Exam 1 Flashcards
1
Q
when looking at the limb of apperance what are you looking at
A
- compare contralateral limb
- edema
- color changes
2
Q
what are the 2 types of wounds
A
acute and chronic
3
Q
what are be allowed to debrided
A
PT scope of practice allows only remove non-viable tissue, so bleeding should be minimal
Non-excisional
====Only need forceps—removing loose blistered skin
Excisional (Sharp)
====Use of scissors or scalpel to aid in removal of necrotic tissue
====Includes cross-hatching of eschar
4
Q
what supplies blood to the epidermis
A
papillary= capillary supplies vascular and nourishment t o epidermis through osmosi
5
Q
what is the corneum
A
top layer
waterproof characteristic, protection from infection
6
Q
what is elevational pallor
A
Raise leg to 60º for 15-60 seconds, note time it takes for visible color change/ pallor
Within 25 seconds = severe occlusive disease
Within 25-40 seconds = moderate occlusive disease
Within 40-60 seconds = mild occlusive disease
7
Q
what are different types of irrigation
A
- high pressure irrigation
- pulsativle lavage
8
Q
what si serous exduate
A
clear but can have a yellow ting
9
Q
what does the subcutaneous/ hypodermis contain
A
-adipose
10
Q
what is ABI
A
ankle brachial index
Comparison of perfusion pressures in the lower leg and upper arm using BP cuff and Doppler probe.
11
Q
what is colonized
A
bioburden present in a wound bed (normal)
-presence of proliferating bacteria without a host response.
12
Q
what is primary excision
A
Surgical debridement of necrotic tissue to achieve viable wound base
13
Q
what types of gaze are ther and how is it made
A
4x4’s, Kerlix, may be woven or non-woven
14
Q
what is anaerobic bacteria
A
can survive without O2
15
Q
how much support for stockings is needed for – lymphedema
A
50-60 mmHg
16
Q
what are some indications for composites
A
partial and shallow full-thickness wounds, minimal to heavy exudate
17
Q
what is the precaution for transparent films
A
not for infected wounds or wounds with mod-heavy exudate
18
Q
what is CVI
A
chronic venous insufficiency (AKA venous stasis)
19
Q
how do you apply wet to dry debridement
A
Apply saline moistened gauze to wound bed and allow it to dry, then pull it off
20
Q
what is topical antibiotics
A
- Presumed to be effective if the invading organisms have not developed resistance
- Agent should be carefully selected based on wound culture results
- –Gram (+) = muprocin, garamycin
- —Gram (+) or (-) = bacitracin, neomycin, sulfamylon, mafenide acetate
- –Anaerobic = mafenide acetate, metronidazole
21
Q
what is a stage 1 pressure injury
A
intact skin with non blanchable redness of a localized area
22
Q
when shoudl maggots be considered
A
Considered for use in wounds that have not responded to other forms of debridement
23
Q
what doesnt a stage 2 pressure injury have
A
NOT: ----Skin tears ----Tape burns ----Maceration ----Excoriated perineal tissue Does not have slough or eschar present NO undermining or tunneling present
24
Q
what do neuropathic/ diabetic ulcers look like
A
Well defined border, often with a callus
Pale or red wound bed
Little to no granulation
Minimal to moderate exudate
25
what is a open technique with topical medication
apply ointment only not covering
26
How do you manage a arterial ulcer
- hyperbaric oxyen
- lifestyle changes
- topicla therpya
- surgical options
27
What is PVD
peripheral vascular disease
28
what is proliferation
Collagen is secreted to form connective tissue
Granulation tissue formation
Wound contraction via myofibroblasts
Epithelialization occurs from migrating wound edges
Skin regrowth occurs with continued differentiation of cells
Very fragile tissue at the end of this phase
29
what is autolysis debridement
Lysis of necrotic tissue by the body’s white blood cells and enzymes which enter the wound site during the normal inflammatory process
Selective, Recommended only for non-infected wounds with limited volume of necrotic tissue, Slower, Done by carefully selecting dressings and topicals (TheraHoney), Monitor for s/s of infection, cellulitis, maceration, etc.
pg 177-178
30
what is non-viable tissue
- Eschar
| - Slough
31
what is the 1st type of burn
superficial
32
what can a pt do for a burn patient
Improve impaired mobility and ROM that resulted from injury.
Assist pt to return to his/her PLOF
Interventions:
33
where shoudl caution with maggots happen
Caution to avoid contact with healthy skin.
