Wound Management Ch. 6 Flashcards Preview

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Flashcards in Wound Management Ch. 6 Deck (170):
1

Localized collection of pus within body tissues.

Abscess

2

Bacteria that require oxygen to survive.

Aerobes

3

Bacteria that cannot survive in an oxygen-
rich environment.

Anaerobes

4

Type of antimicrobial that is effective against bacteria.

Antibacterial

5

Oral or intravenously delivered sub- stance that destroys or inhibits the growth of microorganisms.

Antibiotics

6

Type of antimicrobial that destroys yeasts and molds.

Antifungal

7

Substance that destroys or inhibits the growth of microorganisms.

Antimicrobial

8

Antimicrobial designed to reduce bacterial contamination on intact skin.

Antiseptic

9

Antimicrobial agent that is capable of killing bacteria.

Bactericidal

10

Antimicrobial agent that inhibits bacterial cell growth.

Bacteriostatic

11

Communities of microorganisms that are attached to a wound surface and encased with a glycocalyx.

Biofilms

12

Infection control procedure de- signed to reduce the number of microbes present and decrease the risk of infection.

Clean technique

13

Normal presence of a small number
of microbes (i.e., ... less than or equal to 10e3 organisms/gram of tissue).

Colonization

14

A cascade of proteins produced by the body that enhance the body’s defense
against pathogens.

Complement system

15

Presence or anticipated presence of
blood, wound fluid, or other potentially infectious
waste.

Contamination

16

Point at which increasing wound bioburden begins to adversely affect wound healing.

Critical colonization

17

To clean a surface with an antimicrobial.

Disinfect

18

Method of identifying wound infection in which a physician uses a needle to remove 1.0 mL of fluid from the wound area for analysis.

Fluid aspiration

19

Organisms which are not stained by
crystal violet but are stained by safranin.

Gram-negative

20

Organisms which are stained by crystal
violet.

Gram-positive

21

Invasion and multiplication of microorganisms within body tissues;

wound culture reveals
greater than 10e5 microbes per gram of tissue.

Infection

22

Methicillin-resistant Staphylococcus aureus.

MRSA

23

An infection that is acquired while hospitalized.

Nosocomial infection

24

(Property of) a bacteria that cannot be killed by a certain antimicrobial.??

Resistance

25

A bacteria that cannot be killed by a certain antimicrobial.

Resistant

26

If a bacteria can be killed by a certain antimicrobial.

Sensitive

27

Type of infection control that includes universal precautions, hand washing, and personal protective equipment.

Standard precautions

28

Method of infection control that uses only sterile equipments.

Sterile technique

29

Procedure that destroys all microbes from the area of interest.

Sterilization

30

Methods to identify and quantify microbes present in a wound.

Swab cultures

31

Procedure in which a physician removes a sample of living tissue from the wound to identify infection.

Tissue biopsy

32

Type of infection control in
which all blood and body fluids are considered to be
contaminated.

Universal precautions

33

Vancomycin-resistant Enterococci.

VRE

34

Normal skin microflora include: Staphylococcus, Microboccus, Peptococcus, Streptococcus, Acinetobacter, and yeast.3, 7 Intact skin may be contami- nated with a bacterial count of up to 103 microbes per gram of tissue without any adverse tissue reaction within an individual.

Staphylococcus,
Microboccus,
Peptococcus,
Streptococcus,
Acinetobacter
yeast.

35

Intact skin may be contaminated with a bacterial count of up to ______ microbes per gram of tissue without any adverse tissue reaction within an individual.

10e3

36

The skin’s normal pH of ______ creates a slightly acidic environment, discouraging microbial growth

5.5

37

layers of ______ and _______ present in the skin form a protective barrier against microbial invasion

epithelial cells; lipids

38

_______ are proteins made by virally infected host cells and some lymphocytes. These proteins are then secreted and used by nearby cells to manufacture protective proteins, which then help block viral repro- duction and mobilize the immune system

Interferons

39

??

opsonization

40

_____ ________ occurs if the microflora adhere to the body’s surface and replicate, forming colonies, but do not adversely affect the individual or cause a host response.

