Term
| 10 components of wound assessment |
|
Definition
location
type
measuremnts
description
wound edges
drainage
Amount of drainage
Surrounding skin
Edema
Pain |
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|
Term
| Wound Assessment: Location refers to what |
|
Definition
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|
Term
| Wound Assessment: type refers to what (6) |
|
Definition
pressure
stasis
surgical
diabetic
traumatic
arterial |
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|
Term
| Wound Assessment: measurement refers to what (5) |
|
Definition
length
width
depth
undermining
tunneling |
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|
Term
| Wound Assessment: description refers to what (5) |
|
Definition
% of each:
early/partial granulation
full granulation
slough
eschar
epitheliization |
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|
Term
| Wound Assessment: wound edges refers to what (2) |
|
Definition
|
|
Term
| Wound Assessment: drainage refers to what (3) |
|
Definition
serous
sero sanguinous
purulent |
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|
Term
| Wound Assessment: drainage amount refers to what (4) |
|
Definition
small
moderate
large
copious |
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|
Term
| Wound Assessment: surrounding skin refers to what (5) |
|
Definition
intact
erythema
maceration
denuded
indurated |
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|
Term
| Wound Assessment: edema as in waht (3) |
|
Definition
pitting (1-3)
non pitting
none |
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|
Term
| Wound Assessment: pain as in what (2) |
|
Definition
|
|
Term
|
Definition
clear to light yellow
watery
normal |
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|
Term
|
Definition
darker yellow (straw colored) to red tinged
still watery/normal |
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|
Term
|
Definition
| red slightly thicker than water/normal |
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|
Term
|
Definition
thickened exudate can be white, yellow, green, blue
sign of infection |
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|
Term
| odor with exudate indicates what |
|
Definition
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|
Term
| how can a wound edge be closed (2) |
|
Definition
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|
Term
|
Definition
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|
Term
|
Definition
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Term
|
Definition
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|
Term
|
Definition
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|
Term
| optimal wound healing requirements: (6) |
|
Definition
optimal moisture
get necrotic tissue out
fill dead space or cover
protect periwound skin
manage bioburden
protect and insulate |
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|
Term
| optimal wound healing requirements: how can you get necrotic tissue out (6) |
|
Definition
enzymatic debridement
autolytic debridement
mechanical debridement
conservative sharp
sharp debridement
biosurgery |
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|
Term
| what are the 2 types of dry wounds |
|
Definition
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|
Term
| 2 types of mechanical debridement |
|
Definition
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|
Term
| difference between selective and nonselective debridement |
|
Definition
nonselective takes out good and bad tissue
selective takes out bad tissue only |
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|
Term
| enzymatic debridement agent |
|
Definition
|
|
Term
| what does necrotic tissue impede (2) |
|
Definition
epithelialization
wound contraction |
|
|
Term
|
Definition
open closed wound edges
remove callus
reduce bacterial burden
facilitate angiogenesis
decrease MMPs and senescent cells
stimulate GF release |
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|
Term
| how does debridement stimulate GF release |
|
Definition
| slough blocks cells from recieving GFS |
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|
Term
| indications for selective sharp debridement |
|
Definition
large necrotic areas
slough or eschar
callus |
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|
Term
| contraindications for selective sharp debridement (3) |
|
Definition
ABI <.5
Out of PT comfort zone
Caution with anticoaguloants, immune suppression |
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|
Term
| what is autolytic debridement |
|
Definition
| natural degradation of devitalized tissue and fibrin by using patients own wound fluid which contains proteinase |
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|
Term
| how is autolytic debridement done |
|
Definition
| locking in wound fluids with a moisture retentive dressing |
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|
Term
| autolytic debridement may not work with what population |
|
Definition
| very elderly as they may lack proteinase |
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|
Term
| autolytic debridement contraindications (3) |
|
Definition
dry gangrene
LE wound with ABI <.5
Infected, untreated, deep wound |
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|
Term
| technical definiton of infection |
|
Definition
| 10^5 colonizing bacteria in 1 gram of tissue |
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|
Term
| only enzymatic debrider left on the market is what |
|
Definition
|
|
Term
| how does enzymatic debridement work |
|
Definition
| by breaking the collagen bonds that adhere necrotic tissue to wound bed |
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|
Term
| enzymatic debridement works well on what, less so on what |
|
Definition
| slough, less so on eschar |
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|
Term
| wen using santyl what should be used to cover the wound |
|
Definition
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|
Term
| (3) examples of selective mechanical debridement |
|
Definition
pulse lavage
low frequency ultrasound
jet ox |
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|
Term
| 2 examples of non selective mechanical debridement |
|
Definition
wet to dry dressing
whirlpool |
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|
Term
| why is surgical debridement done (4) |
|
Definition
area to be debrided is too large to use other means
signs of systemic infection is present
lack of blood flow
poor immune system |
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|
Term
| how is surgical debridement performed |
|
Definition
| surgeon in oR most often under general/local anesthesia |
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|
Term
| 3 questions to ask when treating a wound |
|
Definition
is it...
