wound care (M 1-9: measurements, tissue types and staging, exam, diabetes, arterial, venous) Flashcards

Question

wound healing: system factors

Answer 1

* nutrition/hydration * diabetes * peripheral vascular disease (PVD) * GERD * collagen disease * end stage renal disease (ESRD) * immunosuppression * aging * medications * social/health habits * functional status and activity level * infection * paresthesia * perfusion * incontinence

Answer 2

* psychological function - stress, memory, anxiety * hypergranulation * tobacco use * high bacterial burden * biofilms * edema * pressure/friction/shear * maceration/motion * hyperkeratosis * cellulitis * nonviable tissue * lack of growth factors * cytokines * matrixmetalloproteases (MMPs)

Answer 3

* blanchable: reddened area that turns pale under applied light pressure * non-blanchable: an area of redness that does not blanch under applied light pressure -- more concerning for pressure injuries

Answer 4

* deep tissue injury * may be darker or gray in darker skin

Answer 5

* infection or inflammation * could be cellulitis or dermatitis - raised * erythemia - flat, shiny

Answer 6

* abnormal red color * may indicate underlying infection * indicative of Stage 1 pressure injuries if over bony prominence * may be a 1st degree burn

Answer 7

* pediatric multisystem inflammatory syndrome (PMIS) -- purplish lesions on toes and feet, rash * Covid toes * Coronavirus rash

Answer 8

* bulls-eye rash: Lyme disease * rashes - drugs

Answer 9

* white: reynaud's, dully ashy/gray in darker skin * black: necrosis, gangrene * yellow: jaundice, visible in eyes (liver disease, hemolytic disease * hemosiderin staining: mostly in LEs, red/rusty brown or brownish purple, usually in gaiter area (socks), common in chronic venous insufficiency (starts distal and moves proximally

Answer 10

* petechia: small (1-2 mm; < 3 mm), red or purple spot on the skin * purpura: > 3 mm * ecchymosis: > 1 cm, commonly called a bruise * all do not blanch with pressure

Answer 11

* excess fluid in interstitial tissue * can be multi-factorial in cause * impedes healing regardless of etiology * extent and type of edema helps identify wound etiology

Answer 12

* sign of infection * result of inflammatory response in the immediate wound area

Answer 13

* can be indicative of venous insufficiency, DVT, lymphatic blockage

Answer 14

* probably more central body cause -- heart failure

Answer 15

* orange-peel texture * more chronic edema

Answer 16

* rubor - redness * fumor - swelling * calsor - heat * dolor - pain * loss of function * odor, pain, palpation, systemic changes, wound cultures

Answer 17

wounds that fail to progress through a normal, orderly, and timely sequence of repair or wounds that pass through the repair process without restoring anatomic and functional results

Answer 18

* by tissue involvement -- to determine local care: superficial/erosion, partial thickness, full thickness * by etiology -- to determine systemic care: arterial, venous insufficiency, neuropathic, pressure, atypical

Answer 19

* when did the wound begin * how did the wound begin -- trauma, falls, bites * other s/s -- fever, itching, pain * treatments already tried * allergies relevant -- latex, sulfa, adhesives * tobacco, alcohol, drugs

Answer 20

* dimension/extensions * tissue type * staging * wound bed color * drainage * wound edges

Answer 21

* **methods** * perpendicular: widest points x widest points * clock: 12 at head * volumetric: how much saline can you put in * tracing * photography * typically documented as: length (cm) x width (cm) x depth (cm)

Answer 22

* tunneling/sinus tract: narrow passage of tissue destruction within the wound * undermining: destruction of the conenctive tissue between teh dermis and subcutaneous tissue -- extends under the intact skin along the periphery of a wound * fistula: tunneling that connects with a body cavity

Answer 23

* skin is rubbed/scraped * usually not much bleeding * heals fairly quickly * ex: road rash

Answer 24

* partial or complete tearing away of skin/tissue * bleeds heavily and rapidly * ex: violent accidents, crush accidents, explosions, gunshots

Answer 25

* small hole caused by pointy object * may not bleed much, can damage organs * ex: nail, bullet, needle

Answer 26

* deep cut or tearing of skin * bleeding can be rapid and extensive * ex: knives, tools, machinery

