Wound Care Flashcards

Question

Maturation and remodleing

Answer 1

Granular tissue laid down in the proliferative phase must be strengthened and reorganized. - This is called scarring - This process can take up to 2 years - Most change occurs in the first 6 months - A scar that is pink is still remodeling - A flesh color is finished Opportunity to affect the scar

Answer 2

Occurs with any wound - hope to see it soften and flatten after a few weeks - redness is normal - vascularity decreases by 6 months to 2 years A scar that is thickening is referred to by many as hypertrophic. Excessive scaring - raised and outside the boarders of the wound is keloid, some don't differentiate between hypertrophy and keloid

Answer 3

Genetics Race Depth of burn or injury Infection Length of time to heal

Answer 4

Desensitization - C fibers which carry pain can be overridden by stimulating the large A fibers. * pressure, rubbing, vibrations, TENS, motion, and function * typically 10 minute sessions at level of irritation 4-5x a day Scar management - pressure * wraps *elastomers *Jobst - massage - modalities *iontophoresis Surgery - extremes - problems

Answer 5

Stage I: a reddened area on the skin that, when pressed, is "nonblanchable." This indicates that a pressure ulcer is starting to develop Stage II: the skin blisters or forms an open sore; the area around the sore may be red and irritated Stage III: the skin breakdown now looks like a crater where there is damage to the tissue below the skin Stage IV: the pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints Stage V: full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed

Answer 6

Circulation Sensation Mechanical stress Age Nutrition Comorbidities Medication Behaviors - alcohol use - smoking

Answer 7

Sunburn, brief flash burn, brief chemical or heat burn Effects epidermis only Painful, no blisters, only redness Healing: 3-7 days No scarring likely

Answer 8

Severe sunburn, contact with stove, prolonged exposure to chemical or heat Affects epidermis and dermis Redness, wet, blisters, painful Healing: 2 weeks Minimal chance of scarring, usually only if prolonged or infected Must pop blisters if: - the fluid isn't clear - it's on a joint - it significantly impacts function

Answer 9

Prolonged exposure to heat or strong chemicals Epidermis and most of dermis, but enough to heal Redness, painful, large blisters, often pop up to to shear size Typically heal in 2-3 weeks Can convert to full thickness if infection occurs Likelihood of scarring increases, lack of use, contractures and deformities

Answer 10

Extreme heat, prolonged heat Damage through epidermis and dermis, no viable skin under Not painful due to damaged nerve endings, but surround tissue (2nd and 1st degree burns) will be painful Pale in color, nonblanching, dry, black in some cases Requires surgery (grafting) if over 3x3 (silver dollar) Scarring very likely Grafting most likely

Answer 11

Processed pig

Answer 12

From the person Only permanent graft

Answer 13

to help prevent dehydration

Answer 14

usually small areas

Answer 15

Rotational/ free Pedicled

Answer 16

Very expensive and thin

Answer 17

Loss of oxygen

Answer 18

Standard tape measure - cheapest, least effective Gulick Volameter - most expensive, most effective, water displacement Standard tape measure and Gulick are circumferential measurements Can use figure 8 for hand measurement

Answer 19

How did the wound occur? Location of the wound Size of the wound - Direct measurement * length x width = wound surface * depth * always measure in CM * sterilize or dispose - Wound tracing - Photograph

Answer 20

Primary closure - stitches, staples, or steri strips * internal, external, or dissolvable - edges are approximated - deep wounds Z plasty - dupytren's contractures Secondary closure - left open - shallow wounds - infected - surgical preference Tertiary intention - delayed primary - usually surgical wounds or deep lacerations

Answer 21

Wound must be probed to determine if there is any - tunneling: small tunnel due to a break down in tissue - undermining: small opening leading to a large area Both may require packing - pack too tightly is will stop the healing - gauze - hydrogel Measure with probe

Answer 22

Pink or red and granular Pale or faded and granular Slough - yellow gunk Eschar Describe any exposed structures

Answer 23

Defined edges Granular tissue around edges with majority of wound covered with disconnected eschar

Answer 24

Indistinct Distinct or well defined Scarring or rolled edges (epibole) - won't heal ADD PICTURES

Answer 25

Skin rotting To help with this: - adjust bandage - remove topical agent - skin barrier ADD PICTURE

Answer 26

The yellow center Tissue that's beginning to be a problem ADD PICTURE

Answer 27

Excudate - anything coming out of the wound Consistency - thick or thin Amount: - none - minimal: 1 pad/day - moderate: 2 pads/day - copious: 3+ pads/day

Answer 28

Serous - clear or pale yellow Sanguinous - light pink Hemorrhagic - produces blood Purulent or pus - by itself may not be infection - yellow; sterile, noninfected; accumulation of dead cells Pseudomonas - blue/green

Answer 29

When describing: present or absent Odor can be linked to infection, but may also be - body odor - dirty bandage - bandage and topical solution - proteus infection: smells like ammonia - pseudomonas infection: sickly sweet