34
what is hemostasis
Vasoconstriction
| Platelets aggregate to form a clot
35
how does the neuropathy from a burn affect someone
polyneuropathy (multiple sites) vs local (usually from tx for burn)
36
what is hemosiderina staining for venous ulcers
- Another classic sign of LEVD
- Discoloration of the soft tissue that results when extravasated RBCs break down and release pigment hemosiderin
- Results in grey-brown staining of the lower leg
37
what is an unstageable pressure injury
- Full thickness loss in which the base of the ulcer is covered by slough or eschar
- Wound CANNOT be numerically staged until necrotic tissue is debrided
38
what is Granulation
= beefy red new growth, cobblestone
39
what does a pressure injury depend on
Duration and Intensity of pressure
Low pressure for a prolonged period of time
High pressure for a short period of time
40
what fx fo the skin can burn affect
all of them
41
why are foam dressing good to use
Non-adherent, conformable
42
what is a caution with conservative sharp debridement
Use caution with pts on anticoagulants
43
what are the stages a pressure injury can be
stage 1, 2, 3, 4, deep tissue injury, unstageable
44
what is the foam dressing
Semi-permeable hydrophilic foam
45
what does transparent films look like
Thin, transparent polyurethane film
46
what are some traumatic wounds types
Degloving injuries
| Amputation
47
when is a wound culture indicated
- s/s of infections
| - clean wound does not show progress in healing for 2 weeks
48
what is venous dermatitis for venous ulcers
Inflammation of the epidermis and dermis
| Results in scaling, crusting, weeping erosions and intense itching and discomfort
49
how is dakins solution applied
Applied as a wet-dry dressing, BID
50
what are some contraindications for compression therapy
to high level sustained compression
- uncompensated heart failure
- co-existing peripheral arterial disease
51
what is laser debridement
- Form of surgical sharp debridement
- Uses focused beams of light to cauterize, vaporize, or slice through tissue
- Advantages: wound bed is sterilized and blood vessels are cauterized
- Precautions: risk of injury to adjacent healthy tissue
- Not available in all settings
52
what is full thickness
- Damage to the epidermis and dermis and extending into the subcutaneous tissue, muscle, or bone
- Heal with granulation tissue formation, contraction, and then re-epithelialization
53
how long is dakins solution used for
Used for less than 10-14 days
54
how much is the arms rule of nines in a child
.
55
when will wet to dry debridement not be effective
If the gauze is moistened before removal, it’s not as effective
56
what are some factors that impair healing
```
Edema
Vasoconstriction
Vascular Disease
Smoking
Infection
Sepsis
Renal Disease
Diabetes
Obesity
Corticosteroids
Age
Stress
Malignancy
Pulmonary Disease
```
57
what are some skin graft basics
Usually sutured, held by steri-stips, or stapled to the wound bed
Needs good vascular supply to adhere successfully
Area needs to be immobilized, offloaded, and often compressed to prevent separation
May have NPWT placed for 5-7 days after graft placement
NEVER take off a dressing over a graft unless instructed to do so by the surgeon who placed the graft.
If you are instructed to remove dressing, take extreme caution not to remove the graft itself from the wound bed.
Survival depends on:
Circulation, inosculation, and penetration of host vessels into graft site
58
what is friction force
= skin rubbing across a surface
Friction alone does not cause pressure ulcers
Friction DOES remain a risk factor that may contribute to or exacerbate pressure ulcer development due to the shear it creates.
59
what is the granulosum
middle layer
| responsible for water retention
60
how do you get hydrogel
Available as an amorphous gel (in a tube), or as a sheet
61
what does the wound pain look like
- can be constant or only with dressing changes
| - ensure adequate pain relief during dressing changes
62
how do you know if you have venous issues
edema, varicosities, hemosiderin staining, and dermatitis, irregular boarders
63
what is the spinosum
middle layer
| adds layer of protection
64
what is the zone of coagulation
the area where the burn was
65
at what time does scar tissue mature
Scar tissue matures in 12-18 months
66
what is the lifestyle changes for arterial ulcers
Stop smoking, ideal weight, adequate nutrition
67
what are some disadvantages of maggots
Patients report crawling sensation as main disadvantage
68
what are some indications for gaze
partial and full thickness wounds, infected wounds, wounds with tunnels
69
what are some facts of the epidermis
- no blood vessel presen t
- sheds and regenerates
- 80-90% of cells are kerationcytes
70
what are some precautions with whirlpool
- vasodilatation and increased circulation to the wound (not good for venous ulcers)
- Diabetics with loss of protective sensation
71
how much is the head rule of nines
.
72
what is the 3nd type of burn
deep partial
73
what is tunneling
- Opening that leads away from a wound
| - Can lead to abscess formation if not properly packed
74
what does damage to the motor nerves causes
causes structural deformities and gait abnormalities
75
what are the part to the dermis
collagen and elastin
- primary cells are fibroblasts
- lyer that granulates
- need proteins to make collagen
76
how do describe the location of the wound
using anatomical indicators
77
was are the indication for Negative pressure wound therapy
acute and chronic wounds with depth, partial and full thickness wounds, partial thickness burns, over grafts
78
what are some uses of silver nitrate
To control hypergranulation
Epibole (rolled wound edges)
Aids in hemostasis
79
how do you asses the skin temp of the leg
palpate moving form proximal to distal and compare right to left
80
what is the fx of the skiin
```
Temperature regulation
Secretion of oils for moisture
Portal for sweat glands and hair follicles
Vitamin D synthesis
Identity
```
81
what type of hydrocolloid are there
Duoderm, Exuderm
82
primary or secondary for alginate
Primary dressing
83
what are arterial ulcers caused by
Due to severe tissue ischemia, extremely painful
84
how often do you need to change a foam dressing
Changed daily, or up to 3x/ week
85
when is wet to dry debridement used
Used ONLY for heavily necrotic, or infected wounds
86
how do you medically manage a burn
1. Establish and maintain and airway
2. Prevent cyanosis, shock, or hemorrhage
3. Establish baseline data such as extent and depth of burn
4. Prevent or reduce fluid loss
5. Clean the injury—includes early debridement by physician/PT, possible whirlpool therapy
6. Examine injuries
7. Prevent pulmonary and cardiac complications
87
what is infection bacteria
bacteria penetrate into viable parts of tissue and elicit a host response.