Wound colonization

41

________ ____________ is the theoretical turning point at which the increasing number of bacteria becomes a bioburden and adversely affects the individua

Critical colonization

42

Wound ________ occurs when microorganisms multiply and invade viable body tissues.

infection

43

True or False:

While contamination and colonization are normal occurrences, critical colonization and infection are not

True

44

Infection is best represented as part of a continuum which includes (3 factors):

- While wound infection generally does correlate with 10e5 microbes per gram of tissue bacterial quantity is only one of three key pieces required

- certain types of bacteria are more detrimental than others and their mere presence in any quantity is deemed worthy of intervention for infection (e.g. Streptococcus)

- the host’s resistance to the invading organism must also be considered

45

High concentrations of microbes adversely affect the host in what four ways?

1) the microbes compete with host cells for available oxygen and nutrients.

2) bacterial exotoxins, proteins released from gram-positive and gram-negative bacteria during growth, may be cytotoxic, inactivating or modifying host cell processes and ultimately resulting in host cell dysfunction or death.

3) bacterial endotoxins, molecules within the walls of certain types of bacteria (gram-negative bacte- ria), may activate host inflammatory processes, increasing production of matrix metalloproteases (MMPs) and inducing changes such as fever, bleeding, and clotting

4) wound infections delay, and may even prevent, wound healing

46

Besides an overt open wound, skin integrity may also be compromised by:

- dry and cracked skin
- callus
- maceration
- Additionally, the skin may be stripped of its natural lipids or stratum corneum by harsh soaps or strong adhesives.

47

Wound healing =

((number of bacteria + bacterial virulence) + (interaction between microbes)) / (host resistance + modifying factors)

48

Factors predisposing individuals with open wounds to infection can be divided into two categories:

host characteristics and local factors

49

Individuals with an increased risk of infection include persons with:

diabetes, malnutrition, or obesity; steroid users; immunocompromised individuals; and older adults

50

local factors increasing the risk of wound infection include:

ischemia, presence of necrotic tissue or foreign debris within the wound bed (including dressing residue such as gauze), and chronic wounds

51

True or False:

It is not possible to objectively quantify these clinical signs (rubor, calor, tumor, dolor, and functio laesa) to definitively diagnose a wound infection.

True

- However, if the wound is infected, these signs are typically excessive or disproportionate to the size and extent of integumentary damage due to the increas- ing wound bioburden.

- A decline in wound status despite appropriate care is an additional clue that infection may be present.

52

True or False

Bacteria do not invade host tissues in critically colonized wounds, these wounds will not demonstrate the typical signs and symptoms of infection.

True

- A decline in wound status may be the only indicator of heavy bioburden.

53

An inflamed wound has a well-defined erythemal bor- der, and the amount of erythema is proportional to the size and extent of the wound. In contrast, an infected wound...

...has a poorly defined erythemal border, and the amount of erythema is disproportionate to the size and extent of the wound.

54

An inflamed wound will have a localized increase in temperature. In patients with infected wounds...

...this response will be magnified and warmth will extend farther away from the site of injury. They may also present with a systemic increase in temperature (i.e., a fever).

55

Inflamed wounds have a small amount of edema that is proportional to the size and extent of the wound. In infected wounds, the amount of swelling...

...is disproportionate to the size and extent of the wound. In addition, tissue around the wound may be indurated

56

Infection-related edema is confined to the wounded area, has a rapid onset, and occurs in conjunction with other signs of infection. In contrast, edema related to congestive heart failure is...

...bilateral and appears first, and is more severe in the lower extremities.

57

The edema of venous insufficiency or mild lymphatic dysfunction is less severe upon first rising in the morning and generally increases...

...with dependency

58

Edema due to lymphatic dysfunction is generally...

...of slower onset and may be bilateral, or may present after surgical trauma (e.g., surgical removal of lymph nodes during a mastectomy or radiation to the axilla).

59

Inflamed wounds may be painful. However, an increase in pain level...

...is consistent with wound infection. In patients who are immunocompromised, the only sign of wound infection may be pain (or an increase in previous pain level).

60

An inflamed wound may cause a temporary decrease in function of the affected area. In contrast, patients with infected wounds...

...generally do not feel well systemically.

61

Drainage from inflamed wounds generally differs from infected wounds in...

...amount, consistency, color, and odor

62

After being rinsed with saline, inflamed wounds should not have an odor unless there is necrotic tissue present. In contrast, infected wounds...

... frequently are malodorous even when free of necrotic tissue.

63

Proteus infections smell like...

ammonia

64

Pseudomonas infections smell...

...“sickly sweet” and are usually accompanied by a bright blue or green drainage.

