question

What is debridement?

answer

Removal of devitalized tissue and foreign matter from a wound

question

What is the difference between selective and nonselective debridement?

answer

selective removes only necrotic tissue while non-selective removes healthy and necrotic tissue

question

What are the main types of debridement?

answer

sharp, autolytic, enzymatic, mechanical

question

What are the purposes for debridement?

answer

devitalized tissue is a medium for bacterial growth; topical antimicrobials have difficulty penetrating devitalized tissue; bactericidal activity of leukocytes is decreased in devitalized tissue; devitalized tissue in a wound bed perpetuates the inflammatory response; devitalized tissue in a wound bed increases energy required for healing; devitalized tissue acts as a physical barrier to wound healing; decrease wound odor

question

What are the general indications for debridement?

answer

necrotic tissue, foreign material, debris, possibly blisters and calluses

question

Describe a red wound bed

answer

pale pink to beefy red, granulation tissue

question

What are the treatment goals for a red wound bed?

answer

protect the wound; maintain warm, moist environment; protect periwound

question

Describe a yellow wound bed

answer

moist, yellow slough; may vary in adherence

question

What are the treatment goals for a yellow wound bed?

answer

debride necrotic tissue; absorb drainage; protect periwound

question

Describe a black wound bed

answer

thick, black, adherent eschar

question

What are the treatment goals for black wound bed?

answer

debride necrotic tissue

question

What are the general contraindications for debridement?

answer

red, granular wounds; stable heel ulcers with eschar if they do not have S/S of infection; wounds that require surgical debridement; electrical burns

question

what are S/S of infection in a heel ulcer?

answer

edema, erythema, drainage, odor, fluctuance

question

what is fluctuance?

answer

presence of pus/or other fluid inside

question

Which wounds require surgical debridement?

answer

wounds that require debridement of muscle, tendon, bone, etc.

question

Describe a stable heel ulcer

answer

hard, dry, and located distally on an ischemic limb

question

What are the general considerations for debridement?

answer

characteristics of wound; status of patient; exiting practice acts

question

What are the steps to prepare the patient for debridement?

answer

1. Assemble equipment and supplies that may be needed 2. Position patient comfortably, allowing for visualization of wound bed; an aide may be needed to assist with attaining and maintaining this position 3. Use proper posture and body mechanics to allow safe technique and minimize fatigue 4. Ensure sufficient lighting of involved area 5. Wash hands and don clean gloves 6. Remove old bandage and discard according to facility policies 7. Discard soiled gloves and apply clean gloves 8. Inspect the wound to determine if debridement is necessary and, if so, what method is most appropriate. Wound may need to be irrigated with normal saline to prove more accurate inspection 9. Remove soiled gloves 10. Explain procedure to patient 11. Don clean gloves and initiate debridement technique

question

What are the types of selective debridement?

answer

sharp, autolytic, enzymatic, biologic

question

What are the types of nonselective debridement?

answer

mechanical, surgical

question

What are the types of surgical debridement?

answer

serial instrumental debridement and selective sharp instrumental debridement

question

What are the types of mechanical debridement?

answer

wet to dry; scrubbing; wound cleansing via a wound cleanser; wound irrigation with a water pik/soaked gauze; pulsed lavage; whirlpool

question

Describe sharp debridement

answer

use of forceps, scissor, or scalpel; fastest, most aggressive form of debridement; performed by PTs and PTAs where allowed by law; requires MD order

question

What are the indications for sharp debridement?

answer

large amount of necrosis, callus, advancing cellulitis, sepsis, eschar; may be used on wounds with any amount of necrotic tissue; chronic wounds

question

What are the contraindications for sharp debridement

answer

when area cannot be adequately visualized; material to be debrided is unidentified; lack of clinician competency; infected ischemic ulcers with low ABIs; used with caution on patients who are immunosuppressed, thrombocytopenic, or who are taking anticoagulants; wound closure is not consistent with plan of care; hypergranular tissue

question

When should you terminate sharp debridement?

answer

clinician fatigues; pain is not adequately controlled by patient; decline in patient status or tolerance to technique; extensive bleeding; if a new fascial plane identified; nothing remaining to debride

question

What is used for serial instrumental debridement? What do you do? What is another name for it?

answer

maintenance debridement; no scalpels, just forceps, and scissors; removes loosely adherent tissue

question

What is used for selective sharp debridement?

answer

scalpels; may require hemostatic agents (silver nitrate) and topical pain medications (2% lidocaine)

question

Describe the procedure for sharp debridement

answer

scalpel and scissors are parallel to wound surface; debride in layers; rinse wound with saline and reassess

question

What is autolytic debridement?

answer

use of body's endogenous enzymes to digest necrotic tissue with moisture-retentive dressing

question

Describe autolytic debridement

answer

least invasive, least painful method; easy to teach patients and caregivers; requires minimal time by clinician/patient/caregiver; requires time for debridement to occur; does not allow frequent visualization of wound; don't mistake liquified necrotic tissue as an infection

question

What are the indications for autolytic debridement?

answer

all wounds with non-infected necrotic tissue; patients who cannot tolerate other forms of debridement; commonly used in home or long-term care settings

question

What are the contraindications for autolytic debridement?

answer

infected of deep cavity wounds; wounds that require sharp or surgical debridement

question

When should autolytic debridement be terminated?

answer

moisture-retentive dressings can continue after wound bed is clean; if necrotic tissue fails to decrease in expected amount of time

question

Describe the method for autolytic debridement?

answer

eschar should be cross-hatched; moisture retentive dressings should be 2 cm larger than wound (on all sides) and remain for 72-96 hours; periwound area must be protected with skin sealant; may want to perform sharp debridement first

question

Describe enzymatic debridement

answer

requires physician's prescription; currently only one collagenase on the market (Santyl) is FDA approved; requires less skill than sharp or surgical debridement; less painful than other methods; can be expensive

question

What is Santyl? What does it do? Is there sufficient evidence to support its use?

