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Physical Agents > Wound Eval > Flashcards

Wound Eval Flashcards

1
Q

what can cause impaired wound healing?

A
  • inadequate intake of protein, carbohydrates, lipids, vitamins, and minerals
  • dehydration
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2
Q

how many calories does normal wound healing require?

A

30-35 calories per kilogram of body weight per day

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3
Q

How much fluid do patients with open wounds require?

A

30-35 mL

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4
Q

Serum Albumin

A
  • plasma protein
  • normal: 3.5-5.5 g/dL
  • decreased –> protein deficiency –> poor nutrition/malnutrition
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5
Q

Serum Prealbumin

A
  • Transport protein
  • not affected by hydration status
  • normal: 16-40 mg/dL
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6
Q

Total Lymphocyte Count (TLC)

A
  • measures immune function
  • normal: >/= 2000 cells/mm
  • decreased: immunocompromised
  • increased: possible bacterial infection
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7
Q

Blood Glucose/ A1c

A
  • Normal: 70-115 mg/dL for A1c < 6.0%
  • Increased = risk for impaired wound healing
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8
Q

Creatinine

A
  • Kidney Function
  • Normal = 0.1-1.2 mg/dL
  • increased = edema (very high sign of renal failure
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9
Q

Other lab values measured

A
  • RBC
  • Hematocrit
  • WBC
  • platelet
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10
Q

Wound size measurement

A
  • Direct measure: length x width x depth (cm)
  • Measure from longest/widest edges
  • Clock position
  • Depth measurement?
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11
Q

Wound size - Tracings

A

EZ graft
Save for documentation

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12
Q

Wound Size - Photographs

A
  • Polaroid vs Digital
  • Include measurement guide in photo
  • Document date, name, location of wound ON PHOTO
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13
Q

Tunneling

A
  • cm
  • Narrow passage created by separation or destruction of tissues along facial planes
  • common in pressure sores and deeper wounds
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14
Q

Undermining

A
  • cm
  • occurs when tissue edges erode leaving a large wound with a small opening
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15
Q

Sinus Tract

A

Elongated cavity allowing purulent material from an abscess to drain to body surface

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16
Q

Clock Method to Document

A

12 = head
6 = feet
Ex: 3.2 cm undermining from 12 to 3; 1.9 cm tunneling at 3:00 position

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17
Q

Granulation Tissue

A

viable, bubbly bright beefy red tissue (good oxygen supply)

Pink or dusty = ischemia or infection (document as “clean non-granular pink tissue”)

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18
Q

Necrotic Tissue

A

Non-viable tissue, breeding ground fro bacteria, document by color, consistency, and adherence
- Slough and Eschar

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19
Q

Slough

A

i. Color: tan, yellow, green
ii. Consistency: stringy or mucinous
iii. Adherence: ease that it pulls away from wound base non-adherent loosely adherent firmly adherent

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20
Q

Eschar

A

i. Color: black or brown
ii. Consistency: soft or hard
iii. Adherence: adherent or non- adherent
iv. Stability: stable vs. non-stable

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21
Q

Adipose Tissue

A

a. Viable: yellow, globular, slippery
b. Non-viable: grayish, hard/crunchy

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22
Q

Fascia

A

a. Viable: Shiny, white, thick/thin, sheath like
b. Non-viable: grayish, slimy, disintegrating

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23
Q

Bones

A

a. Viable: white, solid
b. Non-viable: yellow/brown, soft –> If wound is down to level of bone possible osteomyelitis must be ruled out

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24
Q

Tendons

A

a. Viable: shiny, white, fibrous, cord like
b. Non-viable: dull white/yellow/gray

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25
Q

Ligaments

A

a. Viable: fibrous flat, yellow/white
b. Non-viable: dull yellow/gray

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26
Q

Muscles

A

a. Viable: dull red, pink, striated, may contract when touched
b. Non-viable: grayish, loose fibers

