Integumentary - Wound Management & Debridement Flashcards

Question

contraindicated | surgical debridement

Answer 1

medically unstable pt or lack of vascular supply to support healing process

Answer 2

NOT in our scope of practice

Answer 3

use scalpel, forceps, scissors, tweezers more conservative removing = beneficial for healing removes eschar and loose slough always make sure to have a sterile area

Answer 4

tunneling undermining with no visualization for the edge of viable vs non-viable tissue low platelet coount anticoagulation therapy

Answer 5

dry gangrene severely imparied arterial blood flow impaired clotting mechanism non-infected pressure ulcer on the heel

Answer 6

monitor and give pressure relief since eschar might be a protective barrier would be INDICATED if eschar is soft or signs of infection

Answer 7

no pain should be felt unless necrotic tissue adherence at borders is tight oral meds to pt 30 mins before topic analgesic can be placed in thick layer on wound - covered 15-30 min

Answer 8

minor bleeding = pressure over site min 10 min to stop it beyond 10 = silver nitrate stick to help with coagulation

Answer 9

soft abrasion wet-to-dry dressing hydrotherapy

Answer 10

advantage: - helps soften or remove tissue disadvantages: - non-selective method - can be performed incorrectly and result in trauma or pain

Answer 11

gauze sponge or swab good for moist necrotic tissue may be painful if applied over healthy granuation tissue can be daily or PRN stop if loose, moist necrotic tissue can't be seen or too dry/hard

Answer 12

anticoagulation

Answer 13

moist guaze dresing placed over the wound dressing will dry the necrotic slough removed when guazed is pulled away pre-medication might be needed

Answer 14

risk of harm to healthy tissue minimal most effective with loose slough

Answer 15

could remove granulation/"viable" tissue bleeding or pain can happen may be too drying for the wound bed time intensitive, costly

Answer 16

NOT recommended if >50% wound bed is granulation tissue anticoagulation therapy

Answer 17

dunking wound in tank filled with water

Answer 18

intensity can affect healthy tissues can't control water pressure forces gravity dependent position macerates surrounding skin possible cross contamination

Answer 19

clean, granulated wound bed new skin graft venous insuffiencient wounds distal extremity edema sensory impairement diabetic ulcers

Answer 20

compromised CV or pulm function acute infection renal failure impaired cognition dry gangrene neuropathic foot severe arterial insufficiency/ischemia already macerated tissues b&b incontinence

Answer 21

pressure cleansing and debridement of wound bed + vacuum pressure of 15 psi is MAX, removes ~ 84% of bacteria in the wound no contraindications

Answer 22

positive pressure helps with debridement negative pressure helps stimulate granulation tissue

Answer 23

venous, neuropathic, pressure, post-op, infected, fasciotomies ok for infected, necrotic or granulating wounds

Answer 24

single use only needs private room elevated limb site specific reach hard areas

Answer 25

insensate areas anticoagulation therapy wounds without full visualization

Answer 26

negative pressure right over the wound bed thru foam or guaze dressing and vacuum pump dressing sealed with protective layer

Answer 27

removing and necrotic tissue debridement + having moist wound environment

Answer 28

improve perfusion increase granuation tissue formation reduce bacterial contamination

Answer 29

moisture-retain dressing helps the body breakdown the necrotic tissue on its own

Answer 30

selective form of debridement and min skill to apply dressing and usually painless slowest debridement method and always monitor for infection

Answer 31

more effective than gauze on diabetic ulcers + increased healing rate

Answer 32

for those who can't tolerate more aggressive forms increased rehydration of a dry wound and used in conjuction with other methods

Answer 33

if infection is suspected - needs to be stopped right away - occulusive dressings are contra change in necrotic tissue not seen in 3 days - different type needed

Answer 34

dry gangrene

Answer 35

a selective form which topical agent is placed to soften wound surface - enzyme dependent on wound presentation - most effective to loosen big necrotic area - close monitor if using with an infected wound - cross hatching dry eschar increased the agent = bigger surface area

Answer 36

maceration irritation pain to periwound region

Answer 37

heavily draining wounds

Answer 38

non healing wounds or those with increased bleeding risk other methods are contra

Answer 39

biotherapy - sterile larvae from green bottle fly - no more than 10 per square cm - left in place 1-3 days

Answer 40

absorptive property for weepy wounds and turns into a gel so keeps a moist environment but absorbs excess fluids

Answer 41

have same absorptive property but do not conform to cavities

Answer 42

many forms: gels, sheets or in gauze - does not contribute to macerations of wound or peri-wound areas

Answer 43

- time for healing - pain during dressing change - frequent dressing change - costs - amount of help needed - dressing type - topical dressing - silver is most common antimicrobial agent in dressing

Integumentary - Wound Management & Debridement Flashcards

(67 cards)