Answer 30

Inflammation - Rubor (color) * well defined boarders, redness is ok * proportionate to size and extent of wound - Calor (temp) * wam around the wound - Tumor (edema) * mild, proportionate to size of wound - Functio laesa (function) * temporary in affected area - Drainage * thin, serous or serosanguinous Infection - Rubor * poorly defined boarders - "runners" * redness is beyond extend of injury * streaks - Calor * warm away from wound * fever - Tumor * extensive and excessive - Functio laesa * malaise * pt feels sick * extreme pain - Drainage * copious amounts * thick, purulent, or creamy * white, yellow, green, or blue * distinctive odor

Answer 31

Decrease risk of infection Increase effectiveness of topical agents Improve activity of leukocytes Decrease the energy required by the body for wound healing Shorten the inflammatory phase Decrease odor

Answer 32

If there is necrotic tissue or purulent tissue Foreign material Scabs Blisters Residual topical agents

Answer 33

Healthy, red granular tissue Very deep, surgical Massive infection - gangrene

Answer 34

Sharp - forceps, scissors, and scalpel (license issues) - serial (forceps and scissors) * only remove what is willing to go with you * bleeding and pain should be minimal - selective sharp (scalpel) Autolytic - using the body - no necrosis or infection Enzymatic Leaches Maggots

Answer 35

Pressure irrigation/ pulsed lavage Whirlpool - 92º Scrubbing Wet to dry dressing

Answer 36

Infection of the cellulite Often occurs with small injuries, but can occur with major injuries too

Answer 37

Prevent dryness Promote healing Keep moist Growth factor

Answer 38

No microbes left Prolonged soaking or autoclave Kept in sterile field Sterile gloves Standard for surgical setting, burns, and fragile wounds

Answer 39

Significantly reduces number of microbes Anything that touches the client is sterile Gloves, table, etc. are not Now the standard for most wound care

Answer 40

Decrease pain Keep wound at proper temperature Barrier to outside microbes Keep good microbes in Fill in dead space (packing) Debridement - wet to dry dressing

Answer 41

Wet to dry Damp to damp Occlusive – tent over wound that doesn’t let anything in or out Absorbent gauze Nonabsorbent gauze (nonstick) Impregnated gauze – usually a Vaseline product is in it Semipereable Hydrogels Foams Alginates Rigid

Answer 42

Firm to hold in place the dressing Should not cut of circulation or cause edema Be cautious of tape Don’t limit AROM Special types - Fingers, feet, faces - Applicators Cylindrical wrap distal to proximal With all dressings, bandages, etc - In most cases, less is more

Answer 43

Whirlpool/hubbard tanks/showering Pulsed lavage Nutrition-protein Estim Ultrasound Barrier

Answer 44

O2-hyperbaric chamber Exercise within pain free parameters increases circulation WoundVac pumps - Negative pressure wound therapy Ultraviolet - Promise for venous insufficiency-needs more research Laser-also needs more research Attitude - Positive attitude, prayer

Answer 45

Typically, 8-14 days There will be a knot Pull the knot up and cut one side Pull other side

Answer 46

When they let go, it’s time to remove Or if the edges are approximated

Answer 47

Use a staple pull Slide under Squeeze Staple will pop up Don’t pull Do one at a time Water and removal - Stitches and Staples - Safe to submerge and get dirty, 24-48 hours after removal

Answer 48

Do not disturb Don’t allow skin to stick Daily cleaning - Hydrogen peroxide Cover as needed for protection Watch activities that will endanger - Wood working etc Cover during ADL’s as appropriate

Answer 49

1. Have all equipment and supplies close by 2. Position pt so they are comfortable and you can see wound bed 3. Explain what you are doing to pt 4. Wash hands and put on gloves (clean or sterile depending on technique) 5. Remove old bandage - dispose as indicated - adhesive bandages: stretch longitudinally to break seal - remove adhered gauze by soaking with saline, unless wet to dry 6. Remove gloves 7. Open any packages you will need 8. Put on clean gloves 9. Inspect the wound, rinse as needed with saline, do any interventions - debridement - modalities 10. Note any changes in the wound once you are done - decreased size - pain - smell - tissue removed 11. Apply - nothing - topical agent - skin sealant or moisture barrier 12. Remove soiled gloves 13. Apply new gloves 14. Apply bandage 15. Remove gloves 16. Many places initial and date the new bandage 17. Wash hands 18. Educate pt 19. Document

Answer 50

Red bag anything with fluids Remove gloves inside out Clean work areas Sterilize instruments

Answer 51

Debride only necrotic tissue Protect the bed

Answer 52

Absorb moisture from wet bed - gauze, semipermeable Keep covered

Answer 53

Add moisture - use product Avoid toxic agents

Answer 54

Lightly fill cavity, check for undermining and tunnels

Answer 55

Prevent it Keep it covered Use universal precautions Use sterile technique Contact physician

Answer 56

Moisturize if dry, skin sealant if maceration

Answer 57

Modalities, growth factors, nutrition, activity

Answer 58

Pick what comes with you

Answer 59

Selective of nonselective debridement as indicated

Wound Care Flashcards

(86 cards)