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MED CON III > Wound Exam: Color, Drainage, Edges > Flashcards

Wound Exam: Color, Drainage, Edges Flashcards

1
Q

Types of exudate (drainage)

A

sanguineous - thin, bright red

serosanguinous - thin, watery, pale red to pink

serous - thin, watery, clear

purulent - thick or thin, opaque tan to yellow

foul purulent - thick opaque yellow to green with offensive odor

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2
Q

Amount of exudate:

A

none- wound tissues dry

scant - moist, no measurable drainage

small - very moist, drainage <25% dressing

moderate - wound tissues wet, drainage involves 25-75% dressing

large - wound tissues fill with fluid, involves >75% dressing

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3
Q

Maceration

A

overly wet area

healthy tissue breakdown

white appearance

*Maceration chronic wounds present with a high level of exudate and whitish, swollen skin. The surface of the skin is roughened and lined with a network of grooves termed as the “sulci cutis”. It is similar in appearance to the white, wrinkly skin observed after spending a long time in a bath.

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4
Q

What should you look for in the areas surrounding the wound?

A

pulse - compare side to side, above to below

skin temperature

skin characteristics:
-blisters, calluses, other lesions
-skin color
-hair and nail growth
-moisture
-texture
-general visual assessment

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5
Q

What can excessive lipids cause the skin to look like?

A

Waxy appearance, dilated pores, acnes

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6
Q

Description of wound edges:

A

EVEN
-arterial wound

IRREGULAR
-venous wound
-may occur as wound epithelializes (shiny, translucent epithelial tissue)

EPIOBLE
-sign of halted healing process
-rolled edges of wound
-cells are termed senescent, meaning they are unable to reproduce

HYPERKERATOSIS
-overdevelopment of the horny layer of the skin
-appears as thickened skin around the edge of a wound or as a callus
-helpful to get layer of skin off to prevent wound

MACERATION
-Maceration chronic wounds present with a high level of exudate and whitish, swollen skin.

DEHISCED
-wound edges come apart
-may be superficial layers only
-can open full depth

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7
Q

When is wound odor test most accurately done?

A

after debridement and rinsing the wound

-get slough and necrotic tissue out of the way

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8
Q

Types of wound odors:

A

ammonia-like

sickly sweet

fout, putrid, fetid

*blue/green colored wound–> bad sign

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9
Q

Types of pain and what they mean:

A

Deep pain (cramping- ischemia or hypoxia; more comfortable in dependent position

Throbbing, localized pain- infection; deep pain that increases with pressure may indicate osteomyelitis

Superficial tenderness- exposed nerve endings, may be accompanied by sharp, shooting pains

Pain with stimulation of red tissue - living muscle!

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10
Q

Sensory testing can include:

A

pressure
vibration
light touch
temperature
proprioception
sharp: wartenberg wheel/pinwheel
reflexes/DTR

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11
Q

Vascular testing: arterial system

A

-pulses: use grading scale, compare BL, above and below

doppler for pulses that are not palpable

ABI

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12
Q

Why would a wound culture be indicated?

A

-infection signs: pus, change in color or character of exudate, redness, induration, changes in odor

-systemic signs of infection: fever, leukocytosis (high WBC count)

-suddenly elevated glucose

-pain in neuropathic extremity

-lack of healing after 2 weeks in a clean wound despite optimal care

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13
Q

CLINICAL DIAGNOSIS: DIMES- what does it stand for?

A

DEBRIDEMENT

INFECTION/INFLAMMATION

MOISTURE BALANCE

EDGES

SUPPORT SERVICES

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14
Q

Characteristics of chronic wounds:

A

-present for at least 6 weeks

CHARACTERISTICS:
-necrotic
-bioburden- The number of microorganisms with which an object is contaminated is referred to as the bioburden
-chronic inflammation
-impaired hemodynamics
-senescent fibroblasts and keratinocytes
-chronic wound fluid with growth inhibiting proteases
-overgrowth of epithelium with lack of underlying CT (epibole)

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15
Q

What are the 4 types of chronic wounds? (90% of chronic wounds)

A

Arterial
-causes: ischemia, micro or macro vascular disease, smoking

Venous insufficiency
-causes: deep vein thrombosis (37%), recent surgery, ankle fusion, prolonged standing, pregnancy, CHF

Neuropathic/Diabetic
-causes: DM, peripheral vascular disease, Hansen’s disease (leprosy)

Pressure
-causes: pressure or shear, immobility, moisture, decreased sensation, poor nutrition

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16
Q

What are the most prevalent types of wounds?