65

A newly infected wound that was previously healing may increase in size. New onset of undermining or tunneling may be noted in infected wounds because of bacterial toxins digesting healthy host tissue. Chronic wounds may exhibit more subtle signs of infection. For example...

...granulation tissue may become friable, easily traumatized, or take on a cobblestone-like appear- ance. The amount of granulation tissue may decrease or the color may change from beefy red to pale or bright red.

66

When a silent infection is suspected, the clinician may need to assess for some of the systemic effects infections can have on the body, such as...

...elevated white blood cell counts, fever, increased heart rate, increased respirations, fatigue, and confusion. Additionally, patients with intact sensation may report an increase in pain when infection arises.

67

The glycocalyx allows microbes to...

...survive in wound environments that would otherwise be unfavorable and may protect the microbes from the effects of antiseptics and topical antimicrobials.

- Leukocytes may also become trapped within the biofilm, making them ineffective.

- Intercellular com- munication between organisms within a biofilm activates certain genes that increase bacterial virulence and resistance, making them respond less predictably to pharmacological interventions.

68

Biofilms are thought to be _____ times more resistant to a drug than free-living bacteria.

50–100;

- If individual bacterial organisms break away from the biofilm, they may maintain this resistance to antimicrobials leading to delayed wound healing and infection.

69

Biofilms are also able to modulate cell growth. By slowing the rate of microbe replication, antimicrobials become...

...less effective in eradicating these communities.

70

Biofilms are generally found on...

...devitalized tissue and implanted devices, such as catheters, as well as within the gastric mucosa, such as Helicobacter pylori (H. pylori) infections.

71

Up to _____ of chronic wounds may have bioflms. In contrast, biofilms have been found in only about ___ of acute wounds.

60%; 6%

72

Checkpoint Question #1
- Your patient’s wound presents with copious amounts of thick, blue-green drainage. Is this wound
likely to be inflamed or infected? Defend your answer.

The wound is probably infected. The significant amount of thick, blue-green drainage is characteristic of an infection.

73

True or False:
Observation alone is insufficient to accurately diagnose a suspected infection.

True:
Wound cultures are needed to confirm the presence or absence of infection.

74

Several methods of wound culturing exist:

Tissue biopsy (gold standard)
--- involve removing a sample of living tissue from the wound for examination
--- Bone biopsy for osteomyelitis

Swab cultures
---method that can be used by clinicians to quantify the number and type of bacteria present on a wound.

Fluid aspiration:
---physician uses a needle to draw up 1.0 mL of fluid within the wound area for analysis in the laboratory.

Blood tests:
---Serology involves identifying microbes by the presence of serum antibodies within the infected individual.
--- because this method is less accurate and more time consuming than wound cultures, it is seldom used in the management of open wounds.

75

The benefits of a swab culture over a tissue biopsy include:

...simplicity, lack of trauma to the wound bed, and avoidance of a surgical procedure.

In addition, swab cultures may be performed by physical therapists, physical therapist assistants, occupational therapists, and nurses without a physician’s order

76

The key disadvantage of this swab culture is that:

...test results may only reflect surface contamination or colonization rather than the infecting microorganism, because swab cultures sample the wound surface (along with fluid expressed from the wound surface or areas of tunneling or undermining),

77

Two types of swab cultures:

...one for aerobic microorganisms and one for anaerobic microorganisms.

78

Aerobic wound cultures are the standard culture procedure because...

oxygen-metabolizing microbes are more likely to be present in most wounds.

79

Wounds with these characteristics should be cultured for both aerobic and anaerobic microorganisms...

...deep, tunneling wounds, wounds with undermining or sinus tracts, or wounds that are occluded by thick layers of topical agents. These characteristics provide an oxygen-depleted environment that may allow proliferation of anaerobic microbes.

80

To perform a swab culture, first...

...debride and rinse the wound as able.

81

To swab an aerobic culture...

...rotate the end of an alginate-tipped applicator over a 1-cm2 viable wound surface area for 5 seconds while applying enough pressure to express tissue fluid ---

Because necrotic tissue harbors surface bacteria and, by definition, an infection can only occur in viable tis- sue, only viable tissue should be swabbed, not exudate, eschar, pus, or slough

82

To swab wounds with a larger viable surface area

...swab the wound in a 10-point pattern while slowly rotating the tip and applying pressure to express tissue fluid.