colonized
contaminated
infected |
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|
Term
| what is the more important factor when determining whether the patient has an infection |
|
Definition
| hosts ability to tolerate the bacteria causing the infection |
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|
Term
| assessment of bacterial burden: wounds and contamination |
|
Definition
| all wounds are contaminated |
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|
Term
| assessment of bacterial burden: what indicates a wound is contaminated |
|
Definition
| presence of non-replicating organisms in the wound |
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|
Term
| assessment of bacterial burden: what indicates a wound is colonized |
|
Definition
| presence of replicating organisms without a host immune response |
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|
Term
| assessment of bacterial burden: what indicates a wound is infected |
|
Definition
| presence of replicating bacteria with a host immune response |
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|
Term
| difference between oral and IV antibiotics |
|
Definition
oral antibiotics won't reach the wound bed
IV antibiotics will |
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Term
| critical colonization may present as (2) |
|
Definition
increase in exudate amount, color, odor
no visible signs other than compromised healing process |
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|
Term
|
Definition
swelling
induration
erythema
warmth
pain
odor |
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|
Term
| 3 types of wound cultures |
|
Definition
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|
Term
| gold standard of wound cultures |
|
Definition
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|
Term
| technique for swab wound cultures |
|
Definition
clean the area first
swab the healthiest part of the tissue making sure there is enough pressure to express fluid |
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|
Term
| what is the ideal dressing (5) |
|
Definition
manages exudate (not dessicating or macerating)
keeps the bacteria out
allows exchange of gasses
thermally insulating
non traumatic upon removal |
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|
Term
| disadvantages of gauze (4) |
|
Definition
traumatic removal
requires a secondary dressing
may leave lint, fibers in wound
allows bacteria in |
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|
Term
| pros of Transparent films |
|
Definition
permits visibility of wound
good secondary dressing
can promote autolytic debridement
up to 7 day wear |
|
|
Term
| characteristics of transparent films (2) |
|
Definition
thin polymer sheet
adhesive coating
semi occlusive |
|
|
Term
| cons of transparent films |
|
Definition
no absorbency
can cause skin tears
requires an absorbent dressing underneath of it |
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|
Term
| characteristics of hydrocolloids |
|
Definition
| top layer is a transparent film with a hydrophillic colloid that forms a gel on contact with wound fluid |
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|
Term
| pros of hydrocolloids (5) |
|
Definition
impermeable to bacteria and moisture
mild to moderate absorptive ability
autolytic debridement
good thermal protections
long wear up to 7 days |
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|
Term
| cons of hydrocolloids (3) |
|
Definition
can macerate wound edges
can tape strip skin
some allergic reactions |
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|
Term
| when ae hydrocolloids contraindicated (2) |
|
Definition
when infection is present
diabetic foot ulcer |
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|
Term
| what wound are hydrocolloids good to use on |
|
Definition
|
|
Term
| characteristics of alginates |
|
Definition
| a composite of fibers derived from salts of algini acid (seaweed) compressed into sheets or ropes |
|
|
Term
|
Definition
highly absorbent
