Integument > Wound Care - Study Guide > Flashcards

Wound Care - Study Guide Flashcards

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1
Q

Epidermis - Function

A
  • Retain moisture
  • Protect from bacteria
  • Rapidly Regenerate
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2
Q

What structure stores cells to regenerate tissue?

A

a. Hair Follicles
b. Sweat Glands
c. Edges of the wound bed
d. Anywhere with keratinocytes

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3
Q

Difference between primary, secondary and tertiary intention

A

a. Primary: Incised – no tissue loss: epithelialization
b. Secondary: Incised – tissue loss: regeneration
c. Tertiary: Trauma – structural loss: replacement

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4
Q

Wound Care - What causes Vasoconstriciton?

A
  • Platelets
  • They release Serotonin
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5
Q

Wound Care - What causes Vasodialation?

A
  • Mast Cells
  • Release Histamine
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6
Q

Wound Care - Polymorphonuclear leukocytes response

A
  • Neutrophils release enzymes for Autolytic Debridement
    – Phagocytosis, lysosome degredation, kill bacteria
  • Esonophils: phagocytosis, WBC
  • Mast Cells: Release histamine, creates Vasodialtion. In addition, produce chemical chemokine for neutrophil migration to site of injury
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7
Q

Homeostasis (forming the platelet plug)

A

Hagemann Factor XII (12)
- Converts prothrombin into thrombin
- Converts fibrinogen into fibrin

Scab Formation
- Platelets come to injury site and release serotonin for VC
- Platelet release platelet derived growth factor that form fibrin clot (platelet plug)

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8
Q

Monocyte to Macrophage - Acute inflammatory to proliferative phase

A

Macrophage
i. 72 to 84 hours
ii. Function in low O2
iii. Phagocytosis (eat debris)
iv. Secrete cytokines, growth factors (helps create granulation) and Matrix Metalloproteinases

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9
Q

What cell types are produced by fibroblasts?

A

a. Synthesis Collagen and Glycosaminoglycans

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10
Q

What is a Positive Homan’s Sign

A

a. Dorsiflex foot and squeeze OR use BP cuff to pump up to 40 mmHg
b. Positive if they have pain

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11
Q

ABI levels and debridement

A

Normal: 1

Abnormal
- >1 Venous Insufficency
- <0.8 Mild Arterial Insufficency – Can debride
- Equal to or <0.5 – DO NOT OPEN – Long time to heal

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12
Q

What is the minimal protective sensation?

A

5.07 monofilament (10 g)

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13
Q

What are the three ways to stage a wound?

A
  • Pressure Ulcer (1-4)
  • Wagner (0-5); Diabetic Foot Patients
  • Other wounds (Partial and Full thickness)
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14
Q

Pressure Ulcer Stages

A

Stage 1
- Non-blanchable erythema
- Slight redness

Stage 2
- Partial Thickness (epidermis and/or dermis, superficial ulcer)
- Abraision, blister or shallow crater

Stage 3
- Full thickness
- Damage or necrosis or subcutaneous tissue
- With or without undermining

Stage 4:
- Full thickness through fascia, bone, muscle

Unstageable
- Can’t see the base of the wound do to slough or eschar

Deep Tissue Injury
- Pressure-related injury to subcutaneous tissues under intact skin
- Appearance of a deep bruise (purple or blue)

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15
Q

Wagner Scale

A

Grade 0:
- Skin Intact. May be bony deformities or hyperkeratotic lesions

Grade 1:
- Superficial Ulcer, may be necrotic or early granulation

Grade 2:
- Lesion goes to bone, ligement, tendon, joint capsule or deep fascia. No abcess or osteomyelitis (NO infection).

Grade 3:
- Previous lesion and infection

Grade 4:
- Toes or forefoot have gangrene; moist or dry

Grade 5:
- No foot healing possible

Use for Diabetic Patients - Feet

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16
Q

All other wounds staging

A
  • Partial thickness (seperation of the epidermis from the dermis)
  • Full thickness (seperation of both epidermis and dermis from underlying structures)
  • If you cannot see the bottom put full thickness/Unstageable and explain
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17
Q

Infection - Bacterial Counts

A
  • > 10^5 colony forming units (CFU)
  • > 10^3 for strep infections
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18
Q

Venous Insufficency Characteristics

A
  1. Increased drainage
  2. Painless
  3. Decreased pain with elevation
  4. Edema
  5. Increased redness (Hemosiderin Staining)

Causes 80% of ulcers

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19
Q

Arterial Insufficency Characteristics

A
  1. Minimal drainage
  2. Very painful and increased pain with elevation or exercise
  3. Rubor of dependency
  4. Pale Base
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20
Q

Mixed Insufficency Characteristics

A
  • Have signs of both
  • This will be determined with ABI and signs/Sx.
  • Primarily treated as Arterial insufficiency but also need to consider Venous Insufficiency playing into it.
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21
Q

What are the 3 methods of wound healing?