83

For an anaerobic culture...

...the applicator should be used to thoroughly probe tunnels and any areas of undermining

84

The advantage of fluid aspiration is that...

...this procedure assesses bacteria present within the tissues rather than surface colonization, which may be sampled by a swab culture.

85

Disadvantages of fluid aspiration...

--- fluid aspiration is only successful if there is sufficient fluid to sample.

--- potential dangers to performing this procedure including the spread of infection along the needle tract, fistula formation, and damage to underlying structures from the needle.

86

Fluid aspirations are primarily reserved for diagnosing:

...wound infections in abscesses.

87

Because of the possibility of a silent infection, wounds that have not made significant progress in _____ weeks of appropriate wound management should also be cultured

2-6 (weeks)

88

Several methods are used to identify the microbe(s) from the wound culture:

...shape, means of reproduction, response to staining, and the environment in which they grow best

89

Bacteria are...

...unicellular organisms ranging in size from 0.2 to 10.0 mm in diameter. Bacteria have a rigid cell wall, lack a nuclear membrane, and require nutrients from an external medium, such as the human body, to survive

90

Bacteria are named by their:

...genus (e.g., Pseudomonas) and species (e.g., aeruginosa).

--- The genus name may describe the shape of the bacteria: spherical bacteria are called cocci, helical bacteria are called spirilla, and rod-shaped bacteria are called bacilli.

91

Bacteria that divide in chains are identified by the prefix ______, and bacteria that divide in clusters are identified by the prefix ______.

strept-; staphyl-

92

________ represent a stasis-like condition that enables bacteria to exist indefinitely. When favorable conditions arise, the spores germinate and then metab- olize and reproduce as before.

Spores

(Bacillus anthracis)

93

True or False:

Both gram-positive and gram-negative bacteria are capable of secreting exotoxins that can cause extensive damage to host tissues, while only gram- negative bacteria produce the less destructive endotoxins.

True:

Gram-negative bacteria also tend to adhere better to the wound surface

94

Some bacteria have the ability to adapt their metabolism to either oxygen-rich or oxygen-free environments. Example:

Staphylococcus aureus: is a spherical-shaped, gram-positive bacteria that divides in clusters. Staphylococci are aerobic bacteria, that is, they prefer an oxygenated environment. However, they are facultative anaerobes, meaning they are also able to sur- vive in an oxygen-depleted environment, if necessary.

95

Among all possible bacteria, wounds with the following (3) bacteria are most likey to become infected:

--- Staphylococcus aureus
--- Pseudomonas aeruginosa,
--- beta-hemolytic Streptococcus

96

The most common skin and nail fungal infections are:

tinea and (the yeast- like) Candida

97

True of False:

Patients taking antibiotics to fight bacterial infections are vulnerable to fungal infections.

True

--- Antibiotics lower the local bacterial counts, leaving colonizing fungi without competition for food.

--- In wound care, patients using antibiotics long term, such as patients with large surface area burns, may develop a fungal overgrowth on or around the open areas

98

Other factors that increase the risk of fungal infections include:

--- moist, occluded areas of skin
--- diseases that attack the immune system
--- diabetes

99

Tinea infections appear as:

red, scaling patches with fissuring and itching.

100

Candida infections present as:

red, papular skin rashes accompanied by burning or itching

101

True or False:

There is a significant relationship between a decrease in bacterial load and a decrease in wound size

True

102

An antiMICROBIAL agent is a substance that is able to destroy ...

unicellular microorganisms

103

Antibacterial agents are types of antimicrobials that are effective against ...

...bacteria.

104

Antibacterials act by...

...inhibiting the bacterial synthesis of proteins, cell walls, proteoglycans, or nucleic acid or by interfering with cellular metabolism.

105

Antibacterial agents may be _______, causing irreparable damage to bacteria resulting in bacterial death, or ________, inhibiting bacterial cell growth while present.

bactericidal; bacteriostatic

106

_______ agents are types of antimicrobials that target the cytoplasmic membranes of yeasts and molds.

Antifungal

107

There are numerous classes of antimicrobials— including:

penicillins
cephalosporins
erythromycins
aminoglycosides
tetracyclines
quinolones
sulfonamides

108

The second part of the wound culturing process...

Determining microbial sensitivity (via growth medium)

---Bacterial smear samples that are unable to grow in the presence of a certain antimicrobial are considered sensitive to the drug, whereas bacteria that continue to multiply are considered resistant.