can be used when infection is present
good for tunneling
can help prevent maceration |
|
|
Term
|
Definition
can dry out a wound bed if there's not enough exudate present
need secondary dressing |
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|
Term
|
Definition
|
|
Term
|
Definition
30-40% more absorptive than alginates
good for cancerous wounds |
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|
Term
| characteristics of hydrogels |
|
Definition
amorphous gels and sheets
can contain silver |
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|
Term
| hydrogels are good for what types of woudns (3) |
|
Definition
diabetic ulcers
arterial ulcers
burns |
|
|
Term
|
Definition
hydrate wound beds
assist in autolytic debridement
rinse easily from wound
reduce pain
sheets may stay in place 2-3 days |
|
|
Term
|
Definition
potential for maceation
gels may require daily dressing change |
|
|
Term
| characteristics of foam dressing |
|
Definition
| polyurethan open cell sheet |
|
|
Term
| pros of foam dressings (7) |
|
Definition
highly absorbent
wick drainage away from wound surface
can be used in infection
with and without adherent edges
enhances autolysis
can be used under compression wraps
good thermal and protective properties |
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|
Term
| cons of foam dressings (1) |
|
Definition
| may macerate edges of wound |
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|
Term
|
Definition
| freeze dried granules, gels, pastes derived from cow hide or tendon, also chicken tendon |
|
|
Term
|
Definition
recognized by tissue cells
provides a 3-D matrix for tissue ingrowth and angiogenesis
chemotactic for macrophages and fibroblasts
modualates effects of too many MMPs |
|
|
Term
|
Definition
potential for allergic response to bovine materials
expensive
requires clean uninfected wound to work
requires secondary dressing |
|
|
Term
| type of collagen found in synovial fluid, skin, umbilical cord, rooste comb and is identical no matter where derived |
|
Definition
|
|
Term
| what is regranex indicated for |
|
Definition
| diabetic lower extremity ulcers |
|
|
Term
| contraindicatinos for regranex (2) |
|
Definition
neoplasm at wound site
ABI <.5 |
|
|
Term
|
Definition
only on a clean infection free wound bed
needs good blood flow
must be refrigerated |
|
|
Term
|
Definition
| contains platelet derived growth factors |
|
|
Term
| gels created from patient's own centrifuged blood |
|
Definition
|
|
Term
| how are autologous platelet gels used |
|
Definition
| pt's own platelets are stimulated to release their contents of their alpha granules (GF's) |
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|
Term
| apligraft is used for what |
|
Definition
| full thickness diabetic ulcers without exposed tendon, jt capsule, or bone |
|
|
Term
| when can apligraft be used |
|
Definition
| 3 week hx of unresponsive to convenetional therapy |
|
|
Term
| tx protocol when using apligraft |
|
Definition
| clean, uninfected wound bed with decent vascularity. offload |
|
|
Term
| what process does dermagraft speed up |
|
Definition
|
|
Term
| silver is only antimicrobial in what state |
|
Definition
|
|
Term
| type of silver shown to be effective again MRSA and VRE |
|
Definition
|
|
Term
| HOw many ppm of silver to kill VRE and MRSA |
|
Definition
|
|
Term
non silver
traditionally cytotoxic
suspended in a starch polymer to provide a sustained relaease of antimicrobial activity for up to 72 hours
proven to be effective against VRE and MRSA |
|
Definition
|
|
Term
|
Definition
| minimum bacetercidal concentration |
|
|
Term
| MBC for clinically relevant bacteria |
|
Definition
|
|
Term
| problem with topical antimicrobials |
|
Definition
|
|
Term
| topical antimicrobials: kills pseudomonas |
|
Definition
|
|
Term
| topical antimicrobials: what is dakin's |
|
Definition
|
|
Term
| topical antimicrobial that is to never be used |
|
Definition
|
|
Term
| how long should iodine be used for |
|
Definition
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