A

MOST
surgical infection
diabetic infection
surgical wound
traumatic wound
skin disorder
venous infection
LEAST

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17
Q

Neuropathic wound characteristics:

A

LOCATION: -usually foot, plantar surface or toes

-CAUSE: mechanical forces or minor trauma

PAIN: relieved with ambulation

APPEARANCE OF FOOT: architectural changes in foot (charcot foot)

APPEARANCE OF WOUND: pink, moist, callus formation, plantar surface, skin usually warm, cellulitis

CO-MORB: diabetes, chemo, Hansen’s

** ABI normal

-patients’ diagnoses: DM, PVD, Hansen’s disease, spina bifida, lupus, toxic syndromes, Charcot-Marie Tooth disease

-patients typically have sensory, autonomic, and motor neuropathies.

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18
Q

Arterial wound characteristics:

A

LOCATION: usually peripheral extremities

CAUSE: ischemia via micro or macrovascular disease

PAIN: occurs with ambulation

APPEARANCE OF FOOT: normal

APPEARANCE OF WOUND: pale color, dry, well-defined margins, limb color pale, hairless extremity, skin cool to touch

Co-morbidities: history of PAD, circulatory problems

**ABNORMAL ABI

MACRO: larger, named artery destruction by PAOD, embolus, thrombus, or trauma

MICRO: disease of the small, unnamed arterioles and capillaries, usually associated with diabetes or small emboli

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19
Q

How many people with DM have wounds?

A

15%

-14-24% of those with diabetic ulcers end up having amputation

–> 50-68% mortality rate following amputation at 5 years

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20
Q

How does hyperglycemia affect vasculature in ppl with DM?

A

hyperglycemia can lead to stiffer blood vessels

-leads to reduced tissue oxygenation

-occluded vessel
-damaged myelinated nerve fiber

*vascular and neurological damage

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21
Q

Is it more common to have DPN with type I or type II diabetes?

A

type II

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22
Q

What is neuropathy (DPN) ?

A

-decreased sensation, vibration, proprioception, loss of reflexes (distal to proximal)
-impacts longer nerve fibers “dying back”

-neuropathic pain can be present

MOTOR EFFECTS
-progressive weakness and atrophy –> changes in foot shape

AUTONOMIC EFFECTS
*decreases sweat and oil production –> dry, in-elastic skin
*heart and vasculature
–> orthostasis
–> silent MI
*GI tract
–> gastroparesis
–> diarrhea

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23
Q

Sensory exam for DPN:

A

-increased temperature by 2.2 degrees celsius

-monofilament for protective sensation, temperature, position sense, vibration, pin, light touch

-usually vibration test is first

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24
Q

What is a common osteopathy that occurs with diabetes mellitus?

A

Charcot’s disease:
(neuropathic arthropathy)

-progressive degeneration of weight bearing joints

-increased skin breakdown risk
–> abnormal pressure distribution
–> more wound risk combined with DPN

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25
Q

Common foot deformities for patients with DM?

A

clock toe deformity

charcot foot

bunions –> may lead to ulceration on toes

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26
Q

Complications of vascular and neuropathic changes for patients with diabetes:

A

-ulceration
–> often painless because they don’t have sensation
–> amputation may be needed

-neuropathic edema

-charcot arthropathy

-callus formation

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27
Q

Skin and nail changes with diabetes:

A

-1/3 patients have dermatologic manifestation

-up to 1/2 of ppl with type 2 DM at risk of developing skin infections

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28
Q

why do ppl with DM have skin and nail changes?

A

-poor glucose control
-abnormal carb metabolism
-atherosclerosis (4x as likely)
-microangiopathic changes
-neuron degeneration
-pharmacological therapy for DM (injection site)

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29
Q

Diabetic foot classification with grading:

A

Grade 0
-intact skin

Grade 1
-superficial ulcer

Grade 2
-deep ulcer

Grade 3
-ulcer with bone involvement

Grade 4
-forefoot gangrene

Grade 5
-full-foot gangrene

WIFI classification- WOUND, ISCHEMIA, FOOT INFECTION
-wound: 0-3
-ischemia: 0-3
–> less pressure, not good
-foot infection: 0-3

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30
Q

Peripheral vascular disease (PAOD)

A

Also called “peripheral arterial occlusive disease”

CRITICAL PHASES:
-collateral circulation is insufficient for metabolic needs–> blood shunts to muscles where there is less resistance
-traumatic wounds with delayed healing

CLAUDICATION- pain with activity
–> decreases with rest
-can be effectively terated with exercise

rest pain–> need surgery

-ulcer development possible

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31
Q

What artery could be involved with thigh and buttock pain (claudication)?

