interpulse interval

Question 2

in HVPC, each pulse is of short duration (typically <____usec) and a high peak voltage (up to ____V)

Answer 2

200, 500

Question 3

evidence for application of HVPC mainly related to its use for what?

Answer 3

stimulation of wound healing, pain relief, and facilitated edema resolution

Question 4

what are the physiological responses to ES?

Answer 4

increased blood flow

increased cell migration

increased collagen production

increased growth factor

bacteriostatic

decreased edema

Question 5

what does bacteriostatic mean?

Answer 5

that it stops the bacteria from working

Question 6

despite what Muskett tells us, can HVPC be used for ms strengthening?

Answer 6

no!!!

Question 7

tensile strength of scars after HVPC are ____% better than wounds that healed naturally

Answer 7

50

Question 8

what are the indications for HVPC for wounds?

Answer 8

stage 3-4 pressure ulcers

neuropathic foot ulcers that haven’t responded to standard care

LE ulcer due to poor blood supply (arterial insuffiency)

LE venous insufficient ulcers

wounds that haven’t responded to 30 days of standard care

Question 9

what is “standard care” in wounds?

Answer 9

clean, moist, get rid of any nonviable tissue

can be done by the pt themself or the PT

Question 10

what electrodes are used in HVPC for wound healing?

Answer 10

typically aluminum foil and gauze soaked in saline with an alligator clip to the foil cut to the size or just just larger than the wound

Question 11

why is aluminum foil used in HVPC?

Answer 11

bc aluminum has little to no resistance, so the stim goes right to the wound

Question 12

what are the HVPC parameters used during days 1-5 (or until the necrosis is removed)?

Answer 12

negative polarity

50-80pps

100-150 volts

Question 13

what are the HVPC parameters used from day 4 to closure of the wound?

Answer 13

positive polarity

80-100pps

100-125 volts

Question 14

if wound healing plateaus with HVPC, what should we do? why?

Answer 14

initiate negative polarity and alternate polarity daily bc negative is bacteriostatic/bactericidal and the plateau is likely due to bacterial growth

Question 15

how often is HVPC done in inpatient?

Answer 15

45-60 minutes daily

Question 16

how often is HVPC done in outpatient?

Answer 16

3x/week

Question 17

what are the contraindications for HVCP for wounds?

Answer 17

basal or squamous cell CA

osteomyelitis

ion residues of iodine or silver

electronic pacing implants

directly over the heart or carotid sinus

Question 18

what is the best diagnostic test for osteomyelitis?

Answer 18

radiographs

Question 19

when a pt has osteomyelitis, what has to be done?

Answer 19

the infection has to be debrided then followed up with 6-8 weeks of antibiotics then either close or keep the wound open

Question 20

what is negative pressure therapy?

Answer 20

negative pressure distributed over the wound surface by an airtight thin-film secondary dressing

Question 21

what are the benefits of negative pressure therapy?

Answer 21

decreased interstitial edema

decreased bacterial count

increased capillary flow

moist wound healing

granulation tissue formation

Question 22

t/f: once there is granulation tissue, you have to switch to white foam with negative pressure therapy

Answer 22

true

Question 23

t/f: negative pressure therapy preps the wound bed for closure, it DOES NOT close the wound

Answer 23

true

Question 24

what is the physiological response to negative pressure therapy?

Answer 24

increased cell proliferation by stretch activated ion channels

mechanical stree stimulates angiogenesis

increased blood flow and O2 delivery

removes edema fluid

decreased bacterial count

Question 25

what are the indications for negative pressure therapy?

Answer 25

pressure ulcers stage 3-4 dehisced and traumatic wounds diabetic, arterial insufficient, and venous insufficient ulcers radiation ulcers meshed grafts, flaps, and donor sites

Question 26

is it preferred for negative pressure therapy to be continuous or pulsed? why?

Answer 26

continuous so that the pt doesn't have to deal with the pain of the on/off suction

Question 27

how long is negative pressure therapy on during the day?

Answer 27

22 hrs/day

Question 28

what is the target pressure of negative pressure therapy?

Answer 28

it wound specific bw 50-125 ideally 50mmHg most often 125 mmHg

Question 29

how often should the dressing (sponge) be changed in negative pressure therapy normally? what if it is infected?

Answer 29

normally every 48-72 hrs every 12-24 hrs if infected

Question 30

t/f: we want the sponge in contact with all surfaces of the wound in negative pressure therapy, including tunneling and undermining

Answer 30

true

Question 31

how long does it usually take to get the dressing set for negative pressure therapy?

Answer 31

~40 min

Question 32

what are the limitations of negative pressure therapy?

