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Integument > Wound Care - Study Guide > Flashcards

Wound Care - Study Guide Flashcards

1
Q

Epidermis - Function

A
  • Retain moisture
  • Protect from bacteria
  • Rapidly Regenerate
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2
Q

What structure stores cells to regenerate tissue?

A

a. Hair Follicles
b. Sweat Glands
c. Edges of the wound bed
d. Anywhere with keratinocytes

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3
Q

Difference between primary, secondary and tertiary intention

A

a. Primary: Incised – no tissue loss: epithelialization
b. Secondary: Incised – tissue loss: regeneration
c. Tertiary: Trauma – structural loss: replacement

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4
Q

Wound Care - What causes Vasoconstriciton?

A
  • Platelets
  • They release Serotonin
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5
Q

Wound Care - What causes Vasodialation?

A
  • Mast Cells
  • Release Histamine
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6
Q

Wound Care - Polymorphonuclear leukocytes response

A
  • Neutrophils release enzymes for Autolytic Debridement
    – Phagocytosis, lysosome degredation, kill bacteria
  • Esonophils: phagocytosis, WBC
  • Mast Cells: Release histamine, creates Vasodialtion. In addition, produce chemical chemokine for neutrophil migration to site of injury
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7
Q

Homeostasis (forming the platelet plug)

A

Hagemann Factor XII (12)
- Converts prothrombin into thrombin
- Converts fibrinogen into fibrin

Scab Formation
- Platelets come to injury site and release serotonin for VC
- Platelet release platelet derived growth factor that form fibrin clot (platelet plug)

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8
Q

Monocyte to Macrophage - Acute inflammatory to proliferative phase

A

Macrophage
i. 72 to 84 hours
ii. Function in low O2
iii. Phagocytosis (eat debris)
iv. Secrete cytokines, growth factors (helps create granulation) and Matrix Metalloproteinases

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9
Q

What cell types are produced by fibroblasts?

A

a. Synthesis Collagen and Glycosaminoglycans

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10
Q

What is a Positive Homan’s Sign

A

a. Dorsiflex foot and squeeze OR use BP cuff to pump up to 40 mmHg
b. Positive if they have pain

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11
Q

ABI levels and debridement

A

Normal: 1

Abnormal
- >1 Venous Insufficency
- <0.8 Mild Arterial Insufficency – Can debride
- Equal to or <0.5 – DO NOT OPEN – Long time to heal

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12
Q

What is the minimal protective sensation?

A

5.07 monofilament (10 g)

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13
Q

What are the three ways to stage a wound?

A
  • Pressure Ulcer (1-4)
  • Wagner (0-5); Diabetic Foot Patients
  • Other wounds (Partial and Full thickness)
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14
Q

Pressure Ulcer Stages

A

Stage 1
- Non-blanchable erythema
- Slight redness

Stage 2
- Partial Thickness (epidermis and/or dermis, superficial ulcer)
- Abraision, blister or shallow crater

Stage 3
- Full thickness
- Damage or necrosis or subcutaneous tissue
- With or without undermining

Stage 4:
- Full thickness through fascia, bone, muscle

Unstageable
- Can’t see the base of the wound do to slough or eschar

Deep Tissue Injury
- Pressure-related injury to subcutaneous tissues under intact skin
- Appearance of a deep bruise (purple or blue)

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15
Q

Wagner Scale

A

Grade 0:
- Skin Intact. May be bony deformities or hyperkeratotic lesions

Grade 1:
- Superficial Ulcer, may be necrotic or early granulation

Grade 2:
- Lesion goes to bone, ligement, tendon, joint capsule or deep fascia. No abcess or osteomyelitis (NO infection).

Grade 3:
- Previous lesion and infection

Grade 4:
- Toes or forefoot have gangrene; moist or dry

Grade 5:
- No foot healing possible

Use for Diabetic Patients - Feet

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16
Q

All other wounds staging

A
  • Partial thickness (seperation of the epidermis from the dermis)
  • Full thickness (seperation of both epidermis and dermis from underlying structures)
  • If you cannot see the bottom put full thickness/Unstageable and explain
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17
Q

Infection - Bacterial Counts

A
  • > 10^5 colony forming units (CFU)
  • > 10^3 for strep infections
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18
Q

Venous Insufficency Characteristics

A
  1. Increased drainage
  2. Painless
  3. Decreased pain with elevation
  4. Edema
  5. Increased redness (Hemosiderin Staining)

Causes 80% of ulcers

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19
Q

Arterial Insufficency Characteristics

A
  1. Minimal drainage
  2. Very painful and increased pain with elevation or exercise
  3. Rubor of dependency
  4. Pale Base
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20
Q

Mixed Insufficency Characteristics

A
  • Have signs of both
  • This will be determined with ABI and signs/Sx.
  • Primarily treated as Arterial insufficiency but also need to consider Venous Insufficiency playing into it.
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21
Q

What are the 3 methods of wound healing?

