215 Integumentary: Examination & Dressings

Front 1

What is the epidermis and blood supply?

Back 1

outer layer

no blood vessels

Front 2

what is the dermis and composition/components?

Back 2

inner layer

-composed of collagen and dense irregular connective tissue

-contains blood vessels, lymph, nerve endings, sebaceous and sweat glands

Front 3

what is the subcutaneous tissue?

Back 3

deep to dermis

AKA superficial fascia or subcutaneous fat

-consists of loose connective tissue and fat

-provides insulation, support, and cushion for skin; stores energy for skin

-deep investing fascia and muscles lie deep to subcutaneous layer

Front 4

what are values and cut-offs for prealbumin and what does it indicate?

Back 4

20-40 mg/dL

malnutrition <15 mg/dL

2-day half life (short-term gauge of nutrition)

Front 5

what are values and cut-offs for albumin and what does it indicate?

Back 5

3.5-5.5 g/dL

(malnutrition < 3.5 g/dL)

18-20 day half-life

(long-term gauge of nutrition)

Front 6

What are values and cut-offs for glucose levels?

Back 6

70-115 mg/dL (fasting)

indicates short-term management of diabetes

Front 7

What are values and cut-offs for Glycosylated hemoglobin (HbA1c)

Back 7

4%-6%

indicates long term diabetes management

good if <7%

Front 8

what is grading scale for edema?

Back 8

1+ barely perceptible indentation <1/4 inch pitting

2+ moderate 1/4-1/2 inch; return to normal < 15 sec

3+ Severe; 1/2 - 1 inch; 15-30 sec

4+ very severe; >1 inch; >30 sec

Front 9

How should vascular status be assessed?

Back 9

1. posterior tibial and dorsal pedal pulses

2. capillary refill (norm is < 3 secs)

3. Rubor of dependency (elevate LE for 1 min, sole of foot goes pale, lower LE to dependent position. Adequate arterial circulation = rubor in 15 secs. Inadequate = hyperemia or >30 secs

4. Ankle brachial index

Front 10

How is ankle brachial index taken and what are the cut-offs?

Back 10

dorsal pedal or posterior tibial systolic BP/ highest arm's SBP

norm = 1.0

< or = 0.9 is abnormal

< =0.5 is severe arterial disease, risk for critical limb ischemia, may have rest pain

Front 11

What is the monofilament for protective sensation?

Back 11

5.07 (10g)

Front 12

What is melanoma examination?

Back 12

A= asymmetry

B = border (irregular)

C = color; when color varies throughout a mole

D = diameter > 6 mm (pencil eraser)

E = elevation or evolving (raised or changing over time)

Front 13

What measurements are taken for wound eval?

Back 13

1. location

2. size and shape (length, width, tunneling and undermining

3. Tissue characteristics (% of viable versus nonviable tissue)

4. exudate characteristics: serous, purulent, sanguineous

Front 14

what does sanguineous exudate mean?

Back 14

red, signifies bloody discharge

Front 15

what does serous discharge mean?

Back 15

clear, signifies watery discharge

Front 16

what does purulent exudate mean?

Back 16

yellow, tan, or green

signifies potential infection

Front 17

what is selective debridement?

Back 17

done by scapel, scissors, enzymes, surgery, or autolytic dressing

Front 18

what is nonselective debridement?

Back 18

hydrotherapy

various dressings (wet to wet, wet to dry, dry to dry) in which necrotic tissue clings to the dressing when removed

Front 19

what should not be used in whirlpools or as topical agents on wounds?

Back 19

various antimircobial agents such as povidine-iodine, bleach and Dakin's solution may retard healing

Front 20

what is dressing selection based on?

Back 20

3 characteristics of the wound

1. color

2. depth

3. necrotic tissue with exudate

Front 21

what are gauze dressings

Back 21

May be used wet, moist, dry, or impregnated with petrolatum, antiseptics, or other agents

Front 22

What are indication for Gauze dressings?

Back 22

useful when

1. early debridement

2. exudate present

3. wound with tunneling

4. necrotic tissue with exudate

Front 23

Indications for wet-to-dry gauze dressing

Back 23

Mechanical debridement of necrotic tissue and slough

Front 24

what are indications for continuous dry gauze dressing?

Back 24

Heavily exudating wounds

Front 25

Continuous moist gauze dressings are indicated for:

Back 25

1. Protection of clean wounds
2. Autolytic debridement of slough or eschar
3. Delivery of topical needs

Front 26

what are advantages of gauze dressings?

Back 26

1. Readily available
2. Can be used with appropriate solutions such as gels, normal saline, or topical antimicrobials to keep wounds moist
3. Can be used on infected wounds
4. Good mechanical debridement if properly used
5. Cost-effective filler for large wounds

Front 27

what are Disadvantages of Gauze Dressings:

Back 27

1. Delayed healing if used improperly
2. Pain on removal {wet-to-dry)
3. Labor-intensive
4. Require secondary dressing
5. Avoid direct contact with granulating tissue

Front 28

when is gauze dressing contraindicated?

Back 28

over granulation tissue without some type of intermediate nonadherent dressing

Front 29

what indications for occlusive dressings?

Back 29

prevent air/gas exchange at wound surface

1. Useful to maintain tissue hydration

2. facilitates autolytic debridement

3. wound healing with less pain

Front 30

when are occlusive dressings contraindicated?

Back 30

1. infected wounds

2. deep ischemic ulcers

3. full thickness burns

4. very heavy exudate

5. Stage IV ulcers

Front 31

What is alginate dressing and indications for use?