A

aortoiliac or iliac

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31
Q

What artery could be involved with calf pain (claudication)?

A

femoral or popliteal

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32
Q

When is revascularization surgery required with PAOD?

A

pain at rest

-could have signs of ischemia at distal digits

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33
Q

Physical examination of arterial wounds: (with peripheral vascular disease)

A

ABI: diminished

PULSES: diminished

CAPILLARY REFILL: > 3 seconds

BUERGERS TEST: pallor with elevation and rubor of dependency

SKIN APPEARANCE: shiny, thin, pale, NO hair

CONDITION OF NAILS AND HAIR

LOCATION: wound on distal toes or fingers

EDGES: even, punched out appearance

WOUND TISSUE: dry, necrotic, little or no granulation tissue

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34
Q

Stage I arterial wound

A

limb viable, not immediately threatened

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35
Q

Stage IIa arterial wound

A

limb marginally threatened, salvageable if promptly treated

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36
Q

Stage IIb arterial wound

A

limb immediately threatened, salvageable with immediate revascularization

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37
Q

Stage III arterial wound

A

limb irreversibly damaged

major tissue loss or permanent nerve damage inevitable

38
Q

What is the recurrence rate of venous wounds?

A

72%

39
Q

What type of wound makes up the majority of LE wounds?

A

venous wounds

40
Q

Venous wounds risk factors:

A

-more common in women

RISK FACTORS
-obesity
-smoking
-lack of exercise
-standing of sitting for long periods
-family hx
-pregnancy
-history of injury, surgery, or DVT of LE
-heart failure

41
Q

Examples of superficial veins:

A

great saphenous

small saphenous

42
Q

Examples of deep veins:

A

femoral

popliteal

43
Q

Chronic venous insufficiency causes and effects

A

CAUSES
-reflux as a result of incompetent valves in the perforator, superficial, or deep veins
-lack of pumping activation during gait cycle

EFFECTS:
-venous hypertension
-excessive moisture in the interstitial tissue
-prevents adequate oxygen and nutrients from reaching the skin

PATHOPHYS CHANGES:
-vessel dilation and elongation
-increased collagen deposition in vein walls and skin
-plasma protein leaks into interstitial space with fibrin cuff around arterioles
-increased inflammatory cells –> tissue remodeling and dermal fibrosis

44
Q

What is venous obstruction called?

A

chronic deep vein thrombosis

45
Q

Characteristics of progression of venous disease:

A

-heavy, aching feeling in legs
-telangiectasia or reticular veins
-varicose veins
-edema without ulceration
-skin changes without ulceration
-skin changes with ulceration
-skin can appear wet and macerated

46
Q

Skin changes characteristics of chronic venous insufficiency:

A

-hyperpigmentation
-lipodermatosclerosis
-dilated long saphenous vein
-atrophie blanche–> result of healed ulcers; tension in skin
-unilateral or bilateral edema
-dermatitis
-thickened skin
-cellulitis

47
Q

What is atrophie blanche?

A

Atrophie blanche describes the result of healed ulcers. These characteristically present as a white, atrophic stellate scar with peripheral telangiectasias.

48
Q

Cellulitis vs dermatitis:

A

Cellulitis is a common skin infection caused by bacteria. Cellulitis causes redness, swelling, and pain. Allergic contact dermatitis is an itchy skin rash caused by contact with something that irritates the skin.

49
Q

What is lipodermatosclerosis:

A

Lipodermatosclerosis, a chronic inflammatory disorder of the lower extremities, is characterized by subcutaneous fibrosis and skin induration. Lipodermatosclerosis is primarily associated with chronic venous insufficiency and venous hypertension and typically affects middle-aged and older adults.

50
Q

What is hemosiderin staining?

A

Hemosiderin staining occurs when the smallest blood vessels, known as capillaries, begin to leak. This can be due to a wound, a broken bone, a surgical incision or other types of trauma. It is also associated with certain illnesses that affect circulation. The most common of these is chronic venous insufficiency.