A
  • Non selective (Remove some healthy tissue with necrotic tissue) Ex:
    i. Mechanical (wet-to-dry dressings)
    ii. Topical agents
    iii. Surgical
    iv. Sharp
    v. Forceful irrigation (>8 psi); Spray surfactant
  • Selective (Remove only necrotic tissue) Ex:
    a. Collagenase (collagen/fibrin specific); Enzymatic
    b. Sharp Debridement
    c. Spray surfactant (<8 psi)
  • Autolytic (Occurs in a sealed wound by Neutrophils)
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22
Q

What are the three phases of healing?

A
  • Acute inflammatory (Stage 1; 1-4 days)
  • Proliferative (Stage 2; 4 days - 11 months)
  • Matrix Formation (Stage 3; 30 days -2 years); basement membrane that collagen sits on
  • Other: Chronic inflammatory
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23
Q

Acute Inflammatory

1

A
  • Platelet Plug
  • Monocytes
    – These are released in transition to Proliferative Phase and turn into Macrophages (Chemotaxis – Cytokines, GF (angiogenesis) and MMP)
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24
Q

Proliferative Phase

2

A
  • Myofibroblasts – secrete collagen and glycosaminoglycans
  • Revascularization
  • Reepithelialization on top of collagen
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25
Q

Chronic Inflammatory

Other

A
  • Monocytes do not turn into macrophages
  • MMPs play a part, TIMP deficits. Leads to biofilm and degrading of proteins
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26
Q

Wound Vac

A
  • Creates a negative pressure environment which pushes the granulation tissue up to the wound bed.
  • Facilitates better healing
  • Can put antibiotic through this
  • Very good for skin grafts
27
Q

Sharp Debridement

A
  • Scalpel
  • Selective or Non Selective
28
Q

Whirlpool - Indications

A
  • Arterial Insufficency
  • Venous insufficiency
  • Pressure Wound
  • Trauma Wound
29
Q

Whirlpool - Goals

A
  • Rehydrate tissue
  • Soften eschar
  • Nonselective material debridement/remove foreign material
  • Increase circulation 2-3 hours post Rx
30
Q

Whirlpool - Contraindications

A
  1. Medical condition where increased body temperature is contraindicated
  2. Painful lesions
  3. Fragile, dry, irritated surrounding tissue
31
Q

Whirlpool - Protocol

A

Warm; 98-101 degrees for 15-20 minutes

32
Q

When should you use collagenase?

A
  • Someone has AI and they won’t let you debride the hard eschar off
33
Q

How to treat Arterial Insufficent Wound?

A

i. Deeper
- First: Premoistened Calcium Alginate
- Second: Vaseline Impregnated Gauze
- Third: Foam + Tegaderm (OR gauze/compression stockinette depends on intactness of surrounding skin) on top OR Hydrocolloid Thin (O2)
OR if patient is too sensitive and need to get rid of eschar
- First: Collagenase
- Second: Calcium Alginate
- Third: Foam + Tegaderm (OR gauze/compression stockinette depends on intactness of surrounding skin) on top OR Hydrocolloid Thin (O2)
ii. More Superficial
- First: Vaseline Impregnated Gauze
- Second: Foam + Tegaderm on top OR Hydrocolloid Thin
iii. Superficial
- Hydrocolloid Thin

34
Q

How to treat Venous Insufficency wound?

A

i. Deep:
1. First: MeSalt
2. Second: Abdominal Pad OR Hydrocolloid thin (O2) OR Hydrocolloid thick (IF NOT INFECTED; absorbs more)
ii. Less weeping
1. First: MeSalt
2. Second: Hydrocolloid Thin (O2) OR Hydrocolloid thick (IF NOT INFECTED)
iii. Little weeping
1. Hydrocolloid thin (O2) OR Hydrocolloid thick (IF NOT INFECTED; absorbs more)

35
Q

How to treat Mixed Insuffiency Wound?

A
  • Similar to Arterial insufficency but also need to consider VI. Look at all considerations we look at for wounds.
36
Q

How to treat a Chronic Inflammatory Wound?

A
  • Use Collagenase Early
  • Eventually switch to silver impregnated guaze
  • Growth Factor - Prescription required
37
Q

When is hydrogel good to use?

A
  • Skin Flaps
  • Place Steristrips then hydrogel on top. Cover with gauze and stockinette
38
Q

____ pad can be used on infected wounds

A
  • Abdominal Pad
39
Q

When should growth factor be placed in a wound?

A

Diabetic patients with chronic inflammatory!

