wound care study guide Flashcards
layers of skin
- stratum corneum
- stratum lucidum
- stratum granulosum
- stratum spinosum
- stratum basale
- basement membrane
stratum corneum
- horny layer
- tough outer layer
- protection from mechanical and chemical injury
- constantly sloughing
- 15-20 layers of dead keratinized cells
- can also indicate hydration
stratum lucidum
- transparent, thin layer
- only at stress points – palms, soles of feet
- transition layer
stratum granulosum
- metabolically active
- keratinocytes (develop keratin) and Langerhands cells (immune function - macrophage)
stratum spinosum
- contain desmosomes - function as cell to cell junction
- contains spiky/spiny projections
- also contain Langerhands cells (immune cells)
stratum basale
basal layer, stratum germinativum
- 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
general risk factors that impact wound healing
- comorbidities
- nutrition
- obesity
- smoking
- alcohol/drug use
- sedentary or limited mobility
- impaired sensation
- risk-prone behavior
extrinsic factors that may impact wound development and/or healing
- shoes
- orthotics/prosthetics
- seating
- positioning
- posture
cardiovascular conditions that may increase risk of chronic wound development
- venous insufficiencies
- arterial insufficiency
- lymphedema
- emboli
neuromuscular conditions that may increase risk of chronic wound development
- spinal cord injury
- stroke
- multiple sclerosis
musculoskeletal conditions that may increase risk of wound development
- fracture
- osteomyelitis
- osteopenia
- bony deformities
- muscle weakness and atrophy
- congenital deformities
what kind of wound is this
- stage I pressure injury
- red, non-blanchable
- no openings
- no DTI (not maroon or purplish skin)
stage II pressure injuries vs arterial
- stage II over bony prominence
- both can be punched out
- arterial are typically very dry
DTI
purplish or maroon coloration and location over buttocks/sacrum
contraindications for conservative sharp debridement
- stable heel eschar
- gangrene
- unidentified structures - nerve, tendon, ligament, fungating wound
- terminally ill
- artial insufficiency (ABI < 0.8)
- coagulopathy
correct order before sharp debridement
- MD order
- chart review
- cleanse
- measure
purpose of cross-hatching
- increases surface area when utilizing topicals like santyl, medihoney, etc
- allows you to get a free edge when doing conservative sharp debridement
film dressings
- 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
autolytic debridement
- hydrocolloid
- hydrogel
- transparent non-occlusive
- medihoney
santyl is an enzymatic debrider
role of layers in a composite dressing
- 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
interventions of DTI
- positioning/offloading
- patient and staff education
- moisture control
interventions for arterial wounds
- progressive graded exercise program
- compression if ABI > 0.5
- do NOT compress if ABI < 0.5
interventions for diabetic foot ulcers
- patient education
- footwear recommendations
- debridement
- moiture control
why is Neosporin not recommended
- overused
- not recommended for chronic wounds
- ~14% alelrgy to neomycin
- dermatitis with increased use
- overgrowth of resistant bacteria
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
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
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
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
biosurgical debridement
- indications: large wounds with significant necrotic tissue
- free range work at least 2x faster than biological bag
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
dry wound dressing
- goal: increase moisture
- dressing option: hydrogel, impregnated gauze, semi-permeable film
- avoid: gauze, foam
- additional considerations: NA
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
granulating wound dressing
- goal: protection
- dressing option: depends on amount of drainage
- additional considerations: e-stim, NPWT
infected wound dressing
- goal: address infection
- dressing option: topical antimicrobials, depends on amount of drainage
- additional considerations: e-stim, NPWT
stalled wound dressing
- goal: cell stimulation
- dressing option: collagen. extra-cellular wound matrix, topical antimicrobial
- additional considerations: e-stim, NPWT, pulsed lavage