51
Q

What is the most common location of a venous woune:

A

From the malleoli to just under the bulk of calf muscle

52
Q

Components of a venous wound exam:

A

Girth at arch, malleolus, calf

Type and amount of drainage

Edges: uneven

Location: gaiter, above the ankle

Pain level: usually severe with venous wound

Healing time: failure to heal with standard care

Pulse exam/ABI in case of absent pulses

Ultrasound can be used to determine valve competency/regurgitation can be detected

53
Q

CEAP Classification System and Reporting Standard Revision 2020

A

CLINICAL MANIFESTATIONS

ETIOLOGY

ANATOMIC DISTRIBUTION

PATHOPHYSIOLOGY

54
Q

What does MAVLU stand for?

A

Mixed venous and arterial wounds

55
Q

Mixed venous and arterial wound characteristics:

A

ETIOLOGY: chronic venous insufficiency with poor healing, coexisting arterial insufficiency

PATHOPHYS: venous hypertension, primary or post-thrombotic venous reflux and/or obstruction, reduction in blood inflow due to PAOD

example: irregular wound borders (venous), full thickness, minimal exudate (arterial), cool pale LE (arterial)

ABI: 0.6-0.8 can indicate a mixed ulcer

<0.6- the first mode of treatment is to re-vascularize for healing, prevent recurrence
–> no compression

> 0.6: no consensus on treatment; less likely need revascularization

56
Q

Arterial vs venous ulcers:

A

ARTERIAL
-LOCATION:distal to ankle, usually foot, toes, lateral mall.
-EDGES: punched out, well defined
-WOUND BED: pale or rubor of dependence, skin shiny and thin, hair loss and nail changes common
-PERIWOUND: thin and shiny, hair loss and nail changes
-POSSIBLE PMH: diabetes, hypertension, smoking, previous vascular disease
-OTHER: typically dry, cold skin, absent/weak pulses
-MANAGEMENT: keep dry and reduce bioburden

VENOUS
-LOCATION: lower leg or above ankle, near medial mall., feet unlikely
-EDGES: irregularly shaped
-WOUND BED: often granulating, with cellular debris/crust, usually shallow
-PERIWOUND: scaly, dry, hemosiderin staining
-POSSIBLE PMH: varicose veins, obesity, pregnancy, previous DVT
-OTHER: wet, warm skin, edema, pruritis (itchy)
-MANAGEMENT: manage moisture

57
Q

Pressure vs Neuropathic wounds

A

PRESSURE
-LOCATION: bony prominences, especially sacrum, ischial tub, greater troch, heels
-EDGES: circular or teardrop, well-defined
-WOUND BED: can be pale, granulating, necrotic or eschar
-PERIWOUND: healthy or red/purple due to pressure
-POSSIBLE PMH: immobility, SCI, dementia, progressive neurologic disorder, dependent w/ mobility, bed or W/C bound
-MANAGEMENT: offloading, nutrition, consider stool/urine contamination, debridement

NEUROPATHIC
-LOCATION: plantar surface of foot, toes, heels, metatarsal heads
-EDGES: callused, well-defined
-WOUND BED: deep and often granulating
-PERIWOUND: thick, dry, callused
-POSSIBLE PMH: diabetes, neuropathy/loss of protective sensation, possible charcot foot
OTHER: decreased sensation, decreased reflexes
-MANAGEMENT: promote granulation and reduce infection

58
Q

STAGES OF PRESSURE INJURIES

A

STAGE 1
-reddened
-non-blanchable
-no skin breadown

STAGE 2
-partial thickness wound

STAGE 3
-full thickness
-not seeing ms., tendon, or bone
-into subcutaneous layer

STAGE 4
-slough, eschar common
-got to ms. tendon or bone

59
Q

Once a pressure injury has been staged, _______

A

the stage cannot be reversed when there is healing happening

60
Q

Why does a pressure injury occur?

A

-ischemia and anoxia to tissue

-shear forces, friction forces, pressure forces, moisture

-Tissues are compressed, blood vessels are compressed and blood flow is
diverted by continual pressure on the skin and underlying structures

-cellular respiration impaired and cells die

61
Q

Are pressure injuries in hospitalized patients considered never events?

A

yes

stage III-IV

62
Q

Pressure forces- relationship between intensity versus duration

A

pressure injuries can be caused by:

-prolonged exposure to mild to moderate force

-short exposure to moderate severe forces

63
Q

Friction vs shear:

A

FRICTION
-is a mechanical force exerted when two surfaces move (i.e.: ‘rub’) against another

SHEAR:
-Shear is a stress resulting from applied forces which cause two objects to deform in the transverse plane
-involves friction and gravity
-body layers are laterally shifted in relation to each other
-skeleton moves but skin stays in same place

64
Q

What is a risk that can occur when you raise the HOB?