40
Q

Hydrocolloid: Thin vs Thick

A
  • Thin (Allows O2, absorbs some moisture)
  • Thick (No O2/infection, lots of absorbing)
41
Q

When is Semiperbiable film good to use?

A

Superficial intact skin. Reduces friction and is clear.

42
Q

When should you clean a wound?

A
  • EVERY TIME
43
Q

How to knoe when do use selective vs non selective to clean a wound?

A
  • > 50% = Nonselective (Whirlpool and Spray Surfactant >8 psi)
  • <50% = Selective (Spray Surfactant <8 psi)
44
Q

If you see a yeast infection you should…

A

have glucose levels checked

45
Q

Semipermeable Thin vs Hydrocollpid Thin

A
  • SMT is clear and cheaper
  • Hydrocolloid can absorb; waterproof
46
Q

MeSalt vs Calcium Alginate

A

CA:
o More expensive
o Better at remaining premoistened
o Better for superficial wounds
o Can stop bleeding and help renal insufficiency people clot
o 20x absorption

Me:
o Good for all infected wounds
o Packs in dead spaces
o 30x absorption

47
Q

____ don’t stick to wounds and hydrates the area

A

Vaseline impregnated gauze

48
Q

Nutritional Requirements and Why?

A

Acetic Acid:
- Lactic acid creates chemokines, signal for neutrophils to come to injury

Zinc:
- Required for MMPs
- Lack will result in only MMPs getting resources and not TIMPs resulting in chronic wounds

Magnesium:
- Smooths out nerve conduction velocity
- Building block of collagen

Protein
- Building blocks for cells and repairment

Vitamin C

Oxygen

49
Q

You should never have people ____ when wound healing

A

lose weight

50
Q

Red Flags - Contact ED

A
  • Positive Homan’s sign/cuff test – DVT
  • Tetanus NOT up to date (> 10 years since last)
  • Systemic Infection (Temperature equal or > 101, night sweats); They are moving into sepsis
51
Q

Non-life threatening: major delays in wound healing

A
  • Infected wound (> 10^5 CFUs)
  • High Blood Sugar (Glucose >100, A1c >6.0)
  • Venous Insufficiency, LE edema
  • Smoking
  • Sedentary Lifestyle
52
Q

Underlying conditions that delay/complicate wound healing

A

Conditions
- Diabetes
- Autoimmune diseases, RA, HIV-Aids-Lupus-RA

Circulation Impairments
- Arterial insufficiency
- Venous insufficiency
- Diabetic wounds (DM > 15 years)

53
Q

Pressure ulcer risk needs to be assessed ____ for all hospitalized patients.

A

at least daily

54
Q

____ wounds need daily dressing changes

A

Infected

55
Q

When you have a dirt infected wound you should use ____

A
  • Antimicrobial dressings (+Ag)
    And
  • Silver impregnated gauze
56
Q

NEVER SEAL AN ____ WOUND

A

INFECTED

57
Q

What can you not use with silver impregnated dressings?

A

Collagenase

58
Q

Elevation and Compression Guidelines for AI and VI

A

AI
* Leg at heart level
* Compression BELOW 32 mm Hg

VI
* Leg above the heart
* Compression at 40 mm Hg

59
Q

8 psi
>10^5 CFUs (10^3 CFUs)
<0.8 ABI
10gm (5.07)
50%
40 mm Hg
32 mm Hg
175 mm Hg (125 mm Hg)

A
  • 8 psi – maximum amount of pressure that does not disrupt granulation tissue.
  • >10^5 CFUs – clinical evidence for infected. 10^3 = contamined, strep
  • <.8 ABI – Arterial Insuffiency that you can still use an occlusive dressing and debride and compress
  • 10gm (5.07) – monofilament testing, protective sensation in extremity
  • 50% - Selective vs Non Selective; 50% or more Non selective; <50% Selective
  • 40 mmHg – Venous Insufficency Stasis compression; amount of pressure in a cuff that indicates a DVT of pain in calf – Homan Test
  • 32 mmHg – pressure to occlude capillaries (If AI must be below this)
  • 175mmHg – Average VAC compression for most wounds; 125mmHg for AI or skin graft site.
60
Q

Pulsed Lavage Indications

A
  • Deep tunneling wounds or >70% necrotic tissue
  • Immobilized or patients with multiple wounds (prevents cross contamination)
  • Patients with wounds in isolation
  • Forceful irrigation with adjustable psi
61
Q

What is the main advantage of using enzymatic debridement with a wound?

A

Removed ONLY necrotic tissue from the wound

62
Q

What is an advantage of an occlusive dressing?

A

Autolytic debridement

63
Q

Skin charge

A

-

64
Q

Tissue charge

A

+

Integument (7 decks)

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