109

Bacterial resistance occurs when:

Bacteria produce enzymes that inactivate the antimicrobial, alter cell metabolism, or alter cell permeability to prevent antimicrobial entry into the bacterial cell.

110

Natural resistance:

...is an inherent lack of sensitivity of a certain bacterial strain to a particular antimicrobial beyond the antimicrobial’s normal spectrum of activity.

111

Acquired resistance occurs when...

...bacteria that were previously sensitive to a certain drug become resistant to the antimicrobial.

---In some instances, acquired resistance can be overcome by increasing the dosage of the antimicrobial. This is called relative acquired resis- tance.

---Premature antimicrobial cessation may lead to recurrence of infection and promotes bacterial resis- tance.

112

The two most prevalent strains of resistant bacteria are:

MRSA (methicillin-resistant Staphylococcus aureus)

VRE (vancomycin-resistant Enterococci)

113

Highest percentage of cases of MRSA being nosocomial and occurring in...

intensive care units

114

Community-acquired MRSA infections are becoming increasingly prevalent in certain populations, including:

prisons,
contact sports such as football and wrestling,
military personnel,
individuals with AIDS

115

In hospitals, spread of MRSA is typically through envi- ronmental contact (contact with contaminated sur- faces or contaminated staff members). In contrast, community-acquired MRSA appears to be spread through...

person-to-person sharing of personal items (towels, close contact).

116

MRSA infections may cause...

cellulitis, osteomyelitis, and abscesses

117

VRE infections are more commonly seen in...

surgical wounds and urinary tract infections.

118

Patients at greatest risk for MRSA or VRE infections include those who...

...are critically ill, are severely immuno-suppressed, have prolonged hospitalizations, or have received multiple antimicrobial therapies.

119

True or False

Although resistant strains of bacteria have become more prevalent, they have not become more resistant.

True

---There are more cases of resistant bacterial infections, but these resistant bacteria have not developed additional resistances to alternative therapies.

120

Which drug continues to be an effective bactericidal for MRSA?

mupirocin (Bactroban)

121

Which drug continues to be effective against VRE?

ampicillin–amoxicillin

122

Why isn’t the use of broad-spectrum antimicrobials to cover a wide variety of potential offending organisms a standard intervention for all patients with open wounds?

---First, there is no evidence to support that uninfected wounds heal any faster with antimicrobial therapy.

---Second, the solution is not to use broad-spectrum antimicrobials wantonly. If used inappropriately, any antimicrobial can actually encourage exposed microbes to build a resistance to traditional therapies.

123

Clinicians should suspect a sulfa allergy if a patient presents with...

...ascending redness and increasing inflammation from the site of topically applied sulfa-containing antimicrobials such as silver sulfadiazine.

124

If severe, allergic reactions may cause...

...hives, difficulty breathing, and even anaphylactic shock.

125

Because some topical agents—such as neomycin (for up to 50% of patients), gentamicin, bacitracin, and lanolin-containing ointments—are known to cause delayed sensitivity...

...prolonged use of these agents is not recommended.

126

Systemic antimicrobials may create a more generalized skin reaction. A sulfa allergy should be suspected if...

...a patient receiving sulfonamide medications develops a generalized skin rash, pruritus, or ascending erythema.

127

Systemic antimicrobial use may also produce a wide range of adverse reactions such as...

...gastrointestinal irritation, stomach cramps, nausea, vomiting, and diarrhea are frequent.

...Photosensitivity is a common side effect, especially with tetracyclines, sulfonamides, and fluoroquinolones.

...Some patients may experience fever.

...Antimicrobial adverse reactions may be toxic, causing permanent hearing loss, hepatitis, and kidney damage.

128

in addition to asking patients if they are taking their antibiotics as prescribed, clinicians should routinely question patients about any...

...potential adverse reactions and report these findings to the attending physician. If an adverse reaction is sus- pected, the clinician should discontinue the antimicro- bial and contact the attending physician.

129

The goal of topical antimicrobial therapy is to...

...provide an agent to destroy the offending organism(s) with relatively few adverse reactions.

130

Topical antimicrobial medications have been shown to penetrate...

the wound bed to the site of infection, inhibiting bacterial growth.

131

Ointments are...

...oil-in-water preparations available in tubes or single-use packets.