Back 31

Soft, absorbent, derived from seaweed and react with wound exudate to form gel mass over the wound

INDICATIONS

1. mod-large amount of exudate

2. combo exudate and necrosis

3. wounds that require packing and absorbing

4. over infected and non-infected exudating wounds

Front 32

what are advantages of alginate dressings?

Back 32

1. Absorb up to 20 times their weight in drainage
2. Can be used over infected wounds
3. Fills dead space
4. Support debridement in presence of exudate
5. Easy to apply

Front 33

what are disadvantages of alginate dressing?

Back 33

1. Require secondary dressing
2. Can dry wound bed (not recommended for dry or lightly exudating wounds)

Front 34

what are transparent film dressings and indications?

Back 34

Clear, adhesive, semipermeable membrane dressings
1. Used to maintain moist wound environment with minimum to moderate exudate often in Stage I and Stage II pressure ulcers

2. secondary dressing

3. autolytic debridement

4. skin donor sites

5. cover for hydrogels

Front 35

Transparent Films are permeable to what?

Back 35

Atmospheric oxygen
Moisture vapor

Front 36

What are transparent films impermeable to?

Back 36

Water
Bacteria
Environmental contaminants

Front 37

What are the advantages of Transparent film dressings?

Back 37

1. Visual evaluation of wound without removal
2. Excellent bacterial barrier
3. Transparent & comfortable
4. Promotes autolytic debridement
5. Minimizes friction

Front 38

what are disadvantages of transparent film dressings?

Back 38

1. Non-absorptive
2. Application can be difficult
3. Not to be used on wounds with fragile surrounding skin

4. not to be used on infected wounds

Front 39

what are foam dressings?

Back 39

semipermable

hydrophilic on wound side (absorb moisture)

hydrophobic on nonwound side

-cushion and protect the wound

Front 40

what are indictions for foam dressings?

Back 40

1. Partial & full-thickness wounds with minimal to moderate exudate
2. Secondary dressing for wounds with packing to provide additional absorption
3. Provide protection and insulation

Front 41

what are advantages of foam dressings?

Back 41

1. Insulate wounds
2. Provide some padding
3. Most ore non-adherent
4. Conformable
5. Manage minimal to heavy exudate
6. Easy to use

Front 42

what are disadvantages of foam dressings?

Back 42

1. Nontransparent
2. Non-adherent foams require secondary dressing, tape, or net to hold in place
3. not for use with dry eschar or wounds with no exudate

Front 43

what are hydrocolloids

Back 43

-Adhesive wafers that interact with wound to form gelatinous mass
-May be either occlusive or semi-occlusive
-Absorbs minimal to moderate exudate

-protects partial thickness wounds

Front 44

what are advantages of hydrocolloid dressings?

Back 44

1. Maintain a moist wound environment
2. Nonadhesive to healing tissue
3. Conformable
4. excellent bacterial barrier
5. Supports autolytic debridement
6. Minimal to moderate absorption
7. Reduces pain
8. Easy to apply
9.Time-saving
10. diminish friction

Front 45

what are disadvantages of hydrocolloid dressings?

Back 45

1. Not used for heavily exudating wounds
2. not for use over infected wounds

3. nontransparent

4. dressing edges may curl

5. may soften or change shape with heat or friction

Front 46

what are hydrogels and indications?

Back 46

Water or glycerine-based gels
-absorb minimal amounts of exudate

-allow some exudate to pass through to a secondary dressing

-Partial- & full-thickness wounds with necrosis
e.g. Burns & tissue damaged by radiation

Front 47

what are advantages of hydrogels?

Back 47

1. Soothing and cooling
2. Fill dead space
3. Rehydrate dry wound beds and maintains moist wound environment
4. Promote autolytic debridement
5. Provide minimal absorption
6. Conform to wound
7. Transparent
8. non-adherent
9. Amorphous form can be used when infection is present

Front 48

what are disadvantages of hydrogel dressings?

Back 48

1. Most require a secondary dressing
2. Not used for heavily exudating wounds
3. May macerate surrounding skin

Front 49

what are Semirigid dressings?

Back 49

Unna boot

-a pliable, non-stretchable dressing impregnated with ointments (zinc oxide, calamine and gelatin)
-Used for venous insufficiency ulcers to control for edema and help with healing

Front 50

what modalities promote wound healing?

Back 50

1. Iontophoresis

2. US

3. Estim

4. VAC

Front 51

How can iontophoresis be used to assist with wound healing?

Back 51

-used with zinc or histamine

Zinc oxide = positive so use anode

Front 52

how can US be used for wound healingq

Back 52

to speed up wound healing

low intensity, pulsed US

3x/wk

Front 53

How is Estim used to promote wound healing and what type is best?

Back 53

used to increase wound healing or reduce bacterial contaminants

-High-volt pulsed current (HVPC) = most common d/t no side effects and evidence shows promotes healing

-Low-voltage continuous direct current = proven beneficial but potential (similar to iontophoresis) to harm client

Front 54

what do the different electrodes do for wound care?

Back 54

-anode (positive): promotes epithelial cell migration and reactivation of the inflammatory phase

-cathode (negative) pole: promotes granulation, control inflammation, and inhibit certain bacteria

Front 55

when is VAC used?

Back 55

vacuum-assisted closure

-negative pressure system

-used for any type of wound (including arterial)

INDICATIONS

1. wound not closing

2. lack of arterial perfusion

3. excessive exudate that cannot be controlled with the dressing

-applied continuously

-can be used in presence of infection