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101 Cards in this Set
- Front
- Back
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what phase are most chronic wounds stuck in?
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the inflammatory phase
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describe what happens in the normal inflammatory phase of wound healing
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Neutrophils enter wound and begin clearing bacteria/debris and secreting lysozyme
monocytes enter the wound and transform into macrophages the macrophages ingest the bacteria, necrotic tissue, and dead neutrophils Exudate is at its peak in this phase |
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what is wrong with having exudate at its peak in the inflammatory phase
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it binds things, like growth factors, or other things need for healing of the wound.
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what occurs in the proliferative phase?
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formation of granulation tissue
wound contraction by myofibroblasts epithelialization angiogenesis to form a new vascular bed |
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what never regenerates once removed in a wound?
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dermis- this is why the it is never as strong as it once was.
The scar is only granuation tissue covered by a thin epithelial layer. Therefore it is more likely to breakdown. |
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what happens in the maturation phase?
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fibroblasts decrease
vascularity decreases tensile strength begins to increase |
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what is the cellular dysfunction seen in chronic wounds?
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hyperproliferation around the wound edges, interferes with normal cell migration because it has inhibited apoptosis within the fibroblasts (don't produce collagen and the fibronectin can't bind to collagen) and keratinocytes.
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what do you do with the hyperproliferation cell around the wound edge?
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debridement
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when would you not use debridement?
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arterial disease
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what biochemical imbalances are seen in a chronic wound?
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abnormal overexpression of ECM components- fibronectin and thrombospondin
accumulation of fibrinogen and fibronectin in the exudate accumulation of metalloproteinases and serine proteases- damages the ECM |
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how is the exudate in chronic wounds different from the exudate in acute wounds?
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it slows down the proliferation phase, it contains macromolecules, and contains elevated levels of metalloproteinases
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what is the most important thing to do with a neurotrophic ulcer?
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offloading
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what is the most important thing to do with a venous stasis ulcer?
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compression- ace bandages, unna boots
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what are the stages of pressure ulcers?
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1- intact skin with non-blanchable erythema
2- partial thickness loss of dermis 3-full thickness loss 4- loss to bone/tendons |
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when do you and when do you not debreed a pressure ulcer on the heel?
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dry and stable- do not
dry and unstable- debreed |
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what are three things that are important to remember when discussing options for heeling a decubitus wound that is dry and stable?
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enzymatic debridement
VAC hypobaric oxygen chamber |
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what needs to be done in wound bed preparation?
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acheive a stable wound that is well vascularized and has minimal exudate.
debreed nectrotic tissue bacterial control exudate management |
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what are different methods for debridement?
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surgical - selective
mechanical (wet to dry) - nonselective enzymatic - stop once you get to granulation tissue autolytic debreedment- use body's own fluid. |
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how is the bacterial burden controlled?
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topical agents used to avoid using oral antibiotics.
Arglaes powder- controlled release antimicrobial silver. Acticoat-- nanocrystalline silver used for exudative wounds. Moisten with sterile water (not saline). Protects against MRSA and VRE. Actisorb silver Iodosorb gel- iodine |
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how do you manage the exudate?
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determine the color and volume of it.manage the exudate without drying out the wound.
Allevyn foam (non-inherent) |
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what things impair wound healing?
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inadequate perfusion
infection edema dry wound fibroblast senescence inhibited keratinocyte migration decreased growth factors cytotoxic agents inadequate debridement inadequate pressure relief |
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what is the TIME system for wound bed preparation?
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T- tissue non-viable
I- infection or inflammation M- moisture imbalance E- edge of the wound |
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what is Hypafix?
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not a wound care product, but good at holding other wound care products on.
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what is a hydrogel sheet used for?
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to provide moisture
can be used on infected wounds if changed daily has the potential to macerate surrounding skin |
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what is hydro-gel
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used on non exudate re-epithilizing wounds
has the potential to macerate surrounding skin Nu-gel altrazeal- powder that is put on as a powder and then saline is added to it and it becomes rubbery |
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what is hydrocolloid?
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adhesive
like a hydrogel sheet, but harder. can cause damage to the granulation skin do not use on infected wounds only use on wounds with low to moderate exudate can leave it on wound for 3-7 days Duoderm/ Duoderm CGF |
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what are the foams?
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used on moderate to high exudate wounds
can be used on infected wounds change every day can be used on venous ulcers Allevyn/polymem/acticoat |
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what is different about acticoat and the other foams?
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it also contains silver
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Alginates
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made from seaweed
gel forms with contact with wound fluid used with granulating wounds can leave it up to 7 days Sorbsam |
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Alginates with collagen?
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fibracol
90% collagen 10% alginate |
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alginates with honey?
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expensive
active leptospernum honey maintains exudate and moist environment |
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Alginates with silver?
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for infected wounds
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collagen based products?
