wound care study guide Flashcards
1
Q
layers of skin
A
- stratum corneum
- stratum lucidum
- stratum granulosum
- stratum spinosum
- stratum basale
- basement membrane
2
Q
stratum corneum
A
- horny layer
- tough outer layer
- protection from mechanical and chemical injury
- constantly sloughing
- 15-20 layers of dead keratinized cells
- can also indicate hydration
3
Q
stratum lucidum
A
- transparent, thin layer
- only at stress points – palms, soles of feet
- transition layer
4
Q
stratum granulosum
A
- metabolically active
- keratinocytes (develop keratin) and Langerhands cells (immune function - macrophage)
5
Q
stratum spinosum
A
- contain desmosomes - function as cell to cell junction
- contains spiky/spiny projections
- also contain Langerhands cells (immune cells)
6
Q
stratum basale
basal layer, stratum germinativum
A
- innermost and most continuous layer of epidermis
- typically 1-3 layers of active keratinocytes - regenerates epidermis
- Merkel cells - touch receptors
- melanocytes - pigment
- cells take 2-3 weeks to mirgrate from basal layer
7
Q
general risk factors that impact wound healing
A
- comorbidities
- nutrition
- obesity
- smoking
- alcohol/drug use
- sedentary or limited mobility
- impaired sensation
- risk-prone behavior
8
Q
extrinsic factors that may impact wound development and/or healing
A
- shoes
- orthotics/prosthetics
- seating
- positioning
- posture
9
Q
cardiovascular conditions that may increase risk of chronic wound development
A
- venous insufficiencies
- arterial insufficiency
- lymphedema
- emboli
10
Q
neuromuscular conditions that may increase risk of chronic wound development
A
- spinal cord injury
- stroke
- multiple sclerosis
11
Q
musculoskeletal conditions that may increase risk of wound development
A
- fracture
- osteomyelitis
- osteopenia
- bony deformities
- muscle weakness and atrophy
- congenital deformities
12
Q
what kind of wound is this
A
- stage I pressure injury
- red, non-blanchable
- no openings
- no DTI (not maroon or purplish skin)
13
Q
stage II pressure injuries vs arterial
A
- stage II over bony prominence
- both can be punched out
- arterial are typically very dry
14
Q
DTI
A
purplish or maroon coloration and location over buttocks/sacrum
15
Q
contraindications for conservative sharp debridement
A
- stable heel eschar
- gangrene
- unidentified structures - nerve, tendon, ligament, fungating wound
- terminally ill
- artial insufficiency (ABI < 0.8)
- coagulopathy
16
Q
correct order before sharp debridement
A
- MD order
- chart review
- cleanse
- measure
17
Q
purpose of cross-hatching
A
- increases surface area when utilizing topicals like santyl, medihoney, etc
- allows you to get a free edge when doing conservative sharp debridement
18
Q
film dressings
A
- indicated for: woudns with little or no exudate, wounds with necrosis, cover donor sites/lacerations/abrasions
- contraindicated for: wounds with moderate to heavy exudate, not ideal for infected wounds
- requires intact periwound skin
- may cause maceration
19
Q
autolytic debridement
A
- hydrocolloid
- hydrogel
- transparent non-occlusive
- medihoney
santyl is an enzymatic debrider
20
Q
role of layers in a composite dressing
A
- inner layer: non-adherent contact layer
- middle layer: absorbs moisture and wicks it away from wound, can help prevent maceration while maintaining moisture
- outer layer: bacterial barrier, commonly semi-permeable
21
Q
interventions of DTI
A
- positioning/offloading
- patient and staff education
- moisture control
22
Q
interventions for arterial wounds
A
- progressive graded exercise program
- compression if ABI > 0.5
- do NOT compress if ABI < 0.5
23
Q
interventions for diabetic foot ulcers
A
- patient education
- footwear recommendations
- debridement
- moiture control
24
Q
why is Neosporin not recommended
A
- overused
- not recommended for chronic wounds
- ~14% alelrgy to neomycin
- dermatitis with increased use
- overgrowth of resistant bacteria
25
JP drains
* need to be compressed to work
* good to pin to gown for mobility
* if over 1/2 full, have RN empty prior to mobility
26
as PTs, how can be best avoid shear and friction forces
* position
* HOB < 30 degrees
* patient and staff education
* surface recommendations
* assess cushion fit
* strengthening exercises to improve functional mobility
27
autolytic debridement
* dressings: occlusive/hydrocolloid, non-occlusive/transparent, hydrogel, medihoney
* indications: for minor or moderate debridement
* contraindications: per lecture (What the hell)
* considerations: requires moist environment, functional immune system, not ideal for infected wounds
* slowest, most conservative option
28
enzymatic debridement
* product: santyl
* indications: can be used on slough and eschar
* considerations: cross-hatching eschar before application to increase effective, not indicated for highly infected wounds
29
biosurgical debridement
* indications: large wounds with significant necrotic tissue
* free range work at least 2x faster than biological bag
30
sharp/surgical debridement
* forceps, slapel, scissors, curette
* indications: fastest option, highly selective, good for large areas
* considerations: risk of bleeding, debride non-viable tissue only
31
dry wound dressing
* goal: increase moisture
* dressing option: hydrogel, impregnated gauze, semi-permeable film
* avoid: gauze, foam
* additional considerations: NA
32
excessive drainage dressing
* goal: absorption
* dressing option: semi-permeable foam, alginate, hydrofiber, super-absorbant, gauze
* avoid: hydrogel, film
* additional considerations: NPWT (wound vac), multi-layer compression if venous
33
granulating wound dressing
* goal: protection
* dressing option: depends on amount of drainage
* additional considerations: e-stim, NPWT
34
infected wound dressing
* goal: address infection
* dressing option: topical antimicrobials, depends on amount of drainage
* additional considerations: e-stim, NPWT
35
stalled wound dressing
* goal: cell stimulation
* dressing option: collagen. extra-cellular wound matrix, topical antimicrobial
* additional considerations: e-stim, NPWT, pulsed lavage
