Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Complex patient MGMT > Wounds care > Flashcards

Wounds care Flashcards

1
Q

Contraindications for Irrigation and uses

A

Recent skin grafts, recent surgical sites, DM feet Active/ profuse bleeding, dry gangrene.

USE FOR: perfect for use of granular wound

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Considerations for silver dressings

A

Use sterile water, do nto use enzymatic debridement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Safe and effective PSI for irrigation

A

4-15 psi, low pressure capsulrs are 4-8, 10 is the max

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Contraindications for PSWL pulsed lavage with suction and positives

A

exposed named tissues, body cavities, facial wounds, recent grafts or incision sites, active bleeding.

GOOD BECAUSE: known PSI, sterile, specific to site, temp range, cleansing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Reasons to use Debridement

A

Help bdy clean wound and decr. E needed, lowers risk for infection, incr topical effectivness, improve leukocytes, get rid of physical barriers, protect tissue, easier exam, decr order.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Contraindications for Debridement

A

Arterial compromise, (consider the following) presence of granular tissue, deep tissues electrical burns

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Contraindications and Precautions for Sharp Debridement

A

Precautions: anticoagulants/clottign probs, pain, immunosupression, unable to be still

Contra: PT comfort/skill, cant ID tissue, too deep, no consent, AI, live tissue, pyoderma gangrenosm

Maybe stop with extensive undermining/bleeding, impending exposure of named tissues, pain, very deep, unexpected purulence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

how to stop bleeding

A

elevate and pressure for 10 mins with silver nitrate and DONT remove, even if it pulsates

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

When and why would you remove a blister

A

If larger than a nickel remove in order to prevent infection and sudden popping.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Other types of debridement and when to use

A

Mechanical- wet-dry is only indicated for 100% non viable tissues. Can be non selective. PLWS, soft abrasion and US are all forms

Enzymatic- good for infected wounds and burns and can be selective to location, pain free. Works by with collgenase digestion of collagen. Cover with moist dressing/ adaptic

Autolytic debridement- good for painful areas, palliative tx, allowing body to do its thing and can be left up to 7 days. Selective and cheap. done by using an occlusive dressing to keep wounds moist and warm.
combo with cross hatching

Maggot Tx - good for osteo infection around hardware, those who are poo candidates for Sx, cant do toehr debridements

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Contraindications for Enzyme debridement

A

Takes too long, if no improvement in 2 weeks - stop and switch.
deep wounds / body cavities
named tissues
facial burns

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Contraindications for Autolytic debridement

A

infection, dry gangrene, deep cavity wounds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Contraindications for Maggot Tx

A

near the eyes, GI or upper Respiratory tract. allergy, exposed vessels, low perfusion, malignant wounds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Regular Gauze

A

good for mechanical debridement bc it drys out and removed debris when taken off, padding

Telfa offers little absorption and no stick

remember to apply at angle and it can soak up ointment and moisture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

cautiosn for impregnated gauze

A

it can be used as 1st or 2ndary dressing, but it can dry out and become adherent and also cause maceration.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Semipermeble film

A

promotes autolytic environment

superficial wounds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Hydrogels

A

provide moisture, promote autolytic,
REQ 2nd dressing
sheets cant be used on infected wounds and may cause maceration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Hydrocolloid dressings

A

very occlusive and adhesive to promote authlytic, paste for deeper wounds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

alginate

A

used in high exuding wounds bc of atraumatic removal and absorption properties it offers. Good for deep wounds b.c can contour. Also can be used for clotting.
BUT CANT BE USED OVER NAMED TISSUES OR NEONATES
Hydrofibers absorb vertical like a shoelace

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Antimicrobials

A

should be used during critical colonization during a trial for 2 weeks for active or high risk infections

should be dicont. when the wound is clean, epithelizing and the risk is removed.
include: honey, silver and iodine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Contraindications for iodine

A

caution with: Breast-feeding, preg, shellfish allergy, younger than 6 mo, prolonged use

DONT use: thyroid disease and deep cavity wounds

22
Q

Treatment for AI

A

Don’t apply moisture or wet dressing, KEEP dry. Determine if AI ulcer is healable or non healable. Tx as non- healable until ABI is over .5 and with MD consult. Protect, monitor, educate, identify.

23
Q

Tx for gangrene

A

Monitor for infection and change, keep dry, moisturize surrounding skin, ROM, flexibility EX, walking guidelines and foot care edu

Wait for auto amp. If it occurs, return to moist wound tx, debride and monitor status. Work with prosthetics for new amputation and control edema.

24
Q

ABI compression guidlines

A

Over .8 use 35-45 mmhg
.8-.6 use 17-25 mhg
under .5 - rest for pain

25
Q

AI vs. VI

A

AI: shiny, hairless, round punched out appearance usually on dorsal foot, toes, ant. lower leg or superior to malleoli. Use compression per ABI and wound healing progression.

VI: will appear to have drainage, if not then likely to be AI. Above malleoli in distal 3rd of leg on M or L sides. If outside this area probs not VI unless mixed etiology. Surrounding skin: thick and scaly, hemosiderin staining, champagne bottle leg, lipodermatosceosis, varicose veins. Diffuse, rolled and uneven edges can be present.
Compression: some is better than none

26
Q

Risk factors for neuropathic wounds

A

DM, impaired healing, mechanical stress, tri-neuropathy, vascular disease, Decr. ROM, foot deformities, prev. ulcer or amputation, Hyperglycemia

27
Q

How can Tri Neuropathy lead to a neuropathic wound?

A

Diabetic neuropathy that presents with sensory, motor and autonomic deficits that lead to systemic deficits in the circulatory, integumentary, vascular, bone, and immune systems. Decr. foot intrinsic muscles, sweat glands, and pain sensation. Callus formation can also increase P in areas to cause an ulcer.

