Wounds Flashcards
(160 cards)
1
Q
What are the roles of OT in wound care?
A
Identify causative factors to skin breakdown
Make recommendations that protect the skin or promote wound healing while promoting participation in meaningful occupation
2
Q
What are the wound interventions provided by OT?
A
Restore habits and routines Prevent loss of roles Prevent occurrence of wounds (positioning, support surfaces, etc.) Modifications to context and environment Fabricate and provide orthotic devices Education Provision of pressure garments Management of wound site
3
Q
Ulcers precede __ % of all amputations.
A
85%
4
Q
One amputation [increases/decreases] the risk of future amputations.
A
Increases.
5
Q
What is the mortality rate 5 years following amputation?
A
Between 40 and 70%
6
Q
What are the phases of wound healing?
A
- Hemostasis: Immediate response to stop blood loss. Clot formation and breakdown (fibrinolysis)
- Inflammation: 2-6 days post injury. Warmth, redness/erythema, edema, and/or pain.
- Proliferation: Accumulation of new tissue synthesis into an unorganized array of collagen. Myofibroblasts cause wound contraction. Pink/red granulation tissue.
- Maturation or remodeling: Reorganization of collagen but never achieves >80% tensile strength of the tissue. Takes up to 2 years.
7
Q
True or False: Atypically progressing wounds stop at the proliferation stage.
A
False. Infected wounds usually stop at the inflammation stage and does not go onto proliferation.
8
Q
What is granulation?
A
New tissue formation. Pink/red. Contained within the wound margins.
9
Q
What is hyper-granulation?
A
New tissue formation that spills over the margins of the wound, preventing wound healing and epithelial cell movement. Friable, i.e. crumbling/brittle, breaks easily
10
Q
What is excoriation?
A
Road rash-type of wound
11
Q
What is slough?
A
Devitalized tissue. Yellow, brown, beige, or green. Loose or fibrous.
12
Q
What is eschar?
A
Dead tissue. Leathery.
13
Q
What is tunneling?
A
Wound creates a tunnel through tissue, where there are two openings to the wound.
14
Q
What is undermining?
A
Wound continues under the skin, and the wound internal margins are much larger than the external margins. Can be caused by prolonged sloughing.
15
Q
What is the best way to heal wounds that are undermining?
A
Try not to let the wound close before the wound has healed from bottom up to that level of skin.
16
Q
What is the exudate?
A
The fluid that comes out of the wound.
17
Q
Describe serous exudates.
A
Clear or pale yellow. Benign.
18
Q
Describe sanguineous exudates.
A
Blood.
19
Q
Describe sero-sang exudates.
A
Contains a mixture of blood and clear fluids
20
Q
Describe purulent exudates.
A
Pus. A variety of colours and may/may not have a distinct smell.
21
Q
True or False: Erythema is unblanchable redness.
A
False. Erythema can be blanchable or unblanchable.
22
Q
What is the effect of rolled edges of a wound on wound healing?
A
Makes wound healing more difficult by making epithelial cell migration more difficult
23
Q
What is maceration?
A
When there is excessive fluid around the wound edge. It easily tears and slows down wound healing.
24
Q
What should be reported when wound assessment?
A
Subjective history Surrounding tissue Wound location Wound base - red, yellow, black Wound edges & undermining Wound size - Length, width, and depth Drainage - exudate colour and consistency Odour
25
How should the measurements of wound size be made?
Measurements of length and width are taken at right angles. Depth is measured by a probe.
26
What are the differences between acute vs. chronic wounds?
Acute wound: Disruption of skin integrity that heals in an uncomplicated manner.
Chronic wound: Wounds that fail to heal in a normal, timely (> 6 weeks), and orderly manner or wounds that do not heal without restoring anatomic and functional results.
27
What are wounds that are on maintenance?
Wound is healing but not in a timely fashion (e.g. due to factors like patient adherence)
28
What are non-healing wounds?
