Wound Care Flashcards
(53 cards)
1
Q
Partial thickness wound healing
A
- steam burn, abrasion
- Re-epithelialization and regeneration
- nl skin function returns
- No scar
- Epithelial cells come from hair follicle or edge of wound
- 10-14 days
2
Q
Full thickness wound healing
A
- heal by scar tissue formation
- lose nl tissue function
- four phases:
1. Inflammation
2. Granulation/proliferation
3. Epithelialization
4. Maturation/remodeling
3
Q
Inflammation stage of full thickness wound healing
A
- First 7 days
- Provide hemostasis and clear bacteria, foreign material, dead tissue
- Can be confused with infection
4
Q
Granulation/proliferation stage of full thickness wound healing
A
- Fibroblasts synthesize collagen
- Angiogenesis infiltrates collagen
- O2 and nutrition demands are high
5
Q
Epithelialization stage of full thickness wound healing
A
- Overlaps with proliferative phase
- Continues from edges like partial thickness wounds
6
Q
Maturation/remodeling stage of full thickness wound healing
A
- May last up to 2 years
- Overlaps proliferation and epithelialization
- Reorganizes matrix collagen along lines of stress
7
Q
Intrinsic factors that affect healing
A
- General health
- Age
- Chronic disease
- Immunosuppression
- Sensory impairment (DM)
- Tissue perfusion (DM)
- Presence of necrotic tissue of foreign body (sutures)
8
Q
Extrinsic factors that affect healing
A
- Medication
- Nutrition
- Chemo/radiation
- Stress
- Infection
9
Q
Iatrogenic factors that affect healing
A
- Local ischemia
- Treatment choices (irrigation material)
- Trauma
- Extent of injury
10
Q
Partial thickness burns
- describe
A
- epidermis is burned
- Red/pink, mildly swollen
- Skin feels raw and tender
- Sunburn is MC example
11
Q
Deep partial thickness burns
- describe
A
- epidermis and dermis burned
- Blistered, swollen, moist
- Very painful
12
Q
Full thickness burn
- describe
A
- completely through dermis
- Destroy fat cells, nerve tissue, muscle
- Dry, leathery, appear dark brown, black, or dry white
- May feel no pain if nerves are burned
13
Q
Burn treatment
- overview
A
- Depends on depth and extent of damage
- Immediate care is important
- Improper care → infection, slower healing, shock
14
Q
What topical agent is usually used to treat burns
A
- silver!
- Lots of silver products
- Good option for pts with sulfa allergy
- Newer options allow fewer dressing changes
15
Q
How to treat blisters
- adults
- children
A
- Adults intact: protect, leave intact bc provide moist dressing for wound
- Adult broken: debride, easily infected with bacteria
- Peds: break intact blisters and debride, will pop anyways cause kids are crazy
16
Q
Burn treatment
- cleansing
- dressing
- chemicals
A
- Cleansing options: Shower, pressurized saline, pulsed lavage
- Dressing: Non-adherent that allows drainage
- Chemicals: Only one chemical debridement treatment remains: Santyl. Hastens the removal of slough and eschar
17
Q
How are facial burns treated differently
A
- do not use silvadene (silver): can permanently stain
- Bacitracin ointment is best
18
Q
Circumferential wounds
A
- risk for compartment syndrome, ischemic limb
- check pulses often
19
Q
Nutrition for burn care
A
- protein
- clear fluids
- multivitamin
20
Q
Burn aftercare
A
- wil be itchy!!
- Benadryl
- Cold pack
- Protect at night from scratching
- Moisturize frequently
- Liberal sunscreen!
21
Q
What is most common cause of leg ulcer
A
venous insufficiency
22
Q
Location of ulcers due to
- venous insufficiency
- arterial
A
- venous: distal 1/3 of medial leg
- arterial: Lower leg, dorsal surface, foot, malleolus, toe joints, lateral border of foot
23
Q
Venous insufficiency ulcer
- characteristics
A
- Irregular shape
- Shallow
- Mild pain (worse with standing, relieved with elevation)
- Pink/red base
- Edema
- Hemosiderin stain around edge of wound (dark)
24
Q
Venous insufficiency ulcer
- RF
A
- Prev trauma in the area
- DVT hx
- Pregnant
- Obese
- Clotting disorder
- Fam hx
- Occupation – stand a lot
25
Venous insufficiency ulcer
| - 4 steps to manage
- Clean
- Debride
- Absorb drainage
- Manage edema
26
Venous insufficiency ulcer
| - clean
* Normal saline (warmed to body temp)
| * If slough: wound cleanser with surfactant
27
Venous insufficiency ulcer
| - Debride
- Chemical
- Sharps (forceps, scissors, scalpel, curette)
- Ultrasonic (new)
28
Venous insufficiency ulcer
| - Absorb drainage
* 7 categories of dressing, gauze, alginates, hydrocolloids, carboxymethlycellulose, foams, ABD pads
* Drainage is caustic to surrounding, healthy tissue
29
Venous insufficiency ulcer
| - Manage edema
• Must check ABI prior to applying compression: >1.0, verify with transcutaneous O2 before applying compression
- Vasopneumatic pump to move fluid caudally
- External bandages
- Multi-layer compression dressings
- Circumferential measurements before and after to assess effectiveness
30
Because healing a wound doesn't treat venous insufficiency, what must occur to prevent recurrence of wound
maintain reduction of edema
31
How to reduce edema for venous insufficiency
* Forever wear support hose or circaids.