28
Q

Common foot deformities in DM

A

valgus hallux and Claw toe

29
Q

Describe common parts of a clinical exam for a diabetic foot ulcer

A

History, systems check, observation, lab values, non invasive vascular screen, motor/ ROM/ gait, sensory, reflexes, leg length discrepancy, check other foot/toes shoes. Wound exam includes looking at the edges, shape (round and deep), location (plantar), mid-mod drainage and no eschar, callus and pain free

30
Q

Wagner Scale

A 
1- no open lesion, deformity my be present 
2- Superficial ulcer 
3- deep ulcer with abscess 
4- localized gangrene 
5- complete gangrene of the foot
31
Q

Describe common interventions for Neuropathic ulcer

A
  • Depending on the vascular status of the callus, we will debride but NOT for stable heel ulcers
  • offloading
  • moist wound environment but no soaking
  • monitor for infection
  • patient edu for inspection, glucose control and prevention
  • silver antimicrobial dressings
  • growht factors
32
Q

What are some offloading options for Neuropathic ulcers?

A

Total contact cast (gold standard), half shoe,CROW walker

33
Q

What are proper shoe recommendations for Neuropathic ulcers?

A

fit to the shape of the foot

  • 3/8-1/2 in btwn big toe and shoe top, no pointy shoes
  • adjustable
  • snug around heel, SOCKS
  • closed toe, no heels
34
Q

Who is at a greater risk for a pressure injury?

A

SCI, Hositalized pts, long term acute patients

35
Q

common locations of pressure injuries

A

Supine: vertebrae, sacrum, elbow, occiput, scap, heel
Prone: ant tib, ant knee, iliac crest, ear, shoulder
Sitting: Ischial tuberosities, sacrum, greater trochanter
SL:ankle, m/l knee condyles, GT, lateral humeral condyles, ear

36
Q

What is the pathophysiology of pressure injuries

A

When P is greater than intracapillary P it results in obstricted lymph channels, decr. BF to soft tissue, which results in ischemia

  • metabollic waste builds up leads to cell death
  • Local edema increases and leads to poor circulation and cell death
  • fibrin deposits exacerbate and occlude vessels,leading to cell death
  • cascade of tissue death
37
Q

What are intrinsic and extrinsic factors for pressure injuries

A

Extrinsic: Amount and duration of P, temp, moisture, shear, friction
Intrinsic: Mus atrophy/ immobility, meds, mal nutrition, decr sensation,prev ulcer, AGE

38
Q

What are the stages of pressure injuries

A

1- non blachable, usulally localized to bony area
2- partial thickness, with exposed dermis, NOT skin tears red/pink without slough/granulation
3- full thickness with skin loss, adipose visible
4- full thickness skin + tissue loss, exposed named structures
Unstagable- covered by slough or eschar

39
Q

What are prevention strategies for a pressure injury?

A

Education - for skin checks, transfer techniques, position changes, incontinence mgmt, lay at 30* lateral instead of SL, bed care, encourage mobility,

40
Q

what are 2 tools to eval a pressure injury

A

Bates and Jensen, PUSH pressure ulcer scale for healing

41
Q

What are treatment options for pressure injuries

A

clean the wound/periwound with normal or saline water, antispetic if infected
- debridement if vasculature is available
-

42
Q

What are the components of a surgical site assessment?

A

Screen to see how much fluid is draining by last dressing change, fever, pain, complicating factors
- Observations of wound - epithelization, periwound and surrounding skin, infection signs, edges
_ palpation

43
Q

What are and - signs of healing?

A

+ (1-4) approx’d edges, normal inflammation, min-mod drainage that is progressing to bloody to sanguineous
(5-9) no drainage/ inflammation, new tissue, healing ridge
(10-14) pink, tiny openings
-scar will return to 8-% of strength
- (1-4)no signs of inflammation, incision line tension
(5-9)little- no pnk epithelium, absent above factors, infection
(10-14) inflammation/infection, drainage, no healing ridge
- hypotrophic scarring

44
Q

What are appropriate dressings and interventions for primary intention?

A

Keep the incision site dry with gauze unless live tissue is seen, then use xeroform. Betadine and boarded foam are also used. Steri strips are used to close wounds

45
Q

Describe appropriate caregiver care for incision

A

watch for infection, dont get wet, nutrition and social habits, antibiotics and pain meds, tell the doc whats going on before its too late.

46
Q

what are complicating factors for surgical incisions

A

drainage, infection, dehiscence, comorbities, absence of healing, no healing ridge by day 5-9

47
Q

Basic incision care

A

debride by using clean water and wipe toward the incision line to remove loose debris. Keep dry, monitor and protect.

48
Q

Traumatic wounds VS Surgical wounds

A

Trauma wounds have many MOIs and are sustained in non sanitary methods - rabbles, tetanus

49
Q

Describe the general Tx for traumatic wounds

A

After hx and review of systems do a fxn exam because we need to look at the person as a whole

  • Psychological stress.
  • Consider DIME and dont get lost in the work “trauma” focus on the goals for healing.
50
Q

What are etiologies of traumatic wounds?

A

Gun, animal, self inflicted, drugs, car, crush crash, burn explosion, fall, skin tears

human bites = 3rd most common. Important to determine health status of other person for hep and HIV

51
Q

What are considerations and do you do with a bite wound?

A

serious infection can occur, -> osteomyelitis, sepsis, endocarditis, brain abscess, disease transmission
- check lymph nodes, antiseptics and antimicrobials
follow up 24-48 hours
dog bite- report to local authorities
-kitty bites may be easier for scalpel for easy cleaning
- agg debridement for slough and thorough irrigation

Complex patient MGMT (6 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions