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Hand and Upper Extremity Conditions > Wound Care > Flashcards

Wound Care Flashcards

1
Q

phases of healing (3)

A
  1. inflammatory phase2. proliferation phase3. maturation phase*all overlapping
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2
Q

inflammatory phase

A

begins the moment of injury and lasts 2 days to 2 weeks initial vasoconstriction to control blood lossprotein-based fluid leaks out of vessels and swelling begins along with clean-up cellswithin 30 minutes mast cells release histamine to cause vasodialation

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3
Q

proliferation phase

A

begins once injured area being clean and free of damaged tissue, foreign matter, and bacteria and last several weeksconsists of granulation, angiogenesis, wound contraction, and epithelialization*moist wound bed desired

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4
Q

maturation phase

A

“remodeling phase”water and amino acids squeezed out of the granulation tissue matrixcollagen fibers produced, forms scar*can last up to 2 years

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5
Q

scar vs skin strength

A

scar is 80% as strong as skin at full maturity*scar management is important

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6
Q

factors that affect healing (9)

A
  1. circulation2. debris in wound bed3. infection4. chemical stress5. temperature of wound bed6. amount of moisture in/around wound bed7. medications and other medical conditions8. nutrition9. age
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7
Q

debridement

A

the removal of necrotic tissue from a wound so the healthy tissue is exposed in the wound bed

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8
Q

slough

A

yellow, white stringy tissuemoist composite of fibrin bacteria, dead cells and exudate*dead tissue

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9
Q

eschar

A

black, hard tissue, occasionally moist in appearance

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10
Q

autolytic debridement

A

when the body breaks down the necrotic tissue on its owncan encourage with dressingscomfortable and effective, but slower*watch for macerated skin

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11
Q

enzymatic debridement

A

use of topical enzymes to break down slough and escharcheck state practice actcollagenase ointment - needs Rx*may cause discomfort

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12
Q

sharp debridement

A

use of sharp instrument (scissors/scalpel) to selectively remove necrotic tissuecheck state practice actneed to be skilled*fastest and most effective method

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13
Q

mechanical debridement

A

remove of dead tissue using methods like whirlpool agitation, high pressure fluid irrigation, or wet-to-dry dressings**NOT RECOMMENDED

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14
Q

hypergranulation tissue

A

looks like shiny, deep-red balls of tissue that grow taller than the wound marginsoft, bleeds easytreat with nitrate sticks (do with dressing changes/turns tissue gray)

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15
Q

wound cleansing frequency

A

wound should be cleansed every time the dressing is changed

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16
Q

best wound cleansing solutions

A

normal salinesterile waterdrinkable tap water

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17
Q

wound cleansing solutions to avoid

A

hydrogen peroxide, Dakin’s solution, povidone iodine/Betadine, soap, bleach*never use anything you would not be willing to put in your eye

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18
Q

hydrogen peroxide and wounds

A

should only be used in home setting to clean cuts/scrapes immediately after injuryonce wound is free from debris, OH can be toxic to granulation tissues and use can slow wound healing

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19
Q

moisture balance

A

moist wound will heal much faster than a wound that is too wet or too dry

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20
Q

goals of wound dressing

A

keep bacteria out, retain some moisture, but still absorb any excess fluid if needed

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21
Q

non-occlusive dressing

A

allows for free passage of water, vapor, and bacteria

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22
Q

occlusive dressing

A

will not allow passage of water, vapor, and bacteria

23
Q

semi-occlusive dressing

A

falls in the middleallows passage of water vapor, but not water or bacteria

24
Q

types of dressings (6)

A
  1. transparent film2. impregnated low-adherence dressings3. hydrogels 4. gauze 5. foams 6. alginates
25
Q

transparent film dressings

A

semi-occlusivethin, see-through films that adhere right to the skin and can be used as primary or secondary dressing*can last up to 7 days

26
Q

impregnated low-adherence dressings

A

non-occlusive to semi-occlusivedesigned to make contact with wound and reduce sticking and tearing of wound tissue during dressing changesrequires secondary dressingreduces risk of infection