Wounds for which causes cannot be removed (e.g. patient adherence, blood flow)
29
What are the types of chronic wounds?
```
Pressure injuries (ulcers)
Diebetic/Neuropathic foot ulcers
Venous leg ulcers
Arterial ulcers
Surgical wound dehiscence
Fistula
```
30
What model is used to help people with chronic wounds?
Wound bed preparation paradigm
31
In the wound bed preparation paradigm, that are the 3 factors to be considered when caring for people with chronic wounds?
1. Treat cause
2. Local wound care
3. Patient-centred concerns
32
In the wound bed preparation paradigm, what are 3 interventions for local wound care?
1. Debridement
2. Infection - Edge non-healing wound
3. Moisture balance
33
What is the most important thing to consider when caring for people with chronic wounds?
Knowing the cause and treating the cause
34
What are pressure injuries?
Localized damage to the skin, usually over a bony prominence or a medical/other devices, as a result of intense/prolonged pressure or pressure in combination with shear
35
What are the risk factors for pressure injuries?
Medical comorbidities that cause immobility, diminished sensation, impaired blood flow, poor venous return, etc.
Inadequate nutrition (protein, vitamin C, zinc)
Moisture/incontinence
Pressure
Friction
Shear
Medications
36
What are the common sites of pressure wounds?
Sacrum, heel, malleoli, coccyx, ischial tuberosity, greater trochanter, elbow, etc.
37
How are pressure injuries staged?
Stage 1: Non-blanchable erythema of intact skin
Stage 2: Partial thickness skin loss with exposed dermis
Stage 3: Full thickness skin loss
Stage 4: Full thickness skin and tissue loss
38
What are unstageable pressure injuries?
Pressure injuries that has obscured full thickness skin and tissue loss due to slough or eschar, such that the extent of the damage cannot be confirmed.
39
What is deep tissue pressure injury?
Persistent non-blanchable deep red, maroon, or purple discolouration
40
True or False: A pressure wound can be back-staged (e.g. go from Stage 3 to 2) if it gets better.
False. You never back-stage a pressure wound.
41
Describe Stage 1 pressure injury.
No skin breakdown
| Appears lightly pigmented
42
Describe Stage 2 pressure injury.
Skin breakdown into part of dermis
43
Describe Stage 3 pressure injury.
Skin breakdown through and past the dermis
| Fat, slough, eschar may be visible, but not tendon, fascia, nor bone.
44
Describe Stage 4 pressure injury.
Skin breakdown through subcutaneous tissue, exposing bone, cartilage, and/or tendon.
45
What are the differences between deep tissue pressure injuries and Stage 1 pressure injuries?
Deep tissue pressure injury tends to be more purple and prolonged, and may feel more cushy/boggy and warmer than Stage 1 pressure injuries.
46
What is the Braden scale?
A scale used to assess risk for developing pressure injuries.
47
What are the 6 indicators assessed by the Braden scale?
```
Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and shear
```
48
How are the indicators scored in the Braden scale?
Ranked from 1 (high risk) to 4 (low risk), except for friction and shear which is ranked from 1 to 3.
49
What do the scores of Braden scale indicate?
Score 15-18: Mild risk
Score 13-14: Moderate risk
Score 10-12: High risk
Score 9 or lower: Very high risk
50
What is the formula for pressure?
Force/Area
51
How does pressure differ for small vs. larger surface area?
Small SA: High peak pressure
| Large SA: Lower peak pressure
52
What are support surfaces?
Specialized devices for pressure redistribution
53
What are the physical factors to consider for support surfaces?
Ability to provide envelopment or immersion
Life expectancy of the device
Ability to provide pressure redistribution
Potential for friction and shear
Stability
Maintenance needs
54
What are the 2 categories of support surfaces?
Reactive: Changes load distribution in responses to patient's weight.
Active: Changes load distribution without the patient. Requires a power source and uses cyclical inflation and deflation.