88
how much support for stockings is needed for -- varicose veins
20-30 mmHg
89
what are skin substitutes
Cultured epidermal autografts
Cultured autologous composite grafts
Allogenic skin substitute
Cultered dermis—temporary and definitive
90
how do you know venous filling time
- visual assessment of time it take for foot veins to fill while leg is in dependent position
-----Normal = 15-20 seconds
> 20 seconds indicates occlusive disease
- capillary refill
- -----Blanche toenail with pressure for several seconds and release. Refill in > 2-3 seconds may indicate arterial occlusion. **Cold room temp may increase capillary refill time.
91
where are neuropathic/ diabetic ulcers found
on the foot
- Plantar surface over metatarsal heads
- Toes and sides of feet
92
how loong do you keep gaze on
Changed as needed based on saturation, usually daily, BID, or TID
93
what is a trac
small underminining that does not connect to another wound area
94
where is 12 oclock pointing to
the head of the pt
95
how long can a contact layers be on
Contact layer stays in place up to 7 days, absorptive layers are changes as needed
96
what is edema with the venous system for venous ulcers
Classic indicator of LEVD
Worsens with dependency and improves with elevation
May become “brawny” (non-pitting) due to fibrosis of the soft tissues
Primarily affects the lower leg
97
what is LEVD
lower extremity venous disease
98
how does the heterotopic ossification from a burn affect someone
from immobilization, most common in elbows, hips, and shoulders
99
what is the best way to manage the same class in the classroom
Compression Therapy
Limb Elevation
Surgical Procedures
Physical Therapy
100
what is hight pressure irrigation
- Irrigation of necrotic wound with fluid delivered at 8-12 psi
- Can use 35-mL syringe with 19-gauge angiocatheter
- Provides enough force to remove debris without damaging healthy tissue
- Most often uses saline
- Must wear PPE (gown, gloves, mask, goggles) for potential splash
101
how do you handle the scar management for a burn
Silicone gel sheet
Masks
Scar Massage
102
what do you need to asses with burns
- wound assessment
- ----what does it look like
- ---- what type of wound
- wound measuremnets
- -- Lx WxE, undermining/ tracts, girth
- LE wounds
- ----palpate/ doppler pulses
- photo- after obtaining consent
103
what is granulation tissue
Red buds which are beginning of new skin formation
| Made from connective tissue and capillaries
104
what is gram (+)
Staph (MRSA/MSSA)
Strep
Enterococcus
Many others
105
what depth does the superficial go to
epidermis
106
what are some surgical wound types
Dehisced
Tertiary Intention
Flaps/ Grafts
107
what is the general assessment of the lower leg
- appearance of the limb
- perfusion
- sensory fx
- range of motion
- pain
- pulse
108
what are the characteristics of superficial
pain
redness
mild swelling
no scarring
109
what are some precautinos for hydrogel
not for heavily exudating wounds, monitor for maceration or yeast development
110
what is viable tissue
- Granulation
- Non-granular
- Muscle or subcutaneous tissue
111
what are some cons to wet to dry debridement
Painful
| Not good for heavily exudative wounds
112
what is hydrocolloid
Adhesive, absorptive, impermeable barrier, can be used for autolytic debridement
113
what are come compressions types
- non-elastic
| - elastic
114
what are the precautions of foam dressing
not for dry wounds or those with tunnels
115
what is chemcial debridement
Enzymes, Dakin’s Solution, Maggots, Silver Nitrate
116
why is conservative sharp debridement preferred
Preferred method of debridement for infected wounds
117
is whirlpool selective or non
Non-selective
118
what are the risk factor fo rvenous ulcers
- valve dysfunciotn
| - calf muscle dysfunction
119
what is impregnated gauze made of
Woven gauze impregnated with petroleum, zinc, saline, etc.
120
how often does the impregnated gauze need to be changed
changed daily
121
what are the values for the abi
ABI > 1.3 = Abnormally high, due to calcification of vessel wall due to diabetes, renders test invalid
ABI ≥ 1.0-1.3 = Normal
ABI ≤ 0.6-0.8 = Borderline perfusion
ABI ≤ 0.5 = Severe ischemia, wound healing not likely without surgical revascularization
ABI ≤ 0.4 = Critical limb ischemia
122
what can cause chronic wounds
```
Underlying pathology
Prolonged inflammatory phase
Low levels of growth factors
Miscellaneous host factors
-Ischemia
-Malnutrition
-Co-morbidities (such as diabetes)
Denervation
```
123
what is the order of the skin
epidermis
dermis
sub Q
124
what is dependent rubor
Place leg in dependent position, look for rubor (purple-red discoloration due to retention of deoxygenated blood in dilated skin capillaries). Normal = no color change
125
what are some indication for hydrogel
partial or full thickness wounds, dry to minimal exudate, necrotic wounds (assists with autolytic debridement), infected wounds
126
what are the characteristics of ful
```
charred
insensate
eschar formation
involves all level of skin
can not re-epithelialize
will need graft for areas without wound contraction
surgical debridement
diabiliyt
no pain
no viable nerve endings
high risk for infection
```
127
where are the 2 leg pusles
dorsalis pedis
=You can feel this pulse by positioning your index and middle fingers in the middle of the anterior part of his foot.
posterior tibial pusle
=To feel this pulse, position your index and middle fingers at the back of his right or left ankle, specifically behind the medial malleolus.