A

-increased load on sacrum and heels in more upright position

-good HOB height: 30 degrees

65
Q

What populations are skin tears common in?

A

-extremes of age
-critically or chronically ill

-10-54% prevalence in LTC

66
Q

Skin tears: cause and characteristics

A

Caused by shear, friction, and/or blunt force trauma

  • Forces separation of skin layers
  • Can be partial- or full-thickness
  • Slow to heal
  • Susceptible to secondary infection
    -acute wound

high propensity
to develop into chronic wounds.

**IT IS GOOD TO PRESERVE THE FLAP!

67
Q

How can documentation on dressing be modified to keep skin flap in mind?

A

ex: remove in this direction with arrow (the skin flap is oriented in this direction)

date and initials of therapist

67
Q

What is the Braden Scale?

A

-objective scale to determine risk of person developing a pressure ulcer

-SNF, IRF, etc

Population: Most commonly used for patients who are bed- or chair-bound, as well as those with an impaired ability to reposition.

CATEGORIES:
-sensory perception - response to pressure-related discomfort (completely limited, very limited, slightly limited, no impairment)

-moisture (constantly moist, very moist, occ. moist, rarely)

-activity (bedfast, chairfast, walks occ., walks frequently)

-mobility
–> ability to change and control body position
–> (completely immobile, very limited, slightly limited, no limitation)

-nutrition (very poor, probably inadequate, adequate, excellent)

-friction and shear (problem, potential problem, no apparent problem)

** 1-3 or 1-4 scale

** LOWER SCORES–> GREATER RISK OF DEVELOPING PRESSURE INJURY

68
Q

Acute wound vs chronic wound:

A

ACUTE
-TIME: 4-6 weeks
-EXAMPLE: surgical, bites, burns, abrasions, traumatic
-TREATMENT:
–> expected healing within predictable timeframe
–> minimal interventions for minor wound and clean source
–> surgical debridement, antimicrobial therapy, wound lavage for severe wound and dirty source

CHRONIC
-TIME: >6 weeks
–> caused by endogenous mechanisms related to a predisposing condition or risk factors (diabetes, AIDS, chemo)
-EXAMPLE: leg/foot ulcers, pressure injury, foot wound from vascular insufficiency or neuropathy

-TREATMENT:
1.) dressing
2.) antimicrobial agents
3.) physical therapy
4.) education
5.) treat co-morbidities
6.) supportive ints: pressure relief, compression, footwear, ADs

69
Q

What should you know about wounds as a generalist PT?

A

-infection
-arterial
-venous
-diabetic/neuropathic ulcer
-pressure injury
-lymphedema

** on the job training is required

70
Q

Components of a basic wound assessment:

A

full or partial thickness
wound type
location
stage
measurements
wound bed
wound edges
drainage
periwound

  • start from inside and work your way outward
71
Q

DIMES

A

-debridement
-infection/inflammation
-moisture balance
-edges - if wound edges are not migrating after wound bed prep and healing is stalled, then advanced therapies should be considered
-support services

72
Q

RED-YELLOW-BLACK SYSTEM (RED)

A

WOUND BED: pale pink –> beefy red, granulation tissue

TREATMENT GOALS: protect wound, maintain warm & moist environment, protect periwound

73
Q

RED-YELLOW-BLACK SYSTEM (YELLOW)

A

WOUND BED: – moist & yellow slough, may vary in adherence

TREATMENT: debride necrotic tissue, absorb drainage, protect periwound

74
Q

RED-YELLOW-BLACK SYSTEM (BLACK)

A

Wound Bed – thick, black, adherent eschar

Treatment Goals – debride necrotic tissue that may appear wet or infected

75
Q

Purpose and goal of debridement (DIMES)

A

PURPOSE:
-remove necrotic tissue
-remove bacteria –> prevent infection
-shorten the inflammatory phase of wound healing
-decrease energy required by body for wound healing
-increase ability to assess wound bed

GOAL: 100% granulation tissue

76
Q

INDICATONS FOR DEBRIDEMENT

A

-necrotic tissue
-foreign material
-debris
-residual topical agents
-blisters
-callus

77
Q

CONTRAS FOR DEBRIDEMENT

A

-granular tissue
-viable tissue
-** stable, hard, dry eschar in ischemic limbs
-urgent need for surgical debridement (gangrene, osteomyelitis)
-electrical burns
-deeper tissue: muscle, tendon, ligament, fascia, capsule, bone, nerves, blood vessels

78
Q

Things to consider before debridement:

A

nutrition

concomitant med conditions

immunosuppression

thrombocytopenia - lack of platelets

use of anticoagulants -bleeding risk

setting where the patient is

79
Q

What are the 4 types of non-selective/mechanical debridement?