132

Creams are...

...oil-in-water emulsions (i.e., they contain more water than oil) available in tubs and tubes.

133

The antimicrobial properties of ointments are generally effective for 8–24 hours, while creams...

...are generally effective for 8–12 hours.

134

Silver kills microbes in many ways including inhibition of cellular respiration, denaturing bacterial nucleic acids, and altering cell membrane permeability.

Perhaps because of silver’s multiple binding sites and multimodal attack on microbes, resistance is rare. However, resistant strains of Escherichia coli and Pseudomonas aeruginosa have been found.

135

List some potential problems with the delivery of antimicrobials via a wound dressing:

--- First, antimicrobial dressings cost more than the equivalent standard dressing, increasing the cost per dressing change.

--- Second, the gratuitous use of broad-spectrum antimicrobials may contribute to the development of resistant strains of bacteria.

--- Third, if the dressing is not in direct contact with the wound bed (e.g., if another dressing is used as the wound contact layer and secured with an antimicro- bial-impregnated roll gauze), antimicrobial effectiveness would presumably be reduced.

--- Fourth, a recent study comparing the effects of an antimicrobial gauze to stan- dard gauze in colonized cavity wounds found a reduction in wound bioburden without any improvements in wound healing.

136

Patients who might benefit from short-term use of these products (topical silver, cadexomer iodine, honey impregnated dressing) include patients with high wound bioburden and those...

...at high risk of infection, such as a patient with a full-thickness burn or an individual who is immunocompromised.

137

The benefits of topical antimicrobial therapy include...

...lower cost than systemic therapy and ease of application.

138

The obvious advantage of topical antimicrobials over nonantimicrobial topical agents, such as an amor- phous hydrogel, is that...

...topical antimicrobials will reduce bacterial load when used appropriately. Because topical antimicrobials are applied directly to the wound bed and do not rely on local circulation, they may be more appropriate than systemic antibiotics to treat infections in wounds with compromised circulation.

139

The disadvantages of topical antimicrobial therapy include...

...increased cost when compared to nonantimicrobial topical agents, the need for frequent applications (one to three times per day), sensitivity or allergic reaction, and the potential for microbes to become resistant to the drug, particularly with prolonged use

140

The clinician is warned against using larger amounts as this [than only a thin layer (one-sixteenth to one-eighth of an inch, or 16–30 mm)] because...

...would needlessly increase treatment cost and could make complete removal of the antimicrobial difficult during the next dressing change. Excessively thick applications, espe- cially of antimicrobial creams, create a more occlusive environment that may increase the risk of fungal infections.

141

Applying the antimicrobial to the dressing is particularly useful:

...when the wound bed is very moist, making it difficult to apply the antimicrobial directly to the wound surface, or when the wound is painful to the touch.

142

bead implants are most commonly used in:

...deep partial-thickness or full-thickness diabetic foot infections.

143

Although the bead implants may be removed (or fall out of the wound bed)...

...they may remain indefi- nitely.

---The bead implants serve as a biological spacer, reducing the need for the body to build granulation tissue to fill the wound void, potentially decreasing wound healing time.

144

Although the Food and Drug Administration (FDA) has approved povidone-iodine products for short- term use in superficial, acute wounds, the FDA has...

...been unable to document that such use is associated with any improvements in wound healing criteria.

145

Antiseptic agents are broad- spectrum antimicrobials, they are also cytotoxic to...

...fibroblasts, keratinocytes, and neutrophils.

146

Antiseptics increase the...

...duration and intensity of the inflammatory response, delay epithelialization, and retard wound contraction. As such, they delay wound healing and avoidance of these substances is a component of prudent wound management.

147

antiseptic agents and surfactants should not be used in the standard treatment of...

... open wounds (pressure ulcers)

148

What are the primary and secondary uses of antiseptics?

---The primary use of antiseptic agents is to decrease bacterial growth on inanimate objects.

---The secondary use of antiseptic agents is to reduce bacterial con- centrations on intact skin. In this capacity, antiseptic agents may be used as a surgical scrub for clinicians to prevent contaminating a surgical field, for health care worker hand washing such as in the workplace, and for cleansing the patient’s intact skin prior to invasive techniques and blood tests

149

In rare cases, antiseptic agents may be appropriate for short-term use on open wounds, for example...