Answer 27

* red, "beefy" looking * result of angiogenesis -- formation of new blood vessels * composed of new capillaries and ECM * varies in color from anemic (pale pink) to bright red * necessary for closure by secondary intention or for split thickness skin grafts * carefully protected in good wound management

Answer 28

* softer, lighter necrotic debris * normal by-product of autolysis * usually seen beneath eschar (black) * more common in the inflammatory phase of healing * differs from adhered connective tissue in that it is soft and mushy, sometimes hard to grasp with forceps * yellowish

Answer 29

* composed of dead cells and fibrin * may be dry and hard or soft and rubbery, leathery * may be dry gangrene or wet gangrene -- wet is infections * can be burn, fungal infectoin, bug bites * can let it be until infected * gangrene generally in hands and feet

Answer 30

* striated * reddish when healthy -- brownish-gray when devitalized * sensate when healthy -- painful when exposed * may see movement if you ask pt to move

Answer 31

* shiny and stringy when healthy -- becomes dull and dry when devitalized/necrotic * covered with a fibrous sheath of connective tissue containing synovial fluid or fatty fluid (paratenon) * may see movement if you ask patient to move

Answer 32

* tan in color -- dark brown when necrotic, can soften (osteomyolitis) * hard to palpation with metal instrument * covered with periosteum when healthy -- has to be debrided if necrotic

Answer 33

* shiny, yellow-white globules when healthy -- shriveled and dry when devitalized * poorly vascularized -- challenging to heal * frequent sources of abscess formation

Answer 34

* erosion: loss of epidermis only (abrasion) * partial thickness: loss of epidermis and part of dermis * full thickness: loss of all epidermis, dermis, and into subcutaneous tissue | NOT pressure injuries -- classification of skin loss

Answer 35

* erosion: loss of epidermis only (abrasion) * partial thickness: loss of epidermis and part of dermis * full thickness: loss of all epidermis, dermis, and into subcutaneous tissue | NOT pressure injuries -- classification of skin loss

Answer 36

* stage 1: warm to touch, no breaks or tears in skin * stage 2: no slough, can look like blister, partial thickness * stage 3: full thickness but no muscle, tendon, or bone; can see tunneling and fat * stage 4: full thickness with muscle, bone, tendon; do see tunneling and undermining, can see eschar and slough * unstageable: cannot see full depth of wound due to eschar or slough in the way

Answer 37

* looks like bad bruise * mushy, boggy, non-blanchable * may be intact or not * from high presure, prolonged pressure, sheer forces * often open as stage 3 or 4 pressure injuries * common over greater trochanter, sacrum, heels -- but can be over any bony prominence * ex: elderly patient who fell and was down for a long time until found

Answer 38

black -- eschar

Answer 39

1. sanguineous: thin, bright red 2. serosanguinous: thin, watery, pale red to pink 3. serous: thin, watery, clear 4. purulent: thick or thin, opaque tan to yellow 5. foul purulent: thick opaque yellow to green with offensive odor

Answer 40

* none: wound tissues dry * scant: wound tissues moist, no measurable drainage * small: wound tissues very moist, drainage <25% dressing * moderate: wound tissues wet, drainage involves 25-75% dressing * large: wound tissues fill with fluid, involves >75% dressing

Answer 41

* type of wound or healing process occurring within a wound bed

Answer 42

arterial wounds

Answer 43

* venous wounds * may occur as wound epithelializes

Answer 44

* sign of halted healing process * cells are termed senescent, meaning they are unable to reproduce * rolled edge is termed epibole

Answer 45

* overdevelopment of the horny layer of the skin * appears as thickened skin around the edge of a wound or as a callus

Answer 46

* too much moisture on skin for too long * can slow healing process * creates high risk for infection and/or wound becoming larger

Answer 47

* wound edges come apart * may be superficial layers only * or can open full depth

Answer 48

* deep pain: cramping, indicative of ischemia or hypoxia, more comfortable in dependent position * throbbing, localized pain: indicative of infection, deep pain that increases with pressure may be indicative of osteomyelitis * superficial tenderness: exposed nerve endings, may be accompanied by sharp shooting pains * pain with stimulation of red tissue: living muscle

