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145 Cards in this Set
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This kind of debridement uses the bodies on enzymes in moisture to rehydrate so often and liquefy, hard, eschar and sloth |
Autolytic debridement |
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This form of debridement uses maggots to reduce devitalized, tissue, bacteria load bio film in to stimulate granulation tissue |
Biological maggots |
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This form of debridement uses a chemical to aggressively degrade necrotic tissue by digesting. The vitalized tissue usually applied after crosshatching of necrotic wound beds. |
Enzymatic debridement |
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Wet moist, guises place in the wound bed guys dries and adheres to wound bed. Dried guys is pulled from one bed removing acrotic tissue. |
Wet to dry dressing’s |
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Are these precautions or contraindications for whirlpool, dehydration, heat, intolerance, weight limit, graft, edema, macerated, wounds |
Precautions |
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Are these precautions are contraindications for whirlpool, fully Coretemp, greater than 101.9 acute phlebitis, cardiac problems, lethargic patients. |
Contraindications |
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When you use tweezers or scalpels to debreed |
Sharp debridement |
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What are the contraindications for black hard adherent stable wound covering heal. Wounds with inflammatory ideology. |
Sharp debridement |
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Finish the sentence is if it’s dead if it’s dry if it’s wet if there’s a whole |
If it’s dead, remove it if it’s dry moist in it if it’s wet manage it if there’s a whole fill it |
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Controlled suction forced to the wound through a filling dressing, covered with an permeable membrane that seals the wound to maintain a moist environment |
Wound VAC |
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Inhalation of 100% O2 delivered at pressures to three times that of the atmosphere to reduce edema and hyper oxygenates tissue |
Hyperbaric oxygen |
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What classification of wound dressing covers and fills the one directly |
Primary |
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Which category of wound dressing covers a primary wound and provides a closed or protect environment? |
Secondary |
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What are the functions of dressings? |
Maintain moist wound bed, absorb exudate, protect from injury, provide barrier to contamination control, paying debride insulate |
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Derived from brown seaweed, absorbent and conforms to wound shape for heavy to moderate ask you dating ulcers absorbs up to 20 times weight |
Alginate |
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For minimally to heavily exiting ulcers, fibrous in soluble proteins, produced by fibroblast |
Collagens |
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Combination of two or more products, manufactured as a single dressing for minimal to heavy accident, healthy granulation, tissue, necrotic, tissue or mixed ulcers |
Composites |
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For minimally to heavily exiting ulcers to cover exposed areas and moon bed, single layer of woven that that doesn’t adhere to an ulcer |
Contact layer |
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Absorbent nonadherent layer that provides nontraumatic removal for minimally to heavily exiting loons primary dressing for absorption, secondary dressing for wounds with packing |
Foam |
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Woven in nonwoven facilitate debridement, when applied as a wet to dry access, moisture retentive, when applied as wet, moist, protect us from trauma and infection |
Gauze |
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For light to heavily expediting, ulcers, multilayer product that provides either a semi adherent quality nonadherent layer, or highly absorptive Lair |
Absorptive’s |
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Adhesive semi permeable, polyurethane membrane dressings Fourth stage one pressure ulcers ulcers with no exudate |
Transparent films |
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Come in a variety of forms, including pastes granules, powders beads gels for one’s requiring packing, infected, and noninfected ulcers with moderate to minimal exudate |
Fillers |
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Goals for red within the red yellow black system |
Protect wound, maintain moist environment |
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Goals for yellow and red yellow black system |
Remove exudate and debris absorb drainage |
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Goals for black and red yellow black system |
Debreed necrotic tissue |
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Avascular water, resistant protection from infection, abrasion chemicals, and heat regulation, integumentary system |
Epidermis |
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Avascular water, resistant protection from infection, abrasion chemicals, and heat regulation, integumentary system |
Epidermis |
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Contains blood vessels, sweat glands hair follicles, sebaceous glands, integumentary |
Dermis |
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Avascular water, resistant protection from infection, abrasion chemicals, and heat regulation, integumentary system |
Epidermis |
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Contains blood vessels, sweat glands hair follicles, sebaceous glands, integumentary |
