NPTE > Wounds > Flashcards

Wounds Flashcards

(90 cards)

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1
Q

Depth of Superficial Wound

A

Epidermis remains intact (non blistering sunburn)

*what depth wound is this?

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2
Q

Depth of Partial-Thickness Wound

A

Through epidermis, possibly into but not through the dermis (abrasions, blisters, skin tears)

*what depth wound is this?

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3
Q

Depth of Full-Thickness Wound

A

Extends through dermis into deeper structures

*what depth wound is this?

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4
Q

Depth of subcutaneous wound

A

Extend through integumentary tissues and involve deeper structures (subcutaneous fat, muscle, tendon, bone)

*what depth wound is this?

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5
Q

Wagner Ulcer Grade = 0

A

No open lesion

*Wagner Ulcer Grade?

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6
Q

Wagner Ulcer Grade = 1

A

Superficial Ulcer (through epidermis and dermis but does not involve subcutaneous tissue)

  • Wagner Ulcer Grade?
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7
Q

Wagner Ulcer Grade = 2

A

Deep Ulcer w/ penetration through subcutaneous tissue (exposing bone, tendon, ligament)

  • Wagner Ulcer Grade?
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8
Q

Wagner Ulcer Grade = 3

A

Deep ulcer with osteitis, abscess or osteomyelitis

  • Wagner Ulcer Grade?
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9
Q

Wagner Ulcer Grade = 4

A

Gangrene of digit

  • Wagner Ulcer Grade?
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10
Q

Wagner Ulcer Grade = 5

A

Gangrene of foot (requiring disarticulation)

  • Wagner Ulcer Grade?
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11
Q

Pressure Injury Stage = 1

A

Intact skin, non-blanchable erythema

  • Pressure Injury Stage?
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12
Q

Pressure Injury Stage = 2

A

Partial-thickness, through epidermis & exposed dermis, wound bed is viable

  • Pressure Injury Stage?
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13
Q

Pressure Injury Stage = 3

A

Full-thickness, adipose is visible, granulation/epibole often present, slough/eschar may be visible, undermining/tunneling may occur

  • Pressure Injury Stage?
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14
Q

Pressure Injury Stage = 4

A

Full-thickness; exposed: fascia, muscle, tendon, ligament, cartilage, bone; slough/eschar may be visible, epibole/undermining/tunneling often occurs

  • Pressure Injury Stage?
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15
Q

Pressure Injury Stage = Unstageable

A

Extent of damage cannot be confirmed due to it being obscured by slough or eschar

  • Pressure Injury Stage?
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16
Q

Pressure Injury Stage = Deep Tissue

A

Persistent non-blanchable deep red/maroon/purple discoloration

  • Pressure Injury Stage?
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17
Q

Exudate Classification = Serous

A

Clear, light color and thin, watery consistency.
Normal, observed during inflammatory and proliferative phases.

  • Exudate Classification?
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18
Q

Exudate Classification = Sanguineous

A

Thin, watery consistency.
Red color due to presence of blood which may become brown.
Indicative of new blood vessel growth or disruption of blood vessels.

  • Exudate Classification?
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19
Q

Exudate Classification = Serosanguineous

A

Light red/pink color, thin, watery. Normal in healthy healing wound. Observed during inflammatory or proliferative phases.

  • Exudate Classification?
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20
Q

Exudate Classification = Seropurulent

A

Cloudy or opaque, with yellow or tan color, thin, watery consistency. Early warning sign of impending infection. Abnormal.

  • Exudate Classification?
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21
Q

Exudate Classification = Purulent

A

Yellow or green color, thick, viscous consistency. Indicator of wound infection. Abnormal.

  • Exudate Classification?
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22
Q

Necrotic Tissue = Eschar

A

Hard, leathery, black/brown, dehydrated tissue, tends to be firmly adhered to wound bed

