Wounds care

Question 1

Contraindications for Irrigation and uses

Answer 1

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

USE FOR: perfect for use of granular wound

Question 2

Considerations for silver dressings

Answer 2

Use sterile water, do nto use enzymatic debridement

Question 3

Safe and effective PSI for irrigation

Answer 3

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

Question 4

Contraindications for PSWL pulsed lavage with suction and positives

Answer 4

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

Question 5

Reasons to use Debridement

Answer 5

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.

Question 6

Contraindications for Debridement

Answer 6

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

Question 7

Contraindications and Precautions for Sharp Debridement

Answer 7

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

Question 8

how to stop bleeding

Answer 8

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

Question 9

When and why would you remove a blister

Answer 9

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

Question 10

Other types of debridement and when to use

Answer 10

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

Question 11

Contraindications for Enzyme debridement

Answer 11

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

Question 12

Contraindications for Autolytic debridement

Answer 12

infection, dry gangrene, deep cavity wounds

Question 13

Contraindications for Maggot Tx

Answer 13

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

Question 14

Regular Gauze

Answer 14

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

Question 15

cautiosn for impregnated gauze

Answer 15

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

Question 16

Semipermeble film

Answer 16

promotes autolytic environment

superficial wounds

Question 17

Hydrogels

Answer 17

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

Question 18

Hydrocolloid dressings

Answer 18

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

Question 19

alginate

Answer 19

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

Question 20

Antimicrobials

Answer 20

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

Question 21

Contraindications for iodine

Answer 21

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

DONT use: thyroid disease and deep cavity wounds

Question 22

Treatment for AI

Answer 22

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.

Question 23

Tx for gangrene

Answer 23

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.

Question 24

ABI compression guidlines

Answer 24

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

Question 25

AI vs. VI

Answer 25

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

Question 26

Risk factors for neuropathic wounds

Answer 26

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

Question 27

How can Tri Neuropathy lead to a neuropathic wound?

Answer 27

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.

Question 28

Common foot deformities in DM

Answer 28

valgus hallux and Claw toe

Question 29

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

Answer 29

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

Question 30

Wagner Scale

Answer 30

``` 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 ```

Question 31

Describe common interventions for Neuropathic ulcer

Answer 31

- 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

Question 32

What are some offloading options for Neuropathic ulcers?

Answer 32

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

Question 33

What are proper shoe recommendations for Neuropathic ulcers?

Answer 33

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

Question 34

Who is at a greater risk for a pressure injury?

Answer 34

SCI, Hositalized pts, long term acute patients

Question 35

common locations of pressure injuries

Answer 35

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

Question 36

What is the pathophysiology of pressure injuries

Answer 36

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

Question 37

What are intrinsic and extrinsic factors for pressure injuries

Answer 37

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

Question 38

What are the stages of pressure injuries

Answer 38

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

Question 39

What are prevention strategies for a pressure injury?

Answer 39

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

Question 40

what are 2 tools to eval a pressure injury

Answer 40

Bates and Jensen, PUSH pressure ulcer scale for healing

Question 41

What are treatment options for pressure injuries

Answer 41

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

Question 42

What are the components of a surgical site assessment?

Answer 42

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

Question 43

What are and - signs of healing?

Answer 43

+ (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

Question 44

What are appropriate dressings and interventions for primary intention?

Answer 44

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

Question 45

Describe appropriate caregiver care for incision

Answer 45

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

Question 46

what are complicating factors for surgical incisions

Answer 46

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

Question 47

Basic incision care

Answer 47

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

Question 48

Traumatic wounds VS Surgical wounds

Answer 48

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

Question 49

Describe the general Tx for traumatic wounds

Answer 49

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.

Question 50

What are etiologies of traumatic wounds?

Answer 50

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

Question 51

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

Answer 51

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