128
what does damage to the sensory nerves cause
loss of protective sensation
129
what is topcial elemental antimicrobials
- The formulation and concentration of the agent is important to it effectiveness
- Use should be limited to 2-4 weeks
- Silver sulfadiazine cream, silver impregnated dressings (good for MRSA), copper, zinc, cadexomer iodine
130
what is cleaning of a wound infection need
- 4-15 psi with water or normal saline
| - aimed at reducing surface contaminant rather than curing infections
131
what is a stage 4 pressure injury
- Full thickness tissue loss with exposed bone, tendon, or muscle
- Slough or eschar may be present on some parts of the wound
- Often includes undermining or tunneling
- Can vary in depth based on location
132
what is a enzymes
Collagenase Santyl
133
what is slough
= yellow, tan, or gray, slimy, moist
134
what types of contact layers are there
Mepitel Silicone Dressing, Tegapore, Sorbact
135
what depth does the deep partial got to
dermis : reticular region
136
what is elastic
Profore
Surepress
Support Stockings
137
what is serosanguineous exudate
yellow with red ting
138
what is critically colonized
clinically assessed as pint wound is about to be infected
139
what is a disadvantage of conservative sharp debridement
Can be uncomfortable for the patient
140
what are some common medicatino for topical medication ffor burns
```
Silver sulfadiazine (Silvadene)
Sulfamyalon
Silver Nitrate solution and sticks
Bacitracin/Polysporin
Collagenase (Santyl®)
```
141
what are the type sof compression for burns
Elastic wraps (ACE)
Tubular bandages (Tubi-grip)
OTC garments
Custom garments
142
what are some precautions of gaze
adheres to wound tissue for non-selective debridement, may dry out wound
143
when do you change the hydrogel
changed dailiy
144
what is aerobic bacteria
needs O2 to survive
145
what is atrophie blanche lesion for venous ulcers
Smooth, white plaques of thin, atrophic tissue speckled with tortuous vessels
Represents spontaneously developing lesions
High risk for ulceration
146
what is an acute wound
normal healing within 21 days
- traumatic or surgical origin
- heal rapidly and predictably through the repair process
- durable closure
- can develop complications that can turn it into chronic
147
how much is the head rule of nines in a child
.
148
what makes up vascualr ulcers
70-75% are primaryily due to chronic venous insufficieny
25-30% are attributed to arterial or mixed disease
149
what is hydrogel amde of
Composed of water or glycerin
150
how much support for stockings is needed for -- treatment for venous ulcers and lymphedema
40-50 mmHg
151
how does Negative pressure wound therapy work
Black or white foam is placed in the wound, sealed with semi-occlusive drape, and connected to pump
152
what is chronic wound
something that does not heal within 30 days and does not have a normal healing process
- fail to close in a timely manner or fail to resut in a durable closure
- by vascular compromise, chronic inflammatoin, or repetitive insults to the tissue
153
what are the characteristics of deep partial
```
white
leathery
relatively painless
growth is slow
grafting is preferred treatment
high risk of infection
severe scarring
can convert to full thickness
```
154
Wound vac application
slide 97
155
how do you know if you have arterial issues
thinning of the epidermis, loss of hair growth, thickened nail
156
what are the different categorizes of wounds
```
⚫ Chronic
⚫ Pressure Ulcers
⚫ Arterial
⚫ Venous
⚫ Neuropathic/ Diabetic
⚫ Traumatic
⚫ Surgical
⚫ Burns
⚫ Other
```
157
what are some concerns with whirlpool
cross-contamination between patients who use the whirlpool
158
what are the objectives of physiologic wound environment
1) Prevent and manage infection
2) Cleanse the wound
3) Remove non-viable tissue
4) Maintain appropriate level of moisture
5) Eliminate dead space
6) Control odor
7) Eliminate or minimize pain
8) Protect the surrounding skin
159
what is a compression therapy
- Application of externally applied pressure to facilitate normal venous flow
- Acceptable to use even with acute dermatitis
- Only controls the underlying venous insufficiency; most patients require long-term therapy to prevent recurrent ulceration
- No stocking until wounds healed
160
what is Negative pressure wound therapy
Wound V.A.C.
161
other modaliliteis notes
slide 82
162
what skin grafts are temporary
Allografts and xenografts are temporary until skin is availabe for autograft
163
what is a secondary dressing
used to increase the ability for the wound needs to be adequately met and/ or secure the primary dressing
164
what is used with whirlpool treatment
Water is most commonly used, optimal temperature 37ºC
165
when should enzymes stopped being used
once viable tissue is revealed and necrotic tissue is removed
166
what is allograft
taken from a cadever
167
what should the wearing schedule be for compression with a burn
23 hours/day, 7 days a week
Wear until scars mature
Could need for 8 months – 1-2 years
Remove only to bathe and if interferes with therapy.
