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unit 9 > e+i > Flashcards

e+i Flashcards

1
Q

how long must a wound be present before medicare will reimburse it as “chronic”?

A

30 days

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2
Q

what are 4 common barriers to wound healing?

A

inadequate microcirculation
prolonged pressure from interstitial edema
bacterial infection
absence of adequate electrical potential

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3
Q

presence of bacteria is called what?

A

bioburden

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4
Q

bioburden, perfusion defects, nonviable tissue, moisture, nutrients, and oxygen are considered what kind of factors in wound healing?

A

local/intrinsic

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5
Q

factors that affect whole body, cormorbid disease, nutritional status, age, obesity are considered what kind of factors in wound healing?

A

systemic/intrinsic

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6
Q

what four types of products maintain moisture in a wound?

A

films
hydrocolloids
hydrogel sheets
amorphous gels

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7
Q

what type of product helps add moisture to a wound?

A

biocellulose

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8
Q

what four types of products absorb moisture?

A

foams
collagen
alginates
superabsorbents

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9
Q

what types of products help manage fluid in wound healing?

A

hydropolymers

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10
Q

what does a retention product do in wound healing? examples?

A

holds dressing in place

film dressings, tapes, stretch gauze

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11
Q

what type of products are made to come in contact with the wound?

A

impregnated gauzes
perforated plastics
silicone coated meshes

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12
Q

what type of dressing touches the wound surface?

A

primary dressing

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13
Q

what type of dressing attaches a primary dressing to the patient?

A

secondary dressing

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14
Q

what type of dressing is constructed with something absorbent in the middle of something adhesive?

A

island dressing

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15
Q

what are 5 wound needs? as in what in common does all wound healing have?

A

optimal ph (slightly acidic), control of bacteria, freedom from necrotic tissue, thermal insulation, adequate hydration

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16
Q

frequent repositioning of the patient is required for what type of wound? how often?

A

pressure ulcer

every 2 hours

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17
Q

diabetic ulcers require what types of treatment?

A

offloading of pressure
good glucose control
test w hemoglobin, A1c

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18
Q

arterial ulcers require what type of treatment?

A

establishment of adequate circulation through movement and exercise

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19
Q

how are venous ulcers treated? is this reversible?

A

use of a compression system

no

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20
Q

what is stage 1 biofilm?

A

free-floating and solitary (planktonic) microorganisms

reversible

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21
Q

what is stage 2 biofilm?

A

bacteria multiple and become sessile

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22
Q

what is stage 3 bioflim?

A

bacteria secrete extracellular polymeric substance (eps) (slime)
components shed and attach to other parts of the wound bed or other wounds
develops within 6-12 hours and in 2-4 days =mature biofilm

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23
Q

what are 5 types of medication that impede healing?

A

nicotine
anti-neoplastics
anti-coagulants
corticosteroids

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24
Q

what constitutes a stage 1 pressure injury?

A

intact skin

area of non-blanchable erythema

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25
Q

what constitutes a stage 2 pressure injury?

A

partial thickness loss of skin w exposed dermis
wound bed: viable, pink, red, moist
may be intact or ruptured serum-filled blister

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26
Q

what constitutes a stage 3 pressure injury?

A

full thickness loss of skin
adipose is visible in ulcer
granulation tissue and epibole are present

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27
Q

what constitutes a stage 4 pressure injury?

A

full thickness loss of skin

exposed fascia, muscle, tendon, ligament, cartilage or bone

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28
Q

what constitutes an unstageable pressure injury?

A

full thickness but cannot be assess due to obstruction by slough or eschar

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29
Q

what constitutes a deep tissue injury?

A

intact or non-intact skin w localized area of non-blanchable deep red, maroon, purple discoloration or epidermal separation

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30
Q

muscle pump failure, pericapillary fibrin deposits, which result in thrombosis, obstruction, dilation, and hemorrhage are from what kind of ulcer?

A

venous insufficient ulcer

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31
Q

what are some characteristics of a venous insufficient ulcer?

A

pain relieved w elevation
irregular edge
medial side of ankle
hemosiderin staining: orange/brown, 6-8 mmm above medial malleolus

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32
Q

where are lymphatic ulcers found?

A

arms
legs
most common: ankle

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33
Q

how does one describe lymphatic ulcers?

A

firm, fibrotic surrounding skin
small ulcers that ooze or are blistered
usually bilateral

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34
Q

what is different about dressing arterial wounds than other types?