  • Necrotic Tissue?
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23
Q

Necrotic Tissue = Gangrene

A

Death and decay of tissue resulting from interruption in blood flow

  • Necrotic Tissue?
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24
Q

Necrotic Tissue = Hyperkeratosis

A

Aka callus, white/gray in color, vary in texture

  • Necrotic Tissue?
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25
Necrotic Tissue = Slough
Moist, stringy or mucinous, white/yellow tissue, loosely attached in clumps to wound bed * Necrotic Tissue?
26
Debridement = Sharp (Selective or Non-Selective? + Describe)
Selective Use of Scalpel/Scissors/Forceps Used for large amounts of thick/adherent/necrotic tissue, cellulitis or sepsis *What kind of debridement?
27
Debridement = Enzymatic (Selective or Non-Selective? + Describe)
Selective Topical application of enzymatic preparation Infected or non-infected Used in non-responding autolytic debridement or in conjunction with other *What kind of debridement?
28
Debridement = Autolytic (Selective or Non-Selective? + Describe)
Selective Establishment a moist wound environment Use of transparent films, hydrocolloids, hydrogels and/or alginates *what kind of debridement?
29
Debridement = Wet-To-Dry (Selective or Non-Selective? + Describe)
Non-Selective Application of a moistened gauze over area of necrotic tissue, allowed to completely dry then removed. Moderate amount of exudate and necrotic tissue. *What kind of debridement?
30
Debridement = Irrigation (Selective or Non-Selective? + Describe)
Non-Selective Pressurized fluid. Pulsation lavage. Used in infected wounds or have loose debris. *what kind of debridement?
31
Debridement = Hydrotherapy (Selective or Non-Selective? + Describe)
Non-Selective Whirlpool tank w/ agitation directed towards wound. Helps soften and loosen adherent. *What kind of debridement?
32
Burn Type = Thermal
Caused by conduction or convection; contact with hot liquid, fire or steam. * Burn Type?
33
Burn Type = Electrical What is typically seen?
Passage of electrical current through the body Often entrance and exit wounds * Burn Type?
34
Burn Type = Chemical
Certain chemical compounds come in contact with body. Common: sulfuric acid, lye, hydrochloric acid, gasoline. * Burn Type?
35
Burn Type = Radiation
Exposure to external beam radiation therapy. DNA is altered. * Burn Type?
36
Burn Classification = Superficial Burn (Layers, appearance, healing timeline)
Only the outer epidermis, red with slight edema, healing occurs without peeling in 2-5 days. * Burn Classification?
37
Burn Classification = Superficial partial-thickness (Depth, appearance, pain?, healing time?)
Epidermis and upper portion of the dermis. Extremely painful, exhibit blisters. Minimal to no scarring 5-21 days. * Burn Classification?
38
Burn Classification = Deep partial-thickness (Depth, appearance, pain?, healing time?)
Complete destruction of the epidermis and majority of the dermis. Discolored with broken blisters and edema. Moderate levels of pain due to damaged nerve endings. Healing occurs in 21-35 days. * Burn Classification?
39
Burn Classification = Full-thickness (Depth, appearance, pain?, treatment/healing)
Complete destruction of the epidermis and dermis + partial damage to subcutaneous fat layer. Eschar formation and minimal pain. Require grafts, susceptible to infection. * Burn Classification?
40
Burn Classification = Subdermal (Depth, appearance, treatment/healing)
Complete destruction of the epidermis, dermis and subcutaneous tissue. May involve muscle and bone. Often multiple surgical interventions and extensive healing time. * Burn Classification?
41
Desiccated
Drying out or dehydration of a wound
42
Desquamation
Peeling or shedding of the outer layers of the epidermis
43
Ecchymosis
Discoloration occurring below intact skin resulting from trauma (bruise)
44
Erythema
Diffuse redness of the skin caused by capillary dilation and congestion or inflammation
45
Friable
Tissue readily tears, fragments, or bleeds
46
Hemosiderosis
Brown/dark red discoloration results from rupture of blood vessels and deposition around a wound
47
Induration
Abnormal hardening of the tissue that occurs at the edges of the wound, results from the accumulation of edema
48
Rule of Nines = What body parts are considered 9%?
Head & Neck Anterior Bilateral Arm/Forearm/Hand Posterior Bilateral Arm/Forearm/Hand *Rule of Nines = what % are these?
49
Rule of Nines = What body parts are considered 18%?
Anterior Trunk Posterior Trunk Anterior Bilateral Leg/Foot Posterior Bilateral Leg/Foot *Rule of Nines = what % are these?
50
Rule of Nines = What body parts are considered 1%?
Genital Region *Rule of Nines = What % is this?
51
Pros for Autolytic Debridement (3)
- safe when sharp not an option - decreased pain - less expensive
52
Cons for Autolytic Debridement (2)
- Slow results - No occlusive dressing to be used with infection
53
Pros for Sharp Debridement (2)
- Fastest - Bleeding can increase healing
