Term
| Name 8 items that affect wound healing |
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Definition
Nutrition
Age
Smoking
Infection/colonization
Medications
Blood sugars
Stress
Temperature |
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Term
| Name the 3 phases of wound healing |
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Definition
Inflammatory
Proliferative
Remodeling |
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Term
| This stage of wound healing includes hemostasis, rush of platelets, macrophages, etc. WBCs. Drugs that decrease this stage interfere. A chronic wound may get stuck in this stage. |
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Definition
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Term
| This stage of wound healing is where granulation tissue forms. Epidermal migration. Stuck here = hypergranulation/chronic wound. This is where the wound matrix is established. |
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Definition
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Term
| This is the stage of wound healing where there is collagen remodeling, the wound will never be more than 80% of the pre-injury strength |
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Definition
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Term
| The removal of non-viable tissue |
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Definition
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Term
| Wet-to-dry dressings can only work on what type of wound |
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Definition
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Term
| Why is it important to debride eschar or slough/non-viable tissue? |
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Definition
| Because it slows granulation and re-epithelialization and harbors microorganisms |
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Term
| This type of debridement is where the pt's body does the work. |
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Definition
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Term
| What is the most selective type of debridement |
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Definition
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Term
| This type of debridement is where you can use gauze to wipe; a wet-to-dry dressing. |
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Definition
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Term
| Which type of debridement is the least selective |
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Definition
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Term
| This type of debridement uses forceps, scissors, and scalpel. You must have experience and an order to do this independently. |
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Definition
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Term
| This type of debridement uses maggots |
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Definition
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Term
| This type of debridement uses a chemical via ointments applied to dissolve eschar |
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Definition
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Term
| In what situation would you need to clean a wound as opposed to leave it alone. |
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Definition
If it is necrotic or "dirty"
-Slough, eschar, odor, worrisome drainage |
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Term
| If the wound appears to be clean then should you clean it anyway? |
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Definition
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Term
| What are some basic questions to ask when first deciding on a dressing |
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Definition
1. Are there any S&S of infection
-Do not use occlusive dressing on an infected wound
2. How much drainage is present
3. Debridement needed vs. maintain a healthy wound |
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Term
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Definition
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Term
| The appropriate amount of moisture is essential in wound healing. If the wound is too wet go to absorptive dressings which include what 3 types |
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Definition
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Term
| This type of absorptive is cheap and good to use when you have to do multiple dressing changes |
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Definition
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Term
| Should you put occlusive dressing over an infected wound? |
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Definition
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Term
| What 2 types of dressings would be appropriate to add moisture to a dry wound |
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Definition
Occlusive
Semi-occlusive
Topicals |
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Term
| What is the exception to not moisturize dry wounds |
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Definition
Stable heel ulcers
Dry gangrene |
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Term
| What type of dressing is an occlusive? |
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Definition
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Term
| Name 3 ways in which dressings can be classified |
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Definition
-Primary/Secondary
-Occlusive/Semi-occlusive/Non-occlusive
-By components (foam, film, gauze) |
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Term
| A fancy word for Clorox bleach. Used on infected wounds |
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Definition
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Term
This type of dressing is cheap, absorbant, non-occlusive, but will stick to granulation.
-4X4s, telfa, vaseline gauze/xeroform, kerlix wraps
-Use on dirty wounds, wounds with heavy exudate, use to pack tunnels, tracts, undermining, use on wounds that have to be changed daily |
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Definition
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Term
This type of dressing is cheap, self-adhesive, semi-occlusive, and aids autolytic debridement
-Opsite, tegaderm
-Use on wounds that are generally clean, have minimal drainage, and the dressing can be left in place for a few days. |
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Definition
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Term
| This will stick but not adhere to the wound. Has a petroleum jelly component in it. |
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Definition
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Term
| Used commonly over IV or PICC line sites. Super sticky, non-absorptive, will tear fragile skin |
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Definition
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Term
| This will not adhere or stick to the wound |
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Definition
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Term
| This type of dressing is semi-occlusive, can be self-adhesive, aids in autolytic debridement, gentle on skin and can absorb significant amounts of drainage. (will not pull of granulation tissue) |
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Definition
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Term
Examples of this are polymem, flexzan, mitraflex, allevyn.
