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Older Adult Exam 2 > Wounds > Flashcards

Wounds Flashcards

1
Q

What stage of wound healing occurs immediately after injury? What skills are involved? What clinical observation is noted? What occurs during this stage?

A

Coagulation

  • Platelets
  • Bleeding stops
  • Hemostasis; formation of fibrin clot
  • Messengers that bring on the inflammatory process
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2
Q

What stage of wound healing occurs immediately after injury until day 4? What skills are involved? What clinical observation is noted? What occurs during this stage?

A

Inflammation

  • Platelets, macrophages, neutrophils
  • Erythema, warmth, edema, pain
  • Prepares wound bed for healing by removing dead tissue and bacteria
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3
Q

What stage of wound healing occurs from day 4 - day 21? What skills are involved? What clinical observation is noted? What occurs during this stage?

A

Migratory/proliferative
- Macrophages, lymphocytes, fibroblasts, epithelial cells, endothelial cells
- Beefy red tissue
(newly formed collagen and blood vessels) which is covered by migrating epithelial cells
- Fills the defect and covers it as quickly as possible

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4
Q

What stage of wound healing occurs from day 21 - 1-2 years? What skills are involved? What clinical observation is noted? What occurs during this stage?

A

Remodeling/maturation

  • Fibroblasts
  • Shrinking, thinning, paling of scar
  • Reworks the new tissue to make it stronger
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5
Q

What factors impede wound healing?

A 
Diabetes
Malnutrition
Smoking
Anemia
Ischemia
Edema
Over-colonization
Infection
-sepsis
-osteomyelitis
Radiation
MOF
Medications
-Steroids
-Immunosuppressants
-Chemotherapy
-Vasopressors
Incontinence
-Fecal
-Urinary
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6
Q

Skin Changes with Aging?

A
  • drier, less elastic, and less well perfused
  • Epithelial and fatty layers become thinner
  • Skin vascularity diminishes, inc atherosclerotic changes
  • Inflammatory response decreases and tissue regeneration slows
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7
Q

What is the most costly hospital acquired condition?

A

Pressure injuries

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8
Q

What is a pressure injury?

A
  • Localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device.
  • Can present as intact skin or an open ulcer and may be painful.
  • Occurs as a result of intense and/or prolonged pressure or pressure in combination with shear.
  • The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue
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9
Q

What characteristics are assessed in the Braden scale?

A 
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction & Shear
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10
Q

What consists of the SKIN CARE bundle?

A

S upport Surfaces
K eep Repositioning
I ncontinence Care
N utrition & Hydration

C heck devices
A ssess risk and skin daily
R educe HOB < 30 degrees
E levate heels

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11
Q

When would you use a low air loss bed?

A

If Braden < 12, moisture is a significant problem or patient has PIs on multiple turning

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12
Q

When would use an air fluidized bed or dynamic immersion therapy?

A

If multiple large, truncal stage 3 or 4 PIs

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13
Q

What is the best position for generating low-pressure?

A

30 degree semi Fowler position

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14
Q

What does of albumin measure? Prealbumin? Which is the most reliable indicator?

A
  • Albumin: picture of past nutrition
  • Pre- albumin: monitored for success of current therapy - Most reliable indicator
    (Normal: 16-30 mg/100mL)
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15
Q

What are the four different types of moisture associated skin?

A
  1. Incontinence associated dermatitis
  2. Intertriginous dermatitis
  3. Peri wound moisture associated dermatitis
  4. Peristomal moisture associated dermatitis
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16
Q

What type of ulcer would you most likely see on the medial aspect of the lower legs? Lateral aspect?

A 
Medial = Venous
Lateral = Arterial
17
Q

What are some characteristics that would put someone at risk for developing arterial ulcers?

A

Predisposing Factors:
PVD
Diabetes
Advanced age

Assessment:
Thin, shiny, dry skin
Loss of hair on ankle and
foot
Thickened toenails
Pallor on elevation &amp;  dependent rubor
Cyanosis
Decreased temp
Absent or diminished
pulses
18
Q

What are some characteristics of arterial ulcers?

A 
Location:
Between toes or tips of toes
Over phalangeal heads
Around lateral malleolus
Where subjected to trauma  or rubbing of footwear
Characteristics:
Even wound margins
Gangrene or necrosis
Deep, pale wound bed
Painful
Cellulitis
19
Q

What is the treatment for arterial ulcers?