Dermis |
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this type of wound healing heals by formation of epithelial cells within 24 to 48 hours by migrating in proliferating to close |
Epithelialization |
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Avascular water, resistant protection from infection, abrasion chemicals, and heat regulation, integumentary system |
Epidermis |
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Contains blood vessels, sweat glands hair follicles, sebaceous glands, integumentary |
Dermis |
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this type of wound healing heals by formation of epithelial cells within 24 to 48 hours by migrating in proliferating to close |
Epithelialization |
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Inflammatory, phase proliferation, phase maturation, capillaries, dilate, remove dead tissue, reconstruct, macrophages, clean, fiberglass play collagen, scar tissue in cell death |
Dermal full healing |
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When is deposition greater than lysis? |
Hypertrophic keloid |
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Raised but with original boundaries |
Hypertrophic scar |
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What does the scar look like if lysis is greater than deposition |
Softer less bulky scar |
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This form of healing brings edges together, suture, staple, grafts |
Primary |
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This type of healing involves closing by a contraction epithelialization or both |
Secondary |
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If the wound reopens, what is it called? |
Dehisced |
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Deeper balloons filled with scar tissue. Why do we stretch |
So that cosmetic deformity doesn’t occur |
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Deeper balloons filled with scar tissue. Why do we stretch |
So that cosmetic deformity doesn’t occur |
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Delayed primary closure a wound healed through surgical debridement allowed to stay open surgeon closes it was a graft |
Tertiary |
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List, some systemic factors that affect wound healing |
Age behavior, oxygen, moisture, diabetes, nutrition, meds, obesity |
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Iatrogenic |
The stuff we control with wounds |
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Where is oxygen important in wound healing |
sells convert oxygen to support healing. They have an antibiotic effect to resist pathogens oxygen delivery is reduced by edema and necrotic tissue. It enhances effectiveness of growth factor. |
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How did intervene with oxygen in wound healing |
No smoking warmth and hydration |
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The most important, external factor for wound healing |
Hydration |
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What is important about occlusive dressing |
They keep endogenous fluids on wound preserving sells |
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What is important about occlusive dressing |
They keep endogenous fluids on wound preserving sells |
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Why is nutrition important was wound healing |
Red blood cells, tissue repair, collagen cross linkage immune function increase need for amino acids for new tissue |
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Does protein matter with wound healing |
There is an increase need for amino acids for new tissue |
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What does Mal nutrition cause? |
Decreased strength, poor stress, response, chronic wounds, need more protein and calories |
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Why do obese people take slow healing? |
Slower wound healing, dehiscence, an infection poor blood supply to add a pose, lack of mobility for pressure, sores, diabetes, heart, disease |
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When there is less 02 to the wound, chronic nonhealing grader susceptibility to infection |
Arterial insufficiency |
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When there is Adema fibrin in tissue space high risk for infection fiber blocks, so you can’t clear waste |
Venous insufficiency |
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Why don’t wounds heal with steroids |
Decrees, collagen, synthesis, suppress immune system’s |
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Why don’t wounds heal with steroids |
Decrees, collagen, synthesis, suppress immune system’s |
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What do NSAIDs do? |
Vasoconstriction’s suppress inflammation in collagen synthesis |
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What does chemo mess things up? |
Interferes with cell proliferation, prolongs, inflammation inhibits protein in collagen synthesis |
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What does chemo mess things up? |
Interferes with cell proliferation, prolongs, inflammation inhibits protein in collagen synthesis |
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What is diabetes do |
Accelerates, atherosclerosis neuropathy, abnormal collagen synthesis |
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What does chemo mess things up? |
Interferes with cell proliferation, prolongs, inflammation inhibits protein in collagen synthesis |
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What is diabetes do |
Accelerates, atherosclerosis neuropathy, abnormal collagen synthesis |
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What does aids do? |
Phagocytosis, decrease immune system delays healing |
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What is depression and anxiety inhibit healing |
