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74 Cards in this Set
- Front
- Back
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you should expect a wound to make significant progress or to be healed in _ to _ week |
2 to 6 weeks |
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what are 5 ways of inappropriate wound mgt |
trauma desiccation dressing choice is poor misuse of topical agents inapp. dressing application |
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malnutrition can be characterized by _& loss per week, _% loss per month, _% loss per 6 months |
1-2% of body wt per week 5% body wt per month 10% of body wt per 6 months |
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how many calories per kg and grams of protein are needed per day for pts with chronic wounds |
30-35 calories per kg 1.25-1.5 g protein per kg of body wt per day |
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healthy indiv's need how much water per day |
30-35 mL/kg a day |
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patients on air fluidized bed need how much water a day? |
40-60 ml/kg |
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neuropathy creates these factors which delay wound healing |
impaired sweat response change in skin acidity sensory, motor, or autonomic dysfx |
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thicker or thinner skin will heal slower |
thicker |
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__ to ___% reduction in surface area w/in 2-4 weeks is a good indicator of healing |
20-40% reduction in size |
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what is normothermic? |
98.6F - 100.4F or 37 to 38 C |
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how long does it take for a wound to start desiccating? |
2-3 hours |
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a wound heals better in cool or warm/hot environments? |
warm/hot |
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chronic wounds are the result of ___ __ ____ ____ most likely |
imbalance of chemical mediators |
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smoking affects which organs? |
every organ |
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effects of nicotine |
vasoconstriction, platelet aggregation, clot formation toxic to osteoblasts |
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an individual who smokes one pack per day is tissue hypoxic for |
15-20 hours each day |
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smoking delays wound healing and increases incidence for |
infection |
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how does nicotine inhibit wound healing? |
hurts fibroblasts and macrophages inhibits epithelialization |
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ideal BMI |
18.5 to 24.9 |
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total lymphocyte count should be >= |
1800 per cc |
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low levels of total lymphocyte could indicate |
immunocompromise and protein deficiency |
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if the pt has multiple turning surfaces available use a ___ ___ unless they bottom out |
static device |
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if a pt does NOT have multiple turning surfaces available use a ____ ___ or ____ |
dynamic overlay mattress |
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if the pt is on a dynamic overlay or mattress and it is not healing, the pt should be placed on a |
low air-loss bed |
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if the pt is on a low air loss bed and the wound is still not healing, they should be placed on a |
air-fluidized bed |
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if an ulcer continues to have purulent discharge, foul odor, or inflammation after debridement and cleansing, the pt may have... |
cellulitis, sepsis, or osteomyelitis |
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what are the tools used for sharp debridement? |
scalpel, scissors, others |
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what are the indications for sharp debridement? |
thick adherent eschar, devitalized tissue, cellulitis, sepsis |
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advantages of sharp debridement |
rapid |
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disadv of sharp debridement |
pain, clinical skill needed, licensure requirements |
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enzymatic drugs used |
accuzyme collagenase elase panafil |
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indications for enzymatic debridement |
devitalized tissue indications specific to the product |
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advantages of enzymatic debridement |
collagenase promotes debridement and growth of granulation tissue |
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disadv. of enzymatic debridement |
adverse rx may be cytotoxic may apply it wrong |
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mechanical debridement uses |
wet to dry dressings hydrotherapy wound irrigation dextranomers |
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indications to mechanical debridement |
removal of foreign debris and devitalized tissue |
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advantages of mechanical debridement |
softens eschar |
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disadv. of mechanical debridement |
nonselective traumatic to granulation tissue may be painful |
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autolytic debridement means |
synthetic dressings or the body self-digests devitalized tissue |
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indications of autolytic debridement |
devitalized tissue |
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advantages of autolytic debridement |
pt tolerance |
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disadvantages of autolytic debridement |
contraindication with infections takes longer than other categories |
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___ and ___ signifies an urgent need for sharp debridement |
advancing cellulitis
sepsis |
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when should you debride a heel ulcer? |
if there is infection, cellulitis, sepsis only |
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how often should you change wet to dry dressings |
every 4-6 hours or until dry |
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when should you cleanse the wound? |
initially and at each dressing change |
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what should you use normally to cleanse the wound? How much pressure? |
normal saline 4-15 psi |
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when should you discontinue whirlpool cleansing? |
when the ulcer is clean |
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wound cleansers can ___ wound healing |
delay due to cytotoxicity |
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the greater the size of the needle, the greater the flow, the greater the |
pressure |
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the larger the syringe, the ___ the pressure |
lower |
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what is the most important factor in reducing the level of bacterial contamination? |
removing devitalized tissue |
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should you use antiseptics in a clean wound? |
no |
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clean non-healing wounds with high levels of bacteria should consider using a |
two week trial of topical antibiotics affective against gram +, -, and anaerobic organisms |
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1/_ of nosocomial infections are preventable |
1/3 |
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____ is the single most important procedure for preventing infections |
hand washing |
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what is MRSA? |
methycilllin-resistant staph. aureus gram + bacteria resistant to penicillin |
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tx of mrsa? |
I.V. of vancomycin and teicoplanin
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what is VRE? |
vancomycin-resistant enterococci gram + bacteria |
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tx of VRE |
ampicillin-amoxicillin |
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normal skin flora includes these bacteria |
enterococcus staphylococcus bacillus |
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an infection means greater than ___ to ___ organisms per g. of tissue |
10^4 and 10^5 |
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what are 6 wound characteristics of inflamed or infected wounds |
rubor (erythema) calor odor exudate color and amount edema |
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rubor inflammed vs. infected wound |
inflammed - well-defined border of redness infected - indistinctive, streaking, intense color change |
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calor inflammed vs. infected wound |
inflammation - localized heat infected - may have systemic fever |
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odor inflamed vs. infected wound |
inflamed - not necessarily infected infection - specific odors for specific infections |
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exudate amount in inflamed vs. infected wounds |
inflamed - gradual decrease over several days infected - remains high or increases in amount |
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exudate color in inflamed vs. infected wounds |
inflamed - serous to serosanguinuous infected - serous and seropurulent to purulent |
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edema inflamed vs. infected wounds |
inflamed - slightly firm or swollen infected - edema, pitting, accompanied by warmth |
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Sanguineous exudate |
red thin, watery shows new blood vessel growth or disruption |
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serosanguineous exudate |
light red to pink thin, watery wound is in inflammatory and fibroplasia phases |
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serous exudate |
clear or light colored thin, watery wound is in inflammatory and fibrplasia phases |
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seropurulent exudate |
cloudy, yellow, tan thin, watery may signal impending infection or a result of dressing |
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purulent exudate |
yellow, tan, or green thick, opaque may signal infection is present, especially is malodorous |