Mature scar- soft, pliable, flat, and skin color is close to normal skin tone
168
what forms does alginate come from
Rope or pad form
169
what is the recurrence rate of venous ulcers
Recurrence rates as high as 57-97%
170
what can the periwound skin look like
- Normal
- Hypopigmented
- Light red/ pink
- Tape Stripped/ Denuded
- Macerated
- Excoriated
- Indurated
- Boggy
- Elevated temperature
- Edema
171
how much support for stockings is needed for -- venous ulcer treatment
30-40 mmHg
172
what are some treatment of a wound infection
- oral antibiotics
- cleaning
- debridement
- topicla therapy
173
how much support for stockings is needed for -- ted hose
15-17 mmHg
174
what does it mean with unilateral coolness and sudden coolness form proximal to distal of the leg
arterial disease
175
how do the maggots work
The larvae secrete proteolytic enzymes and break down necrotic tissue
176
how shoudl a culture be taken
form a clean, healthy-appearing tissue, not form pus, slough, eschar, or necrotic materail
177
what is PAD
peripheral arterial disease
178
how does the metabolic from a burn affect someone
Metabolic demand increases with burn injury with increased TBSA, decrease in body weight and energy stores, causes increase in core body temp~2 degrees, (helps to keep room warmer ~86 degrees so pt doesn’t lose excessive amount of body heat which will reduce metabolic activity, protein from muscle is used for energy causing muscle atrophy (in addition to bedrest);
179
what are some facts of the dermis and what does it contain
- Responsible for vascular supply and nourishment to skin/epidermal layer
- Nerves
- Glands
- Fibroblasts
180
how much are the legs rule of nines in a child
.
181
what are the different types of wound care dressings
```
Alginate
Composites
Contact Layers
Foam Dressings
Gauze
Hydrocolloid
Hydrogel
Transparent Film
Negative Pressure Wound Therapy (NPWT)
```
182
what is contact layers not used for
not for use in shallow or dry wounds, or with viscous exudate
183
what types of foam dressing are there
Allevyn, Lyofoam, Mepilex
184
what is a Hypertrophic scar
- Confined to area of original injury
- Commonly over joints
- May regress spontaneously
- Associated with contractures
185
what is non- elastic
Unna Boot
Circ-Aid
Comprilan (lymph wraps)
186
how does the infection from a burn affect someone
leading cause of death in combination with organ system failure, can develop sepsis, MDROs
187
wha tis necrotic tissue
Can be loose or adherent
Usually yellow, but can also be brown, tan, black, or green
Needs to be removed to allow good tissue to form IF pt has adequate blood flow
Occasionally requires surgical debridement
188
what is sanguineous exudate
red or bloody
189
what is antiseptics
- Non-selectively kills or inhibit the growth on the external surfaces of the body
- Use is generally discouraged because their cellular toxicity exceeds their bactericidal activity
- Use should be restricted to 1-2 weeks for specific indications
- Alcohol, acetic acid, betadine, hydrogen peroxide, hypochlorite (Dakin’s solution)
190
what depth does the full
hypodermis (subcutaneous tissue)
191
what is the scar massage for burns
start just moving skin with no friction; begin with skin is durable enough to not blister
192
what are the zones aroudn the burn
- zone of coagulation
- zone of stasis
- zone of hyperemia
193
what does damage to the autonomic nerves cause
decreased sweating cause cracks, fissures, and callus
194
what are the indication for impregnated gauze
partial or full-thickness wounds, infected wounds, wounds with tunnels
195
how do you get enzymes treatment
prescription
196
what depth does the superficial partial go to
dermis: papillary region
197
what are the layers of the epidermis
- corneum
- lucidum
- granulosum
- spinosum
- basale
198
what is alginate good for
full thickness, undermining, tunnel, moderate to heavy exudate, infected wounds, malodorous wounds
199
what types of alginate are their
Aquacel, Sorbsan, etc
200
what is stage 2 pressure injury
- Partial thickness loss of dermis
- Shallow opening or crater
- May present as an intact or ruptured blister
- Shallow ulcer without slough or bruising
- Red or pink wound bed
201
how often do you change hydrocolloid
Changed up to 3x/ week
202
what are some methods of debridement
- autolysis
- chemical
- mechanical
- sharp
203
what is mechanical debridement
Wet-to-Dry Debridement, Irrigation, Whirlpool
204
how do you pick a wound care dressing
using the 8 objective of physiologic wound enviroment
205
what is a stage 3 pressure injury
- Full thickness tissue loss
- Subcutaneous fat may be visible
- Slough may be present but does not obscure the depth of tissue loss
- May include tunneling or undermining
- Bone, tendon, or muscle is NOT exposed
- Can vary in depth based on location
206
what are some characteristics of arterial ulcers
```
Located on tips of toes and pressure points on feet
“Punched out” well defined borders
Pale wound bed
Little to no granulation
Minimal to no exudate
Black toes
Leave dry, stable eschar INTACT!
```
207
precautions for hydrocolloid
not for 3rd degree burns, or wounds with heavy exudate, or wounds with depth, may contribute to hypergranulation
208
what do composites combine
impermeable barrier, an absorptive layer, a non-adherent contact layer, and an adhesive border
209
what is a pressure injury
Localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear
Blood supply is decreased which leads to tissue anoxia and tissue death
210
how is more vulnerable for pressure injuries
```
Elderly (over 65 y.o.)
Spinal Cord Injuries
Children in the ICU
Surgical Patients
Patients dependent for mobility
Patients with incontinence
```
211
when does the transparent films need to be changed
Changed up to every 7 days
212
what is pseudomonas exudate
has bright green tinted exudate and sweet but foul oder --- they need antibotics
213
do you need a secondary dressign for alginate
Secondary dressing is required
214
what is the rule of nines
.