A

DRY dressings

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35
Q

What types of wounds have an inadequate blood supply, low ankle/brachial index of less .5 not likely to heal, 20/10 pain, pain decreases w dependent position, has eschar/necrosis?

A

arterial insufficient ulcer

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36
Q

where are arterial insufficiency ulcers found?

A

toes, fingers, interdigital spaces

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37
Q

what type of ulcers are generally found on the lateral side of the calf?

A

vasculitic ulcer

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38
Q

how can you identify a surgical wound?

A

straight wound margins

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39
Q

what are three characteristics of traumatic wounds?

A

generally irregular wound margins
visible inflammatory response margin
indurated wound margin

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40
Q

what is a plantar ulcer, a deep neutrotrophic ulcer of the sole of the foot, resulting from repeated injury because of lack of sensation or bony deformity seen with diseases, such as…?

A

diabetic foot ulcer

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41
Q

6 factors associated with diabetic foot ulcer?

A 
peripheral neuropathy
pressure friction and shear
peripheral vascular disease
limited joint mobility (foot deformities, decreased ROM in heel cord, decreased heel strike)
loss of protective sensation
42
Q

what is a way to describe the appearance of a dfu?

A

round punched out lesion w elevated rim

43
Q

are dfu’s painful?

A

no, not until bone is infected

44
Q

what is a 0 on the wagner scale? what is the wagner scale for?

A

pre-ulcerative lesion, healed ulcers, presence of bony deformity

45
Q

what is a 1 on the wagner scale measuring?

A

superficial ulcer w/o subcutaneous tissue involvement

46
Q

what is a 2 on the wagner scale measuring?

A

penetration through subcutaneous tissue, may expose bone, tendon, ligament or joint capsule

47
Q

what is a stage 3 on the wagner scale measuring?

A

osteitis
abscess
osteomyselitis

48
Q

what is stage 4 of the wagner scale considered?

A

gangrene of digit

49
Q

what is stage 5 of the wagner scale measuring?

A

gangrene of foot requiring disarticulation

50
Q

what does serum albumin measure? what is a normal level? too little?

A

protein over 90 days

>3.5 g/dL, <2.5g/dL

51
Q

what does prealbumin measure? normal? too little?

A

protein over a few days
15-43 mg/dL normal
0-5 mg/dL severe depletion

52
Q

what is the normal range of hemoglobin for a female? `

A

12–15. gm/dL (males slightly higher)

53
Q

what is the normal percent of hematocrit for a female?

A

37-48%, males slightly higher

54
Q

what is an average lymphocyte count?

A

1000-4000mL

55
Q

what vitamin levels are important to measure in determine wound care?

A

A, K, D

56
Q

what two lower extremity locations should you check for pulses? are these biphasic or monophonic?

A

dorsalis pedis

posterior tibial

57
Q

what are two tests to examine arterial insufficiency?

A

capillary refill

rubor of dependency

58
Q

how is a capillary refill test conducted? what is the normal time associated with this test?

A

pinch great toes and count seconds for the skin to return to normal color
should within 2 seconds

59
Q

how is rubor of dependency determined?

A

lie your patient supine, elevate foot to a 30 degree angle, if skin pales (palor on elevation), it is a positive sign of arterial insufficiency
have your patient sit upright w foot in dependent position, dramatic red color change indicates severe tissue ischemia
-color changes should occur within 30 sec

60
Q

What is the thresh hold for an emergency ABI? (according to Professor Unger)

A

.5

patient seen by specialist that day

61
Q

What are 5 locations in the ankle that are used for circumferential measurements?

A

arch
figure 8 ankle
10 cm above medial malleolus
20 cm above medial malleolus

62
Q

what is one test to examine the risk of diabetic foot ulcers (lops)? how much force does it utilize?

A

5.07 semmes-weinstein monofilament

10 grams of force to bend it when you touch a patient’s skin

63
Q

what are three high risk persons at risk for friction injuries?

A

agitated
spastic
sliding down in bed

64
Q

how often should a bed-bound individual be be repositioned?

A

every 2 hours

65
Q

how often should a chair-bound individual be repositioned?

A

every 15 min

66
Q

how many degrees should a person be turned to remove pressure from the sacrum?

A

40 degrees

67
Q

what height should a hospital bed be kept to reduce friction and shear?

A

avoid more than 30 degrees of head-of-bed elevation unless medically needed

68
Q

what are four ways to reposition a patient that do not include a bed covering?