55
What is the only available type of active support surface in hospital settings?
Alternating air pressure reduction surface
56
What are the indications for alternating air pressure reduction surface?
Acutely ill and/or immobile patients with existing pressure ulcer or at high risk for developing a pressure ulcer.
57
True or False: Alternating air pressure reduction surface can replace regular repositioning.
False. Not always.
58
What are the features of support surfaces?
```
Air-fluidized
Alternating pressure
Lateral rotation
Low air loss (good for managing moisture)
Zone
Multi-zoned
```
59
What are the 4 main reactive devices for pressure redistribution?
Mattress
Overlays
Integrated bed systems
Cushions
60
What is the purpose of Prevalon boot?
Pressure relief on lateral and medial malleolus
61
What is the purpose of leg trough?
Pressure relief on heel and malleoli
62
Describe Vicare cushions.
Cushions with different zones that are filled with different amounts of small units filled with air
63
Describe Elastomer cushions.
Cushions with comb-like texture
64
Describe Roho cushions.
Cushions with many cells that are equally filled with air
65
What factors should be considered when matching a client with a device?
```
Cost/Availability
Sitting balance
Transfer independence and mobility
Moisture/Heat management
Maintenance
Comfort
Friction/Shear
```
66
What is the donut effect, and why is it bad?
The donut effect is the strong tendency for clinicians to use the donut cushion for relieving pressure. The rim of the donut actually creates a pressure area, so it is not used anymore.
67
True or False: Roho cushions or air beds should be used without any pads or additional covering material.
True. Anything that you put over an emersion product will reduce the emersion effect.
68
What is shear?
Movement of skin in opposition to bone movement
69
What is one major way to prevent friction and shear?
Proper transfer technique and equipment
70
How can shear be reduced when transferring?
Use equipment - Transfer boards and slider boards
Move the sheet not the skin
Awareness and protection of high risk areas
Sheepskin to reduce shear
71
What are the 4 approaches for local wound care (DIME)?
Debridement
Infection prevention/management
Moisture balance
Edge
72
What is debridement?
Removal of foreign material and devitalized or contaminated tissue from the wound bed until surrounding healthy tissue if exposed.
73
What are different types of debridement?
Mechanical - Usage of outside force
Autolytic - Usage of moisture retentive dressings to encourage liquefaction
Enzymatic - Usage of exogenous enzymes
Biological - Usage of maggots or leaches
Sharp/surgical - Usage of scalpel, scissors, tweezers, or other sharp instruments
74
What are the considerations to be made prior to sharp debridement?
A through basic skin and wound assessment should be completed.
A physician order is made.
A vascular assessment (ABI or PPG) is required to ensure potential for wound healing.
Patient must give informed consent.
75
What are the contraindications for debridement?
Pain
Poor vascularity
Non-healing wound
Anticoagulation
76
True or False: All chronic wounds should be free of all micro-organisms.
False. Not all micro-organisms are harmful to the wound, and all chronic wounds are colonized by micro-organisms. Wound healing only becomes compromised if the bacterial burden becomes too great.
77
What are the potential indications of infection (NERDS and STONES)?
NERDS: Non-healing, Exudative, Red and bleeding, Debris, Smell
STONES: Size (bigger), Temperature (increased), prObes to exposed bone, New area of breakdown, Erythema/redness, Smell
78
What level of moisture is ideal in wounds?
Level of moisture in your eye
79
What is the role of moisture in wound healing?
Facilitates the wound healing process
Increases the rate of re-epithelization
Decrease in pain
Exudate delivers certain growth factors and nutrients
80
What should you look out for when looking at the edge of the wound?
Is the wound closing?
Look for undermining, rolling edges
What does the surrounding skin look like?
81
What are the principles of wound care for healable wounds?
```
Wound cleansing
Debridement
Moisture balance
Elimination of dead space
Provision of thermal insulation
Protection of wound and peri-wound area
Inflammation and infection control
```
82
What are the principles of wound care for non-healable wounds?
