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67 Cards in this Set
- Front
- Back
- 3rd side (hint)
Epidermis:
where made of function |
- outermost
- epithelial cells and melanocytes; no blood supply - protection regenerates |
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Dermis:
Where function contains |
- below epidermis
- blood supply to nourish epi - fibroblasts, macrophages, mast, nerve cells - epidermal appendages (hair follicles, sweat glands, sebaceous glands) |
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SubQ
- where - made of - function |
- below dermis
- adipose, connective, bl vessels, lymph, nerve endings - protection from pressure and padding against shear |
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Fascia/ muscle
- where - sensitive to |
- under subQ
- ischemia (pressure damage) due to being highly vascularised |
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What is the function of skin (6)?
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Protection
heat regulation sensory perception excretion VD expression and body image |
SHEEPS
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How is infant skin different?
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thinner skin and nails
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How is skin different in older adults?
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- epi thin
- decreased collagen - reduced sebaceous and sweat activity - loss of subQ - reduced blood flow - increased capillary fragility - |
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what is senile pupura
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caused by increased capillary fragility
purple coloured ecchymoses resolving to brown discolouration |
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What does healthy skin look like compared to at risk?
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Healthy - supple, dry, acidic
At risk - flakey and dry, or moist |
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How do you prevent skin breakdown?
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H2T Ax
braden scale manage nutrition/hydration maintain perineal skin integrity mobilize frequently multidisciplinary |
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What are the classification systems for wounds?
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Acute vs chronic
partical thickness vs full thickness pressure ulcer staging system |
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What is an acute wound?
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Occurs in a sudden manner
follow orderly and predictable healing |
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What is a chronic wound (2 ways to get)?
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Acute wounds that fail to heal
Wounds that result from loss of perfusion or some other brkdwn in tissue integrity |
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What is a partial thickness wound?
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involves epi and part of dermis
superficial and painful heals by regeneration |
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What is a full thickness wound?
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Epi and dermis completely gone
heals by granulation results in loss of normal function |
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What is a stage 1 ulcer?
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reddened and non-blancheable
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What is a stage 2 ulcer?
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through epi and into dermis
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What is a stage 3 ulcer?
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into SubQ
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What is a stage 4 ulcer?
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into fascia
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What is a DTI?
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Deep tissue injury
purple/maroon discoloured INTACT skin |
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What is an unstageable ulcer?
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Base of ulcer is covered by slough and/or eschar, don't know how deep it goes
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What is primary intention?
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surgical incision
wound edges approximated small granulation and epi regen to heal |
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What is secondary intention?
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Left open to heal through
granulation contraction epithelialization |
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What is tertiary intention?
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delay between injury and surgical closure
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How does the epidermis heal?
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regeneration
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How does the dermis heal?
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most regenerate
appendages lost scar formation - granulation |
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how does subQ and fascia/muscle heal
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Scar formation
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What are the 3 phases of wound healing?
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1) inflammatory - hemostasis
2) proliferation - angiogenesis, granulation, epithelialization 3) maturation - remodeling |
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What is the defensive phase of healing?
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- immediate
- hemostasis and inflammation - 1-4 days for acute - chronic wound remains in this phase |
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What is hemostasis?
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platelet in contact with collagen in tissue - activates response to form platelet plug (fibrin)
- stop bleeding |
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What happens during inflammation?
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- vasodilation - incr bl flow to area and leaky capillaries
- GF released by plug attracts WBCs to deal with necrotic and bacteria - short in acute, long in chronic |
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What are S&S of inflammation (3)
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1. erythema
2. warmth 3. induration (hardened) |
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What are 3 events of proliferation?
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1. granulation
2. contraction (open wounds only) 3. epithelialization |
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What happens during granulation?
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wound filled with granulation tissue
- capillaries (neoangiogenesis) - collagen (fibroblasts) acute = 5-15 days chronic = variable |
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What is contraction?
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- open wounds only
mobilization of wound edges by myofibroblasts to reduce size |
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What happens with epithelialization?
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Resurface wound by growth of epi from edges
incisional - 3 days chronic - longer |
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What (2) happens during maturation phase of healing?
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1. lysis of established collagen
2. synthesis of new collagen to improve tensile strength of scar (to 80%) takes 1-2 years |
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What factors affect wound healing?
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1. perfusion - so conditions that affect perfusion, affect healing! (edema, anemia, PVD, DM, cardiac probs...)
2. Nutrition - sp need protein, VC, Zinc 3. Infection - delays collagen, prevents epithelialization, cytotoxic 4. DM - reduced collagen, leukocyte, perfusion 5. steroids - suppress inflammatory 6. Age 7. Stress 8. Immunosupporession 9. other diseases |
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What do you look for (8) in Ax a wound
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- location
- size (LWD) - base - undermining/sinus tract - edges - exudate - periwound - pain |
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What does the anatomical location of a wound tell you?
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- ID cause
- healing potential |
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What does the size of a wound tell you?
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- measure weekly to get healing indication
- debridement changes size |
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What does wound base colour tell you?
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healthy is red/pink
necrotic is yellow, tan, black document in percentage of each colour look for tendon, muscle, bone... |
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What is undermining?
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tissue destruction underlying intact skin along wound margins
Product of shearing forces |
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What is a sinus tract?
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pathway that extends in any direction from wound surface - probe to assess
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What do you look for in exudate?
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Colour
Odor Consistency Amount |
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What (2) do you look for in edges of open wound?
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1. presence/absence of new tissue
2. contributing factors - nutrition, necrotic, maceration, infection...) |
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What do you look for in periwound area?
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- erythema
- maceration - induration - hematoma - denuadation |
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What is a critical colonization?
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When the load o microorganisms prevents wound from healing - may not look infected
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What is an infection?
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when host has a response against invading microorganisms
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What are S&S of infection?
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Acute - erythema, inducation, fever, pain, elevated WBC, purulent drainage, + CnS
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What are S&S of chronic wound infection?
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- wound brkdwn
- delayed healing - increased pain - friable granulation tissue - foul odor |
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What is the most important thing in wound management?
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Determine and address cause of wound
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What are 4 principles of wound healing?
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1. determine and address cause
2. provide systemic support 3. determine patient desired outcome 4. apply appropriate topical therapy |
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What are the principles in topical therapy?
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IDIPAMOP
ID infection, Debride, insulate, pack, absorb, Moist, open edges, protect |
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What are some methods of debridement?
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1. autolytic - moist wound envt
2. mechanical - wet to dry 3. biological - maggots 4. enzymatic - santyl |
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How do you select a dressing?
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manage moisture
consider form of dressing, and function |
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what is hydrogel used for?
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dry wounds
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What is transparent film used for?
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minor abrasions and friction
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What is hydrocolloid used for?
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Stage I and II
Minimal exudate not on heals |
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What is hypertonic gauze used for?
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yellow, sloughy wounds
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What is non-adherent dressing used for?
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fragile wound bases
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What is hydrofiber used for?
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heavy exudate wounds
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What is foam used for?
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moderate draining
mepilex, allevyn |
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what is antimicrobial used for?
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iodosorb, when animicrobial effect required
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What are silvers used for?
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When heavily colonized
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How do you treat heals?
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- off load pressure at all times
- prevent ulceration - no tegasorb |
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How do you treat skin tears?
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- treat immediately
- cleanse NS - approximate - mepitel/ dry dressing, change Q3-7d |
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