A

teach individual to reposition using trapeze
use lifting devices to move individuals who cannot assist
place pillows or wedges between knees and ankles (top leg in front of bottom)
heels elevated off bed, but avoid hyper-extension of knees

69
Q

what constitutes a dmerc category 1 support surface? who qualifies?

A

static overlays
mattresses: foam, air, gel
patients who are RISK of pressure injury

70
Q

what constitutes a dmerc category 2 support surface

A

alternating pressure and air floatation

71
Q

what constitutes a dmerc category 3 support surface? what kind of injury qualifies?

A

stage 4 pressure injury on multiple surfaces or skin graft

$200/day for rental

72
Q

what are four things to check when assessing the performance of a support surface?

A

bottoming out (surface totally compressed)
memory foam shape remains
bunching in gels
deflation in air filled

73
Q

what is one way to measure the size of a pressure injury? what parts of the body do you use for these determinants?

A

longest length * width, cm squared

head as reference to determine which is length and which is height

74
Q

what is one way to measure the size of a pressure injury using a clock? benefit?

A

top of pressure injury is 12 oclock, etc
acetate tracing
can describe locations of specific type of tissues within injury

75
Q

what are four aspects of a wound you will evaluate?

A

size
color
odor
consistency

76
Q

what is the odor of anaerobic organisms?

A

fecal

77
Q

what is the odor of aerobic organisms?

A

various including fish

78
Q

what is the color of a pseudomonas?

A

aquamarine

79
Q

how would you describe slough?

A

stringy runny nose of small child that is extended w a wipe

soft yellow or tan

80
Q

how would you describe eschar?

A

thick black or brown

avascular

81
Q

how would you describe granulation?

A

bumpy

shiny red

82
Q

how would you describe epithelial tissue?

A

dry

usual skin color

83
Q

how would you describe fibrin tissue?

A

white that won’t come off to touch

84
Q

when describing skin surrounding pressure injury, what factors are you taking into account?

A 
erythema
maceration
edema
tape injury
induration
crepitus
pain
warmth
fluctuance
85
Q

What is tunneling? How to do you document it?

A

tissue loss parallel to the skin surface
may or may not have exit site
document clock location and depth of undermining

86
Q

what is a fistula?

A

abnormal passage between two organs or between and organ and the outside of the body

87
Q

what can permeate a semi-occulsive dressing?

A

not bacteria and liquids
oxygen and carbon dioxide can
moisture vapor can

88
Q

what are 5 benefits of semi-occulsive dressings?

A 
help create optimal local wound environment
increase healing rates
decrease cost of care 
reduce pain
improve cosmesis
89
Q

what is a popular type of semi-occulsive dressing?

A

hydrocholid

90
Q

what are 7 potential way to do harm to a pressure injury?

A 
dehydration
reinjury
hypergranulation (too much fluid)
maceration
granuloma
skin stripping
contact dermatitis
91
Q

what are 5 things a wound needs?

A 
adequate hydration
thermal insulation
freedom from necrotic tissue
control of bacteria
optimal ph
92
Q

is the ideal ph for a wound acidic or alkaline?

A

acidic

93
Q

what are 6 materials used to make dressing?

A 
water
polymer
collagen
cellulose
hydropolymer
"top secret" patented ingredient
94
Q

what three wound contact layers in a dressing?

A

impregnated gauzes
perforated plastics
silicone coated meshes

95
Q

what types of dressings maintain moisture?

A

films
hydrocolloids
hydrogel sheets
amorphous gels

96
Q

what are three physiological benefits of response to gentle pulsatile lavage?

A

increased granulation tissue formation
increased rate of wound closure and resolution of fibrosis
decreased wound bioburden

97
Q

when taking tegaderm off, how should you remove it?

A

lift corner and pull towards you

98
Q

how does an autolytic dressing cause debridement?

A

uses body own processes to remove devitalized tissue

99
Q

what are four types of autolytic dressings?

A

transparent films
hydrocolloids
hydrogels

100
Q

what are two benefits to using an autolytic dressing?

A

minimal trauma

less frequent dressing changes

101
Q

what is one contraindication for wound debridement?

A

several arterial insufficiency

102
Q

order of preparing for wound debridement?

A
  1. wash hands
  2. prep skin first with betodine
  3. flush w saline
  4. if part of medical order, can use analgesic
  5. 1/4 strength betodine
  6. debride

unit 9 (4 decks)

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