Answer 49

* pulses: use grading scale, compare side to side/above and below * doppler: for pulses that are not palpable * ABI: ankle brachial index

Answer 50

* local signs of infection: pus, change in color or character of exudates, redness, induration, changes in wound odor * systemic signs of infection: fever, leukocytosis * suddenly elevated glucose * pain in neuropathic extremity * lack of healing after 2 seeks in a clean wound despite optimal care

Answer 51

* debridement * infection/inflammation * moisture balance * edges * support services

Answer 52

* 25.8 million children and adults in US (8.3% of population) * up to 14.5% in ethnic groups * 15% of people with DM will have wounds: 14-24% of those with diabetic ulcers will ultimately have an amputation * mortality following amputationincreases with level of amputation and range from 50-68% at 5 years * hyperglycemia can lead to stiffer blood vessels: leads to reduced tissue oxygenation, more difficult healing, more likely to get a wound

Answer 53

* **neuropathy**: diabetic peipheral neuropathy * type I: after 20 years of disease duration, at least 20% of people have DPN * type II: after 10 years of disease duration, 50% of people have DPN (more likely) * **sensory**: decreased sensation, vibration, proprioception, loss of reflexes (distal to proximal) -- impacts longer nerve fibers * experience neuropathic pain: gabapentin * **motor**: progressive weakness and atrophy * **autonomic**: decreases sweat and oil production: leads to dry, inelastic skin * heart and vasculature: orthostasis and silent MI * GI tract: gastroparesis, diarrhea * neuropathy/DPN: most common complication of DM type I and II * testing should involve neuromuscular assessment

Answer 54

* for protective sensation

Answer 55

* more sensitive than monofilament testing * 128 Hz tuning fork * clanging tuning fork test * 4s - 100% sensitive for sensory loss: monofilament testing 76% sensitive

Answer 56

* Charcot's disease: neuropathic arthropathy -- progressive degeneration of weight-bearing joints, increase risk of skin breakdown * due to abnormal pressure distribution * combined with DPN -- increased wound risk

Answer 57

* ulceration (often painless): can lead to amputation * neuropathic edema * charcot arthropathy * callus formation: wound can develop under callus

Answer 58

* nearly 1/3 of patients with DM have some type of dermatologic manifestation * up to 50% of patients with type 2 DM are at an increased risk of developing skin infections * related to: poor glucose control, abnormal carbohydrate metabolism, artherosclerosis (4x more likely in pts with DM), microangiopathic changes, neuro degneration, pharmacological therapy for DM (use of insulin) * diabetic thick skin: loss of elasticity, commonly with shiny appearance, can lead to limited joint mobility and contractures, more common in hands and fingers, usually dorsum, overall thickening * diabetic yellow skin: yellow nails and skin discoloration, usually on palms of hands or soles of feet

Answer 59

* nearly 1/3 of patients with DM have some type of dermatologic manifestation * up to 50% of patients with type 2 DM are at an increased risk of developing skin infections * related to: poor glucose control, abnormal carbohydrate metabolism, artherosclerosis (4x more likely in pts with DM), microangiopathic changes, neuro degneration, pharmacological therapy for DM (use of insulin) * diabetic thick skin: loss of elasticity, commonly with shiny appearance, can lead to limited joint mobility and contractures, more common in hands and fingers, usually dorsum, overall thickening

Answer 60

* **diabetic yellow skin**: yellow nails and skin discoloration, usually on palms of hands or soles of feet * **diabetic dermopathy**: most common cutaneous change, present in 30-60% of patients with DM, usually seen in men > 50 YO * presents as round/oval atrophic, hyperpigmented raised lesions, usually on pretibial area of LEs * **xerosis**: 75-82% had dryness of the skin with fissures/cracks, most common on heels and feet, increased risk of infection * **acanthosis nigricans**: development of dark, thick, velvety skin in body folds and creases, can indicate benign and malignant conditions, common in axilla, groin, posterior neck * **acquired perforating dermatosis**: large papules with central keratin plugs, usually on LEs * **vitiligo**: progressive, 1-7% of pts with DM * **nail changes**: thickening, yellowing, red/borwn/black discoloration, green, whitening of entire nail or transverse white bands, toenail deformities