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Prisma - used on colonized or infected wounds. and has granulation tissue
promagran- same but without silver, not to be used with infected wounds. Only one proven to bind to bind MMP medifil |
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collagen gel with silver?
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silvakollagen
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activated collagen
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collagen segments are a fraction of the size of the native collagen. gel for minimal exudate and a powder for moderate exudate
cellerate |
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what is regranex?
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platelet derived growth factor
attracts monocytes and fibroblasts in the inflammatory phase keep refrigerated was widely used, but can cause malignancy |
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what is procuren?
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growth factor from the patient's own blood.
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grafts?
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apligraft- bilayered skin equivelent, must be used immediately, shipped fedex
dermagraft- human dermal replacement (no epidermis) made from newborn foreskin oasis- non-living, small intestine submucosa of a pig. Natural occuring ECM with growth factors that recruit the patients own cells. Integra- collagen, non-living glycosaminoglycan biodegradeable matrix. graft jacket- non living processed human dermal membrane. a 3-D framework for the patients cells to come into. For deeper wounds. Gammagraft- irradiated human skin allograft. Non-living. no secondary wound covering after 24 hours. |
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topical enzymes?
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santyl- degrades collagen in necrotic tissue, but does not attack live collagen. used with powder antimicrobials.
papain urea ziox |
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xenederm?
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topical agent for local blood flow, balsam of peru. Caster oil maintains moist environment.
Trypsin maintains moist wound bed. |
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VAC?
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vacuum assisted closure. externally applied negative pressure. draws wound together. removes excess fluid and reduces bacterial load.
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chief complaint?
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why the patient is there
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what do you need to know about the cheif complaint?
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nature
location duration onset characteristics alleviating/aggrivating factors treatment |
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what else needs to go in the same area as the chief complaint and the HPI?
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primary care physician and when last seen. Put date, not how long ago patient said.
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next section?
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allergies and what happens
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next?
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medictions, individually.
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past medical history?
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list all pertinent past history
make sure that medications match past medical history. |
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past surgical surgery
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find out location and when they had the surgery. Note any complications. Must use medical terminology on this section for the procedures done.
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social history?
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list marital status
children para and gravida # of births tobacco- what type, did you ever smoke. alcohol drug use employment hobbies excersize sexual activity |
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family history
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parents
chidren grandparents |
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review of systems
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screening device to uncover potentially significant symptoms not otherwise ellicited. Only current things.
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everything previously was part of which group?
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subjective
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what is the first step of the objective?
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vitals- it has to be added in a special tab.
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what do you put after that?
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mental status
patient shoegear- patient is ambulating in........list assisitive devices note if they are accompanied by a caregiver. observe the gait. |
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what does the objective has to reflect?
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the cheif complaint
must include all pertinent negatives must describe all things in this section, do not give an assesment in this section |
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with the vascular exam, if the pulse is non-palpable, what do you have to do before presenting? what else needs to be done with the vascular exam?
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doppler exam and say if it was mono, bi or triphasic
capillary fill time. specify which digits skin temp from prox to distal. edema- pitting or non-pitting, focal or diffuse and where. Homan's sign |
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what needs to be done in the neuro exam?
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vibratory- start at IPJ of hallux.
protective- note where it is absent (not diminished) proprioception- intact or absent reflexes- intact or absent babinksi- absent or present clonus- clonus - absent sharp/dull light touch Tinnel or Valleix sign to check for tarsal tunnel syndrome |
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what needs to be done with the derm exam?
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toenails- if normal put non-dystrophic. if they are dystrophic, describe it.
incurvated, severity of it? web spaces- dry clean and intact or not. Woods lamp? hyperkeratotic tissue- where, diffuse or local. skin texture and turgor ulcers- length after debridement. width, depth. what does the base of the ulcer look like. what does the rim look like. does it undermine, does it probe? |
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w2hat needs to be done on hte musculoskeletal exam?
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muscle strength for flexors, extensors, inverters, and everters.
ROM for ankle, STJ, MTJ, 1st met. pain? crepitus? structural deformities need to be described, not defined. foot type- specify when weight bearing or not. |
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what goes in the lab results section?
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radiographs
MRI/CT PAS/fungal culture non-invasive vascular testing biopsy results |
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what causes peripheral arterial disease
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systemic athersclerosis.
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what are the risk factors for developing PAD?
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age
smoking diabetes coronary heart disease HTN obesity hypercholesteremia family history |
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if a patient presents with gluteal pain it is usually the result of what
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aortoilliac disease
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if a patient presents with calf pain it is usually the result of what?
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femoral disease
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if a patient presents with foot disease, it is probably the result of what?
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popliteal disease or trifurceal disease
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what is the name of the early stage of PAD?
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intermittent claudication
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what symptoms are seen with intermittent claudication?
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calf pain after a reproducible distance
better with rest inabilitiy to meet the metabolic needs of the muscle with excersice. muscle cramps |
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what is the name of the second stage of PAD?
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rest pain
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what are the symptoms seen with rest pain?