A
  • Non selective (Remove some healthy tissue with necrotic tissue) Ex:
    i. Mechanical (wet-to-dry dressings)
    ii. Topical agents
    iii. Surgical
    iv. Sharp
    v. Forceful irrigation (>8 psi); Spray surfactant
  • Selective (Remove only necrotic tissue) Ex:
    a. Collagenase (collagen/fibrin specific); Enzymatic
    b. Sharp Debridement
    c. Spray surfactant (<8 psi)
  • Autolytic (Occurs in a sealed wound by Neutrophils)
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22
Q

What are the three phases of healing?

A
  • Acute inflammatory (Stage 1; 1-4 days)
  • Proliferative (Stage 2; 4 days - 11 months)
  • Matrix Formation (Stage 3; 30 days -2 years); basement membrane that collagen sits on
  • Other: Chronic inflammatory
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23
Q

Acute Inflammatory

1

A
  • Platelet Plug
  • Monocytes
    – These are released in transition to Proliferative Phase and turn into Macrophages (Chemotaxis – Cytokines, GF (angiogenesis) and MMP)
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24
Q

Proliferative Phase

2

A
  • Myofibroblasts – secrete collagen and glycosaminoglycans
  • Revascularization
  • Reepithelialization on top of collagen
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25
Chronic Inflammatory | Other
- Monocytes do not turn into macrophages - MMPs play a part, TIMP deficits. Leads to biofilm and degrading of proteins
26
Wound Vac
* Creates a negative pressure environment which pushes the granulation tissue up to the wound bed. * Facilitates better healing * Can put antibiotic through this * Very good for skin grafts
27
Sharp Debridement
* Scalpel * Selective or Non Selective
28
Whirlpool - Indications
- Arterial Insufficency - Venous insufficiency - Pressure Wound - Trauma Wound
29
Whirlpool - Goals
- Rehydrate tissue - Soften eschar - Nonselective material debridement/remove foreign material - Increase circulation 2-3 hours post Rx
30
Whirlpool - Contraindications
1. Medical condition where increased body temperature is contraindicated 2. Painful lesions 3. Fragile, dry, irritated surrounding tissue
31
Whirlpool - Protocol
Warm; 98-101 degrees for 15-20 minutes
32
When should you use collagenase?
* Someone has AI and they won't let you debride the hard eschar off
33
How to treat Arterial Insufficent Wound?
i. Deeper - First: Premoistened Calcium Alginate - Second: Vaseline Impregnated Gauze - Third: Foam + Tegaderm (OR gauze/compression stockinette depends on intactness of surrounding skin) on top OR Hydrocolloid Thin (O2) OR if patient is too sensitive and need to get rid of eschar - First: Collagenase - Second: Calcium Alginate - Third: Foam + Tegaderm (OR gauze/compression stockinette depends on intactness of surrounding skin) on top OR Hydrocolloid Thin (O2) ii. More Superficial - First: Vaseline Impregnated Gauze - Second: Foam + Tegaderm on top OR Hydrocolloid Thin iii. Superficial - Hydrocolloid Thin
34
How to treat Venous Insufficency wound?
i. Deep: 1. First: MeSalt 2. Second: Abdominal Pad OR Hydrocolloid thin (O2) OR Hydrocolloid thick (IF NOT INFECTED; absorbs more) ii. Less weeping 1. First: MeSalt 2. Second: Hydrocolloid Thin (O2) OR Hydrocolloid thick (IF NOT INFECTED) iii. Little weeping 1. Hydrocolloid thin (O2) OR Hydrocolloid thick (IF NOT INFECTED; absorbs more)
35
How to treat Mixed Insuffiency Wound?
* Similar to Arterial insufficency but also need to consider VI. Look at all considerations we look at for wounds.
36
How to treat a Chronic Inflammatory Wound?
* Use Collagenase Early * Eventually switch to silver impregnated guaze * Growth Factor - Prescription required
37
When is hydrogel good to use?
* Skin Flaps * Place Steristrips then hydrogel on top. Cover with gauze and stockinette
38
____ pad can be used on infected wounds
* Abdominal Pad
39
When should growth factor be placed in a wound?
Diabetic patients with chronic inflammatory!
40
Hydrocolloid: Thin vs Thick