54
Cons for Sharp Debridement (3)
- Can be painful - Can require surgery - Risk of vessel, nerve, tendon damage
55
Pros for Maggots (2)
- Highly selective - Fast
56
Cons for Maggots (3)
- Expensive - Limited resources - Reputation
57
Pros for Enzymatic Debridement (2)
- Effective for Eschar - Decreased Pain
58
Cons for Enzymatic Debridement (2)
- Very expensive - Slow results
59
Definition of Non-Selective Debridement
Use of outside forces to perform non-selective debridement Ex: Wet-to-dry, whirlpool, pulsating lavage, scrubbing
60
Definition of Enzymatic Debridement
Topical application that breaks down proteins in necrotic tissue
61
Definition of Autolytic Debridement
The body’s use of its own enzymes to destroy necrotic tissues; often used with wound dressings Ex: thin films, honey, alginate, hydrocolloids, hydrogels
62
Definition of Sharp Debridement
The use of instruments to selectively Debridement non-viable tissue from a wound Ex: scalpel, curette, scissors, forceps
63
What does DIMES stand for?
D - Debridement I - Infection M - Moisture E - Edges & Environment S - Support
64
Characteristics of Inflammation (vs Infection) (Edema, Temp, Drainage, Erythema, Pain)
Edema: Slight (within 4cm) Temp: Local increase Drainage: Mild amount, thin, clear fluid Erythema: Well defined near wound edges Pain: Proportionate to wound
65
Characteristics of Infection (vs. Inflammation) (Edema, Temp, Drainage, Erythema, Pain)
Edema: Disproportionate Temp: Broad area, hot to touch compared to other side, fever & malaise Drainage: large to copious amount, purulent or clear, thick or thin Erythema: broad, red streaking, blistering (clear or blood filled) Pain: severe, no position of comfort, change, disproportionate
66
What do you use to clean wounds? Non-infected vs infected?
Non-infected: soap & water Infected: antiseptic x2 weeks, then wash w/ water VERY LIMITED: hydrogen peroxide & iodine
67
Definition of Maceration
Softening and breaking down of skin due to prolonged exposure to moisture
68
Definition of Excoriation
Chafing/raw/irritated lesion, linear erosion of the skin by mechanical means (scratching, rubbing)
69
Definition of denuded
Loss of epidermis due to exposure to urine, feces, body fluids, wound exudate or friction
70
What does Ultrasound do for healing wounds? (4)
- enhances all phases of wound healing - increases collagen deposition, granulation tissue formation, angiogenesis - enhances wound contraction - improves scar pliability
71
Films: Indications (4)
- little or no exudate - necrosis - donor sites, lacerations, abrasions - protect intact blisters
72
Films - Contraindicated (3)
- moderate to heavy exudate - infected wounds - full-thickness burns
73
Hydrogels - Perks (4)
- often added to sheets and gauze - provides moisture to a dry wound - cool temperature reduces pain - fills dead space of deeper wounds
74
Hydrogels - Indications (5)
- partial and full-thickness wounds that are dry or moist - granulating wounds - wounds with necrosis - minor burns, skin tears, donor sites - infected wounds
75
Hydrogels - Contraindicated (2)
- wounds with moderate to heavy exudate - full thickness burns
76
Foams - Perks (4)
- absorbs - can be used as impregnation & layers - adhesive boarders - fills dead space
77
Foams - Indication (5)
- partial and full-thickness wounds - minimal to heavy exudate - softened necrotic tissue - fills dead space - reduce hypergranulation tissue
78
Foams - Contraindications (3)
- dry wounds - full-thickness burns - sinus tracts
79
Alginates - Perks (2)
- breakdown and absorb into a jelly substance - traps necrotic tissue
80
Alginates - Indications (3)
- partial and full thickness wounds with moderate to heavy exudates - bleeding wounds - fill dead space
81
Alginates - Contraindicated
- full-thickness burns - eschar covered wounds - minimal exudate or dry wounds
82
Hydrocolloids - Perks
- very sticky adhesive - get warm first, then it contours nicely - can absorb exudate
83
Hydrocolloids - Indications (3)
- partial and full-thickness wounds, with or without necrotic tissue - skin tears - lacerations
84
Hydrocolloids - contraindications (6)
- burns or dry wounds - heavy exudate - tunneling - infected - exposed tendon or bone - fragile periwound
85
Wound Fillers - Indications (4)
- partial and full-thickness wounds - infected - draining - deep
86
Wound Fillers - Contraindication (1)
- dry wounds
87
Silicone Gel Sheets - Indications
- prevention or improvement of appearance of old and new hypertrophic and keloid scars
88
Silicone gel sheets - contraindicated
- allergy/sensitivity - unhealed, open wounds
89
Collagen - Indications (6)
- chronic, non-healing wounds - partial and full-thickness wounds - granulation or necrotic wounds - infected and non-infected wounds - tunneling - minimal to heavy exudate
90
Collagen - contraindicated (3)
- heavy eschar - full-thickness burns - sensitivity to bovine products
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