215
how to take a photo of a wound
- pt identifier in the picture
| - have disposable tape measure in the picture
216
is wet to dry debridement selective and non
non-selective
217
where does it come from alginate
Derived from seaweed
218
what are the types of burns
```
Scalds- liquid,grease,steam
Contact burns
Fire-flash and flame burns
Chemical
Electrical
Radiation
```
219
what are the different odors can there be in a wound
absent
mild
moderate
strong
220
what are some complication form a burn
```
Infection
Pulmonary
Metabolic
Cardiovascular
Heterotopic Ossification
Neuropathy
Pathological Scars
```
221
what does debridement of a wound infection need
removes dead tissue to facilitate healing
222
how do you describe the extent of tissue involvement
- ONLY use "number stages for pressure ulcers
| - use superficial, partial and full thickness for all other wounds
223
what is sharp debridement
Conservative Sharp Debridement, Surgical Sharp Debridement, Laser Debridement
224
what causes neuropathic/ diabetic ulcers
damage to ---
- sensory nerves
- motor nerves
- autonomic nerves
225
what is tertiary intention
- Also known as: Delayed Primary Intention
- Often used in abdominal incisions complicated by significant infection (i.e. ruptured appendix with peritonitis)
- Wound is kept open for several days, then the superficial edges are approximated and the center of the wound heals by granulation tissue formation
226
what are the characteristics of superficial partial
```
very pain
blisters
spiotchy skind
severe swelling
good blood supply
no scars
```
227
how does the reticular layer attach to the subQ
with fibrous connective tisse
228
what is autograft
taken from pts own skin, allograft
229
what are some other wound types
```
Necrotizing Fasciitis
Extravasation injuries
Fistula
Pyoderma Granulosum
Calciphylaxis
```
230
what are the tocial therapy for arterial ulcers
Keep dry if possible
| Debride only if infected
231
what is pulsatile lavage
- Machine that provides high-pressure irrigation (8-15 psi) combined with suction
- Loosens necrotic tissue and facilitates removal by other forms of debridement
- Can be costly, attachments are single-use
- Use caution to avoid blood vessels, grafts sites, and exposed bone, muscle, and tendon. Also with pts on blood thinners
- Must wear PPE
232
what is the lucidum
middle layer
| only present in thicker areas soles of feet, palms, and pads of fingertips
233
what are the types of wound closure
- primary intention
- secondary intention
- tertiary intention
234
what is shear force
= combination of friction and gravity
Sliding down the bed when HOB is elevated greater than 30º
Common in sacral area
235
what are local signs of infeciton
increased purulent exudate
- induration
- warmth
- pain or tenderness
- erthema
236
Does contact layers need a 2n layer
Requires secondary dressing
237
what is the basale
bottom layer
| contains cells that allow epidermis to regenerate and melanocytes which give the skin its color.
238
what does Negative pressure wound therapy do
wound closure
239
how fast is the enzymes treatment
slow
240
what is maturation
Remodeling of scar tissue occurs for one year post wound closure
Scar tissue will only regain ~2/3rds the original strength
241
how to tell stage 1 in darker pigmented skins
Special consideration should be made to identify stage I ulcers in patients with darker pigmented skin.
```
In darker pigmented skin may be:
Painful
Firmer (indurated)
Softer (mushy or boggy)
Warmer or cooler
```
242
how is aggressive is conservative sharp debridement
Most aggressive form of debridement that can be done by non-physicians
243
how do you help a dry eschar with enzymes
must be cross hate\ched and wound must be kept moist
244
what are some systemci signs of infection
- fever
- malaise
- chills
- confusion
245
how is pressure injury stages
using numbers and NEEDS to be done right
| -- you can never go backward
246
what are pressure injury prevention plans
```
Risk Assessment
---Formal and Informal
Skin Inspection
Pressure Redistribution
Positioning
Support Surfaces
Nutritional Support
Holistic Care
```
247
what structure determines how easily skin can tear
```
Rete pegs ( btw epidermis and dermis
- size decreases wth age and skiin is more likely to tear/ blister
```
248
what is maggots
Biologic debridement
| Sterile fly larvae are placed in the wound
249
what are some surgical management for burns
- primary excision
- skin grafts
- skiin substitutes
- correction of scar contrature
250
what is a primary dressing
therapeutic or protective covering applied directly to the wound bed
251
how does the cardiovascular from a burn affect someone
shift in dynamics of fluid will lead to edema in interstitial spaces and leads to decreased cardiac output, require IV fluids to perfuse organ which leads to more edema
252
what is closed technique with topical medication
cover with dressing if drainage presents
253
what is purulent exudate
infected wounds will have pussy tan/ yellow
254
what is primary intention
- Surgical Wounds
- Wounds are approximated and secured with sutures, staples, or adhesive tapes
- Healing occurs by epithelialization and connective tissue deposition
- Heal quickly with minimal scar formation
255
what is dakins solution
Diluted sodium hypochlorite (bleach)
256
what are some issues with using enzymes
transient erythema or burning
257
what is the indication for transparent films
partial thickness, minimally draining or closed wounds, stage I pressure ulcers, skin tears, promotes autolysis
258
what is limb elevation
this is a simple way to reduce edema
| -essential for pts that cannot adhere or tolerate compression therapy
259
what are some contraindicated for debridemnet
- Dry, stable ischemic wounds or those with dry gangrene
| - Stable eschar covering heels
260
how do you use the silicone gell sheet for burns
used alone or under compression if compression alone is not effective; can be washed daily and re-used
261
what are the valve dysfunction for venous ulcers
Obesity
Pregnancy
Thrombophlebitis
Leg trauma
262
what is secondary intention
- Pressure, vascular, and diabetic
- Wound edges are not approximated
- Healing occurs by granulation tissue formation, contraction of wound edges, and epithelialization
- Heal slowly because of the volume of connective tissue required to fill the defect
- More prone to infection since they lack the epidermal barrier to microorganisms
263
what is the management of venous ulcers
Management includes short-term wound healing and long-term disease management to prevent recurrence.