Should be kept dry.
Goals should be comfort, maximizing function, reducing risk of infection and prevention of further deterioration.
Do not remove eschar, as the wound may still heal underneath the eschar.
83
What are the roles of dressings?
Add, retain, or remove moisture.
Add anti-microbials
Insulate
Eliminate dead space
84
What is venous leg disease?
Also called chronic venous insufficiency.
| Impaired drainage of the venous system with resulting venous hypertension.
85
What is the etiology of chronic venous insufficiency?
Vascular incompetence or venous reflux.
Obstructed veins (e.g. deep vein thrombosis, DVT).
Failure of the calf muscle pump.
86
Why is venous leg disease associated with edema?
Venous leg diseases often results in venous hypertension, which leads to fluid escaping into the interstitial space, and consequently edema and hemosiderin staining.
87
What is hemosiderin staining?
Discoloration on lower calves that appear red, purple, or black.
RBCs are forced out of capillaries and into the interstitial space due to the venous hypertension, and the dead RBCs release iron that stains the skin for long periods of time.
88
How many classifications of edema are there?
7
| C0 to C6
89
What are the classifications of edema?
C0: No visible or palpable signs of edema
C1: Telangiectasia or reticular veins
C2: Varicose veins
C3: Edema
C4: Skin changes due to venous disease (eczema, pigmentation, lipodermatosclerosis)
C5: Above with healed venous ulcer
C6: Active venous disease
90
What is telangiectasia?
Dilated venules up to 1 mm, not palpable
91
What are reticular veins?
Blue venules up to 4 mm, not palpable
92
What are varicose veins?
Larger, twisted veins, palpable
93
What is lipodermatosclerosis?
Scarring of the skin in the lower legs due to inflammation in the fatty tissue
94
True or False: Chronic venous insufficiency (CVI) is the most common cause of lower extremity wounds.
True. 80-90% of lower extremity wounds are caused by CVI.
95
What are the common visible characteristics of venous leg disease?
Edema
| Gaiter area ulcers
96
What is the gaiter or sock area?
The area between the ankles and the knees
97
True or False: There is usually only one venous leg ulcer at once.
False. Venous leg ulcers can be extensive, and there usually are several of them.
98
What is the typical appearance of venous leg ulcers?
Appears shallow and irregular in shape.
Wound base may contain yellow fibrin or ruddy granulation tissue.
Usually produces moderate to heavy amounts of exudate and is wet-looking.
99
When does lymphedema occur?
Disruption in the lymphatic system and an abnormal accumulation of lymph fluid.
100
In which population is lymphedema common?
Individuals after receiving cancer treatment
101
What are the characteristics of lymphedema?
Usually unilateral rather than bilateral.
Usually not pitting; Rebound is present.
Skin folding, especially on the ankles and the toes.
102
What is arterial insufficiency?
Insufficient blood supply and a reduction in oxygen delivery to cells, tissues, and organs.
103
What is the common etiology of arterial insufficiency?
Atherosclerotic disease or trauma (less common)
104
What are the common characteristics of arterial insufficiency?
Intermittent claudication or pain, which occurs with moderate to heavy activity and is relieved with rest.
Can conversely exhibit rest pain, relieved when the legs are in a dependent position.
Lower extremities are cool to the touch.
Pale, shiny, and thin skin
Minimal to no hair growth
Unilateral dependent rubor (esp. if caused by trauma)
105
What are the characteristics of ulcers associated with arterial insufficiency?
```
Tend to occur over bony prominences.
Have a punched out appearance and tends to be round.
Pale in color.
Produce little discharge.
Tends to be painful.
```
106
How can diabetes cause neuropathy?
Prolonged exposure to high blood sugars can lead to damage of nerve fibers as well as weakening of capillaries that supply nerves.
107
Which nervous systems are affected by diabetic neuropathy?