Repairs immunity, self neglect, poor appetite, disturb sleep, decrease interest in activity, pressure ulcers avoid eating |
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What illnesses do you watch out for mentally with wound healing? |
Bipolar schizophrenia, self mutilation Munchhausen’s |
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What type of factors are these infection? Blood supply meds dressings, desiccation necrotic tissue eschar |
Local factors |
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Signs and symptoms of infection |
Arrhythmia Adema pain, impaired mobility, fever, purulent drainage, increase white blood cells, increase vitals and confusion smell |
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Signs and symptoms of infection |
Arrhythmia Adema pain, impaired mobility, fever, purulent drainage, increase white blood cells, increase vitals and confusion smell |
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Presence of bacteria without host reaction |
Contamination |
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Signs and symptoms of infection |
Arrhythmia Adema pain, impaired mobility, fever, purulent drainage, increase white blood cells, increase vitals and confusion smell |
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Presence of bacteria without host reaction |
Contamination |
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Bacteria that mean, multiply or initiate host reaction |
Colonization |
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Signs and symptoms of infection |
Arrhythmia Adema pain, impaired mobility, fever, purulent drainage, increase white blood cells, increase vitals and confusion smell |
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Presence of bacteria without host reaction |
Contamination |
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Bacteria that mean, multiply or initiate host reaction |
Colonization |
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Multiplication of bacteria, causing delay associated with an exacerbation of pain no over host reaction |
Critical colonization |
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Inhibition of fibroblast migration in collagen synthesis, make it susceptible to infection and breakdown debris in bacteria increase pathogen spread fast to find out what |
Why blood supply is important for healing |
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Or wet to dry dressing selective one removed |
No |
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Does necrotic tissue and Escher need to be removed |
Yes, increases infection interferes with wound contraction |
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Does necrotic tissue and Escher need to be removed |
Yes, increases infection interferes with wound contraction |
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Common things we mess up when treating wounds |
Failure to diagnose arterial disease didn’t remove eschar failure to offload failure to control environment in appropriate treatment plan poor pain control |
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Where is pain control important for healing |
Greater stress response, low OXY tension and perfusion, restricted breathing lower mobility, DVT |
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Suddenly caused by trauma surgical or infection |
Acute |
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Deviates from expected sequence of repair time appearance response to stress |
Chronic |
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Examples of chronic wounds |
Pressure leg ulcers arterial or Venus diabetic wound |
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Decreased oxygen to wound chronic nonhealing wound grader susceptibility to infection |
Arterial insufficiency |
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Edema fibrin in tissue high-risk infection |
Venous insufficiency |
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Venous or arterial when there’s pain with elevation, relieved with dependency worse at night |
Arterial |
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Venus or arterial swollen leg relieved with dependency better with elevation compression therapy helps prevent reoccurrence |
Venous |
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Venus or arterial usually distal to medium malleolus dorsum of the foot or toes severe pain. Nocturnal relieved by dependency little or no bleeding regular edge punched out poor granulation tissue. |
Arterial |
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Proximal to medium malleolus, lateral lower leg, mild pain, relieved by elevation, Venus use shallow, irregular shape, granulating base with rounded edges |
Venus |
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Test where you hold a leg up for 30 seconds White and bring it down turns red again |
Rubor of dependency |
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Inadequate drainage of venous blood from a body part, resulting in edema |
Venous insufficiency |
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80% of all ulcers are venous disease true or false |
True |
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Contributing factors to venous insufficiency |
Age, lack of oxygen obesity, long hours, standing or sitting pregnancy heredity |
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Disorders that interfere with arterial or venous blood flow of extremities |
Peripheral vascular disease |
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Factors affect, peripheral vascular disease |
Smoking, cardiac disease, diabetes, hypertension, renal disease, high cholesterol, obesity |
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Factors affect, peripheral vascular disease |
Smoking, cardiac disease, diabetes, hypertension, renal disease, high cholesterol, obesity |
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Pink/pale, necrotic tissue, well defined edges small in Moderat round oblong over bony prominence |
