Wound Care Part 2 Flashcards
what is HVPC?
twin peaked monophasic waveform with 2 single pulses having a short phase duration and long interpulse interval
in HVPC, each pulse is of short duration (typically <____usec) and a high peak voltage (up to ____V)
200, 500
evidence for application of HVPC mainly related to its use for what?
stimulation of wound healing, pain relief, and facilitated edema resolution
what are the physiological responses to ES?
increased blood flow
increased cell migration
increased collagen production
increased growth factor
bacteriostatic
decreased edema
what does bacteriostatic mean?
that it stops the bacteria from working
despite what Muskett tells us, can HVPC be used for ms strengthening?
no!!!
tensile strength of scars after HVPC are ____% better than wounds that healed naturally
50
what are the indications for HVPC for wounds?
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
what is “standard care” in wounds?
clean, moist, get rid of any nonviable tissue
can be done by the pt themself or the PT
what electrodes are used in HVPC for wound healing?
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
why is aluminum foil used in HVPC?
bc aluminum has little to no resistance, so the stim goes right to the wound
what are the HVPC parameters used during days 1-5 (or until the necrosis is removed)?
negative polarity
50-80pps
100-150 volts
what are the HVPC parameters used from day 4 to closure of the wound?
positive polarity
80-100pps
100-125 volts
if wound healing plateaus with HVPC, what should we do? why?
initiate negative polarity and alternate polarity daily bc negative is bacteriostatic/bactericidal and the plateau is likely due to bacterial growth
how often is HVPC done in inpatient?
45-60 minutes daily
how often is HVPC done in outpatient?
3x/week
what are the contraindications for HVCP for wounds?
basal or squamous cell CA
osteomyelitis
ion residues of iodine or silver
electronic pacing implants
directly over the heart or carotid sinus
what is the best diagnostic test for osteomyelitis?
radiographs
when a pt has osteomyelitis, what has to be done?
the infection has to be debrided then followed up with 6-8 weeks of antibiotics then either close or keep the wound open
what is negative pressure therapy?
negative pressure distributed over the wound surface by an airtight thin-film secondary dressing
what are the benefits of negative pressure therapy?
decreased interstitial edema
decreased bacterial count
increased capillary flow
moist wound healing
granulation tissue formation
t/f: once there is granulation tissue, you have to switch to white foam with negative pressure therapy
true
t/f: negative pressure therapy preps the wound bed for closure, it DOES NOT close the wound
true
what is the physiological response to negative pressure therapy?
increased cell proliferation by stretch activated ion channels
mechanical stree stimulates angiogenesis
increased blood flow and O2 delivery
removes edema fluid
decreased bacterial count
what are the indications for negative pressure therapy?
pressure ulcers stage 3-4
dehisced and traumatic wounds
diabetic, arterial insufficient, and venous insufficient ulcers
radiation ulcers
meshed grafts, flaps, and donor sites
is it preferred for negative pressure therapy to be continuous or pulsed? why?
continuous so that the pt doesn’t have to deal with the pain of the on/off suction
how long is negative pressure therapy?
22 hrs/day
what is the target pressure of negative pressure therapy?
it wound specific bw 50-125
ideally 50mmHg
most often 125 mmHg
how often should the dressing (sponge) be changed in negative pressure therapy normally? what if it is infected?
normally every 48-72 hrs
every 12-24 hrs if infected
t/f: we want the sponge in contact with all surfaces of the wound in negative pressure therapy, including tunneling and undermining
true
how long does it usually take to get the dressing set for negative pressure therapy?
~40 min
what are the limitations of negative pressure therapy?
fistulas to organs or body cavities
presence of >20% necrotic tissue
osteomyelitis
cancer in wound margins
how is negative pressure therapy applied?
sponge placed in wound bed
adherent cover dressing applied
suction attached
monitor the dressing adherence and type of drainage in the collection system
if there is necrotic tissue, with negative pressure we can put _____ over the necrotic tissue
mesh mat
what are the types of LE ulcers?
ischemic (arterial) ulcers
lymphatic ulcers
vasculitic ulcers
venous insufficiency ulcers
t/f: the likelihood of seeing lymphatic ulcers and vasculitic ulcers outside of a specialty wound clinic is low
true
_______ carry blood away from the heart to every fxning cell in the body, _______ carry blood to the heart
arteries, veins
t/f: we can’t treat the venous system without knowing what’s going on with the arterial system
true
when treating the vascular system, what should we also check?
the kidney fxn
how do we assess the CV system?
BP
how do we assess blood flow?
pulse palpation
capillary refill
rubor on dependency
ABI
Wells criteria for DVT
when taking tissue cultures of a wound older than 60 days, what method are we using?
the 12 point swab method back and forth across the wound
when taking tissue cultures of a wound older than 6 months, what method are we using?
biopsy
where are arterial insufficiency wounds usually found?
on the lateral ankle
on the webbed spaced of the toes
t/f: there is no inflammatory stage for wound healing when a pt is on steroids (ie for RA)
true
where are venous insufficiency wounds usually located?
on the medial ankle
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
true
what causes ischemic/arterial insufficiency wounds?
poor perfusion to the LE deprives the skin and tissue of oxygen, killing these tissues and causing an open wound to form
what does an ischemic/arterial insufficiency wound look like?
pale, dry wound bed with well demarcated wound edges
what causes pain with arterial insufficiency?