Answer 32

fistulas to organs or body cavities presence of >20% necrotic tissue osteomyelitis cancer in wound margins

Question 33

how is negative pressure therapy applied?

Answer 33

sponge placed in wound bed adherent cover dressing applied suction attached monitor the dressing adherence and type of drainage in the collection system

Question 34

if there is necrotic tissue, with negative pressure we can put _____ over the necrotic tissue

Answer 34

mesh mat

Question 35

what are the types of LE ulcers?

Answer 35

ischemic (arterial) ulcers lymphatic ulcers vasculitic ulcers venous insufficiency ulcers

Question 36

t/f: the likelihood of seeing lymphatic ulcers and vasculitic ulcers outside of a specialty wound clinic is low

Answer 36

true

Question 37

_______ carry blood away from the heart to every fxning cell in the body, _______ carry blood to the heart

Answer 37

arteries, veins

Question 38

t/f: we can't treat the venous system without knowing what's going on with the arterial system

Answer 38

true

Question 39

when treating the vascular system, what should we also check?

Answer 39

the kidney fxn

Question 40

how do we assess the CV system?

Answer 40

BP

Question 41

how do we assess blood flow?

Answer 41

pulse palpation capillary refill rubor on dependency ABI Wells criteria for DVT

Question 42

when taking tissue cultures of a wound older than 60 days, what method are we using?

Answer 42

the 12 point swab method back and forth across the wound

Question 43

when taking tissue cultures of a wound older than 6 months, what method are we using?

Answer 43

biopsy

Question 44

where are arterial insufficiency wounds usually found?

Answer 44

on the lateral ankle on the webbed spaced of the toes

Question 45

t/f: there is no inflammatory stage for wound healing when a pt is on steroids (ie for RA)

Answer 45

true

Question 46

where are venous insufficiency wounds usually located?

Answer 46

on the medial ankle

Question 47

t/f: pain with wounds is dependent on the depth of the wound, with deeper being less painful bc there are no more exposed nerve endings

Answer 47

true

Question 48

what causes ischemic/arterial insufficiency wounds?

Answer 48

poor perfusion to the LE deprives the skin and tissue of oxygen, killing these tissues and causing an open wound to form

Question 49

what does an ischemic/arterial insufficiency wound look like?

Answer 49

pale, dry wound bed with well demarcated wound edges

Question 50

what causes pain with arterial insufficiency?

Answer 50

LE elevation

Question 51

what are the signs of poor perfusion?

Answer 51

cool skin thick/thin, pale yellow nails loss of leg hair weak/absent pulses hx of claudication and/or resting pain

Question 52

t/f: claudication is a true indicator that something vascular is wrong

Answer 52

true

Question 53

claudication pain is due to what?

Answer 53

decreased blood flow

Question 54

what causes claudication pain? what relieves it?

Answer 54

activity makes it worse rest relieves it

Question 55

what causes venous insufficiency ulcers?

Answer 55

improper fxning of the venous valves (or incompitent perforators) of the legs venous stasis

Question 56

______ insufficiency occurs in 70-90% of leg ulcer cases

Answer 56

venous

Question 57

what is a venous stasis ulcer?

Answer 57

an ulcer caused by pooling of blood in veins that creates an inflammatory response in the body and cracks the veins leading to RBCs leaking out

Question 58

what is a classic signs of venous insufficiency caused by the pressure of pooling cracking vessels and leaking RBCs?

Answer 58

hemosiderin staining

Question 59

t/f: valves in the veins get more brittle with age and fluid stretching the vessel can cause backflow when the valves can't overlap anymore

Answer 59

true

Question 60

what causes medial ankle ulcers?

Answer 60

venous insufficiency

Question 61

what do venous insufficiency wounds look like?

Answer 61

red, wet wound bed with irregular edges heavy drainage

Question 62

what is the difference bw cellulitis and dermatitis?

Answer 62

dermatitis is inflammation of the dermis cellulitis is inflammation of the cellular matrix surrounding the wound

Question 63

what is dermatitis a sign of?

Answer 63

venous insufficiency

Question 64

what can decrease venous insufficiency pain?

Answer 64

LE elevation

Question 65

what are the signs of venous insufficiency?

Answer 65

pitting edema hemosiderin staining varicosities hx of DVT

Question 66

what factors in the Wells criteria increase risk of DVT?

Answer 66

LE trauma, surgery, or plaster immobilization for >3 days or surgery within the last month tenderness along the femoral or popliteal veins entire limb swelling non-varicose dilation of collateral superficial veins calf >3cm bigger circumference 10 cm below tib tub pitting edema hx of confirmed DVT malignancy IV drug use

Question 67

what are vasculitic ulcers?