answer

enzyme isolated from clostridium; when applied to a wound, it will digest collagen and promote healing; sufficient evidence to support its use

question

What are the indications for enzymatic debridement?

answer

infected and uninfected wounds with necrotic tissue; appropriate for those who cannot tolerate sharp debridement or as an adjunct to sharp debridement; appropriate in home or long-term care settings; can usually be mixed with topical antibiotics but check product information

question

what are the contraindications for enzymatic debridement?

answer

wounds with exposed deep tissues - ligaments, tendons, capsule, etc; facial burns; calluses (not effective); wounds free of necrotic tissue; exogenous enzymes should not be applied to wounds being autolytically debrided since autolytic debridment usually leaves the dressing on for 3 days; can be inactivated by heavy metal ions and acidic solutions - silver sulfadizine, acetic acid, H2O2, silver dressings

question

When should you terminate enzymatic debridement?

answer

once satisfactory debridement has occurred; if necrotic tissue fails to decrease in expected amount of time

question

Describe the procedure for enzymatic debridement

answer

follow manufacturer's guidelines; physician's prescription; eschar to be crosshatched prior to application; moist environment; change dressing every 24 hours and clean wound; observe for signs and symptoms of infection; prophylactic topical antimicrobial therapy prn, especially for those with an increased risk for infection

question

What is biologic debridement?

answer

uses a live medical device for debridement of necrotic tissue; maggot debridement therapy

question

Describe maggot debridement therapy

answer

larvae release enzymes that degrade/liquefy necrotic tissue; larvae ingest necrotic tissue and bacteria; need 10 larvae for 1 cm2 surface area; left on the wound for ~48-72 hours open to air or covered in a net-type dressing

question

What does the literature MDT use for?

answer

pressure and neuropathic ulcers; traumatic wounds; and chronic leg ulcers

question

What is mechanical debridement?

answer

use of force to remove devitalized tissue, foreign material, and debris

question

Describe wet-to-dry dressings. What are they indicated for?

answer

saline-moistened gauze; only indicated for wounds with 100% devitalized wound bed; allowed to dry 8-24 hours and then removed

question

Describe scrubbing

answer

use of sponge, brush, or gauze with water or saline; start in the center and move outwards

question

What is scrubbing contraindicated for?

answer

granulating wounds

question

What is scrubbing used for?

answer

superficial wounds

question

Describe wound cleansing

answer

delivery of wound cleanser with mechanical force; cleansers contain surfactants to loosed superficial debris; may contain cytotoxic agents

question

What is wound cleansing contraindicated for?

answer

partial or full-thickness necrotic wounds or pressure ulcers

question

What is wound cleansing indicated for?

answer

acute, minor integumentary injuries

question

Describe surgical debridement

answer

use of scalpels, scissors, or lasers in sterile environment; performed by physician or podiatrist; allows for extensive exploration of wound's bed and debridement of deeper structures

question

What are the indications for surgical debridement?

answer

ascending cellulitis, osteomyelitis, extensive necrotic wounds, undermining; necrotic tissue near vital organs/structures; gangrene

question

What are the contraindications for surgical debridement?

answer

patients who are unlikely to survive procedure or patients with palliative care plans

question

Describe the procedure for surgical debridement

answer

shaving of eschar with dermatome or removal with scalpel; MD often removes a large margin of healthy tissue too to decrease infection risk (removing all microbes) and to promote healthy cell advancement into the wound; incision and drainage (I and D); possible tissue biopsy; followed by appropriate antimicrobiral therapy

question

When is I and D done?

answer

done for a suspected deep cavity infection

question

What are the advantages of sharp debridement?

answer

expedient, can be used on wounds with any amount of necrotic tissue

question

What are the disadvantages of sharp debridement?

answer

requires skilled personnel, may be painful

question

What are the advantages of autolytic debridement?

answer

allows for debridement outside of skilled care, easy to instruct patient/caregiver, can be used on wounds with any amount of necrotic tissue, virtually pain-free, may be lower in cost than other methods

question

What are the disadvantages of autolytic debridement?

answer

requires more time than other methods, should not be used on infected wounds

question

What are the advantages of enzymatic debridement?

answer

faster than autolytic; allows for debridement outside skilled care, easy to instruct patient/caregiver; virtually pain-free; can be used on both infected and uninfected wounds

question

What are the disadvantages of enzymatic debridement?

answer

requires more time than sharp or surgical debridement, may be costly

question

What are the advantages of mechanical debridement?

answer

removes loosely adhered devitalized tissue, foreign material, and debris

question

What are the disadvantages of mechanical debridement?

answer

non-selective, traumatizes wound bed, may be cytotoxic

question

What are the advantages of surgical debridement?

answer

sterile environment, fast, can fully explore wound and address all tissue layers

question

What are the disadvantages of surgical debridement?

answer

physical and emotional stress, high cost, sacrifices some healthy tissue, requires skilled personnel

question

Study wound debridement algorithm!

answer

...

question

When does wound colonization occur?

answer

if the microflora replicate but do not adversely affect the individual/cause a host response

question

What is critical colonization?

answer

the theoretical turning point where the number of bacteria become a bioburden

question

When does wound infection occur?

answer

when the microorganisms multiply and invade viable body tissues

question

How do high concentrations of microbes adversely affect the host?

answer

microbes compete with host cells for available oxygen and nutrients; bacterial exotoxins may be cytotoxic; bacterial endotoxins may activate host inflammatory processes (causes increase in MMPs); wound infections delay and may prevent wound healing

question

What factors increase risk of infection?

answer

admission to a hospital; factors that predispose individual with open wounds to infection

question

What host characteristics predispose individuals with open wounds to infection?

answer

diabetes, malnutrition, obesity, steroids

question

What local factors predispose individuals with open wounds to infection?

answer

ischemia; presence of necrotic tissue or debris in the wound, and chronic wounds

question

How are the S/S of infection similar to inflammation? How do they differ?