Sensory
Autonomic
Motor
108
What are the functional impacts of sensory neuropathy?
Increased likelihood of injury due to impact or falls.
Inability to detect and seek treatment for injury.
Failure to comply with treatment due to lack of immediate feedback.
109
What are the signs of sensory neuropathy?
Loss of protective sensation
| Sensory ataxia
110
What are the signs of autonomic neuropathy?
```
Anhidrosis or inability to sweat
Callus
Cracks/fissures
Fungal nail
Dry/yellow cracked nails
Waxy looking skin
```
111
What are the functional impacts of autonomic neuropathy?
Dry, cracked skin which is more prone to injury.
| Calluses create a pressure point which can cause injury to the underlying tissue.
112
How does diabetic motor neuropathy typically present?
Atrophy of intrinsic muscles of the foot.
113
What are the signs of motor neuropathy?
```
Claw toes
Hammer toes
Bunion
Muscle weakness
Pes equinus
Pes planus
Hallux limitus or limited ability of the toes to move
```
114
What are the functional impacts of motor neuropathy?
Decreased mobility
Altered gait pattern
Altered weight bearing surfaces, increasing pressure to vulnerable areas
115
What are the characteristics of diabetic or neuropathic ulcers?
Tend to occur over pressure points on the plantar surface of the foot.
Usually over calloused, bony prominences.
The wound base may be covered with eschar or slough, or be pink and bleed easily.
Can be quite deep and even probe to bone.
Tend to be pain free.
Tend to produce minimal exudate.
Often surrounded by a highly calloused rim
116
What is Charcot foot or Charcot deformity?
A complication of diabetes characterized by acute localized/inflammation which may lead to bone destruction and/or deformity.
117
What is the hallmark deformity of Charcot foot?
Midfoot collapse or "rocker-bottom" foot
118
What are the components of a comprehensive lower extremity assessment?
1. Medical history
2. Social history
3. Vascular exam
4. Foot architecture
5. Sensation
6. Wound assessment
119
What is cellulitis?
Inflamed skin
120
What kind of edema does left-sided congestive heart failure lead to, and why?
Pulmonary edema due to back pressure on lungs which leads to back up of fluid in the lungs.
121
What kind of edema does right-sided congestive heart failure lead to, and why?
Peripheral and/or abdominal edema due to back pressure on the venous system.
122
Why should smoking be considered when taking the medical history for lower leg assessment?
Smoking impacts the client's ability to heal
123
Why should liver disease be considered when taking the medical history for lower leg assessment?
Portal hypertension can result in fluid accumulating in the legs (edema) or in the abdomen (ascites).
The impaired ability of the liver to produce albumin can also lead to edema.
124
What are components of social history that should be considered for lower leg assessment?
Mobility -- Gait aids, falls history, social supports
| Stockings/shoes -- Use of pressure gradient stockings, orthotics, custom footwear
125
What are some ways to assess the circulation of the client?
```
Palpation
Observation
Ankle brachial index (ABI)
Toe brachial index (TBI)
Photoplethysmography (PPG)
```
126
Where on the lower leg can palpation be used to assess the circulation?
Dorsalis pedis
| Posterior tibial
127
Which signs should be monitored when observing lower legs for circulation?
Cyanosis or discoloration
Ischemic rubor
Capillary refill
128
What is normal ankle brachial index (ABI)?
The blood pressure in the ankles are equal or slightly higher than that in the arm.
129
When can the ankle brachial index (ABI) be falsely raised?
Presence of calcified vessels, e.g. diabetes
130
What are the procedures for measuring the ankle brachial index (ABI)?
Performed after 10-20 minutes of rest with the client lying supine. Calculated by dividing the highest systolic pressures in the ankle and in the arm.
131
What is the indication for using toe brachial index (TBI) rather than ankle brachial index (ABI)? Why?
When there is blood vessel stiffening, e.g. calcified vessels.
Toe vessels are less susceptible to blood vessel stiffening.