Answer 67

cutaneous vasculitis resulting from inflammation of superficial blood vessels

Question 68

where are vasculitic ulcers commonly located?

Answer 68

on the lateral side of the calf

Question 69

what are lymphatic ulcers?

Answer 69

ulcers that result when lymphedema causes damage to integument

Question 70

what do lymphatic ulcers look like?

Answer 70

small, oozing blisters or ulcer surrounded by fibrotic, thickened skin

Question 71

how do we assess limb and vascular status?

Answer 71

systemic BP limb blood flow (ABI, pulses, capillary refill, rubor of dependency) limb girth measurements tissue cultures lab values

Question 72

what locations should we measure with LE girth measurements?

Answer 72

at the met heads arch figure 8 ankle 10 cm above med mal 20 cm above med mal

Question 73

what are the chronic wound classifications (venous, arterial, traumatic, post-op wounds)?

Answer 73

partial thickness full thickness

Question 74

what is a partial thickness wound?

Answer 74

breakdown of the epidermis and possibly penetrating into but not through the dermis

Question 75

what is a full thickness wound?

Answer 75

breakdown of the dermis into the subQ tissue through fascia, and may involve muscles, tendon, and/or bone

Question 76

what wounds are not classified as full or partial thickness?

Answer 76

pressure ulcers diabetic foot ulcers

Question 77

what are adjunctive biophysical agents we can use for venous and arterial wounds?

Answer 77

compression debridement exercise and ambulation dressings non-contact low frequency US

Question 78

what is compression used for?

Answer 78

chronic VENOUS ambulatory hypertension

Question 79

what does compression do?

Answer 79

moves fluid from interstitial spaces through lymphatics

Question 80

what does the evidence say about elastic vs inelastic compression?

Answer 80

that elastic compression is better

Question 81

t/f: evidence suggests that there is probably a shorter time to complete healing venous leg ulcers in people wearing compression than those not wearing compression

Answer 81

true

Question 82

t/f: those using compression bandages/stockings are more likely to experience complete ulcer healing within 12 months compared with ppl with no compression

Answer 82

true

Question 83

what are the non stretch compression bandages?

Answer 83

gauze paste bandage (unna boot)

Question 84

what are the types of compression?

Answer 84

non-stretch short stretch long stretch compression stockings hook and loop intermittent/gradient sequential pneumatic compression

Question 85

t/f: no bandaging/wrapping is necessary following compression

Answer 85

false

Question 86

what is the most ideal compression? why?

Answer 86

gradient sequential bc it mimics the natural muscles pump actions the best with most efficiency distally

Question 87

the goal is to not see >__cm increase in circumference girth measurements bw visits

Answer 87

1

Question 88

what is the first sign of chronic venous insufficiency?

Answer 88

aching legs

Question 89

what is the second sign of chronic venous insufficiency?

Answer 89

marks from socks

Question 90

how should we position a pt with compression?

Answer 90

in supine with the LEs elevated higher then the hip (higher than the heart is better)

Question 91

what are the indications for using compression?

Answer 91

venous insufficient ulcers LE edema lymphedema

Question 92

what are the limitations of compression (when would we not use compression)?

Answer 92

acute DVT acute infection or untreated infection acute CHF arterial insufficiency

Question 93

t/f: if a wound is red, but not hot, it is likely chronically inflammed, not infected

Answer 93

true

Question 94

what is non-contact low frequency US?

Answer 94

ultra MIST device delivers low frequency 40kHz (no more no less) nonthermal ultrasonic energy w/o contract through fluid saline mist to the wound bed

Question 95

why is saline used in non-contact low frequency US?

Answer 95

bc energy travels faster through saline than through water or air

Question 96

how does non-contact low frequency US work?

Answer 96

the US energy creates a pressure wave that pushes on the cells below the wound surface that causes micro-strains that deform the cell membranes and create a physiologic responses resulting in promotion of healing

Question 97

does the 8 minute rule for billing apply to non-contact low frequency US?

Answer 97

nope!

Question 98

is 1mHz or 3mHz deeper US?

Answer 98

1mHz

Question 99

how deep can non-contact low frequency US reach in tissues?

Answer 99

~9mm (enought to get through to subQ tissue)

Question 100

what are the benefits of non-contact low frequency US?

Answer 100

reduces a wide variety of bacteria (including biofilm!!!!) reduces pro-inflammatory cytokines stimulates angiogenesis through VEGF (vascular endothelial growth factor)

Question 101

all benefits of non-contact low frequency US occur within ____ days, so if there is still no response in this time frame, it is not the right tx for the pt

Answer 101

14

Question 102

as long as the pt is responding to non-contact low frequency US, how many sessions can we do?

Answer 102

up to 18 sessions at least 2x/week