LE elevation
what are the signs of poor perfusion?
cool skin
thick/thin, pale yellow nails
loss of leg hair
weak/absent pulses
hx of claudication and/or resting pain
t/f: claudication is a true indicator that something vascular is wrong
true
claudication pain is due to what?
decreased blood flow
what causes claudication pain? what relieves it?
activity makes it worse
rest relieves it
what causes venous insufficiency ulcers?
improper fxning of the venous valves (or incompitent perforators) of the legs
venous stasis
______ insufficiency occurs in 70-90% of leg ulcer cases
venous
what is a venous stasis ulcer?
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
what is a classic signs of venous insufficiency caused by the pressure of pooling cracking vessels and leaking RBCs?
hemosiderin staining
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
true
what causes medial ankle ulcers?
venous insufficiency
what do venous insufficiency wounds look like?
red, wet wound bed with irregular edges
heavy drainage
what is the difference bw cellulitis and dermatitis?
dermatitis is inflammation of the dermis
cellulitis is inflammation of the cellular matrix surrounding the wound
what is dermatitis a sign of?
venous insufficiency
what can decrease venous insufficiency pain?
LE elevation
what are the signs of venous insufficiency?
pitting edema
hemosiderin staining
varicosities
hx of DVT
what factors in the Wells criteria increase risk of DVT?
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
what are vasculitic ulcers?
cutaneous vasculitis resulting from inflammation of superficial blood vessels
where are vasculitic ulcers commonly located?
on the lateral side of the calf
what are lymphatic ulcers?
ulcers that result when lymphedema causes damage to integument
what do lymphatic ulcers look like?
small, oozing blisters or ulcer surrounded by fibrotic, thickened skin
how do we assess limb and vascular status?
systemic BP
limb blood flow (ABI, pulses, capillary refill, rubor of dependency)
limb girth measurements
tissue cultures
lab values
what locations should we measure with LE girth measurements?
at the met heads
arch
figure 8 ankle
10 cm above med mal
20 cm above med mal
what are the chronic wound classifications (venous, arterial, traumatic, post-op wounds)?
partial thickness
full thickness
what is a partial thickness wound?
breakdown of the epidermis and possibly penetrating into but not through the dermis
what is a full thickness wound?
breakdown of the dermis into the subQ tissue through fascia, and may involve muscles, tendon, and/or bone
what wounds are not classified as full or partial thickness?
pressure ulcers
diabetic foot ulcers
what are adjunctive biophysical agents we can use for venous and arterial wounds?
compression
debridement
exercise and ambulation
dressings
non-contact low frequency US
what is compression used for?
chronic VENOUS ambulatory hypertension
what does compression do?
moves fluid from interstitial spaces through lymphatics
what does the evidence say about elastic vs inelastic compression?
that elastic compression is better
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
true
t/f: those using compression bandages/stockings are more likely to experience complete ulcer healing within 12 months compared with ppl with no compression
true
what are the non stretch compression bandages?
gauze
paste bandage (unna boot)
what are the types of compression?
non-stretch
short stretch
long stretch
compression stockings
hook and loop
intermittent/gradient sequential
pneumatic compression
t/f: no bandaging/wrapping is necessary following compression
false
what is the most ideal compression? why?
gradient sequential bc it mimics the natural muscles pump actions the best with most efficiency distally
the goal is to not see >__cm increase in circumference girth measurements bw visits
1
what is the first sign of chronic venous insufficiency?
aching legs
what is the second sign of chronic venous insufficiency?
marks from socks
how should we position a pt with compression?
in supine with the LEs elevated higher then the hip (higher than the heart is better)
what are the indications for using compression?
venous insufficient ulcers
LE edema
lymphedema
what are the limitations of compression (when would we not use compression)?
acute DVT
acute infection or untreated infection
acute CHF
arterial insufficiency
t/f: if a wound is red, but not hot, it is likely chronically inflammed, not infected
true
what is non-contact low frequency US?
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
why is saline used in non-contact low frequency US?
bc energy travels faster through saline than through water or air
how does non-contact low frequency US work?
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
does the 8 minute rule for billing apply to non-contact low frequency US?
nope!
is 1mHz or 3mHz deeper US?
1mHz
how deep can non-contact low frequency US reach in tissues?
~9mm (enought to get through to subQ tissue)
what are the benefits of non-contact low frequency US?
reduces a wide variety of bacteria (including biofilm!!!!)
reduces pro-inflammatory cytokines
stimulates angiogenesis through VEGF (vascular endothelial growth factor)
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
14
as long as the pt is responding to non-contact low frequency US, how many sessions can we do?
up to 18 sessions at least 2x/week