* Leg elevation 2 hr a day, 20-30 min at a time, leg higher than heart, NOT bed rest
* Exercise that activates calf muscles (use compression)
* NO smoking
* Don’t’ cross legs
* Feet and leg hygiene
* Avoid trauma
* Nutrition, low sodium
* Inspect legs/feet daily
32
Arterial ulcers
| - characteristics
* Pain, esp at rest
* Foot is cold or cool
* Weak, absent pulses
* Absence of hair growth
* Skin is shiny, dry, pale
* Thickened toenails
* Necrotic ulcers with min drainage
* ABI <0.5
* Pallor with leg elevation
* Rubor of dependency (white when elevated, red when down)
* Hx: HTN, smoking, claudication
33
Arterial ulcers
| - risk factors
* Card hx
* HTN
* High cholesterol
* Smoking
* DM
* Fam Hx
34
Arterial ulcers
| - eval of arterial flow
* Pulses: dorsalis pedis, posterior tibial, popliteal, femoral
* ABI: <0.8 → arterial compromise
* Transcutaneous O2 <30 mmhg → no healing potential
* Refer to vascular surgeon or cardiologist
35
What should NEVER be done to an arterial ulcer
debridement, will lead to further necrosis
36
Arterial ulcer
| - treatment
```
- PT to increase circulation
• Hot pack to femoral triangle
• Rooke boots, bed cradles, and other protective gear and positioning
• Antimicrobials:
• Electric stimulation
- STOP smoking!!
- If gangrene keep dry
- Wound on leg, encourage exercise to increase blood flow
```
37
Negative pressure therapy
- Wound vac
- Can be used on all kinds of wounds
- Wound must be fairly clean
- Cut foam slightly smaller than wound, do not overpack
38
Biological wound treatment
- Oasis
- Porcine small intestinal submucosa. Provides matrix for collagen to use as a framework.
- Do not remove, keep adding to it if it works
- Might produce inflammatory response but that is ok (it's not infected)
39
Cultures for wound management
- Punch biopsy is best but swab is adequate
| - Used to base topical treatment options
40
Hyperbaric oxygen
is another type of wound treatment
41
Topical commonly used
* Clobetasol
* Cyclosporin or dexamethasone
* Gentamycin
42
Why are pressure injuries important (business aspect)
* Stage III and IV are hospital acquired, won’t be paid to treat
* Inspect FULL body of patient when admitted to ensure none present. If present, document size and location
43
What can be confused with pressure injuries
* DM foot ulcers
* Skin tears and lacerations
* Maceration dt diarrhea or infection
* Arterial or venous leg ulcers
44
Pressure injuries
| - risk factors
* Pressure
* Moisture
* Friction
* Shear
* Hypotension (poor perfusion)
* Lengthy immobilization
* Poor nutrition
45
Pressure injuries
| - Common locations
```
bony prominences:
• Occiput
• Sacrum
• Ischium
• Heels
• Trochanter
• Knee
• Ankle
```
46
Describe stage 1 pressure injury
Non-blanchable erythema of intact skin
47
Describe stage 2 pressure injury
* Partial-thickness loss of skin with exposed dermis
* Wound bed is viable, moist, pink/red
* May be intact or ruptured serum-filled blister
48
Describe stage 3 pressure injury
* Full-thickness loss of skin
* Adipose is visible, granulation and rolled wound edges are often present
* Slough or eschar may be visible
* Depth depends on location
* No exposure of fascia, muscle, tendon, ligament, cartilage, bone
49
Describe stage 4 pressure injury
* Full-thickness skin and tissue loss
* Exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, bone
* Slough and eschar may be visible
50
Describe unstageable pressure injury
* Can’t evaluate dt presence of eschar or slough
| * If can’t see base of wound, is unstageable
51
Describe deep tissue pressure injury
Often seen in patients who have “been down” for a long time, injury is still evolving, not sure how bad it will be
52
Describe pressure injury d/t medical device
* New category
| * Tubes, drains, cannula, etc.
53
Describe facility acquired pressure injury
* Usually sacrum (also heels and occiput)
* Can occur in children
* Many pts have scI, spinal orthotics
* Perineal dermatitis or excoriation dt diarrhea is NOT a pressure injury but does place pt at increased risk for one
