Term
| What is the main question to ask when evaluating a wound. |
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Definition
| Does the pt have the opportunity to heal normally? |
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Term
| Used to assess how much packing is in each wound. The patient will have more packing in the wound following surgery. After that, you will never get as much packing in as they did during surgery due to the fact that the pt is now awake and swelling has increased. |
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Definition
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Term
| What all should you take note of when removing packing from a wound. |
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Definition
-only use one strip of material
-note what drainage looks like
-what kind of packing was used the first time |
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Term
| Name 7 aspects for documenting wounds |
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Definition
-Location
-tunnel?
-undermining?
-measurments - be specific
-description of tissue/wound bed
-Exudate
-Periwound |
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Term
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Definition
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Term
| Name 4 ways to measure wounds |
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Definition
-Grid (length and width)
-Facility rules about digital pics
-Length, width, depth (with q-tip)
-Clock method (3 o'clock)
-Describe each wound individually |
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Term
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Definition
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Term
| This exudate is clear. This is normal during inflammation and proliferation. |
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Definition
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Term
| This exudate is pink and watery (a little blood in it). This is normal in the early stages |
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Definition
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Term
| This exudate is cloudy - yellow. This is the first signal of wound infection and you should be concerned. |
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Definition
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Term
| This exudate is yellow, green, and thick. This means the wound is infected and may have an odor. |
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Definition
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Term
- Edema - well defined
- Increased temp at wound site
- Odor - necrotic tissue
- Exudate - gradual decrease over 3-5 days
- Exudate - bleeding and serous
- Pain - variable |
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Definition
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Term
-Edema - diffuse
-Systemic fever
-Odor - specific to bacterial organism
-Exudate - large amounts; remains high
-Exudate - seropurulent
-Pain - persistent |
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Definition
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Term
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Definition
-Tissue biopsy
-Needle aspiration
-Swab technique |
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Term
| Which type of culture is PT allowed to do? |
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Definition
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Term
| The process of a group of organisms living together, whereas infection is the invasion of tissues by microorganisms, resulting in a systemic reaction |
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Definition
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Term
| Odor is usually associated with __ organisms |
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Definition
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Term
| Name 6 things to note of the periwound area |
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Definition
-Erythema
-Induration (hardness)
-Warmth
-Maceration
-Scarring
-Wound margins |
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Term
| Would you put a snake bit in a whirlpool? |
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Definition
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Term
| What are some causes of maceration? |
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Definition
Moisture (from wound or dressing)
Laying in urine
Sweat |
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Term
| When would cleaning not be required? |
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Definition
-Granulation tissue
-Scant drainage
- without dressing residue
- without odor |
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Term
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Definition
| Sterile water and syringe (no debridement) |
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Term
| Name 2 types of debridement |
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Definition
hydrotherapy
pulsed lavage (suction)
-these might pull off granulation tissue and do more harm than good |
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Term
-Non-selective
-Cleansing of residual topical agents (silvadene)
-Softens eschar to promote debridement |
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Definition
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Term
-May damage healthy tissue
-Dependent position
-Increased metabolic demands (heat)
-Diabetic pt is temp sensitive
-Over hydration (maceration at edges)
-Elevated temp may cause further damage to burn site |
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Definition
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Term
| What type of debridement is good for pts who have dry crusty stuff on their wound? |
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Definition
| Hydrotherapy (to soak it) |
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Term
| When do you need to monitor vitals? |
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Definition
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Term
| What do you do with excessive bleeding |
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Definition
| Stop the bleeding, apply pressure, no hydrotherapy |
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Term
| What should you do with exposed tendon? |
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Definition
| Always keep tendon moist. If tendon is exposed, ROM should be gentle, watch it when stretching. Low reps, longer hold. |
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Term
| What should you do with exposed bone? |
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Definition
| Be very sterile, pack well to cover. May need IV antibiotics |
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Term
| What should you do when your pt has exposed organs? |
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Definition
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Term
| This is only to be used on wounds with large amounts of necrotic tissue or gross contaminants |
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Definition
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Term
| What does non-selective debridement mean? |
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Definition
| It removes everything from necrotic tissue to healthy tissue. (mechanical) |
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Term
| What type of debridement is the most selective? |
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Definition
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Term
-Traps exudate in a wound to allow macrophages and endogenous enzymes to perform debridement (slow)
-Little pain with this |
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Definition
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Term
-Borderline area for PT
-No scalpels for the novice, use forceps, tweezers, scissors
-May need to pre-medicate
-Can be painful and cause bleeding
-Know your structures. Never cut what you cannot see. May put license on the line
-In clinicals, always be supervised
-Must have physican order to do this |
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Definition
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Term
| These types of wounds might require packing or wicking of the wound. Fill the entire space including a tunnel without filling it too tightly |
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Definition
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Term
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Definition
| Keeping the exit wound open so it can heal from the inside out. Don't want the outer layer of skin to grow over wound |
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