A 
Conservative Treatment:
Bedrest as feasible
Treat any cellulitis
Topical care
Patient ed &amp; support

Surgical Treatment:
Revascularization
Angioplasty

20
Q

What are some characteristics that would put someone at risk for developing venous ulcers?

A 
Predisposing factors:
Valve incompetence in  perforating veins
H/O deep vein  thrombophlebitis &amp;  thrombosis
Advanced age
Obesity
Assessment:
Firm (“brawny”)  edema
Dilated superficial  veins
Dry, thin Skin
Evidence of healed
ulcers
Lipodermatosclerosis
21
Q

What are some characteristics of venous ulcers?

A

Location:
Medial aspect of lower leg and ankle
May extend into malleolar area

Characteristics:
Irregular wound  margins
Superficial (into  dermis)
Ruddy, granular tissue
Usually painless
Exudate may be  present
22
Q

What is the treatment for venous ulcers?

A 
Conservative Treatment:
Elevate extremity as
feasible
Therapeutic vascular  compression
Unna boots, high  compression wraps,  stockings
Topical care
Absorption dressings
Debridement as  needed

Surgical Treatment:
Skin Grafting

23
Q

What are some characteristics that would put someone at risk for developing neuropathic (diabetic) ulcers?

A

Predisposing Factors:
Diabetic with peripheral neuropathy

Assessment:
Diminished or no sensation in  foot
Foot deformities
Palpable pulses
Warm foot
If pt has PVD, same
assessments as arterial
24
Q

What are some characteristics of neuropathic (diabetic) ulcers?

A

Location:
Plantar aspect of foot
Over metatarsal heads
Under heel

Characteristics:
Painless
Even wound margins
Deep
Cellulitis or underlying  osteomyelitis
Granular tissue present  unless coexisting PVD
25
Q

What is the treatment for neuropathic (diabetic) ulcers?

A 
Conservative Treatment:
Treat cellulitis
R/O osteomyelitis
Metabolic diabetic control
No weight bearing
Contact casting
Topical Care
Orthotics
Patient Ed &amp; support

Surgical Treatment:
Aggressive debridement
Revascularization (if
coexisting PVD)

26
Q

When not to debride?

A 
Intact, stable heel eschar
-No odor
-No pain
-No drainage
-No cellulitis
Severe PVD
Dry gangrene
*Know the vascular status
27
Q

When to Debride?

A

Open wound edges
Drainage, odor
Fever, other signs of cellulitis, sepsis
Debridement may need to be sharp for cellulitic wounds

28
Q

Types of Debridement?

A 
Autolytic
-Uses body’s own processes to remove devitalized tissue
-Occlusive dressings
Mechanical
-Wet-to-dry dressings
Enzymatic
-Collagenase
Surgical or Sharp
29
Q

What are the criteria for determining if a wound is critically colonized?

A

Nerds

  • Nonhealing wound
  • Exudative
  • Red and bleeding
  • Debris
  • Smell
30
Q

What are the criteria for determining if a wound has a deep tissue infection?

A

Stonees

  • Size is bigger
  • Temperature increase
  • Os (Probes to or exposed bone)
  • New area of breakdown
  • Erythema/edema
  • Exudate
  • Smell
31
Q

What topical therapy would you use for a wound in order to:

Add moisture to dry wound bed?

A

Hydrogel

32
Q

What topical therapy would you use for a wound in order to:

Maintain moist wound bed/absorb drainage?

A
  • Hydrocolloid

- Calcium alginate

33
Q

What topical therapy would you use for a wound in order to:

Absorb drainage/decrease bioburden?

A

Hydro fiber with AG

34
Q

What topical therapy would you use for a wound in order to:

Debride?

A
  • Collagenase (Chemical)

- Medihoney (Autolytic and mechanical)

35
Q

What topical therapy would you use for a wound in order to:

Gentle adhesive/absorb drainage?

A

Foam dressings

36
Q

What topical therapy would you use for a wound in order to:

Promote granulation tissue/control exudate?

A

NPWT (wound vac)

37
Q

What topical therapy would you use for a wound in order to:

Stalled wounds?

A

Promogran Prisma

Older Adult Exam 2 (8 decks)

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