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27
Q

Wound Edges

A

tissue perimeter
periwound

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28
Q

Types of Wound Edges

A
  • Defined/undefined
  • Attached/unattached
  • Epibole (Epiboly)
  • Xerosis
  • Ecchymosis
  • Maceration
  • Erythema
  • Fibrosis or induration
  • Hyperkeratotic
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29
Q

Wound Drainage: Exudate - Type

A

Serous, Sanguineous, Serosanguineous, Purulent

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30
Q

Wound Drainage: Exudate - Color

A

Clear, yellow, red, dark brown, blue/green (pseudomonas infection)

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31
Q

Wound Drainage: Exudate - Consistency

A

Thin/watery and thick

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32
Q

Wound Drainage: Exudate - Amount

A

Scant, Minimal, Moderate, Heavy, Copious

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33
Q

Wound Odor

A

Present vs. Absent
Cleans wound prior to assessing
Descriptors: foul, sweet, pungent

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34
Q

Types of Edema

A

Induration
Pitting

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35
Q

Classification for pitting edema

A

1+ barely perceptible
2+ easily identified depression (EID), but rebounds < 15 sec
3+ EID, rebounds in 15-30 seconds
4+ EID, rebounds in > 30 sec

36
Q

Circulation

A
  1. Pulses –> ABI
  2. Doppler US
  3. Capillary refill
  4. Rubor of Dependency
  5. Toe pressure
37
Q

Sensory Integrity

A

Semmes-Weinstein Monofilaments
5.07 loss of protective sensation

38
Q

Pain Assessment

A
  1. VAS
  2. Pain with palpation
39
Q

Arterial Insufficiency - Etiology

A

Arteriosclerosis or acute thrombosis

40
Q

Arterial Insufficiency - Location

A

Lateral malleolus, anterior lower leg, toes

41
Q

Arterial Insufficiency - Appearance

A

Small, shallow/deep, round with regular edges, pale, often necrotic
eschar present

42
Q

Arterial Insufficiency - Pain

A

Severe, at rest, night, intermittent claudication

43
Q

Arterial Insufficiency - Perfusion

A

ABI < 0.90
If < 0.5, REFERRRRR!!!
delayed capillary refill
rubor of dependency
cool to touch
diminished or absent pulses

44
Q

Arterial Insufficiency - Periwound and general integument condition

A

Ischemic; shiny; taut; thin, dry, alopecia, trophic changes (thick toe nails)

45
Q

Venous Insufficiency - Etiology

A

vascular incompetence

46
Q

Venous Insufficiency - Location

A

Medial malleolus and medial leg

47
Q

Venous insufficiency - Appearance

A

Shallow, irregular shape, moderate/high drainage, glossy,
macerated

48
Q

Venous Insufficiency - Pain

A

Mild/moderate; alleviated with elevation

49
Q

Venous Insufficiency - Perfusion

A

ABI 1.0 or less; Normal capillary refill; poor venous fill; warm or
normal temperature

50
Q

Venous Insufficiency - Periwound and general integument conditions

A

white wound edges due to maceration; Hemosiderin staining/Lipodermatosclerosis; significant edema

51
Q

Neuropathic- Etiology

A

Hyperglycemia/Diabetes Mellitus

52
Q

Neuropathic- Location

A

plantar surface of foot/heel; altered pressure points

53
Q

Neuropathic - Appearance

A

round; punched out; little to no drainage; necrotic base

54
Q

Neuropathic- Pain

A

None… that’s the problem

55
Q

Neuropathic - Perfusion

A

ABI normal or may be false positive; pulses normal to absent; Normal to warm temperature

56
Q

Neuropathic - Periwound and general integument condition

A

callus periwound; dry cracked skin; structural deformities (toe clawing; rocker bottom foo; Charcot foot deformity)

57
Q

Neuropathic - Wagner Classification System

A

0 = No open ulcers
1 = Superficial Ulcer
2 = Deep ulcer, tendon, capsule or bone present
3 = Deep ulcer, abscess, sepsis, or osteomyelitis
4 = Localized gangrene
5 = Entire foot gangrenous