27
Q

hydrogel dressings

A

non-occlusive to semi-occlusivedesigned to hydrate wounds and promote autolytic debridementrequires secondary dressingneeds to be changed every 24-72 hours

28
Q

gauze dressings

A

non-occlusivemost widely available and commonly usedcan be used to clean, pack, or cover woundsas primary dressing it cannot easily create moist wound environment and also tends to shed fibersgood secondary to keep other dressings in place

29
Q

foam dressings

A

semi-occlusivemosty polyurethane and used to absorb moderate amounts of exudate and provide cushioningcan be primary or secondary depending on branddoesn’t conform well to hand

30
Q

alginate dressings

A

non-occlusive to semi-occlusivederived from seaweedhighly absorbent and made for moderate-large amounts of exudateas alginate absorbs fluid, it is converted to a gel that provides moisture to the wound bedrequires secondary dressing

31
Q

primary intention

A

wound is closed with sutures or staples*wound heals by fibrous adhesion and little to no granulation tissue

32
Q

secondary intention

A

the wound is left open and left to heal through the granulation process*requires close monitoring

33
Q

tertiary intention

A

“delayed primary wound closure”wound is left open initially then closed a few days later

34
Q

patient education on wound care and smoking

A

educate them that nicotine decreases the delivery of O2 to tissue and can increase the risk for wound healing complications 1 cigarette can reduce blood flow to hand*encourage clients to temporarily stop smoking until wound is healed (or at least cut back)

35
Q

eval - location of wound

A

when describing the location of a wound, be precise do so in terms of anatomical positionex. “The wound is on the anterior medial aspect of the distal forearm, 2 cm proximal to the pisiform”

36
Q

eval - size of wound

A

length, width, depth recorded in mm or cmclock method or length and width at longest points

37
Q

eval - wound depth

A

depth measure by inserting a moistened sterile cotton-tipped applicator into the deepest part of the wound*look for tunneling

38
Q

tunneling

A

a narrow and deep hole that runs away from the main part of the woundcreates “dead space” and increases risk of abscess formationrecord depth and location using clock face method

39
Q

eval - wound margins

A

note color and condition of edges of the woundhealthy: pink and flat, firmly attached to tissue underneathwatch for undermining

40
Q

undermining

A

space under the wound margins *sign that wound is not healing effectivley

41
Q

eval - periwound skin

A

note color and condition of skin around the woundshould be skin-colored or maybe a little pinkredness, inflammation or hardening could indicate infectionsmall lesions could indicate damage from adhesive dressingssoft, white indicates skin has absorbed too much fluid

42
Q

macerated skin

A

soft, white skin that results from wound exudate not being adequately absorbed by the wound dressing*fragile and easily damaged

43
Q

denuded skin

A

when the epidermis around the wound starts to breakdown

44
Q

eval - wound characteristics

A

describe wound using “red-yellow-black” system and document with digital photos to record wound healing progression

45
Q

“red-yellow-black” system

A

estimate what % of the wound is colored by each colorred: healthyyellow: sloughblack: eschar

46
Q

photographing wounds

A

helpful in documentingalways do at same point of treatment, same camera, same settings, same distance, NO FLASH

47
Q

eval - wound exudate

A

describe color, consistency, odor and amount of discharge*hydrocolloid dressings produce foul odor; this is normal so assess after cleaning

48
Q

serous

A

clear and watery exudate*normal

49
Q

serosanguinous

A

thin and pink exudate*normal

50
Q

sanguinous

A

thin and bright red exudate*may or may not be normal depending on amount and type of tissue in wound bed

51
Q

purulent

A

thick or thin, tan to yellow exudate*sign of possible infection

52
Q

foul purulent

A

thick, yellow to green exudate with bad odor*sign of infection

53
Q

signs of infection (9)

A
  1. pain2. foul odor3. pus drainage4. redness5. warm to touch6. hardening around wound7. lymphangitic streaking/red streaks8. malaise9. fever
54
Q

wound care clinical reasoning (5)

A
  1. moist wound healing is best2. create a clean wound bed3. wound bed is fragile4. infection must be identified5. do no harm

Hand and Upper Extremity Conditions (27 decks)

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