integ quiz 2

A1C lab value indicates

diabetes

albumin lab value indicates

protein malnutrition

BUN lab value indicates

kidneys

hematocrit lab values indicates

oxygen carrying capacity

lymphocytes lab value indicates

immune

platelets lab value indicates

clotting

perpendicular method

measures the wound at the longest dimension as the length, and the longest dimension perpendicular to the length as the width

clock method

measures surface area, 12:00 is cephalic and 6:00 is caudal

tracing a wound

recommended for serpentine wounds that do not have well-defined lengths and widths to measure

tunneling

two openings that are connected beneath the skin

fistula

connection between an organ and the skin, often occurring after intestinal resection or gastric surgery

undermining

the shadow that extends across the borders of the wound indicates undermining where the skin is detached from the underlying structure, usually a result of autolysis of the subcutaneous tissue

how is undermining documented

ex: 3-5 mm from 10-5

sinus or fascial track

dark opening in the visible wound bed

eschar

dead tissue

slough

yellow substance on the wound surface that is a result of autolysis of subcutaneous or connective tissue

epithelial migration

migration of the epithelial cells across a healthy granulated wound bed.

epithelializations

occurs at the wound margins or at hair follicles and sweat glands in partial-thickness wounds, as indicated by the islands of new skin growth seen scattered through out the wound bed

granulation tissue

composed of new capillaries in an extracellular matrix and has a granular, beefy red appearance

hyperkeratosis

overdevelopment of the stratum corneum, is common at wound edges where friction is a contributing factor

hyperkatosis is common

on the plantar surface of the diabetic foot

hyperkatosis is composed of

dead cells and must be derided

rolled edges

adhered to the adjacent tissue and must be debrided in order for the granulation tissue and healthy epithelial cells to progress to re-epithelialization of the wound bed

epibole

occurs when the epidermal cell roll down over the lower epidermal cells, preventing the progression of epithelial migration

scant

barely any drainage visible , none visible after dressing removal

minimum drainage

drainage visible on the inner side of the dressing only, may be some visible on the wound after dressing removal, no new drainage during treatment

moderate drainage

drainage visible on the inner side and small amount on the outer side of the dressing, some drainage visible on the wound bed after dressing removal, some drainage occurring during prolonged periods

heavy drainage

drainage visible on both the inner side and outer side of the dressing, drainage visible immediately after dressing removal and after wound cleansing, may continue through out the treatment

copious drainage

drainage not contained by a dressing deemed appropriate for the wound, drainage continuous throughout the treatment requiring continuous cleansing, suctioning, or in the case of bleeding, pressure or thrombotic applications

serous drainage

Clear fluid from a wound.

sanguineous drainage

medical term for bleeding

serosanguineous drainage

pink serous drainage because of the presence of a few blood cells in the fluid

purulence

thick, odiferous drainage

excoriation

erythema that is a result of excoriation, or loss of the epidermis

cellulitis

eryhtema, edema and increased temp

ecchymosis

bruising is visible around the skin tear as a result of acute trauma

induration

the hard, discolored area around the wound, a sign of severe edema and fibrosis of the subcutaneous tissue

maceration

occurs when the skin is exposed to moisture over a prolonged period of time

pseudomonas odor

distinctive sweet order

infection odor

putrid smell

malignant odor

musky

things to consider with cleansing

pain tolerance, viable vs nonviable tissue, nature of bioburden, presence of infection

cytotoxic examples

hydrogen peroxide, Dakin solution, betadine, alcohol, acetic acid

Dakin's solution

bleach + boric acid

acetic acid

changes PH within wound

non-cytotoxic agents

saline, sterile water, surfactants, VASHE

mechanical debridement advantages

inexpensive and low level of skill

mechanical debridement disadvantages

non selective, can cause tissue trauma, often painful, use of cytotoxic agents

whirpool

mechanical forces in the water can help soften nonviable tissue and cleanse a wound

whirlpool is an inappropriate intervention

for patients with chronic venous insuffiency and diabetic foot ulcers

disadvantages of whirpool

cross contamination and breeds bacertia

pulsed lavage with suction

non-selective debridement using negative pressure to remove (15-30 minutes). Treats tunneling and undermining; can use with clean and infected wounds.

wet to dry debridement

This type of debridement is nonselective; disrupts fragile capillaries and damages new granulation tissue

low frequency ultrasound

provides immediate selective debridment of nonviable tissue through sound waves

soft abrasion debridement

use of gauze to gentle remove non adherent debris and congealed surface exudate, does not work with eschar, removes slough

autolytic debridement

endogenous enzymes and macrophages digest and liquify necrotic tissue when kept in a moist healing environment

advantages of autolytic debridement

painless, highly selective, simple

disadvantages of autolytic debridement

slow process, risk of infection, risk of maceration

autolytic debridment does not work for patients

who are immunocompromised

enzymatic debridment

uses a topical pharmaceutical preparation to target and break down the devitalized collagen in the wound bed