Should be used on generally glean wounds, but can handle more drainage than thin films |
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Definition
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Term
| "seaweed", calcium alginate or synthetic, non-occlusive, absorbs TONS of drainage |
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Definition
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Term
| Max absorbant, gentle on wound bed. Comes in foam or rope like forms. Needs a secondary dressing over it for added drainage control |
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Definition
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Term
| Thin ointments, very versatile for barrier (incontnence) or shallow wound healing (now have deneric allanderm) |
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Definition
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Term
| These type of creams are skin protectants |
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Definition
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Term
| These usualy come as a wipe-on or spray to prevent tape stripping of skin or maceration of wound edges. |
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Definition
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Term
| This type of ointment is OK for shallow wounds |
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Definition
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Term
Occlusive, good for autolytic debridement, cannot handle very much drainage, can tear fragile skin.
-Duoderm, signadress (will not let anything in or out) |
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Definition
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Term
-Papain/urea (gladase, accuzyme, panafil, ziox) breaks down non-viable protein. Papain ureas have just been removed from market
-Collagenase (santyl) breaks down non-viable collagen
-Used with n.s damp/dry or semi-occlusives
-Must be kept damp to work, not on dry eschar |
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Definition
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Term
| What is the half life of Silvadene? |
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Definition
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Term
-An old stand-by, can be used on lots of wounds
-Contraindicated on young kids
-Use with caution on pts with decreased renal or hepatic function
-Nice antibacterial and antifungal
-Can be covered with gauze or used without dressing |
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Definition
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Term
-PDGF, approved by FDA only for "diabetic" ulcers
-Very expensive
-Applied with damp-dry saline dressing
-Use on clean wounds only |
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Definition
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Term
| Used to hydrate or maintain hydration in a wound, come as a sheet or gel in a tube. Curagel, Vigilan |
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Definition
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Term
| Silver can be added to gels, gauzes, or foams. Effective against MRSA and pseudomonias. Only have to change once a week, just re-wet in the meantime |
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Definition
| Silver-Containing Dressings |
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Term
| Sodium hypochlorite, used to saturate gauze/packing; can be used for grossly necrotic/infected wounds, not for wounds with significant amounts of granulation tissue. |
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Definition
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Term
| Full strength of Dakin's is best for what? |
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Definition
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Term
| Half strength of Dakin's is best for what? |
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Definition
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Term
| Chlorine is the active ingredient; harsh on granulation |
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Definition
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Term
| Can be useful for pt with pseudomonias |
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Definition
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Term
| Name 4 aspects of wound classification |
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Definition
-Depends on type of wound
-Pressure sores use a staging system
-Other wounds use a classification system of full thickness - thru the dermis
-Some special classification systems are used at times (burns, diabetic neuro) |
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Term
| Full thickness with usually require what? |
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Definition
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Term
| The outermost layer, provides protection, moisture barrier |
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Definition
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Term
| Epithelial cells, has basement membrane where new cells are born, cells mature as they are pushed out to the epidermise |
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Definition
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Term
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Definition
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Term
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Definition
Epidermis
Dermis
Subcutaneous
Muscle, Bone, Organs |
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Term
| Name the 6 stages of pressure sores |
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Definition
1. Non-blanchable erythema
2. A blister or shallow crate, not into subcutaneous
3. A wound thru the dermis into the subcut, but not into ms or bone
4. A deel wound involving ms, bone, etc
5. Unstageable: eschar or slough on bed not allowing you to see the bottom of the wound
6. Deep tissue injury |
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Term
| A term being used more widely recently to describe the deep purplish discoloration seen on patients when a severe insult has occurred,but he tissue is not opened (epidermis intact) |
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Definition
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Term
| Do not make the mistake of staging this as stage 1 b/c its almost always deeper |
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Definition
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Term
| What should you stage a deep tissue injury |
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Definition
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Term
| Occurs from having prolonged pressure over a bony prominence usually but can be any area of the body. Can happen in as little as 15-30 minutes on bony areas under direct pressure (heels, ischial tuberosity) |
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Definition
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Term
| These are thought to originate deeply and expand outward. Weight-shifts and pressure-reducing surfaces are used to prevent these. |
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Definition
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Term
| Supposed to prevent capillary closing pressure, therefore allowing blood to continue to perfuse tissues. Ex: Clinitron Beds (air-fluidized) |
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Definition
| Pressure Relieving Suface |
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Term
| Does not completely prevent capillary closing, so still requires weight shifts or turning. EX: low air loss mattress, w/c cushion |
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Definition
| Pressure Reducing Surface |
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Term
-Occur on lower leg or foot
-Round wound with sharply demarcated edges
-Usually have a pale, red base |
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Definition
| Arterial Insufficiency Ulcers |
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Term
-Occur in patients who have poor arterial perfusion to the legs
-Rubor of dependency*, thin shiny skin, no hair, cold extremity (poikilothermia)
- Usually painful, especially with elevation or gait (claudication)
- ABI less than 0.8 |
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Definition
| Arterial Insufficiency Ulcers |
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Term
| These look like hole punches |
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Definition
| Arterial insufficiency ulcers |
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Term
-Usually occur on the ankle, with medial ankle being the most common area, but can occur anywhere on lower leg.
