Exam 1- Wounds 3 and Wounds part of 4 Flashcards Preview

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Flashcards in Exam 1- Wounds 3 and Wounds part of 4 Deck (50):

Quiz question: three things that need to be present for a wound to heal

~blood flow
~environment (moist)


Quiz question: compare and contrast arterial and venous wound

~Arterial- deep, pale, dry, lateral, more likely to be painful, less common
~Venous- shallow, reddish, weepy, medial, less likely to be painful, more common (by 4x)


Quiz question: three types of debridement that are selective (vs nonselective)

(Selective- This is only going to get rid of the stuff that we want it to get rid of and Non selective- this will get rid of everything)
~Maggots (get only the dead tissue)
~Pulse lavage- only if the stuff under the pulse lavage is dead tissue; if the stuff under is also good tissue, it could also take away good tissue (Whirl pool- Non selective)
~Enzymatic- some would be selective and some non-selective
~Forceps/ wet gauze/ scalpel (mechanical)- can be selective depending on how you apply them (If a physician does it, it is more likely to be non-selective)
~Autolytic- your body should be completely selective unless something is going wrong


Quiz question: three points of education that you would want to give to a patient with a diabetic ulcer

~Wound positioning
~What’s your sugars; how often do you check it (80-120); when’s the last time you went to the doctor? Etc.
~Don’t go to nail salon; soak feet
~Don’t remove calluses
~Foot check
~Don’t wear compressions garments/ tight shoes/ shoes
~Proper shoes


What do you do before examining the wound?

Take vitals!
~you will have a baseline and comparison


What else will you do beside look at the wound?

~look at the whole person
~if they can walk, have them walk/ get them up
~do a gross motor screen
~sensory screen
~you have the same subj and obj
~see if they are active, if they smoke, etc


Wound: what are ways to record the size of a wound?

~Can draw it/ sketch a picture of it
~Take a picture of a wound
~trace the wound


Wound: what details of the size of the wound will you record?

~width, depth, length
~shape (is applicable)
~if there is undermining/ tunneling


Wound: what are details that you want to record about the wound? (8)

~direction of where the wound is located
~wound bed (wet/dry/ moist)
~is there neurotic tissue?


Periwound: what are details that you would want to record about the periwound? (3)

~turgor (firm, squishy, bogey, etc)
~regular/ irregular
~macerated/ desiccated


What do you look at during an examination of the wound? (5)

~the wound (wound bed)
~the periwound
~removal of dressing


Details about the exam of drainage

~the amount of the drainage








Details about the exam of pain

~before and after the dressing and after the cleaning of the wound
~you want to asses when it is the most painful and are you causing pain


Detail about the exam of removal of dressing

~How well did the dressing come off
~Did any not come off
~Was the dressing Wet/dry when it came off; (will you have to apply moisture if it is dry)
~Need to record everything so that the next person will know what to expect when they come in next time


What do you do with a black, dry heel?

~Don't do anything
~the heel is there for protection
~if you open it up, you can let in an infection


Are all wounds infected?



Are all wounds contaminated?

~it takes until 10^5 MRSE/VRE to became infected


what are signs of an infected wound? (6)

~changes in the wound: amount of drainage, color, odor
~periwound- irregular (can hit a vein)
~may not be able to walk easily
~temperature changes/ fever


Wound closure

~primary closure
~secondary closure
~tertiary closure


What is a primary closure? (3)

~When a physician closes a wound
~Staples, stitches, skin flap/ grafts, glue
~Dehiscence- breaks open/ can pop open (too much movement, infection); need to heal secondary then (Happened a lot with total knees, amputations, etc)


What is a secondary closure?

~mother nature/ when your body heals you on its own
~most happens this way


What is a tertiary closure?

~you body heals it on its own for a while and then a physician closed it up
~can't close up after too long bc of infection
~happens with burns- grafts


What is a primary dressing?

inside the wound; fills the wound and makes it look like the anatomy (never dip)


What is a secondary dressing?

on top of the primary dressing; will be dry


Details on gauze

~A woven material that can fit into any shape
~Can fit in any shape, squared, round, etc
~Folded, unflold
~Can wounds are already contaminated: They are all infected so no worries about keeping things sterile
~Most wounds are filled with gauze- cheap
~Fluff up and fill wound- don’t shove them in- can create pressure


Details on packing gauze

~Great for Tunnels
~Comes in packing stripes
~Leave a tail, have it moist
~Use the q-tip end (moisten) to help the packing gauze into the tunnel


When you put gauze (or anything else in a wound,

KEEP COUNT!! record what you put into a wound so that the next person will know exactly how much to remove


What do you call when the moisture gets through the primary dressing?