answer

both have rubor, calor, tumor, dolor, and decreased function; infection S/S are typically excessive or disproportionate to the size and extend of the wound

question

what is another sign of infection that doesn't have the qualities of inflammation?

answer

decline in wound status despite appropriate care

question

Describe rubor during infection

answer

poorly defined erythemal border; disproportionate to the size and extent of the wound; may have red streaks leaking from the wound; redness goes proximally

question

Describe calor during infection

answer

greater amount of localized tissue temperature increase spreading over a wider surface area; patient may be febrile

question

Describe tumor during infection

answer

swelling is disproportionate to the size and extend of the wound; may be indurated

question

describe dolor during infection

answer

new onset or increase in pain

question

describe loss of function during infection

answer

malaise; patient may feel sick

question

describe drainage during infection

answer

amount is disproportionate to the size and extent of the wound, may be copious; thick, purulent, or creamy consistency; may be white, yellow, green, or blue in color; may have a distinctive odor

question

describe the decline in wound status during infection

answer

plateau in wound healing; changes in granulation tissue - decrease in amount, friable, cobblestone-like appearance, or color change

question

Who is at greater risk for silent infections?

answer

patients who are immunocompromised or have inadequate perfusion

question

What are some examples of silent infection?

answer

abscess (microbes are contained but not eliminated); patient with arterial insufficiency and gangrenous toe

question

What should clinicians look for if a silent infection is suspected?

answer

systemic signs of infection - fever, increased HR, RR, WBCs, confusion, fatigue

question

What are biofilms?

answer

communities of microorganisms that attach to the wound surface encasing themselves in a matrix

question

What do biofilms allow microbes to do?

answer

allows microbes to survive in wound environments and protect microbes against antiseptics/antimicrobials

question

What may biofilms increase?

answer

may increase bacterial virulence and resistance

question

Where are biofilms generally found?

answer

on necrotic tissues and chronic wounds (up to 60% have biofilms present)

question

What can confirm the presence or absence of infection?

answer

cultures

question

What is the gold standard for wound cultures/tests? What is a disadvantage?

answer

tissue biopsy; can cause trauma to the wound bed

question

What are the options for wound cultures/tests?

answer

tissue biopsy, fluid aspiration, blood tests, swab cultures

question

What are swab cultures used for?

answer

to quantify number and type of bacteria - aerobic and anaerobic

question

What are the indications for a swab culture for aerobic microorganisms?

answer

patient exhibits S/S of infection; patient presents with a non-healing wound despite appropriate wound management

question

Describe the steps to perform a swab culture for aerobic microorganisms

answer

obtain physician's order for wound culture; debride necrotic tissue per protocol and rinse with saline; remove and discard soiled gloves; obtain a culturette and label it with the date, patient's name, identification number, and site cultured; don clean gloves; using applicator, apply gentle pressure to express tissue fluid, swab a 1-cm2 area of viable wound surface for 5 seconds, rotate applicator while traveling over wound bed, swab into wound tunnels if present; securely replace applicator into culturette; squeeze ampule of fluid at bottom of culturette to bathe applicator; place culturette in a biohazard bag labeled with patient's name, identification number, and site cultured; remove and discard soiled gloves, perform separate cultures on each wound, complete any necessary documentation, send culture to lab

question

What are the indications for a swab culture for anaerobic microbes?

answer

patient presents with a deep, tunneling wound that exhibits signs and symptoms of infection; patient's wound present with undermining or sinus tracts and S/S of infection; patient does not present with S/S of infection but has a nonhealing, deep, tunneling wound despite appropriate wound management

question

Describe the steps to perform a swab culture for anaerobic microorganisms

answer

obtain physician's order for wound culture; debride necrotic tissue per protocol and rinse with saline; remove and discard soiled gloves; obtain a anaerobic culture test tube and label it with the date, patient's name, identification number, and site cultured; don clean gloves; using a calcium-alginate tipped applicator, apply gentle pressure to express tissue fluid, swab a 1-cm2 area of viable wound surface for 5 seconds, rotate applicator while traveling over wound bed, swab into wound tunnels, undermined areas, and sinus tracts if present; securely replace applicator into agar at base of culture test tube, if necessary break off any portions of applicator that do not fit within length of culture test tube, securely close cap of culture test tube; place culture in a biohazard bag labeled with patient's name, identification number, and site cultured; remove and discard soiled gloves, perform separate cultures on each wound, complete any necessary documentation, send culture to lab

question

What are ways to identify microbes?

answer

shape; means of reproduction; response to staining; growth environment

question

What are the types of bacteria?

answer

spherical (cocci), helical (spirilla), and rod-shaped (bacilli); aerobic and anaerobic

question

What are the ways bacteria can divide?

answer

in chains (strept-), division in clusters (staphyl-)

question

What are gram-positive and gram-negative bacteria stained?

answer

gram-positive: crystal violet; gram-negative: safranin

question

What are the most common types of fungi?

answer

skin and nail fungi - tinea and Candida

question

Who is vulnerable to fungal infections?

answer

patients taking antibiotics

question

What increases the risk for fungal infection?

answer

moist, occluded areas of skin; diseases that affect the immune system; diabetes

question

What are the most common type of infections for pressure ulcers and other large wounds?

answer

staph, pseudomonas, e. coli

question

WHat are the most common types of infection for cellulitis?

answer

stap and strep (sometimes); if immunocompromised, could be pseudomonas (usually diabetics)

question

What are the common types of infection for diabetes?

answer

multiple organisms

question

what are the most common types of infection for osteomyelitis?

answer

staph

question

What are antibacterial agents?

answer

antimicrobials that are effective against bacteria

question

What does bactericidal mean?

answer

resulting in bacterial death

question

What does bacteriostatic mean?

answer

inhibits bacterial growth

question

What do antifungals do?

answer

target membranes of yeasts and molds

question

What are the two most prevalent strains of resistant bacteria?

answer

MRSA and VRE

question

Describe typical MRSA infections

answer

typical infections are nosocomial but community acquired infections are on the rise

question

Where is VRE commonly seen?