132
How does photoplethysmography (PPG) work?
The sensor emits infrared light which detects changes in blood filling of digits.
133
How is edema graded?
0+ : No pitting edema.
1+ : Mild pitting edema. 2 mm depression that disappears rapidly.
2+ : Moderate pitting edema. 4 mm depression that disappears in 10-15 seconds.
3+ : Moderately severe pitting edema. 6 mm depression that may last more than 1 minute.
4+ : Severe pitting edema. 8 mm depression that can last more than 2 minutes.
134
Which characteristics of toenails should be observed when assessing lower extremities?
```
Dry
Cracked
Colour
Length
Thickness
```
135
What is used to assess sensation in lower extremities?
Semmes-Weinstein monofilament
136
What are the diameter thresholds for sensation loss in Semmes-Weinstein monofilament test?
0.01 g - Normal
10 g - Intact protective sensation
75 g - Loss of protective sensation
> 75 g - Severe loss of sensation
137
True or False: If the client says that they can feel the monofilament, then their sensation is intact.
False. Their ability to localize the sensation should also be tested, which is often impaired in clients with diabetes.
138
What are some conservative methods to manage edema?
Elevation
Reducing salt intake
Exercise
139
How should all compression therapy systems graded?
There should be a pressure gradient from ankle to knee, such that there is higher compression at the ankles than at the knees.
140
The [less/more] layers there are, the greater the compression.
More
141
What are the indications/counter-indications for anti-embolism compression therapies, like TEDS?
Only effective for people who are bedridden, as you need at least 18 mmHg to counter gravity for weightbearing individuals.
142
Who is 15-20 mmHg compression therapy usually for?
For traveling or working
143
Compression therapies greater than __ mmHg needs a prescription.
20
144
Who is > 40 mmHg compression therapies for?
Individuals with lymphedema, who need significantly larger compression than venous insufficiency.
145
What are intermittent pneumatic compression devices?
Devices that intermittently pump air into inflatable sleeves with a power source.
146
What are possible contraindications to compression?
Uncontrolled congestive heart failure
Uncontrolled cellulitis
Ischemia
Uncontrolled pain
Signs of contact dermatitis or skin irritation
Inadequate arterial blood flow (low ABI)
Low patient/staff/family compliance
Acute deep vein thrombosis
Acute or severe liver or renal failure -- Can lead to organ failure
Ankle circumference less than 18 cm -- Have to increase compression
147
Who are wraps for?
For individuals who have open wounds or are edematous.
148
Wraps are [single/multi] use with [set/variable] wear times.
Single
| Variable
149
True or False: Clients with wraps can take baths.
False.
150
True or False: Wraps can be applied over open wounds and dressings.
True.
151
When are pressure gradient stockings used?
When individuals get their edema down (get "dry"), for maintenance of edema.
152
What are the contra-indications for pressure gradient stockings?
Not for reducing edema.
| Not for when open wounds are present.
153
True or False: Pressure gradient stockings are reusable, removable, and washable.
True.
154
What is the most commonly used range of compression in pressure gradient stockings? How about for lymphedema?
30-40 mmHg is the most common.
| Lymphedema often requires higher levels of pressure.
155
What topics should the patient be educated on for diabetic neuropathy?
```
Foot inspection
Callous/nail care
No soaking -- Macerates skin and make it prone to bacterial infection
Moisturizing
Proper footwear/protection
Gait aids
```
156
What are some ways to offload weight from pressure ulcers?
DARCO boot with custom insole
| Custom footwear
157
What are the functions of DARCOs?
Provide protection temporarily
Offload open wounds
Redistribute pressure
158
What material is often used for custom insoles?
Plastazote
159
What are the indications for debridement?
Superficial callous
Slough or debris in wound bed
Necrotic tissue
160
What are the contraindications for debridement?
Inadequate blood flow
Wound sealed with eschar
Patient unwilling
Lack of trained professional