Answer 61

* lipoatrophy: occurs within 6-24 months of starting treatment, most common in children and women * lipohypertrophy: resemble lipoma * both though to be related to repeat injection sites

Answer 62

* present for at least 6 weeks * characteristics: necrotic tissue, bioburden, chornic inflammation, impaired hemodynamics, senescent fibroblasts and keratinocytes, chronic wound fluid with growth inhibiting proteases, overgrowth of epithelium with lack of underlying connective tissue (epibole)

Answer 63

* arterial: ischemia, micro or macro vascular disease, smoking * venous insufficiency: DVT, recent surgery, ankle fusion, prolonged standing, pregnancy, congestive heart failure * neuropathic/diabetic: diabetes, PVD, Hansen's disease * pressure: pressure or shear, immobility, moisture, decreased sensation, poor nutrition

Answer 64

* occur on the foot, usually on plantar surface or toes * caused by mechanical forces or minor trauma * occur in patients wit hdiabetes or PVD, Hansen's disease, spina bifida, lupus, toxic syndromes, Chacot-Marie-Tooth * patients typically have sensory, autonomic, and motor neuropathies

Answer 65

* caused by ischemia * usually located at the peripheral extremities * caused by macro- or microvascular disease * macro: obstruction of the larger named arteries by PAOD, emobolus, thrombus, trauma * micro: disease of the small unnamed arterioles and capillaries, usually associated with diabetes or small emobli

Answer 66

critical phases 1. collateral circulation insufficient for metabolic needs: shunting of blood to muscles where there is less resistance, delayed healing of traumatic wounds 2. claudication: pain with activity: can be effectively treated with exercise (thigh and buttock claudication - aortoiliac or iliac involvement, calf claudication - femoral or popliteal involvement 3. rest pain: requires revascularization surgery, may be accompanied by signs of ischemia at distal digits

Answer 67

* ABI: diminished * pulses: diminished * capillary refill time: > 3s * buergers test: elevation and rubor of dependency * skin appearance: shiny, thin, pale, no hair growth * conditoin of nails and hair * location: distal toes or fingers * wound edges: even, punched out appearance * wound tissue: dry, necrotic, little or no granulation

Answer 68

* relate to 70% of LE wounds * 500,000-1,000,000 in UE * 40% occur before age of 50 * recurrence rate is as high as 72% * estimated cost of care is $40k/case * superficial veins: great saphenous, small saphenous, perforator veins, lymphatic system * deep veins: femoral, popliteal

Answer 69

causes * reflux as a result of incompetent valves in the perforator, superficial, or deep veins * obstruction: e.g. chronic deep vein thrombosis * lack of venous pump activation during gait cycle * results in venous hypertension and excessive moisture in the interstitial tissue * prevents adequate oxygen and nutrients from reaching the skin

Answer 70

* vessel dilation and elongation * increased collagen deposition in both vein walls and skin * plasma protein leaks into interstitial space with resulting fibrin cuff around arterioles * increased inflammatory cells resulting in tissue remodeling and dermal fibrosis

Answer 71

* history of DVT (37%) * history of hip/knee/calf surgery * ankle hypomobility/fusion * employment involving prolonged standing * morbid obesity * pregnancy * heart failure * progression: heavy, aching feeling in legs, telegentsia or reticular veins, varicose veins, edema without ulceration, skin changes without ulceration, skin changes with ulceration

Answer 72

* hyperpigmentation (hemosiderin) * lipodermatosclerosis * dilated long saphenous vein * atrophie blanche * unilateral or bilateral edema * dermatitis * thickened skin * cellulitis * located in gaiter area

Answer 73

* presenation isn't clean for one or the other * ABI is gold standard test to determine * ABI 0.6-0.8 is "mixed ulcer * accounts for approximately 10% of LE ulcers * origin primarily due to chronic venous insufficiency with poor healing, with coexisting arterial insufficiency * pathophysiology: typically a combination of venous HTN, primary or post-thrombotic venous reflux and/or obstruction, and reduction in blood inflow due to PAOD

wound care (M 1-9: measurements, tissue types and staging, exam, diabetes, arterial, venous) Flashcards

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