answer

in surgical wounds and UTIs

question

What are adverse reactions from antimicrobial therapy more severe in?

answer

systemic antimicrobials compared to topical ones

question

What are the adverse reactions to antimicrobial therapy?

answer

reactions vary from mild skin reactions to hives, difficulty breathing, and anaphylactic shock

question

What are the most common sensitivities for antimicrobial therapy?

answer

common sensitivities are to penicillin and sulfa drugs

question

Describe how topical antimicrobial therapy is applied

answer

applied to the wound surface and reapplied regularly

question

Describe an anti microbial-impregnated wound dressing

answer

has silver; silver is a broad-spectrum antimicrobial (works on bacteria, virus, yeast); resistance is rare but will develop so don't use on everyone

question

What are the problems with antimicrobial-impregnanted wound dressings?

answer

increased cost; overuse of broad-spectrum antimicrobials may contribute to development of resistant bacteria; if the dressing does not stay in contact with wound bed, effectiveness is decreased; can be toxic in large doses; more research is needed on effectiveness

question

What are the advantages of antimicrobial therapy?

answer

lower cost than some systemic therapies; less likely to cause systemic side effects; reduction of bacterial load; effective in treating wounds where circulation is compromised

question

What are the disadvantages of antimicrobial therapy?

answer

higher cost than non-antimicrobial agents; need for frequent applications; sensitivity or allergic reaction; potential for resistance

question

What is bacitracin? What is it effective against?

answer

topical antimicrobial; effective against gram-negative and gram-positive cocci and bacilli

question

What are the common uses for bacitracin?

answer

superficial and partial-thickness wounds; facial burns (may leave open to air or cover); use as a sulfa-free alternative for burn patients who are allergic to sulfa (as an alternative to silver sulfadiazine)

question

What is Gentamicin sulfate 0.1%? What is it effective against?

answer

topical anti-microbial; effective against gram-negative bacteria, Streptococcus and Staphylococci

question

What are the common uses for gentamicin sulfate 0.1%?

answer

superficial and partial thickness wounds; because of side-effects, should not be used prophylactically, and use should be discontinued as soon as signs of infection have resolved

question

What is sulfamylon? What is its effectiveness?

answer

topical anti-microbial; broad-spectrum anti-microbial effective against gram-positive and gram-negative bacteria including pseudomonas aeruginosa; penetrates wound eschar

question

What are the common uses of sulfamylon?

answer

burn wounds; readily penetrates eschar (good on nose and ear burns); may leave open to air (face, ears) or cover

question

What is another name for Mupirocin? What is it? What is it effective against?

answer

bactroban; topical antimicrobial; effective against gram-negative and gram-positive organisms including MRSA

question

What are the common uses for Mupirocin?

answer

generally reserved for patients with MRSA to reduce potential for resistant bacterial strain development

question

What is neomycin sulfate? What is effective against?

answer

topical antimicrobial; broad-spectrum antimicrobial particularly effective against gram-negative and some gram-positive bacteria

question

What are the the common uses for neomycin sulfate?

answer

superficial and partial-thickness wounds

question

What is Polymyxin B sulfate? What is it effective against?

answer

topical antimicrobial; effective against gram-negative organisms

question

What are the common uses for Polymyxin B sulfate?

answer

superficial and partial-thickness wounds; burns; commonly mixed with Santyl

question

Which topical antimicrobial is found in antibiotic creams?

answer

neomycin sulfate

question

What is Polysporin powder? What is it effective against?

answer

topical antimicrobial; broad-spectrum antimicrobial

question

What are the common uses for Polysporin powder?

answer

mixed with collagenase for use on infected, necrotic wounds

question

What are the other names for silver sulfadiazine 1% cream?

answer

Silvadene, SSD cream, Thermazene

question

What is silver sulfadiazine1% cream? What is it effective against?

answer

topical antimicrobial; broad-spectrum antimicrobial especially effective against gram-negative bacteria (e. coli, Enterobacter, Klebsiella), gram-positive bacteria (S. aureus), and Candida albicans

question

What are the common uses for silver sulfadiazine 1% cream?

answer

most widely used topical agent for burns; wounds of all depths/sizes

question

What is neosporin?

answer

triple antibiotic; ointment containing a blend of neomycin, bacitracin, and polymyxin B sulfate

question

Describe the effectiveness of triple antibiotic

answer

may provide a broader spectrum coverage than each drug individually; may enhance epithelialization

question

What are the common uses for triple antibiotic?

answer

superficial and partial thickness wounds; 1o facial burns (may leave open to air or cover)

question

What are the antifungals used for wounds?

answer

nystatin (mycostatin); oxiconazide nitrate (oxistat) and miconazole (lotrimin)

question

Which antifungal is effective on Candida?

answer

Nystatin

question

What antifungal is effective on tinea?

answer

oxiconazide and Miconazole

question

What should you check for when applying a topical antimicrobial therapy?

answer

check expiration date prior to use because of limited shelf-life

question

What is an alternative to topical anti-microbial therapy?

answer

surgically implanted antimicrobial-impregnated beads

question

What are surgically implanted antimicrobial-impregnated beads commonly used in?

answer

deep partial- to full-thickness diabetic infections

question

Explain procedure for application of topical antimicrobials

answer

...

question

What are antiseptic agents?

answer

antimicrobial solution that prevents infection by killing microorganisms; cytotoxic

question

How do antiseptic agents affect wound healing?

answer

increase duration and intensity of inflammatory process and retard wound healing

question

When can antiseptic agents be used?

answer

may be used as a surgical scrub, hand washing, cleansing intact skin; occasionally may be appropriate for short-term use on open wounds

question

What is acetic acid (0.25-.5%)?

answer

antiseptic

question

What happens when acetic acid is diluted to a level that is non-cytoxic?

answer

solution is no longer bacteriostatic

question

What are the uses for acetic acid?

answer

Pseudomonas infections; if infection persists after 2 weeks, use should be reassessed

question

What is Chloramine-T?