Advantages of enzymatic debridement

highly selective, fast acting, can be used for maintenance debridment

disadvantages of enzymatic debridement

requires prescription, may cause periwound irritation, expensive, may impede wound bioelectricity

advantages of sharp debridement

highly selective, fast, improved healing time

disadvantages of sharp debridement

painful, risk of infection, requires high level of skill

can't debride

tendons and bones

conservative sharp wound debridement contraindications

inadequate blood supply, stable, dry eschar on heel or ischemic wound, uncontrolled bleeding, anticoagulation risk

what do you need to assess before sharp debridement

ABI, identify wound etiology

maggot debridement therapy

highly selective debridment, antimicrobial, facilitates granilation tissue formation

why do we keep the wound moist

creates a slightly acidic environment, to stop bacterial growth, and low oxygen levels, to encourage new blood vessels formation

benefits of moist wound healing

decreased necrosis, stimualtes the accumulation

benefits of moist wound healing

decreased necrosis, stimulates the accumulation of growth factor, enzymes, neutrophiles, and lysosomes, stimulates angiogenesis and fibrplasia, proliferation and migration of keratinocytes

benefits of occlusive dressings

increased rate of re-epithelialization, earlier epithelialization, faster healing rates, faster healing rates, increased collagen synthesis, barrier against water and bacteria

advantages of gauze

convenient, cost effective, effective secondary dressing

disadvantages of gauze

permeable promotes drying

impregnanted gauze

generally petroleum, nonadherent, more occlusive

advantages of calcium alginate

absorb large amount of fluid, provide a moist environment once hydrated, facilitate autolyitc debridement, conform to wound bed, provide protection from contamination, available in multiple sizes, natural fibers, decreased local inflammation

disadvantages of calcium alginate

adhere to wound bed if exudate is inadequate, are not suitable for dry eschar, not indicated for third degree burns, requires daily changes for an infected wound, requires a secondary dressing

advantages of semipermeable films

visualization of the wound bed and the wound exudate, protects skin in high trauma, is impermeable to fluids and bacteria, conforms to body contours, facilitates autolyitc debridement, useful as secondary dressing, cost-effective

disadvantages of semipermeable films

may tear fragile skin upon removal, does not absorb exudate, may not adhere well to dry skin, may macerate skin if fluid collects underneath the film, may exacerbate fungal growth of persistent on skun, tends to roll at edges in areas

foam advtanges

create and maintain a most environment, are easy to apply, are effective under compression wraps, absorb light to heavy amount of exudate, conform well, do not adhere to a moist wound surface, are available with microbial agents, protect the skin against trauma/pressure

doam disadvantages

may require a secondary dressing, not effective for dry eschar, may macerate periwound skin if foam becomes saturated, are costly

advantages of hydrofiber

absorb large amount of fluid, provide a most environment once hydrated, facilitate autolytic debridment, conform to the wound bed (full spaces, tracts, undermining), provide protection, available in multiple sizes, available with silver and honey

disadvantages of hydrofiber

adhere to wound bed if exudate is inadequate, not suitable for dry eschar or low exudating wounds, not for third degree burns , requires daily changes

advantages of hydrogel

hydrate dry wound bed, facilitate autolytic debridment, rinse or clean easily from the wound surface, conforms, soothe "hot" wounds and reduce pain, serve as delivery system for other agents such as silver, collagen, growth factors, or lidocaine, available as saturated gauze pads

disadvantage of hydrogel

macerate the periwound skin if becomes too wet, do not absorb drainage, dry out if not adequately covered, requires a secondary dressing, requires daily changes

advantages of hydrocolloid

maintain moist wound environment, facilitate autolytic debridment, keep bacteria, misture, and contimation from oncontinence, absorb minimal to moderate exudate, provide thermal insulation, stays in place up to 7 days, are effective under compression wraps, self adhering, conforms, come in various shapes

disadvantages of hydrocolloid

prevent visualization from wound bed, do not absorb heavy exudate, are not recommended for covering exposed structures, are contraindicated for infection, difficult to remove from fragile skin, may lead, require a primary dressing to fill spaces

super absorbent dressing advantages

multilayer designed for absorption, maybe primary or secondary, nonadherent, useful for multiple wounds etiologies, designed for fewer dressing changes

disadvantage for super absorbent dressing

risk of maceration and bulky

collagen advantages

provide temporary scaffolding and attracts cells to the wound site, create moist environment after interaction with wound fluid, are easy to apply, provide cost effectve advanced wound care

collagen disadvantages

not for third degree burns, not effective on necrotic tissue, may not be appropriate for patients with sensitivity or cultural restriction, requires a secondary dressing

silicone advantages

nonadherent (ideal for fragile skin), can be removed and reapplied, useful as a primary or secondary dressing, can be worn for longer durations

silicone disadvantages

no absorption

gauze is best for

dry wounds as a secondary dressing

film is good for

visualizing wounds

hydrocolloid

promotes autolysis, can have a foul smell upon removal

hydrogel is best for

dry ulcers, nectroic wounds, exposed bone

foam is best for

boney prominences, prevention of pressure injuries

alginate is best for

deep and wet wounds, pressure ulcers, tunneling or sinus cavities

hydrofiber

reduces risk of maceration, promotes autolysis