Integ & Wound Healing Flashcards Preview

NPTE Other Systems > Integ & Wound Healing > Flashcards

Flashcards in Integ & Wound Healing Deck (30)
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1

What are the key functions of the integ system?

- Protection
- Sensation
- Thermoregulation
- Excretion of sweat
- Vitamin D

2

What happens during the Inflammatory Phase of wound healing and when does it take place?

1 to 10 days
- Initial response
- Re-establish homeostasis
- Clean wound bead
- Signals tissue restoration to begin

3

What happens during the Proliferative Phase of wound healing and when does it take place?

3 to 21 days
- Capillary buds and granulation tissue form
- Skin integrity restored
- Wound closure

4

What happens during the Maturation Phase of wound healing and when does it take place?

7 days to 2 years
- Remodeling phase
- Shrink and thinscar
- Strengthened scar

5

What is primary intention wound healing?

- Heal quickly
- Minimal scarring
- Minimal tissue loss

6

What is secondary intention wound healing?

- Ongoing wound care
- Associated with pathology (ex: DM2)
- Larger scars

7

What is tertiary intention wound healing?

aka Delayed Primary Intension
- Temporarily left open until risk is gone
- Closes using primary intention

8

Arterial vs Venous vs Neuropathic:
Where are they located?

Arterial
- Lower 1/2 leg
- Toes
- Web spaces

Venous
- Prox to med malleolus

Neuro
- Areas susceptible to pressure or shear

9

Arterial vs Venous vs Neuropathic:
What is there appearance?

Arterial
- smooth edges/deep

Venous
- Irregular/shallow

Neuro
- oval or circle
- no necrosis -> good granulation

10

Arterial vs Venous vs Neuropathic:
How much exudate?

Arterial: min

Venous: mod/heavy

Neuro: low/mod

11

Arterial vs Venous vs Neuropathic:
How much pain?

Arterial: SEVERE

Venous: mild/mod

Neuro: None - may have dysesthias

12

Arterial vs Venous vs Neuropathic:
Is there a pedal pulse?

Arterial: diminished/absent

Venous: Normal

Neuro: diminished/absent

13

Arterial vs Venous vs Neuropathic:
How edema?

Arterial: Normal

Venous: INCREASED

Neuro: normal

14

Arterial vs Venous vs Neuropathic:
What is the skin temp compared to other parts of the body?

Arterial: DECREASED

Venous: normal

Neuro: DECREASED

15

Arterial vs Venous vs Neuropathic:
What are the tissue changes?

Arterial:
- thin and shiny
- hair loss
- yellow nails

Venous:
- flaking, dry skin
- brownish discoloration

Neuro:
- dry, inelastic
- shiny skin
- dec/absent sweat and oil production

16

Arterial vs Venous vs Neuropathic:
What are the misc considerations?

Arterial: legs up = pain

Venous: legs down = pain

Neuro: loss of protective sensation

17

What are the rankings on the Wagner Ulcer Grade Classification Scale?

0 = No lesion
1 = Superficial
2 = Deep to fat
3 = Deep to bone
4 = Gangrene
5 = Gangrene needing amputation

18

What types of ulcers does the Wagner Ulcer Grade Classification Scale evaluate?

Dysvascular ulcers:
- Diabetic foot ulcers
- Neuropathic, ischemic, or arterial etiology

19

What are the stages of Pressure Ulcer Staging?

Stage I = intact, blanchable
Stage II = Partial thickness loss
Stage III = Full thickness (maybe fat)
Stage IV = Full thickness - exposed bone tendon or muscle
Suspected Deep Tissue Injury: Discolored intact skin or blood blister
Unstageable: Full thickness - base covered by slough

20

For Exudate Classification, what is Serous?

- Clear
- Light color
- Thin, watery consistency
**normal in healthy healing

21

For Exudate Classification, what is Sanguineous?

- red color (blood)
- thin, watery consistency
**new blood vessel growth of disruption of blood vessels

22

For Exudate Classification, what is Serosanguineous?

- light red or pink color
- thin, watery consistency
**Normal in inflammatory and proliferative phases of healing

23

For Exudate Classification, what is Seropurulent?

- cloudy, opaque + yellow or tan color
- thin, watery consistency
**Early warning sign of infection

24

For Exudate Classification, what is Purulent?

- Yellow of green
- Thick, viscous consistency
**Wound infection

25

What is Eschar?

hard, leathery, dehydrated tissue - firmly adhered to wound

26

What is Gangrene?

death/decay from lack of blood flow
- typically in extremities

27

What is Hyperkeratois?

callus
- firm to soggy

28

What is Slough?

- Moist
- Stringy or mucinous
- White/yellow
- loosely attached to wound bed in clumps

29

What are the types of Selective Debridement?

- Sharp Debridement
- Enzymatic Debridement
- Autolytic Debridement

30

What are the types of Non-selective Debridement?

- Wet-to-dry dressings
- Wound irrigation
- Hydrotherapy