584 Wounds

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Author:
alannaheeres
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197220
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584 Wounds
Updated:
2013-02-01 17:37:26
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584 Wounds
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584 Wounds
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  1. Which phase of healing?
    Plug damaged vessels & remove debris
    Homeostasis
  2. Which phase of healing?
    Reaction phase
    Stimulation of fibroblasts to produce collagen
    Erythema/pain/heat/edema
    Inflammatory Phase (4-6 days)
  3. Which phase of healing?
    Angiogenesis
    Collagen is laid down
    Granulation tissue forms
    Epithelial cells migrate
    Scar is formed
    Proliferative Phase (4-24 days)
  4. Which phase of healing?
    Collagens reorganizes, remodels and matures
    Tensile strength reaches only maximum 80% after 2 years
    Maturation Phase (21 days - 2 years)
  5. If the wound lasts for more than ________ it is deemed chronic
    3-4 weeks
  6. What can affect the phases of healing? (3)
    • Infection
    • Lack of blood flow
    • Traumas
  7. What wounds/ulcers often get stuck in the inflammatory phase?
    • Dehiscence wound
    • Diabetic ulcers
    • Pressure ulcers
    • Venous stasis ulcers
    • Ischemic wounds
    • Inflammatory ulcers
  8. How will secondary intention wounds heal?
    Grow up and in from the sides
  9. What does 'maintenance' mean for intervention?
    • Closure is not expected
    • Not a surgical candidate due to multiple complications
    • Palliative patient
    • Palliative wound 
  10. What are the 3 steps for wound assessment?
    • 1. Remove the old dressing
    • 2. Cleanse the wound
    • 3. Measure and record wound parameters
  11. Wound Bed:
    žyellow, stringy, adherent, necrotic
    tissue
    Slough
  12. Wound bed:
    žblack, dry, hard, adherent, necrotic tissue
    Eschar
  13. Wound bed:
    žred, perfused tissue/buds
    Granular
  14. Wound bed:
    žpink, wound closure tissue 
    Epithelial
  15. How can you tell the difference between slough and fat?
    You need to know the level of the dermis
  16. Exudate
    Color is clear
    Synovial fluid
  17. Exudate:
    Color is red
    Sanguinous
  18. Exudate:
    Color is yellow
    Purulent (puss)
  19. Exudate:
    Color is Green
    Pseudomonas
  20. Odor:
    Foul
    infection
  21. Odor:
    Sweet
    Pseudomonas infection
  22. Which type of skin?
    žRedness(erythema)
    žCallus
    žDryness
    žDermatitis (rash)
    žMaceration
    žBlistered
    žEdema
    žDermatological signs
    Periulcer skin
  23. žA proven inhibitor of healing
    žLocalized edema around every wound due to
    the destruction of the local lymphatic anatomy 
    Edema
  24. ž↑ redness
    ž↑ exudate
    ž↑ pain
    žFoul odor
    žLocal edema
    žFriable wound bed
    žTracking/undermining
    žNon-healing
    žDermal temperature >3º relative to
    local structures
    Infection
  25. What do you need to have to determine infection?
    A history of change in presentation
  26. žProvides the necessary environment for epithelial cells to thrive
    Moist Wound Healing
  27. Significantly delays cellular migration and increases scarring
    Dry wound bed
  28. What is OTs main role in wound care
    Managing the cause of the wound
  29. What are the local factors that inhibit healing?
    • žInfection
    • žEdema
    • žPressure:the exertion of force by one body on the surface of another
    • žFriction:The action of one surface or object
    • rubbing against another
    • žShear: A strain produced by pressure in the
    • structure of a substance, when its layers are laterally shifted in relation to each other.
    • žTrauma
    • žPoor moisture balance
    • žCytotoxins
  30. What are the clinical signs of ischemia
    • žCool
    • žMottled 
    • žHairless
    • žThin, shiny skin
    • žPulseless 
    • žDependent rubour
    • žPallor on elevation
    • žIntermittent claudication: -cramping/squeezing pain
    • žRest pain
  31. Which type of edema?
    žHereditary
    žUnbalanced distribution of adipose in the legs.
    Obesity
    Non/mild pitting
    No am/pm edema fluctuation
    Prone to cellulitis
    Responds minimally to compression therapy
    Lipedema
  32. Which type of edema?
    žCongenital
    žTrauma/Surgery
    žMalignancy
    žProlonged chronic venous insufficiency
    žObesity
    žFilariasis (parasitic infection)
    Lymphedema
  33. Which type of edema?
    žLarge system failure
    žMedications: corticosteroids, NSAIDS, anti-hypertensives, DM meds
    žHypothyroidism
    žMalignancy: pelvic, abdominal, prostate
    žCellulitis
    Central Edema
  34. Which type of edema?
    žObstruction/ DVT
    žCalf pump failure
    žValve dysfunction/failure
    žFracture/trauma
    žCellulitis
    žGenetic/congenital
    žSitting/standing jobs
    žObesity
    žPregnancy
    Chronic Venous Insufficiency
  35. Which type of edema?
    žSkin changes
    žProne to ulceration
    žEdema
    -Bilateral /unilateral
    -Medial lower 1/3 (gaiter region)
    -Below the knee
    -Tender on palpation
    -Late day accumulation
    -Relieved with elevation
    -Digits are spare
    Chronic Venous Insufficiency
  36. Staining when RBCs go to surface
    Hemosiderin Staining
  37. Key Management Strategies for Edema (4)
    • Management of central causes
    • Compression therapy to reduce/eliminate  edema. (Compression wraps, Compression garments)
    • Elevation
    • Ambulation
  38. When is ABI contraindicated? (8)
    • ABI < 0.6
    • žUntreated cellulitis
    • žAcute CHF/CRF/Pulmonary Disease/Liver
    • Failure
    • žUntreated DVT
    • žBleeding Disorders
    • žPatient centered Concerns
    • žCognitive Impairment
    • žFunctional Impairment (donning/doffing)
    • žSocial Support
  39. Compression Therapy:
    What are your short term goals?
    • Edema reduction
    • Determine minimum therapeutic compression strength
    • -Plan: Compression therapy wraps
  40. Compression Therapy:
    What are your long term goals?
    • Edema maintenance
    • -Plan: Compression therapy garments
  41. žMinimum ___mmHg pressure on the tissues in the presence of +1 pitting edema
    32
  42. Should compression garments have the same pressure everywhere?
    No, graduated compression with 100% at foot and 50% below knee
  43. What are the 4 stages of pressure ulcers?
    • Stage 1 – redness that lasts more than 30 minutes
    • Stage 2 – blistering
    • Stage 3 – subcutaneous layer seen
    • Stage 4 – through to muscles, tendons and bone
  44. Sensory Neuropathy (8)
    • žNumbness
    • žBurning
    • žTingling/pins and needles
    • žShooting pains
    • žLoss of pain
    • žLoss of temperature
    • žLoss of vibration
    • žLoss of proprioception
  45. Causes a lack of protective sensation (LOPS), therefore; undetected pressures over boney areas/calluses leads to tissue ischemia 
    Peripheral Neuropathy
  46. žSecondary to autonomic neuropathy
    žLocal increase in circulation causes demineralization of the bone
    -“Tofu” bone
    -Multiple small boney fractures
    -Reabsorbtion of bone
        -Ie: red, hot, +/- pain
        -Dx: bonescan
    Charcot Foot

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