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Integ - wounds Flashcards

(62 cards)

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1
Q

6 things to document regarding a wound

A

-location
-size
-shape/borders
-edges
-tunneling
-undermining

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2
Q

serous drainage (color, thickness, healing phase)

A

-clear, light
-thin, watery
-inflam and proliferative

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3
Q

sanguineous (color, thickness, healing phase)

A

-red
-thin, watery
-inflam and proliferative

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4
Q

serosanguineous (color, thickness, healing phase)

A

-clear or slight red/pink
-thin, watery
-inflam and proliferative

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5
Q

seropurulent (color, thickness, healing phase)

A

-cloudy, opaque, yellow/tan
-thin, watery
-early warning of infect (abnorm)

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6
Q

purulent (color, thickness, healing phase)

A

-yellow, green
-thick
-wound infect (abnormal)

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7
Q

2 abnormal drainage types

A

seropurulent and purulent

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8
Q

what does CODES stand for

A

color
odor
drainage
extent
Surrounding

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9
Q

3 key wound mgt principles

A

-debride necrotic tissue
-control infect
-balance moisture

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10
Q

4 things that impede wound healing

A

-age
-nutrition
-poor tissue oxygenation
-infection

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11
Q

5 hallmark symptoms of poor perfusion

A

-pain
-pallor
-paresthesia
-pulselessness
-paralysis

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12
Q

what is the most accurate dx imaging for osteomyelitis? gold standard?

A

MRI

bone biopsy

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13
Q

what are 2 ways to perform surgical debridement

A

-operating room under anesthesia
-removal viable/non-viable w/ sharp instruments

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14
Q

when is surgical debridement required

A

when undermining can’t be seen

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15
Q

extreme caution for surgical debridement

A

anticoags

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16
Q

2 contraindications for surgical debridement

A

medically unstable OR lack vascular supply to support healing

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17
Q

3 healthcare professionals that can perform surgical debridement

A

physician, podiatrist, certified PA

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18
Q

what type of tissue involved with sharp debridement

A

non-viable

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19
Q

what 2 type of specific tissue removed with sharp debridement

A

eschar and loose slough

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20
Q

what needs to happen BEFORE wound re-dressing during sharp debridement

A

remove sterile gloves and soiled debridement field

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21
Q

6 main cautions for sharp debridement

A

-tunneling
-undermining w/ no visualization for edge
-low platelet count
-anticoag therapy
-pain
-bleeding

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22
Q

how long pressure for minor bleeding

A

10 min

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23
Q

4 main contraindications for sharp debridement

A

-dry gangrene
-severely impaired arterial BF
-impaired clotting
-non-infected pressure ulcer on heel

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24
Q

5 types of mechanical debridement

A

-soft abrasion
-wet to dry dressing
-hydrotherapy/whirpool
-pulsatile lavage w/ suction
-negative debridement

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25
what is precaution for soft abrasion
anticoag therapy
26
what is soft abrasion
removal of dead tissue using soft material, such as gauze sponge or swab
27
what type of tissue is soft abrasion good for
moist necrotic tissue
28
when to discontinue soft abrasion
if loose, moist necrotic tissue no longer visible or tissue becomes dry/hard
29
what is wet to dry dressing
moist gauze on wound, dressing dries, remove gauze
30
6 disadvantages of wet to dry dressing
-could remove granulation tissue -bleeding -pain -too drying for wound bed -time intensive -costly
31
2 advantages of wet to dry dressing
-risk harming healthy tissue minimal -most effective w/ loose slough
32
2 cautions for wet to dry dressing
not recommended when >50% wound bed granulation anticoag therapy
33
5 disadvantages of hydrotherapy/whirlpool
-intensity of agitation may impede -unable to control water pressure forces -gravity dependent pos -macerates surrounding skin -potential cross contamination
34
6 precautions for hydrotherapy/whirlpool
-clean, granulated wound bed -new skin graft -venous insuff wounds -distal extremity edema -sensory impairment -diabetic ulcers
35
9 contraindications for hydrotherapy/whirpool
-compromised CV or pulm fxn -acute infect -renal failure -impaired cog -dry gangrene -neuropathic ft -severe arterial insuff/ischemia -macerated tissue -incontinence
36
what does + pressure do in pulsatile lavage w/ suction
aids in debridement
37
what does - pressure do in pulsative lavage w/ suction
helps stimulate granulation tissue
38
what is the maximum pressure for pulsatile lavage w/ suction
15 psi
39
what % of bacteria is removed with pulsatile lavage w/ suction
84%
40
6 wounds/indications for pulsatile lavage w/ suction
-venous -neuropathic -pressure -post op -infected -fasciotomies
41
what 3 types of wounds are okay for pulsatile lavage w/ suction
infected, necrotic, granulating
42
contraindications for pulsatile w/ lavage
no known
43
3 precautions with pulsatile w/ lavage
-insensate areas -anticoag therapy -wounds w/o full visualization
44
what is negative debridement
negative pressure over wound through foam or gauze and vacuum pump
45
purpose of negative debridement
helps with drainage removal and necrotic tissued debridement while keep moist environment
46
3 benefits of negative debridement
-improves perfusion -enhances granulation -reduces bacterial contamination
47
advantage of mechanical debridement
softens or removes tissue
48
2 disadvantages of mechanical debridement
-non selective method -can be incorrectly and result in trauma or pain
49
what is autolytic debridement
moisture retaining dressing helps body breakdown necrotic tissue on own
50
when should you use a different mode of dressing when using an autolytic debridement
3 days
51
what is a contraindication for autolytic debridement
dry gangrene
52
3 indications for autolytic
-anticoag -can't tolerate other forms -med stable
53
3 indications for alginates
-pack into wound to absorb exudate -mod to lg exudate -used w/ or w/o wound infection
54
when to change alginate
when exudate leaking or every 3 days
55
when to change foam
when exudate is leaking or at least every 5 days
56
what are hydrogels
solid sheets or in gauze bandage, absorption varies
57
4 indications for hydrogel
-necrosis and slough -burns -tissue damage from radiation -sheet form used on partial-thickness ulcers
58
what type of wound should hydrogel not be used on
infected ulcers
59
how often should hydrogel be changed
1-2 days
60
what is hydrocolloid
adhesive wafer handles exudate, changes to gel
61
4 indications for hydrocolloid
-autolytic debridement -mild exudate -maintains moist environment -non adhesive, conforms, minimal pain, com
62
when to not use hydrocolloids
infection or tunneling

546 (11 decks)

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