Why is strike through bad?

~when the fluid gets through the secondary dressing, the infection can get straight through to the wound


What happens when moisture moves to the edges of the secondary dressing?

failed dressing
(no longer a strike though because it is now macerated. need to redo)


What happens if you add too much primary dressing?

~too much pressure


What does BID stand for?

twice a day


What does TID stand for?

three times a day


Details on impregnated gauze

~Take a gauze and add the meds to it; very difficult to but the meds straight to the wound so you add the gauze first
~You can impregnated the gauze with anything that the doctor has prescribed
~Used with venous wound
~NEVER DOUBLE DIP; never touch something that has touched the wound to anything else


Types of things used for impregnated gauze

~Silvadene- take gauze and lather it with the silvadene; trying to put it on the wounds and it won’t come off; put it on the gauze!- Antibacterial
~can use honey- great for wounds; keeps it mosit and keeps the bad stuff out
~zinc- unna boot- is a ridge gauze that is an impregnated gauze with zinc; wrap with this around wound then use coban on top to keep the zinc from keep out; walk them then elevate them (compression and elevation with the zinc)
~can do anything that a doc prescribes


Details on transparent films

~Expensive, comes in various shapes and sizes
~Very thin, hard to roll, outside is thinner so that it will not roll; going to stick to the periwound
~Best for autolytic debridement (need to tell the pt about what’s going to happen ahead of time) {Clear on the first day then will turn yellow to brownish}
~Not your primary dressing, usually your secondary
~For road rash- you will only have this (like your primary and secondary)
~Won’t let fluid/ moisture out, will let air in, won’t let bugs in


Details on foam

~Going to stuck stuff up (fluid); comes in little shapes like pillows
~Good for really wet wounds


Details on hyrdogel

~Good for desiccated/ dry wound
~Like ultrasound gel; fills in the space with the gel


Details for hydrocolloid

~your primary and your secondary are attached
~Will change opaqueness as the moisture changes
~Will soak up moisture in the primary
~Comes in all shapes and sizes
~Stage 2 pressure wounds- will take place of our epidermis and part of your dermis


Details for Alginates

~primary dressing- will absorb a lot of moisture
~calcium alginate- comes in sheets (feels like cotton)
~do not pre-moisten this


Details for hydrofibers

~comes in sheets
~can cut to the shape of the wound
~absorb wet


Details on Beladine-whirlpool

~Don’t have to put a lot in there, just a little bit in the whirlpool


Details on Daikins

~A watered down bleach- .001%- .0025% (can be .005%) that will be with the gauze
~Kills stuff, good for a couple of days
~Have to talk to physician to stop using it because it slows healing because it is irritating the wound bed;; may have to use it in sacral area bc its so close to b/b


What are the type of modality for wound care? (7)

~wound vac


Details on Wound Vac

~An accordion foam in the wound cut to the shape of the wound; big piece of plastic sheet over it; make a little hole in it; put the nipple in the whole and add the pump over it; creates a negative pressure
~Heals quickly, but not covered yet by insurance but hospitals use it like crazy because it works!
~Great for abdominal surgery, incontinence


Details of Ultra sound

~Will bring a lot of blood and nutrients to the area ~Restart the inflammation stage
~Realign the collagen
~Gets rid of swelling/edema
~Put ultra sound gel in the wound- then use it
~More likely to be in the nursing home where we can get paid for it


Details of E-stim

~Put it in the wound- gauze (wet) with AL foil, tongs, and a ground


Details on HBO

*Hyperbaric oxygen therapy
~Can be rooms or a tank; but them in a camber to create more pressure- this will get more O2 into the tissue and will help to open up the little vessels to enhance healing
~More oxygen is diffused into the tissues with more negative pressure
~Allows wounds to get the oxygen it needs