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pain is constant and worse at night
pain decreases when legs are dependenttrifurcation disease |
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night pain relieved by walking usually indicates what kind of problem?
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venous
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with the rest pain stage, where is the pain normally felt?
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the plantar aspect of the metatarsals
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what is the difference between wet and dry gangrene?
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wet- sudden occlusion due to burns, freezing, or embolism with a subsequent bacterial infection
dry- result of gradual loss of blood supply and is not associated with a bacterial infection. |
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what does treatment for PAD begin with?
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a good history and physical
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for every 1% increase in the HbA1C what is the amount of increased risk for PVD?
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28%
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what dou you check for in a physical exam when testing for PAD?
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pulses
hair temp skin integrity wounds pedal deformities |
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what is a normal ABI ratio?
what ABI ratio indicates claudation? what ABI ratio indicates rest pain? what ABI ratio is usually indicative of probably tissue loss? |
>0.9
0.5-0.9 0.21-0.49 <0.2 |
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what is the limitation of the ABI?
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limited to the ankle, doesn't say what is happening further down in the toes
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when do you give an ABI?
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>50 years with diabetes
<50 years with diabetes and other risk factors repeated every 5 years if normal, if abnormal refer to |
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what shape of a reading do you want to see on a PVR?
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teepees, not igloos
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transcutaneous oxygen monitoring?
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increases vasodilation at skin surfaces
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what factors affect the TCOM?
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obesity
edema cellulitis bony prominence thickened skin drugs inflammation |
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what is a normal value with TCOM, what are the bad values?
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60 mmHg - normal
>40mmHg- still likely to heal 30-40- moderate 20-30 maybe <20 - unlikely |
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what is SPP
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skin perfusion pressure test- doppler laser is used to check perfusion, it it NOT affected by calcified vessels. It is faster and can be used on the plantar foot.
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what is the rutherford classification system?
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grade 0 - asymptomatic homodynamic manifestations
grade I - 1-mild cladation, 2-moderate claudation, 3 - severe claudation grade II - 4- pain at resting, 5- minor tissue loss, chronic ulcer, focal gangrene with diffuse ulcer grade III - 6- major tissue loss behind transmetatarsic level. Unrecoverable foot functionality |
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if you drain the superficial veins in the leg, apply a tourniquet ,and then allow them to stand and the leg fills quickly from the top, what is the problem?
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incompetant great saphenous vein.
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what if it rapidly fills up from the bottom?
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the communicating veins are incompetant
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what is the standard problems that cause DVTs?
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venous dilation
stagnation of flow |
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when is the unna boot not recommended?
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when the patient is on bed rest or non-ambulatory.
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what are some other methods used in treating venous ulcers?
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skin grafts
integuous bilayer matrix (no harvest sight) cool touch - shrinks veins PPG APG duplex ultrasound |
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Describe the CEAP system
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0- no signs of venous disease (no testing needed)
1- telangectasias or reticular veins (no testing needed) 2- vericose veins (duplex reflux exam) 3- edema (APG, PPG) 4- skin changes (APG, PPG) 5- healed ulceration (evaluate for surgery) 6- active ulceration (evaluate for surgery) |
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what are the criteria to be a surgical candidate for superficail venous problems?
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symptomatic varicose veins with or without swelling
recurrent superficiil phlebitis varicosity bleeding or erosion chronic skin discoloration or induration active or recurrent venous stasis ulcer |
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what are the criteria that evclude people from surgery?
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DVT
outflow obstruction PAD planned future pregnancy non-compliance severe obesity |
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what is the difference between primary and secondary CVI?
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primary- superficial or deep veins
perforating veins may be involved combo of the two secondary- post thrombotic syndrome destruction of the valves |
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what are the causes of CVI?
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venous outflow obstruction
previous DVT persistent aambulatory venous hypertension |
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what is virchow's triad?
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3 things that can cause a DVT
1- endothelial injury- trauma 2- stasis - immobility 3- hypercoagubility - cancer, coag, deficiency |
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is atherosclerosis a factor in causing a DVT?
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NO
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what is the pharmacological prophylaxix for DVT?
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heparin (5000 U SQ 2 hr pre-op, 8-12 hours post op)
adjusted dose heparin low molecular weight heparin (lovenox - 30mg SQ pre-op, 40 mg SQ qd for 2-4 weeks) |
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what are the advantages to using a low molecular weight heparin?
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improved bioavailability
longer half life more predictable anticoalgulant effect less platelet binding |
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what people should not get DVT prophylaxis?
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active major bleeding
known hypersensitivity epidural or spinal spinal or eye surgery |
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what Test has a very strong negative predictive value?
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D-dimer test (under 500 is good, over 500 means you have to get more testing)
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what are the 2 cardinal symptoms of PE?
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dyspnea
pleuritic chest pain other symptoms include - tachypnea, tachycardia, cough, hemoptysis, hypotension |
