Wounds Flashcards
Venous insufficiency wounds
Pain with palpation (not very painful) Pedal pulses present Irregular edges Edema Shallow wound bed Moist/drainage hemosiderin staining proximal to medial malleolus
Most influenced by compression therapy
Arterial insufficiency wound
Extreme pain decreased with rest (intermittent claudication) Decreased/absent pedal pulses Deceased distal limb temp Well defined edges Deep wound bed Cyanosis, cool skin Dry lateral malleoli, dorsum of feet, toes
Diabetic ulcer
Painless Absent pedal pulses Decreased distal limb temp Deep wound bed at pressure points Shiny skin ulcertion located on weightbearing surfaces of foot
Pressure ulcer stages
Suspected deep tissue injury- localized discoloration under intact skin.
Stage 1- intact/red that doesn’t blanch
Stage 2- open wound red/pink wound bed, partial thickness of dermis, blister
Stage 3- subQ fat visible, full thickness, tunneling/undermining, slough possible
Stage 4- tendon, muscle, bone exposed, slough/eschar
Unstagable- slough/eschar covering full thickness
Purulent drainage
Thick, white, pus; may be infected
Serosanguineous drainage
Contains blood
Autolytic debridement
Body uses its own enzymes to lyse necrotic tissue
Moisture retentive dressings
Films, hydrocolloids, hydrogels, calcium alginates
When is autolytic debridement contraindicated?
Pts who are immunosuppressed
Enzymatic debridement
Topical application of enzymes that lyse collagen, fibrin & elastin
When is enzymatic debridement indicated?
Stage 3 & 4 wounds with yellow necrotic material
Mechanical debridement
Pulsed lavage, whirlpool, dry gauze dressings, irrigation, wet to dry dressings
When is enzymatic debridement contraindicated?
Exposed tendons, ligaments, joint capsule, blood vessels,nerves,bone
Which dressings CAN be used in infected wounds?
Alginates
Foam - need to be changed daily
Safe pressure for pulsed lavage
4-15 psi
When to discontinue pulsed lavage
When wound is clean
Wound closure
If no change in necrosis in one week
Indications for film dressings
autolytic debridement
Stage I and II pressure ulcers
Skin donor site
NOT with infected wound
Superficial wounds with minimal drainage
Indications for foam dressings
Minimal to Moderate drainage
May use with hydrogel for autolytic debridement
Partial or full thickness wounds
Indications for hydrogels
Partial and full thickness wounds Necrosis/slough Burns Assist autolytic debridement NOT in infected wounds Most require secondary dressing
Indications for hydrocolliods
Partial thickness wounds
Autolytic debridement of necrosis/slough
Mild exudate-Somewhat absorbent/thermal insulation
Occlusive–NOT for infected wounds
Indications for alginates
Absorbent - wounds with moderate to large amounts exudate/necrosis
Wounds that require packing
Can be used to control bleeding
Non-occlusive: can use in infected wounds
Require secondary dressing (film/gauze)
Indications for gauze
Exudative wounds Dead space, tunneling, sinus tracts Exudate/necrosis Wet to dry for mechanical debridement Can be used on infected wounds Require secondary dressing
Unna boot
Semirigid dressing impregnated with ointments
Used for venous insufficiency ulcers to control edema
Which estim protocols can be used for wound care?
High volt pulsatile current***
Microcurrent
Alternating/biphasic current
Anode vs cathode for wound care estim
Anode- promote epithelial cell migration, deactivation of inflammatory phase
Cathode- promote granulation, control inflammation & inhibit certain bacteria
VAC for wound care
Negative pressure/subatmospheric (125 mmHg below ambient) for any wound
When wound is not closing,lack of arterial perfusion or uncontrolled exudate
Can be used with infection
Open cell foam dressing placed into wound
Methods of wound cultures
tissue biopsy, needle aspiration or swab cultures
taken after debridement of thick eschar & necrotic material & wound cleansing
Which medications can delay wound healing?
steroids, antihistamines, NSAIDs, oral contraceptives
chemotherapy/radiation
When should antiseptics be used?
infected wounds
ex. iodine, acetic acid, hydrogen peroxide
Silvadene
primarily for thermal injuries
Positioning to prevent pressure ulcers
heels protected/elevated
head of bed not > 30 deg. unless necessary
pressure relief technique ever 2 hour in bed
not weightbearing over greater trochanter
not full weightbearing over existing wound
pillows/wedges to separate bony prominences
Can compression be used for arterial wounds?
NO
Compression therapy for venous wounds
short-stretch bandages with high working pressure & low resting pressure (calf pump) <40 mmHg at ankle
pneumatic pump can also be used
Can compression be used for neuropathic wounds?
dependent on blood flow, check ABI
Contraindications to compression therapy
DVT, acute infection, heart failure, hypertension, cardiac/kidney dysfunction, AMS