264
what debridement
Removal of non-viable tissue and foreign matter from a wound
Indicated for any wound, acute or chronic, when necrotic tissue or foreign bodies are present, or in the presence of infection
265
what is partial thickness
- damage to the epidermis and partial dermis
| - heal primarily by re epithelialization
266
what are arterial ulcers prone to
Prone to infection and gangrene
| Potential for amputation
267
what is a deep tissue injury pressure injury
- Purple or maroon localized area of intact skin
- May look like a blood-filled blister
- Due to pressure or shear
- May be difficult to detect in darker skin tones
- Expected to evolve rapidly (into stage III or IV wound) even with optimal care
268
what is eschar
= hard, black, leathery, dry
269
how much is the trunk and back rule of nines in a child
.
270
is an enzymes treatment selective or non
selective
271
what is inflammation
Neutrophils (type of WBC) are first to scene and act along with Macrophages to remove the harmful substances
Growth factors are secreted by macrophages to stimulate new blood vessel growth (angiogenesis)
Edema is present
272
what types are there for hydrogel
Vigilon, Hypergel
273
is dakins solution selective or non and what makes the treatment easy
Non-selective due to cytotoxic properties
Denatures protein making it more easily removed
274
how much is the arms rule of nines
.
275
what doyou need to assess when looking at the periwound
```
Induration
Redness
Erythema
Is it Blanchable?
Callus
Venous changes
Edema
Dry skin
```
276
what are the precautions for Negative pressure wound therapy
active bleeding, over fistulas or exposed blood vessels, over untreated osteomyelitis, in wounds with >20% necrotic tissue, malignancy in the wound
277
what does a topical therapy for wound infection need
topical antimicrobial are sometimes indicated to reduce wound bioburnden
278
what is the 4th type of burn
full
279
how do you asses the dimensions of a wound
```
LxWxD
with using the clock
length = 12-6
width = 9-3
depth = the deepest part
OR you may doing tracings
```
NO quarter sized OR 2 1/2 always 2.5 cm
280
what type of skin graft are there
Autograft, allograft, xenograft
| STSG, FTSG, sheet graft, mesh graft
281
what are the different amount of exudate you can state the pt has
scant
min
mod
large
282
what are ohter modalities in woundcare
- e stim
- ultrasoudn
- mist low frequency non contact us
283
how have maggots become popular
Becoming more popular with the rise of antibiotic resistance infections
284
what is contact layers made of
Non-adherent woven silicone net placed over wound bed
285
what are the calf muscle dysfunction for venous ulcers
Sedentary lifestyle
Jobs that require prolonged standing
Reduced mobility/ shuffling gait
Advanced age
286
What is a Keloid Scar
- Extend beyond original wound border
- Likely to occur on upper back, chest, deltoid, and -earlobes
- Very rarely regress
- Lack myofibroblasts and therefore not associated with contractures
287
how much are the legs rule of nines
.
288
what is a venous ulcer
-Occur as a result of impaired return of venous blood to the heart, or chronic venous insufficiency (CVI)
- Normal Venous Function
- ----Depends on competent valves in the veins and normally functioning calf muscle pump
- Valve failure causes reflux of the blood which is clinically manifested as edema
- When the calf muscle fails to contract effectively, the deep veins are incompletely emptied
```
-Located from mid-calf to ankle, often at medial malleolus
Irregular borders
Usually shallow, can have slough present
Generalized edema to lower leg
Moderate to heavy exudate
Hemosiderin staining of lower leg
```
289
go through all under slide notes
before exam
290
what is conservative sharp debridement used for
Removes necrotic tissue quickly, can be done in a serial manner
291
what are other components you must assess when looking at the area of the wounds dimensions
- undermining
| - tunneling
292
what color changes in the leg are you looking for
elevational pallor
| -dependent rubor
293
what type of composites are there
Mepilex, Optifoam Gentle
294
what is the hyperbaric o2 therapy for arterial ulcers
Increases the amount of oxygen dissolved in the plasma, which results in the delivery of oxygen-rich blood to the tissues.
295
what is LEND
lower extremity neuropathic disease
296
what are the forces that lead to skin breakdown
1 shear
2 friction
Each clinician must consider all factors and determine to what extent friction played a role in the development of the pressure ulcer.