---Patients with wounds infected with Pseudomonas may benefit from short-term use of acetic acid soaks. However, if the infection lasts longer than 2 weeks, the clinician should reculture the wound and recon- sider the effectiveness of this regimen, as the risks of continued antiseptic treatment likely outweigh the potential benefits.

---patients with acute open wounds due to an animal bite or farming accident may benefit from short-term (2–7 days) use of an antiseptic solution, such as povidone–iodine. The rationale behind this recommendation is that these wounds are typically multimicrobial. As such, it may be beneficial to destroy everything within the wound bed initially to prevent infection. The antiseptic should be discontinued shortly (within 2–7 days) to prevent delays in wound healing that are associated with the use of antiseptics on open wounds

150

Research to date on the use of antiseptic agents on open wounds demonstrates that these solutions are...

cytotoxic to human cells
delay wound healing
have limited efficacy

151

Physicians typically prescribe antibiotics for patients with...

...sepsis or signs of advancing infection despite the use of topical antimicrobials.

---Deep space infections also require antibiotic therapy.

152

Advantages of systemic antibiotics include...

...reduction in bacterial load and ease of application for oral medications. In fact, because antibiotics do not require a dressing change to apply and laypeople are familiar with antibiotic regimens, adherence with oral antibiotics may be higher than with topically applied medications.

153

Disadvantages of systemic antibiotics include...

...more frequent and more severe adverse reactions, the development of resistant bacterial strains, problems with missed doses, higher cost, and, for intravenous medications, disruption in patient lifestyle

154

Regular debridement of necrotic tissue and removal of exudate from the wound surface helps...

...reduce bacterial bioburden and can transform a chronic, recalcitrant, infected wound into an actively healing wound.

155

True or False:

Prior to the development of antimicrobial therapy, debridement, particularly amputation, was the only intervention for wound infections.

True

156

Surgical debridement continues to be an important intervention when...

the offending microbe is resistant to other interventions,

when infection is rapidly progressing,

or when the antimicrobial cannot reach the site of infection (as with an abscess or decreased tissue perfusion)

157

Surgical debridement is required in the presence of osteomyelitis or sepsis. The preferred treatment strategy for osteomyelitis includes...

surgical excision of the infected portions of bone along with a short course of intravenous antibiotics.

This is fol- lowed by oral antibiotics for a total of 4–6 weeks of antimicrobial therapy

158

Successful treatment of an abscess requires...

...incision and drainage.

---Surgical debridement is required for deep space abscesses.

159

Checkpoint Question 2

Miss Smith presents with the following prescription for physical therapy: “PT evaluate and treat, acute second-degree burn dorsal right foot, apply silver sulfadiazine bid.” The amount of inflammation is proportional to the size and extent of the wound, there is minimal serous drainage, and the wound is 50% eschar covered. When you follow up with the patient 3 days later, you notice an increase in inflammation and ascending erythema from the wound site but no other objective or subjective changes.

a. What is the most likely cause of these new findings? b. What changes in treatment do you recommend?

a. Because there are no other subjective and objective changes, it is unlikely that this response is due to infection. The patient may have an allergy to sulfa.

b. You should describe your findings to the referring physician and suggest changing to a sulfa-free antimicrobial, such as bacitracin.

160

Combination therapy may result in fewer cases of resistance than monotherapy and should be used when...

...the offending microbes cannot be effectively covered with one drug.

---For example, the combination of rifampin and vancomycin has been found to be more effective in the treatment of chronic osteomyelitis than either drug used in isolation.

161

The best way to prevent wound infections is to...

actively prevent wound occurrence.

162

Keys to wound prevention include:

---Aggressive management of medical conditions known to increase the risk of wound formation, such as dia- betes mellitus, malnutrition, obesity, and inconti- nence.

---Proper positioning of patients with impaired mobility and proper foot care for patients with diabetes also reduce the risk of skin breakdown.

---Clinicians should work to protect the barrier function of the integument by treating dry skin, avoiding harsh soaps and detergents, and limiting the use of adhe- sives directly on the skin.

---The incidence of fungal infections may be reduced by the judicious use of antibiotics as well as proper skin and wound care.

163

Once a wound exists, the single most important means of preventing wound infections is to meticulously fol- low proper infection control procedures. This includes..

....hand washing, standard precautions, the appropriate use of either sterile or clean technique, and proper wound care procedures.