-Associated with hemosideran staining
-Waxy, thick skin, edema = probably mostly venous
-Thin, frail skin may indicate areterial componenet also
-THe entire leg can be oozing serous fluid in severe cases, with dozens of small open ulcers, or can be one large ulcer with eschar/slough |
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Definition
| Venous Insufficiency Ulcers |
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Term
-These are typially shallow wounds with significant slough and irregular borders, minimal pain
-Can be present for years without significant change |
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Definition
| Venous Insufficiency Ulcers |
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Term
| How can venous insufficiency ulcers be treated? |
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Definition
-Compression (MOST IMPORTANT)
-Good local wound care
-Unna's boots (effective ONLY if pt is ambulatory)
-Layer compression wraps provide more consistent compression in many professionals' opinions
-Sequential compression pumps (lymphedema) (good for ambulatory or not) |
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Term
| How are the location different for venous and arterial ulcers? |
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Definition
1.Venous - medial/ant ankle, medial lower legs
2.Arterial - anywehre on foot/leg |
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Term
| What does the wound/skin look like with venous insufficiency ulcers? |
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Definition
| Slough, irregular borders, lots of drainage, hemosideran stain, wet appearance |
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Term
| What does the wound/skin look like with arterial insufficiency ulcers? |
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Definition
| pale, granulated base, uniform round wound, rubor of dependency, thin and shiny skin |
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Term
| <0.8 indicates impaired arterial perfusion (do not trust pulse palpation) |
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Definition
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Term
| How is pain different with arterial and venous insufficiency ulcers? |
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Definition
Arterial - painful, with LEs painful when elevated
Venous - minimal pain |
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Term
| What does TCOM stand for? |
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Definition
| Transcutaneous Oximetry Measurement |
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Term
| a non-invasive method of testing for arterial insufficiency by measuring the cutaneous oxygen saturation |
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Definition
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Term
| What might low values indicate with a TCOM? |
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Definition
| The need for arteriography and revascularization |
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Term
| What might marginal values indicate with a TCOM? |
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Definition
| The use of hyperbaric oxygen therapy |
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Term
| Surgeons commonly use the TCOM test to help determine levels of what? |
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Definition
| Amputation (at which level a pt is most likely to heal) |
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Term
| The true "diabetic" wounds. People with diabetes can have any type of wound. Classify them carefully. |
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Definition
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Term
| If a diabetic person has a pressure sore how do you classify it? |
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Definition
| Using the pressure system (not as a neuropathic wound) |
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Term
| __ __ wounds occur typically on the bony prominences on the plantar surface of the foot, especially the met heads, but can also occur on other surfaces of the foot. |
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Definition
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Term
| The origin of these wounds are altered biomechanics of the foot, resulting in excessive shear to areas of the foot. People with diabetes lose protective sensation to the feet, and the result is that over time the feet are subjected to many small insults that result in altered structure |
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Definition
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Term
| What do neuropathic wounds typically look like? |
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Definition
| Round with large amounts of callous built up around the perimeter |
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Term
| Can neuropathic wounds occur in anyone with neuropathy or just people with diabetes? |
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Definition
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Term
| How can you treat neuropathic wounds |
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Definition
1. Must remove the shear. Pts must be placed in total contact casts, custom boots, custom insoles, etc or become NWB for these wounds to heal. Pt compliance is a must.