297
what are some intervention for burns
Therapeutic exercises/ROM
Positioning/splinting
Resistive and conditioning exercises—monitor vitals signs
Ambulation
Scar Management—pressure dressings, Silicone gels, massage, camouflage makeup
Prior to discharge instruct in HEP, splinting and positioning program, and skin care routine
298
what are the phases of healting
- hemostasis
- inflammation
- proliferation
- maturation
299
what is the treatment focus for arterial ulcers
minimize risk of infection, ongoing assessment of wound deterioration, interventions to reduce pain
300
what is gram (- )
Pseudomonas
Acinobacter
Enterobacter
Many others
301
how do you asses the pulse of the leg
- Compare right-left and proximal to distal
- Noted as present or absent, weak, bounding
- If unable to palpate, should use Doppler
- Absence of bilateral pulses by Doppler is indicative of LEAD
302
how do you do limb elevation
lay own and elevate the legs above the level of the heart of 1-2 hrs/day and at nigh t
-avoid prolonged sitting or standing
303
what is dakins solution used for
Indicated for large amounts of slough and the wound is infected or malodorous
304
what are 2 scar formations that happen
- hypertrophic scar
| - keloid scar
305
what is the indication for hydrocolloid
partial and full thickness wounds, minimal to moderate exudate, may be used in combination with other dressings (alginates, etc)
306
how is wet to dry debridement used
this is a conventional treatment
307
what is the zone of stasis
is a risk for further injury if pt does not have adeduate treatment w/i 24-28 hrs
308
what are chronic wound signs of infection
often lack classic signs
- new pain
- delayed healing despite optimal care
- friable granualtion tissue
- new area of breakdwon
- change in exudate
309
what is the components of wound assessment
- duration of wound
- location of wound
- extent of tissue involvement
- wound bed
- dimensions
- exudate
- odor
- periwound skin
- signs of infection
- wound pain
- photographs
310
how much is the trunk and back rule of nines
.
311
what is varicosisties for venous ulcers
- Swollen, twisted veins that appear blue and close to the surface of the skin
- May bulge, throb, and cause the legs to swell and feel heavy
- Varicosities are a clear indicator of LEVD and a predictor of venous ulceration
312
what is surgical sharp debridement
- Used when you need to remove large amounts of tissue or involving life-threatening infection
- Most often a one-time procedure
- Risk to patients include: anesthesia, bleeding, sepsis, plus increased costs
313
how long does/ can Negative pressure wound therapy stay on
Changed 3x/ week
314
what is undermining
Tissue destruction along wound margins under intact skin
315
what is lipodermatosclerosis for venous ulcers
Fibrosis or hardening of the soft tissue in the lower leg
Indicative of long standing venous disease
Typically confined to the gaiter or sock area, gives the leg the appearance of an inverted champagne bottle
316
when should composites be changed
Changed every 2-3 days
317
what doyou need to filll out in a chart review of burns
```
Subjective
When wound started?
What has been done so far?
Have you had this type of wound before?
What is your pain level?
How is your diet?
Do you smoke?
How are your blood sugars?
```
Current reason for admission—does it relate?
Check PMH for comorbidities that may effect wound healing
Labs: Platelets, Hgb A1C, INR, WBC, Albumin, wound culture
Imaging: MRI/X-ray—checking for infection/abscess, vascular scans (arterial doppler/CTA)
318
what is alginate not recommended for
not recommended for non-draining wounds
319
how does the pulmonary from a burn affect someone
inhalation injury to cause carbon monoxide poisoning, tracheal damage, airway obstruction, pulmonary edema, and pneumonia…may need ventilation or bronchoscopy
320
what types are their for impregnated gauze
daptic, Iodoform
321
what does it mean if there is an increase in temp around the ankle
venous disease
322
what are you looking at with perfusion of the leg
- venous filling time
- skin temp.
- pulses
- ABI
323
what are some topcial antimicrobial
- antiseptics
- topical antibiotics
- topical elemental antimictobial
324
what is the 2nd type of burn
superficial partial
325
what is edema
- Assess for edema/ pitting edema
- Press firmly for several seconds on the dorsum of each foot, behind the medial malleolus, and over the shins.
- Edema is “pitting” if there is a visible depression that doesn’t rapidly refill and resume original contour
326
how do you know what type of burn they have
-calssification as they do not do the staging anymore
- superficail
- superficial partial
- deep partial
- full
327
what is whirlpool used for
Used for large wounds with significant amount of necrotic tissue
328
what types of transparent films
Tegaderm, Op-Site
329
what is LEAD
lower extremity arterial disease
330
what is the role of compression for burns
```
Protects skin
Increases circulation
Decreases pain/itching
Reduces amount of scarring
Realigns collagen fibers
Used to prevent hypertrophic scarring
Increases skin length (provides pressure to contracture bands
```
331
what are the best dressing selection for burns
Foam
Non-adherent
Gauze/Padding
Rolled gauze/netting
332
how do you asses a wound bed
in percentages
- viable
OR
-non-viable/ necrotic
333
what ae the surgical options for arterial ulcers
Blood flow needs to be re-established
| If unable to re-establish—amputation is likely
334
what is xenograft
taken from another species (usually pig).
335
what are some characteristics of venous ulcers for venous ulcers
- edema
- atrophie blanche lesions
- hmeosiderin staining
- varicosities
- lipodermatosclerosis
- venousdermatitis
336
what are the precaution for impregnated gauze
dressing dependent
337
is conservative sharp debridement selective or non
selective
338
what are the different types of exudate
- serous
- serosanguineous
- purulent
- pseudomonas
339
what is the best way to augment healing for enzymes treatment
the appropriate dressing for good healing
340
what is non-granular
= pale red or pink, smooth
341
how often do you need to change alginate
Changed daily d/t highly draining wound
342
how much support for stockings is needed for -- double layer of tubi grip
18-20 mmHg
343
what are some surgical management for edema
- indicted with severe lipodermatosclerosis or persistnet or recurrent ulcerations if they underlying pathology is valve incompetence
- Most common= ligation and stripping of the veins
344
what is contact layers used for
full thickness granular wounds, minimal to heavy exudate, over skin grafts, on painful wounds
345
what are the indication for foam dressing
partial and full thickness wounds, minimal to heavy exudate, infected wounds