164

Hand washing with water, 3–5 mL of soap, and friction for at least 10–15 seconds will...

remove debris and transient microbes from the skin
and is acceptable for most casual patient interactions

165

Health care workers should wash their hands with an antimicrobial soap or alcohol-based hand rub before and after...

...invasive procedures such as wound care.

166

Sterile technique is gen- erally reserved for...

...wounds that require packing, large surface area wounds, severe burns, and wounds in patients who are immunosuppressed.

167

Wound dressings should be changed if they become contaminated or ineffective. List four ways this can occur:

---First, wound contamination can occur if a dressing slips such that it no longer covers the wound bed, or if a channel develops, providing a passage for microbes and foreign debris from the environment into the wound bed.

---Second, water-permeable dressings, such as gauze, may be contaminated if they get wet.

---Third, urine or stool frequently contaminate sacral or perineal wounds covered with permeable dressings.

---Last, dressings should be changed if strike-through is evident, or impending, because of the potential for con- taminants to enter the wound by osmotic forces

168

Checkpoint Question 3:

What personal protective equipment should be used in the following clinical situations?
a. When removing a patient’s wound dressings
b. When debriding over a whirlpool
c. When debriding a patient with second-degree burns over his trunk and upper extremities
d. When measuring or culturing a wound
e. When cleaning up wound supplies after a wound treatment session

a. Clean gloves.
b. Gloves (forearm length or longer if necessary),
water-impermeable gown, protective eyewear,
and surgical mask or face shield.
c. Sterile gloves.
d. Clean gloves.
e. Clean gloves.

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RQ1:

Your patient, Mr. V, is a 58-year-old accountant with a history of a coronary artery bypass graft using a left saphenous vein graft, and a nonhealing ulcer on his right lower leg. Previous wound treatment included wet-to-dry dressings for 6 months and twice-daily povidone–iodine soaks for the last 3 months. On examination you find an ulcer measuring 2.3 * 4.5 cm with a 0.2-cm depth. The wound bed contains 100% pale granu- lation tissue with a 0.4-cm perimeter of erythema. The wound is mildly tender to probing and there is a mild increase in skin temperature within a 1- cm radius of the wound. There is no evidence of edema. Mr. V’s ankle-brachial index is 0.9. The old bandages have a yellow-brown tinge as well as a small amount of dried blood.

a. What portions of this patient’s examination and history might lead you to suspect a wound infection?
b. What portions of this patient’s examination and history might lead you to suspect inflammation?
c. Based on the information provided, does the wound appear to be infected or inflamed?
d. What changes in treatment do you recommend?
e. Would you use clean or sterile technique when treating Mr. V’s wound?

a. The wound’s chronicity despite adequate macro- circulation may be an indicator of an infection.

b. The proportional amount of erythema, the slight local temperature increase, the amount and type of drainage, and the gross lack of edema are consistent with inflammation. The yellow-brown discoloration of the old band-ages is due to the povidone–iodine.

c. The wound appears to be chronically inflamed.

d. The povidone–iodine should be discontinued.
Rather, a moisture-retentive dressing should be
chosen (see Chapter 7).

e. Clean technique is appropriate.

170

Your patient is a 52-year-old with a history of rheumatoid arthritis. She presents with a lateral forearm ulcer sustained while gardening one week ago. The ulcer measures 1.0 * 0.5 cm with a 2.0-cm erythemal border. The wound is 50% granular and 50% yellow slough. While probing, you find a 3.0-cm tunnel at the 12-o’clock position and are able to milk a moderate amount of thick, white material from the tunnel. The periwound is indurated and painful to palpation. She has been washing the wound daily with soap and water before applying first aid cream and a Band-Aid. The patient reports her forearm has been getting progressively sorer over the past 2 days.

a. Based on the information provided, does the wound appear to be inflamed or infected? Defend your answer.

b. What wound management procedures are appro- priate for this patient at this time?

c. Would you use clean or sterile technique when treating this patient’s wound?

a. Induration, purulent drainage, excessive ery- thema, and increasing pain despite appropriate care are suggestive of infection. Additionally, the patient’s history of rheumatoid arthritis increases her risk for infection.

b. The wound should be irrigated and debrided as much as possible. You should contact the patient’s physician and request an order for both an aerobic and an anaerobic swab culture. You should also ask the physician if topical or systemic antimicrobial treatment should be initiated at this time.

c. Sterile technique should be used when filling the wound tunnel.