Integumentary Flashcards
(30 cards)
examination of a wound should include:
edema measurement
vital signs
circulation
skin integrity
skin observation/changes
risk assessment scales
pain
sensory integrity
ROM/strength
posture
gait/function/cognition
wound characteristics
wound characteristics for documentation should include:
location
size
shape
borders
edges
tunneling
undermining
wound base
peri wound area
pain
CODES acronym
color
odor
drainage
extent
surrounding skin
goals of wound care
debride necrotic tissue
control infection
balance moisture
what factors impede wound healing?
age
malnutrition
vitamin deficiencies: A, B, C
poor tissue oxygenation (PVD)
infection: osteomyelitis risk
surgical debridement
performed by drs only under anesthesia
remove viable and non viable tissue
fast and most effective way to remove, turns wound into acute wound and is necessary when an undermining wound can’t be visualized
why do we need to debride necrotic wounds?
need to evaluate the depth and tissue quality under the necrotic tissue plug to assist in healing
contraindications/precautions to surgical debridement
P: anticoagulants
C: medically unstable, lack of vascular supply
not done by PTs
sharp debridement
debride non viable tissue only with scalpel/forceps/tweezers
conservative
use sterile field
precautions and contraindications to sharps debridement
P: tunneling, undermining without visualizing edge of viable tissue
low platelets
anticoagulation
C: dry gangrene, impaired arterial flow, impaired clotting mechanism, non infected pressure ulcer
why would you not debride a non infected pressure ulcer?
necrotic plug is acting as protection preventing infection
should provide pressure relief and debride if the eschar softens or signs of infection appear
considerations for sharps debridement
pain: necrotic tissue shouldn’t feel pain, but may pull on viable tissue, monitor pt
bleeding: if pt bleeds, firm pressure for 10 minutes without checking, then use meds if still bleeding
mechanical debridement: types
soft abrasion
wet to dry
whirlpool
pulsatile lavage
negative pressure
soft abrasion debridement
use a sponge and scrub over moist necrotic tissue
can be painful
wet to dry dressing
moist gauze placed over wound, allowed to dry out over slough, pull away gauze and it takes some slough with it
may be painful if necrotic tissue is adhered
can remove viable tissue
causes bleeding, pain, drying
whirlpool therapy
submerge the wound in agitated water
lack of evidence, infection risk
precautions and contraindications to whirlpool
P: clean granulation, skin graft, venous insufficiency wounds, distal extremity edema, sensory impairment, diabetic ulcers
C: compromised CV function, infection, renal failure, impaired cognition, dry gangrene, neuropathic foot, severe arterial insufficiency, macerated tissue, incontinence
pulse lavage
pressure cleansing and debridement with vacuum to remove debris
positive pressure aids debridement and negative pressure stimulates granulation tissue
PSI for pulse lavage
5-10 PSI, don’t go over 15
indications for pulse lavage
venous, neuropathic, pressure, post surgical , infected, fasciotomy
precautions and contraindications to pulse lavage
P: insensate areas, anticoagulant therapy, wounds without full visualization
must occur in private room w closed door
negative pressure wound therapy
negative pressure over wound with vacuum pump
aid drainage removal and debridement
protection
autolytic debridement
moisture retaining dressings help the body breakdown necrotic tissue on its own
painless application
slow
rehydrate to soften eschar applied to dressing, monitor over 3 days
contraindications to autolytic debridement
dry gangrene - don’t get moist