answer

antiseptic

question

What are the acceptable uses for Chloramine-T?

answer

acceptable use is questionable; may be ok with short-term pulsed lavage in very infected wounds at 100-200 ppm solution; dog-bites

question

What is Chlorhexidine gluconate? What is another name for it?

answer

antiseptic; Hibiclens

question

What are the acceptable uses for Chlorhexidine gluconate?

answer

cleanser for intact skin (avoid eyes); surgical scrub; hand washing solution for health care workers; perisurgical skin prep

question

What is Dakin's solution? What are other names for it?

answer

antiseptic; sodium hypochlorite, bleach

question

Describe the effectiveness of Dakin's solution

answer

bactericidal, virucidal, fungicidal

question

At what level is Dakin's solution not cytotoxic to human cells?

answer

.005% = bacteriostatic

question

What is the acceptable use for Dakin's solution?

answer

cleaning surfaces of inanimate objects

question

What is hydrogen peroxide? At what percentage is it used?

answer

antiseptic; 3%

question

At what dilution is hydrogen peroxide no longer bactericidal but still cytotoxic to human cells?

answer

1:50 or 1:100

question

What are the acceptable uses for hydrogen peroxide?

answer

removing dried blood and exudate over superficial wounds such as pin sites and sutures; rinse with normal saline after use

question

What is Povidone-iodine? What is another name for it?

answer

antiseptic; Betadine

question

What is Povidone-iodine effective for?

answer

gram-positive and gram-negative bacteria

question

What are the acceptable uses for Povidone-iodine?

answer

surgical scrub on intact skin; 1.0% may be appropriate for short-term use on acute wounds

question

What is systemic antimicrobial therapy commonly called?

answer

antibiotics

question

When is systemic antimicrobial therapy prescribed?

answer

for sepsis, signs of advancing infection, with or without topical antimicrobials

question

How is antimicrobial therapy administered?

answer

may be done intravenously

question

What are the advantages of systemic antimicrobial therapy?

answer

reduction in bacterial load; ease of use; maybe higher adherence

question

What are the disadvantages of systemic antimicrobial therapy?

answer

more frequent/severe adverse reactions; development of resistant bacterial strains; problems with missed doses; higher cost

question

What must happen for an antimicrobial to be effective?

answer

microorganism present in the wound must be sensitive to the selected antimicrobial

question

How does debridement help with infection?

answer

regular debridement of necrotic tissue and exudate helps reduce bacterial bioburden; debridement may increase effectiveness of topical antimicrobials and antibiotics

question

When is surgical debridement required?

answer

for osteomyelitis or sepsis

question

Describe sterile technique

answer

only sterile equipment may come in contact with a patient's wound

question

When is sterile technique used?

answer

reserved for wounds that require packing, large surface area wounds, severe burns, and wounds in immunocompromised patients

question

Describe clean technique

answer

procedures designed to reduce overall number of microorganisms present to decrease risk of transmission

question

When is clean technique used?

answer

standard technique for wound management

question

What are the advantages of a moist wound environment?

answer

facilitates all three phases of wound healing; traps endogenously produced enzymes to facilitate autolytic debridement; preserves endogenously produced growth factors and enhances fibroblast proliferation, collagen synthesis, and angiogenesis; reduces patient pain complaints; results in more cosmetically appealing scar

question

What are the functions of wound dressings?

answer

create moist environment; provide thermal insulation; hemostasis; control edema; eliminate dead space within wound bed

question

What can happen if a large wound cavity is not filled?

answer

it can close prematurely prior to granulation tissue formation, leaving a potential space and sealing in colonizing organisms; normal colonizing bacteria will multiply causing an abscess and potentially increasing the size of the wound

question

What are the categories of wound dressings?

answer

primary and secondary

question

What is a primary dressing?

answer

dressing that comes into direct contact with wound (contact layer)

question

What is a secondary dressing?

answer

dressing placed over primary dressing for increased protection, cushioning, absorption, or occlusion

question

What are moisture-retentive dressings?

answer

synthetic or organic dressings that are typically more occlusive than gauze

question

What is occlusion?

answer

ability of dressing to transmit water, vapor, and bacteria from the wound bed to the atmosphere

question

What is a truly occlusive substance?

answer

latex

question

What are the characteristics of a moisture-retentive dressing? What does this allow them to do?

answer

have a lower moisture vapor transmission rate -> more occlusive; they are better at trapping wound fluid rich in enzymes, growth factors, neutrophils, and macrophages

question

Why should you use moisture-retentive dressings?

answer

lower moisture vapor transmission rates are associated with faster healing and lower pain; allows patients to bathe, wash dishes, or swim without wound contamination; many are adhesive, precluding need for tape; more expensive for one time use but cheaper long-term; require fewer dressing changes; serve as a bacterial barrier; are impermeable to urine and stool; facilitate neutralization of microorganisms; facilitate removal of necrotic tissue and debris; designed to stay in place for 3-7 days; can be used on red, yellow, and black wounds and all depths

question

What are the common fears associated with moisture-retentive dressing usage and infection?

answer

Infection: many clinicians believe that maintaining a moist environment facilitates colonization; however, wounds with occlusive dressings have lower infection rates compared to nonocclusive dressings; dressings should be changed if the barrier becomes compromised; immunocompromised patients may require more frequent dressing changes; most of these dressing should be discontinued if infection is suspected; this type of dressing is contraindicated in known infected wounds (semi-permeable foams, alginates, and antimicrobial dressings are exceptions to this rule)

question

What are the common fears associated with moisture-retentive dressing usage and damage to surrounding skin?

answer

adhesives are less tacky than traditional silk tape; dressing removal does not pose significant threat to healthy skin; breakdown can occur if dressings are changed too frequently; skin sealants or barriers applied to intact skin can prevent maceration

question

What happens if there are wrinkles or creases in a wound dressing?

answer

provides a pathway for (1) wound fluid to escape from under the dressing and (2) for microbes from the environment to enter the wound bed, increasing risk of wound infection

question

What is the most occlusive and least occlusive dressing?