2. Shave the perimeter callous to enable the epithelial cells to migrate over the granulation.
3. Good local wound care, moist not wet
4. Good control of blood sugars |
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Term
| Can you test sensation over a callous area? |
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Definition
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Term
| What classification scale is used for diabetic sores? |
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Definition
|
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Term
| list the 5 grades of the Wagner scale |
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Definition
Grade 0: Preulcerous lesion, healed ulcer or bony deformity
Grade 1: Supeficial ulcer, no subcutaneous involvement
Grade 2: Subcutaneous, and may involve bone, ligaments or joint capsule
Grade 3: Osteitis, abscess, or osteomyelitis
Grade 4: Gangrene of a digit
Grade 5: Gangrene requiring foot amputation |
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Term
| Name the 3 categories of skin tears |
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Definition
Category 1: Fully approximated (less than 1mm space), usually occurs in a wrinkle
Category 2: partial thickness wound, but flap is present
Category 3: still partial thickness wound, but there is no viable flap |
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Term
| How should you try to manage skin tears? |
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Definition
-Try to save the flap
-Moist wound care for open wound, possibly just a topical for category 1's. Polymems work great.
-If flap dies or you cannot unroll, will need to be debrided. |
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Term
| Every wound eval should include the following: |
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Definition
-Color: describe the wound bed (%granulation, %slough, %necrosis, % bone, etc)
-Odor: musty, foul, sweet (pseudomonias)
-Drainage: amount, color, texture
-Extent: measure of the wound
-Surrounding skin: describe the perimeter, surrounding skin |
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Term
| How often should you measure the wound? |
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Definition
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Term
| Name the different methods of measuring wounds |
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Definition
-Use width x length x dept (width is horizontal, length is vertical)
-Use the clock system with dorsum or head of the person being 12:00
-Use volume (rare)
-Trace the wound on special film |
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Term
| A shelf along the perimeter of a wound |
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Definition
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Term
| Long thin opening in wound, a tunnel is open at both ends with a tract "dead ends" |
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Definition
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Term
| What are 6 questions you can ask to get the big picture about the wound? |
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Definition
1. What is etiology?
2. What has been tried before?
3. What medications are being taken?
4. Is cellulitis present, and is the pt on antibiotics?
5. Is the pt going to be able/willing to be compliant with your plan of care?
6. What allergies does the pt have? |
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Term
| The original vacuum dressing, uses foam on wound base, covered with film dressing, vacuum applied. Usually changed MWF |
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Definition
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Term
| This type of vacuum dressing uses gauze or foam to wound base. Changed BIW if gauze, TIW if foam |
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Definition
| Smith and Nephew Vista/Versatile One |
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Term
| Lessens the amount of dressing changes you have to do |
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Definition
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Term
| Can you use topicals under a vacuum dressing? |
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Definition
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Term
| Which type of vacuum dressing is cheaper and the gauze is easier to use with undermining and tunnels? |
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Definition
| Smith and Nephew Vista/Versatile One |
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Term
| This type of wound dressing has more options, it instills solutions into wounds. Fenestrated dressing for body cavities |
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Definition
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Term
-Special pressure chambers used
-1.5 to 3 times normal atmospheric pressure
-Used for gas gangrene, osteomyelitis, most often
-Medicare will cover if standard wound care has not been effective and wound demonstrates progress with HBO |
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Definition
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Term
-Human skin has endogenous biocurrents
-Current types used are DC, TENS, and HVPC.
-High volt has the most support int he literature
-Medicare covers if wound has shown no progress with standard wound care, MD has to recently approve for OP coverage |
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Definition
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Term
-Has been rumored to be effective in producing more fibroblasts and collagen
-Never gained widespread acceptance
-Not reimbursed by Medicare
-Now have ultrasound technology for debridement, which is Medicare reimbursed, called MIST |
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Definition
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