A

-wet to dry: “waxing a wound” - with fully necrotised tissue; standard 30-40 years ago
-irrigation: saline
-hydrotherapy: whirlpool (breakdown of necrotic tissue) –> not efficient
-abraded technique: rubbing on tissue; non-selective; not good for granulation tissue

80
Q

4 types of selective debridement:

A

AUTOLYTIC - assist body’s enzymatic cells in digesting necrotic tissue; often used with wound dressings
*occlusive- hydrocolloid- non infected wounds, days to work
*transparent- non-occlusive, not good for deep wounds or infected wounds
*hydrogel- add moisture and nutrients to area
*med honey- high in osmolarity; low pH (acidic nature helps to neutralize the naturally alkaline wound area) ** manuka honey

BIOSURGICAL
-maggots: they eat bacteria; control exudate; aren’t affected by antibiotics; can bag them or have them be free range

ENZYMATIC
-breaks down proteins necrotic tissue
-good for infected wound with topical antimicrobial
-cannot be used with silver based products
-**promotes angiogenesis
*EXPENSIVE!
EX: collagenase santyl

SHARP/SURGICAL
-conservative: can be done by PT
–> must have physician’s order, goal of 100% granulation tissue
-surgical: only by MD under anesthesia
–> large wound, lots of necrosis, heavily infected,
–> ascending cellulitis, osteomyelitis, extensive necrosis, extensive undermining

81
Q

CONS OF AUTOLYTIC DEBRIDEMENT

A

-slow results
-no occlusive dressing to be used with infection

82
Q

CONS OF SHARP DEBRIDEMENT

A

-pain
-can require surgery
-risk of vessel, nerve, tendon damage

83
Q

CONS OF MAGGOTS

A

-expensive
-limited resources
-reputation

84
Q

CONS OF ENZYMATIC DEBRIDEMENT

A

-very expensive
-slow results

85
Q

CONTRAS FOR SHARP DEBRIDEMENT

A

-stable heel eschar
-gangrene (NEED SURGICAL DEBRIDEMENT)
-unidentified structures–> nerve, tendon, ligament, muscles, vessel, fungating wound

-terminally ill
-ABI < 0.8
-coagulopathy: INR, PT/PTT, platelets, hemoglobin

86
Q

MUST HAVES before sharp debridement

A

-Phys. order
-chart review
-check labs
-gather tools
-pre-medicate
-comfortable positioning
-adequate lighting
-cleanse before you debride with saline! (angiocatheter, skin/wound cleanser, bulb syringe)
-measure!!- paper tape measure, cotton tip applicator

87
Q

Should you measure the wound before or after you debride it?

A

before AND after

88
Q

Techniques for selective debridement:

A
  • Hold scalpel like a pencil
  • Cut parallel to skin, not perpendicular
  • Work in layers
  • Use forceps or tweezers to grasp onto layers
89
Q

What is the cross hatching technique of selective debridement used for?

A

Increases surface area for enzymatic debridement

** can help to improve healing of areas with epibole –> increase wound edge closure
-can do this with a curette

-silver nitrate can be used in epibole management as well

90
Q

Function of silver nitrate:

A

The silver nitrate stick is considered an antimicrobial and is used in enhancing anti-inflammatory healing. A silver nitrate stick uses a chemical cautery agent made up of 75% silver nitrate and 25% potassium nitrate. When the tip of the applicator stick is moistened by wound fluid, a chemical reaction occurs: killing bacteria, removing necrotic tissue, reducing hypergranulation, reducing fibroblast proliferation, and coagulating tissue.

91
Q

Types of sharp debridement tools:

A

scalpel, curette, scissors, forceps

92
Q

Consideration of temperature regulation:

A

PT’S CORE BODY TEMP (necessary for wound healing): 91.4-107.6 for wound healing

-moisture loss= cooling

-degree change of 2 degrees affects healing
–> increase infection risk, inhibit platelet activation, reduction in wound strength due to decline in collagen deposition

MED CON III (14 decks)

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