answer

most occlusive - hydrocolloids; least occlusive - gauze

question

WHat are the types of gauze?

answer

woven gauze (cotton); nonwoven gauze (synthetic, more absorbent); gauze pad; layers of gauze padding

question

What is the advantage of gauze with finer weave and smaller pores?

answer

minimize risk for trauma to wound bed

question

Describe gauze dressings

answer

highly permeable and relatively non-occlusive; can be used as primary or secondary dressing; inexpensive, used for one-time or short-term use

question

What are the common uses for gauze dressings?

answer

infected and non-infected wounds of any size, shape, depth, or etiology

question

When is gauze the dressing of choice?

answer

very frequent dressing changes; heavily draining wounds; decreased cost; infected wounds being treated with enzymatic debriding agents; wounds requiring packing; patients with fragile integument (roll gauze)

question

What are the precautions/contraindications for gauze dressings?

answer

woven gauze may require more force for removal; woven gauze may leave residue or lint in bed causing formation of granuloma (use non-woven to decrease risk); if allowed to dehydrate, dressing will adhere to wound bed; Telfa (non-stick) dressings are reserved for superficial, minimally or nondraining wounds

question

What are the benefits of gauze dressings?

answer

are universally available; have a low one-time cost; can be used on infected and non-infected wounds; can be used alone or in combination with other classes of dressings and topical agents; can add more layers to increase absorption capabilities; provide cushioning; keep adhesives off patients' skill (roll gauze)

question

What are the limitations of gauze dressings?

answer

are costly over time; may adhere to wound bed; may leave particulate matter in wound bed; are highly permeable; require more frequent dressing changes; have a higher infection rate than occlusive dressings

question

Describe impregnated gauze dressings

answer

mesh gauze dressings impregnated with petrolatum, saline, bismuth, or zinc; used as contact layer requiring a secondary dressing; nonadherent; increase occlusiveness of a standard gauze dressing

question

What are the common uses of impregnated gauze dressings?

answer

wound contact layer on granulating wound bed; prevents exposed bone, tendons, etc. from dehydrating or adhering to dressing; burn wounds; epithelializing wounds; wounds that bleed easily; painful wounds

question

What are the precautions/contraindications of impregnated gauze dressings?

answer

dressings with bismuth (Xeroform) are cytotoxic to inflammatory cells and may cause an inflammatory response in patients with venous insufficiency ulcers; iodine-impregnated gauze are cytotoxic and only mildly antimicrobial

question

What are the benefits of impregnated gauze dressings?

answer

decrease trauma to wound bed during dressing changes; decrease pain of dressing changes; may increase occlusiveness of gauze dressing

question

what are the limitations of impregnated gauze dressings?

answer

costly; require secondary (gauze) dressing; may present a barrier to keratinocyte migration if highly impregnated; have minimal absorptive capabilities

question

Describe semipermeable film dressings

answer

thin, flexible sheets of transparent polyurethane with adhesive backing; permeable to water vapor, O2, CO2, but impermeable to bacteria and water; have little absorptive capabilities; allow for visualization of wound bed; highly elastic and conform to body contours

question

How should semipermeable film dressings be applied?

answer

should be secured to 1-2 border of intact skin; should be applied without tension or wrinkles; may be left in place for 5-7 days; should not be used for wounds with moderate to heavy drainage or on patients with fragile skin

question

What are the common uses for semipermeable film dressings?

answer

superficial wounds, lacerations, abrasions, skin tears; partial-thickness wounds, sutured wounds, and donor graft sites; granular wounds and yellow slough-covered wounds with minimal drainage; may be used in areas of friction

question

What are the precautions/contraindications for semipermeable film dressings?

answer

use a skin sealant to prevent maceration; must maintain good edge seal; should not be used on infected wounds

question

what are the benefits of semipermeable film dressings?

answer

are moisture retentive; encourage autolytic debridement; reduce friction; allow visualization of wound bed; are waterproof; cost less over time

question

What are the limitations of semipermeable film dressings?

answer

adhesive may traumatize periwound upon removal; cannot be used on highly exudating wounds; can be difficult to apply, especially larger sizes; should not be used on infected wounds

question

What are the common uses for semipermeable film dressings?

answer

skin tears; donor sites; areas of friction; abrasions; over intravenous catheters to allow bathing/whirlpool; over wounds for ultrasound treatment

question

Describe hydrogels

answer

80-99% water or glycerin-based wound dressings available in sheets, gels, or impregnated gauzes; absorb minimal amount of fluid; donate moisture to dry wounds; permeable to gas and water; may decrease pain; almost nonadhesive, requiring secondary dressing

question

What are the common uses for hydrogels?

answer

indicated for minimally or moderately draining wounds; used on superficial and partial-thickness wounds; gel can be used in wounds as a coupling agent for ultrasound with a gel sheet overlay; sheets can provide padding to decrease shear forces in casts and splints; effective for softening eschar

question

What are the precautions/contraindications for hydrogels?

answer

should not be used on heavily draining wounds or bleeding wounds; absorb fluids slowly (minimal); should not be used on infected wounds; use a skin sealant

question

What are the benefits of hydrogel dressings?

answer

are moisture retentive; encourage autolytic debridement; reduce pressure; are non- or minimally adherent

question

What are the limitation of hydrogel dressings?

answer

may dehydrate; cannot be used on highly exudating wounds; generally require secondary dressing; should not be used on infected wounds

question

What are the common uses for hydrogel dressings?

answer

minimally to moderately exudating wounds; pressure ulcers; blisters; abrasions; skin tears; burns (thermal and radiation); donor sites; coupling medium for ultrasound; padding for splints and total contact casts; amorphous hydrogels can be used to soften eschar and provide a moist environment to dry wounds

question

describe semipermeable foams

answer

polyurethane foam with a hydrophilic wound side and hydrophobic outside; permeable to gas but not to bacteria; provide thermal insulation; less likely to cause trauma upon removal; easy to apply; good for use on pressure ulcers

question

What are the common uses for semipermeable foams?