Diabetic ulcer |
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Treatment for diabetic ulcer |
Reduce year off load foot where glucose in control revascularized |
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How long for superficial burn? |
3 to 6 days |
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Days for superficial partial |
7 to 20 |
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Days for deep partial thickness |
21 |
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Days for deep partial thickness |
21 |
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Days for full thickness |
Never |
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Days for deep partial thickness |
21 |
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Days for full thickness |
Never |
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Sunburn, dry, red blanches with pressure painful |
Superficial |
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Days for deep partial thickness |
21 |
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Days for full thickness |
Never |
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Sunburn, dry, red blanches with pressure painful |
Superficial |
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Scolding, short, flash blisters, moist, red and weeping. Also blanches painful to air and temperature. |
Superficial partial |
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Days for deep partial thickness |
21 |
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Days for full thickness |
Never |
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Sunburn, dry, red blanches with pressure painful |
Superficial |
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Scolding, short, flash blisters, moist, red and weeping. Also blanches painful to air and temperature. |
Superficial partial |
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Scalding, immersion, Steve, oil, chemicals, electricity, waxy, white leather and gray to Chardon black dry and inelastic doesn’t blanch |
Full thickness |
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Burn that extends deep into the subcutaneous mean involve muscle fascia or bone |
Fourth degree |
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All factors affecting pressure sores |
Impaired sensation, moisture, physical activity, mobility, nutrition, friction in sheer poor oxygenation for profusion |
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What is important to know about the Braden in Norton scale for pressure sores |
The higher, the number, the lower the risk |
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Localized injury to the skin, and or underlying tissue usually over a bony prominence as a result of pressure |
Pressure sore |
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Intact skin with non-blanchable redness of a localized area usually over a bony prominence |
Stage one |
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Loss of dermis, presenting as a shallow open ulcer with a red pink wound bed without sloth, may also be presented as an open serum filled blister |
Partial thickness stage two |
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Loss of dermis, presenting as a shallow open ulcer with a red pink wound bed without sloth, may also be presented as an open serum filled blister |
Partial thickness stage two |
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Full thickness, tissue lost subcutaneous fat may be visible, butt, bone tendon, or muscle or not laugh may be present, but does not have scare the death of tissue loss may involve underlying in tunneling |
Stage 3 full thickness |
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Full thickness, tissue loss was exposed bone tendon. A muscle sloth in eschar may be present on some parts of the wound bed includes undermining in tunneling. |
Stage four |
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Full things to do loss for the base of the ulcer is covered by sloth, yellow tan, gray, green, or brown, and or eschar in wound bed |
Unstageable |
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Treatment options for pressure sore |
Debridement cleansing dressings |
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How to measure wounds |
Length X width depth in anatomical position, undermining tunneling wound tracing photography |
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What are these sharp surgical enzymatic target specific tissue? |
Selective debridement types |
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Mechanical enzymatic targets all tissue |
Nonselective debridement |
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Edema, acute, inflammation, feels firm, abnormal, hardening of tissue at wound margin related to histamine release, causing vasodilation and increased vascular permeability you test for it by pinching |
Induration |
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Soft bathwater skin that’s easily tease depart |
Maceration |
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Clear, light yellow |
Serous |
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Bloody |
Sanguinous |
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Combo of serous and blood |
Serosangenous |
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Pus, thick, or thin and yellow |
Purulent |
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What is foul purulent |
Purulent with smell |
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What are these pulses blood pressure auscultation Ruber of dependency ankle brachial index Doppler |
Vascular and neurological exams |
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What is Venus testing and pitting edema? What number is severe |
Hi number |
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Which test is the blood pressure cuff around the ankle? |
Doppler |