58
Q

Pressure Ulcers - Etiology

A

unrelieved pressure

59
Q

Pressure Ulcers- Location

A

Sacrum, greater trochanter, ischial tuberosity, posterior calcaneus, lateral
malleolus

60
Q

Pressure Ulcers- Appearance

A

Deep; tunneling and undermining; eschar; profuse drainage

61
Q

Pressure Ulcers - Pain

A

Sensation varies and pain varies

62
Q

Pressure Ulcers - Perfusion

A

Often normal

63
Q

Pressure Ulcers - Periwound and general integument conditions

A

ring of erythema; nonblanchable erythema; localized warmth; Fibrous induration; dermatitis

64
Q

Scales for Pressure Ulcers

A

Sessing scale; Pressure Sore Status Tool; Braden Scale; Norton Pressure Scale

65
Q

Braden Scale

A
  • Prevention tool for assessing risk of ulceration
  • Subscales Measure: Mobility
    – Activity
    – Sensory Perception
    – Skin Moisture
    – Nutritional Status
    – Friction and Shear
    ** A score of 18 or less = risk; the lower the score the greater the risk
66
Q

Norton Risk Assessment

A

Subscales measure:
- physical condition
- mental condition
- activity
- mobility
- incontinence
*** a score of 16 or less = risk; lower the score, the greater the risk

67
Q

Risk factors for pressure ulcers

A

Impaired mobility, Malnutrition, Impaired sensation, age, hx of previous pressure ulcers

68
Q

Why do pressure ulcers occur?

A

o Combination of time and amount of pressure
o Pressure of > 32 increase risk of sore, but even lower pressures for longer period of
time can cause capillary closure.
o Shear and friction →shearing force between skin and deeper tissues →stretching
and angulation of vasculature, compromising perfusion
o Moisture increases shear forces

69
Q

Stage I Pressure Ulcer Staging

A
  • Nonblachable erythema
  • Skin intact
  • Blue/purple appearance
  • Change in local tissue temperature, tissue consistency & sensation
70
Q

Stage II Pressure Ulcer

A
  • Super ulcer
  • Blister
71
Q

Stage III Pressure Ulcer

A
  • Deep Ulcer
  • Crater
  • May have undermining
    *** if you see necrosis, it is at least a stage III
72
Q

Stage IV Pressure Ulcer Staging

A
  • Deep ulcer
  • Extensive necrosis
  • Undermining/ tunneling/ sinus tracts
73
Q

Unstageable Pressure Ulcer

A

Used if base of wound is obscured by eschar or slough

74
Q

Suspected Deep Tissue Injury (Pressure Ulcer)

A
  • Discoloration/ blood filled
  • Painful
  • Boggy
  • May evolve to eschar
75
Q

Cardinal Signs of Infection

A
  • Rubor
  • Calor
  • Pain
  • Tumor
  • Odor
  • Systemic signs (fever, chills, sudden shift in glucose levels)
76
Q

How to confirm wound infection

A
  • tissue biopsy: GOLD STANDARD
  • swab culture: aerobic, anaerobic, see Meyers for procedure
77
Q

Types of infection

A

Gram positive
Fungal

78
Q

Bioburden

A

All tissues have a “normal amount”
When critical levels are reached = infection

79
Q

Wound location

A

Quantity
Location
Shape

80
Q

Systems review

A

Integument
Cardiovascular
Musculoskeletal
Neuromuscular
Gi
Ug

81
Q

Epibole

A

Pizza crust
Edges of skin fold over wound

82
Q

Xerosis

A

Hyper dry skin
Typically seen in diabetics

83
Q

Maceration

A

White ring around wound
Too wet

84
Q

Fibrous or induration

A

Palpate around wound and it feels like dough, creates indentation

85
Q

Pruitis

A

Itching
Most common in diabetes
, drug hypersensitivity, hyperthyroidism

86
Q

Urticaria

A
  1. Smooth, red, elevated patches of skin, hives
  2. Indicative of allergic response to drug or infection

Physical Agents (11 decks)

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