answer

wounds with minimal to heavy exudate; granulating or slough-covered partial-thickness wounds; donor sites, ostomy sites, minor burns, diabetic ulcers, and venous insufficiency ulcers

question

What are the precautions/contraindications for semipermeable foams?

answer

not indicated for dry or eschar-covered wounds; not indicated for arterial ulcers - they are too dry; not ideal for heel ulcers or areas of high friction; skin sealant should be used to protect periwound

question

What are the benefits of semipermeable foam dressings?

answer

are moisture retentive; encourage autolytic debridement; provide thermal insulation; many provide cushioning; are available in both adherent and nonadherent forms; absorb moderate amounts of exudate

question

What are the limitations of semipermeable foam dressings?

answer

adhesive may traumatize periwound upon removal; may roll in areas of friction; should not be used on infected wounds unless changed daily

question

Describe hydrocolloids

answer

contain hydrophilic colloidal particles with a strong film or foam adhesive backing; vary in absorptive abilities; absorb fluid slowly by swelling into gel-like mass; residue often remains after removal; provide thermal insulation; impermeable to water, O2, and bacteria

question

What is Duoderm?

answer

hydrocolloid that is an effective barrier against urine, stool, MRSA, hepatitis B, HIV-1, and Pseudomonas

question

What are the common uses for hydrocolloids?

answer

partial- and full-thickness wounds; granular and necrotic wounds; several dressings are designed for sacral and coccygeal pressure ulcers; minor burns and venous insufficiency ulcers; hydrocolloid pastes/powders can be used to fill cavities in draining wounds

question

What are the precautions/contraindications for hydrocolloids?

answer

not appropriate for bleeding or heavily draining wounds - absorbs too slowly; contraindicated in infected wounds; use with caution on immunocompromised patients - can promote anaerobic bacterial growth; should not be used on dry wounds, arterial ulcers, 3rd degree burns, or wounds with minimal drainage; should not be used on wounds with exposed tendons/fascia; should only be used on patients with good border skin integrity, along with skin sealant

question

What are the benefits of hydrocolloid dressings?

answer

moisture retentive; encourage autolytic debridement; are impermeable to urine, stool, bacteria; provide thermal insulation; are waterproof; some have beveled edges to prevent dressing from rolling up; provide moderate absorption

question

What are the limitations of hydrocolloid dressings?

answer

will likely traumatize fragile periwound upon removal; leave residue within wound bed; may cause hyper granulation; may roll in areas of friction; should not be used on infected wounds

question

Describe alginates

answer

salts of alginic acid are extracted from brown seaweed and converted into calcium/sodium salts; react with serum and wound exudate to form a hydrophilic gel to provide a moist wound environment; highly permeable and non occlusive, requires secondary dressing

question

What forms are alginates available in?

answer

sheets, ropes, alginate-tipped applicators

question

What are alginate sheets for?

answer

to absorb drainage

question

What are alginate ropes used for?

answer

to fill tunnels, cavities, or undermining

question

What are alginate-tipped applicators used for?

answer

to probe wounds, perform swab cultures, and to measure wound depth

question

How much can alginates absorb?

answer

up to 20x their weight in exudate

question

what are the common uses for alginates?

answer

moderate to highly draining wounds; partial- and full-thickness draining wounds; ideal for infected wounds; venous insufficiency wounds

question

how often do alginate dressings need to be changed?

answer

daily

question

what are alginates not indicated for?

answer

dry or minimally draining wounds

question

What are the precautions/contraindications for alginates?

answer

not recommended for 3rd degree burns (full thickness) - will dry it out too much; not for use on wounds with exposed tendon, joint capsule, or bone; skin sealant should be used; don't use on neonates since it can cause electrolyte imbalances

question

What are the benefits of alginates?

answer

encourage autolytic debridement; are highly absorbent; can be used on infected and uninfected wounds; are biocompatible; are nonadherent

question

What are the limitations of alginate dressings?

answer

require secondary dressing

question

What is a composite dressing?

answer

multilayer dressing that can be used as primary or secondary dressing

question

what layers make up a composite dressing? Describe what each layer does

answer

inner contact layer - non adherent, prevents trauma to wound bed; middle layer - absorbs moisture and wicks it away to prevent maceration yet maintains moist wound bed; outer layer - serves as a bacterial barrier

question

What does the middle layer of a composite dressing consist of?

answer

hydrogel, semipermeable foam, hydrocolloid, or alginate

question

what is the outer layer of a composite dressing consist of?

answer

commonly a semipermeable film

question

what is silver?

answer

antiseptic agent that has been incorporated into all classes of dressings

question

What can release of silver ions in the wound bed result in?

answer

blue-black discoloration

question

describe the research on silver use

answer

limited research to support that silver is effective against multiple organisms within a wound or against biofilms

question

What do some silver dressings require?

answer

premoistening with water

question

What cannot be used to premoisten a silver dressing? Why?

answer

saline; deactivates the silver

question

What will give best results when using silver?

answer

free silver release should be >20 mg/l

question

What types of wounds should silver dressings be used with caution? Why?

answer

use with caution in epithelializing or granulating wounds because of cytotoxicity

question

Should silver dressings be used in uninfected wounds?

answer

no evidence that silver dressings help prophylatically in healing uninfected wounds

question

True or False: Silver dressings cost more than standard moisture-retentive dressings

answer

true

question

Who can silver dressings not be used on? Why?

answer

neonates due to toxicity

question

What is the key function of charcoal dressings?

answer

to control odor by absorbing odor-producing gases released by bacteria

question

True or False: Charcoal dressings enhance wound healing rates more than any other type of moisture-retentive dressing

answer

False: charcoal dressings do not enhance wound healing rates more than any other type of moisture-retentive dressing

question

What are the benefits of Manuka honey?