- Thin (Allows O2, absorbs some moisture) - Thick (No O2/infection, lots of absorbing)
41
When is Semiperbiable film good to use?
Superficial intact skin. Reduces friction and is clear.
42
When should you clean a wound?
* EVERY TIME
43
How to knoe when do use selective vs non selective to clean a wound?
- >50% = Nonselective (Whirlpool and Spray Surfactant >8 psi) - <50% = Selective (Spray Surfactant <8 psi)
44
If you see a yeast infection you should...
have glucose levels checked
45
Semipermeable Thin vs Hydrocollpid Thin
* SMT is clear and cheaper * Hydrocolloid can absorb; waterproof
46
MeSalt vs Calcium Alginate
CA: o More expensive o Better at remaining premoistened o Better for superficial wounds o Can stop bleeding and help renal insufficiency people clot o 20x absorption Me: o Good for all infected wounds o Packs in dead spaces o 30x absorption
47
____ don't stick to wounds and hydrates the area
Vaseline impregnated gauze
48
Nutritional Requirements and Why?
Acetic Acid: - Lactic acid creates chemokines, signal for neutrophils to come to injury Zinc: - Required for MMPs - Lack will result in only MMPs getting resources and not TIMPs resulting in chronic wounds Magnesium: - Smooths out nerve conduction velocity - Building block of collagen Protein - Building blocks for cells and repairment Vitamin C Oxygen
49
You should never have people ____ when wound healing
lose weight
50
Red Flags - Contact ED
- Positive Homan’s sign/cuff test – DVT - Tetanus NOT up to date (> 10 years since last) - Systemic Infection (Temperature equal or > 101, night sweats); They are moving into sepsis
51
Non-life threatening: major delays in wound healing
- Infected wound (> 10^5 CFUs) - High Blood Sugar (Glucose >100, A1c >6.0) - Venous Insufficiency, LE edema - Smoking - Sedentary Lifestyle
52
Underlying conditions that delay/complicate wound healing
Conditions - Diabetes - Autoimmune diseases, RA, HIV-Aids-Lupus-RA Circulation Impairments - Arterial insufficiency - Venous insufficiency - Diabetic wounds (DM > 15 years)
53
Pressure ulcer risk needs to be assessed ____ for all hospitalized patients.
at least daily
54
____ wounds need daily dressing changes
Infected
55
When you have a dirt infected wound you should use ____
- Antimicrobial dressings (+Ag) And - Silver impregnated gauze
56
NEVER SEAL AN ____ WOUND
INFECTED
57
What can you not use with silver impregnated dressings?
Collagenase
58
Elevation and Compression Guidelines for AI and VI
AI * Leg at heart level * Compression BELOW 32 mm Hg VI * Leg above the heart * Compression at 40 mm Hg
59
8 psi >10^5 CFUs (10^3 CFUs) <0.8 ABI 10gm (5.07) 50% 40 mm Hg 32 mm Hg 175 mm Hg (125 mm Hg)
* **8 psi** – maximum amount of pressure that does not disrupt granulation tissue. * **>10^5 CFUs** – clinical evidence for infected. **10^3** = contamined, strep * **<.8 ABI** – Arterial Insuffiency that you can still use an occlusive dressing and debride and compress * **10gm (5.07)** – monofilament testing, protective sensation in extremity * **50%** - Selective vs Non Selective; 50% or more Non selective; <50% Selective * **40 mmHg** – Venous Insufficency Stasis compression; amount of pressure in a cuff that indicates a DVT of pain in calf – Homan Test * **32 mmHg** – pressure to occlude capillaries (If AI must be below this) * **175mmHg** – Average VAC compression for most wounds; **125mmHg** for AI or skin graft site.
60
Pulsed Lavage Indications
* **Deep tunneling wounds or >70% necrotic tissue** * Immobilized or patients with multiple wounds (prevents cross contamination) * Patients with wounds in isolation * Forceful irrigation with adjustable psi
61
What is the main advantage of using enzymatic debridement with a wound?
Removed ONLY necrotic tissue from the wound
62
What is an advantage of an occlusive dressing?
Autolytic debridement
63
Skin charge
-
64
Tissue charge
+
Integument
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