answer

antimicrobial (acidic); reduces pain; stimulates proliferative phase; reduces edema

question

Describe collagen dressings

answer

may facilitate wound healing; has been incorporated into sheets, ropes, wound dressings, and topical agents such as gels or particles; adhere to wound bed but not to periwound

question

what can collagen dressings be used on?

answer

both infected and uninfected wounds, including superficial burns and donor sites

question

How long do you leave a collagen dressing on a wound?

answer

typically left in place until the wound is resurfaced underneath

question

What do skin sealants and moisture barriers do?

answer

both form a protective layer or coating over the skin prevent skin breakdown

question

describe skin sealants

answer

alcohol-based wipes; used on intact periwound skin; makes the skin tacky to provide a better edge seal and protects skin from adhesive

question

Describe moisture barriers

answer

ointments or creams that contain petrolatum, dimethicone, and/or zinc oxide; prevent rashes and skin breakdown in areas of incontinence

question

What are the benefits of skin sealants and moisture barriers?

answer

protect the skin from maceration; minimally protects the skin from adhesives

question

what are the limitations of skin sealant and moisture barriers?

answer

may build up around the wound edge; cream version cannot be used with adhesive dressings

question

what are the common uses for skin sealants and moisture barriers?

answer

any time moisture-retentive dressings are used; when adding a topical agent to the wound bed; on macerated periwound/perineum

question

What is the key component of basic skin care?

answer

moisturizers

question

What do moisturizers do?

answer

help restore barrier function of epidermis; increase water content of epidermis; maintain skin hydration and appearance

question

What types of moisturizers should be avoided? Why?

answer

moisturizers with perfume or alcohol due to possible skin reactions

question

How often and where should moisturizers be applied?

answer

should be applied to intact skin 2x/day

question

which types of moisturizers are more occlusive?

answer

ointments are more occlusive than creams or lotions

question

what is another name for tissues adhesives?

answer

skin glues

question

How often are skin glues used in a PT setting?

answer

rarely used but available OTC

question

what are tissue adhesives?

answer

specially formulated compounds that allow primary wound closure without use of staples or sutures

question

what are tissue adhesives appropriate for?

answer

acute linear wounds without tissue loss

question

what should tissue adhesives not be used for?

answer

heavy contaminated wounds, puncture wounds, or wounds >12 hours old; wounds crossing a joint

question

compare strength of wounds closed with tissue adhesives vs. sutures

answer

wounds closed with tissue adhesives have 12x less tensile strength when compared to wounds closed with sutures immediately on application; after one week, there is no difference in tensile strength

question

What are the types of growth factors?

answer

cytokines, interleukins, and colony-stimulating factors

question

what are growth factors?

answer

growth-promoting substances that enhance cell size, proliferation, or activity

question

What do growth factors do to wounds?

answer

wounds treated with certain growth factors improved significantly more than wounds treated with a placebo

question

describe growth factors and delayed wound healing

answer

at this time, growth factors to facilitate delayed wound healing is extremely costly and limited to chronic wounds that are recalcitrant to traditional interventions

question

What is Becaplermin?

answer

Regranex; growth factors approved for use on diabetic foot ulcers

question

What is oasis?

answer

a wound dressing that contains a cellular matrix of collagen and growth factors that have been effective in wound healing

question

What does a draining wound require?

answer

a dressing with the ability to absorb moisture and protect the surrounding wound from maceration

question

what does a nondraining wound require?

answer

a dressing that provides moisture or prevents evaporative fluid loss; since moisture will be added to the wound, a skin sealant should be used

question

what does a granular wound require?

answer

a dressing that will protect the wound from trauma

question

What does a necrotic wound require?

answer

debridement

question

What type of dressing should be used if autolytic debridement is indicated?

answer

a moisture-retentive dressing should be selected and should remain in place for several days

question

what type of dressing should be used if enzymatic debridement is indicated?

answer

gauze is appropriate with dressing changes 1-3 time/day

question

what types of dressing should be used if mechanical debridement is desired?

answer

wet-to-dry or other similar technique

question

What should you do with a granular and non-draining wound?

answer

wound is healing as expected; moisture may need to be added with hydrogel or a more occlusive dressing should be used

question

What should you do with a granular and draining wound?

answer

granulation tissue and periwound should be protected; a more absorptive dressing should be applied; if heavily draining, infection may be present

question

what should you do with a necrotic and nondraining wound?

answer

requires debridement and softening of eschar; moisture may need to be added; enzymatic debridement; surrounding tissue should be protected with skin sealant

question

What should you do with a necrotic and draining wound?

answer

requires debridement, absorption, and protection of surrounding tissue; wound should be observed for S/S of infection

question

What are the short-term goals for a granular, nondraining wound? And what dressing should be used for each goal?

answer

obtain/maintain moist environment - gauze; protect surrounding tissue - impregnated gauze, transparent film, hydrogel

question

What are the short-term goals for a granular, draining wound? And what dressing should be used for each goal?

answer

observe for infection - gauze; absorbe exudate - alginate; protect surrounding tissue - semipermeable foam, hydrocolloid

question

What are the short-term goals for a necrotic, non draining wound? What type of debridement should be used? What dressing should be used for each goal?

answer

Soften eschar - surgical - gauze; remove eschar - sharp - impregnated gauze; obtain/maintain moist environment - enzymatic - transparent film; protect surrounding tissue - autolytic - hydrogel, hydrocolloid

question

What are the short-term goals for a necrotic, draining wound? What type of debridement should be used? What dressing should be used for each goal?

answer

observe for infection - surgical - gauze; absorb exudate - sharp - alginate; remove eschar - enzymatic - semipermeable foam; protect surrounding tissue - autolytic - hydrocolloid

question

What should you do for infected wounds?

answer

should not be occluded (typically) and should be rebandaged daily

question

What are good dressing choices for infected wounds?

answer

gauze dressings with additional gauze layers, an alginate, or semipermeable foam for heavily draining wounds

question

What type of dressing should be used for small wounds?

answer

gauze or moisture-retentive dressings

question

what type of dressing should be used for large wounds?

answer

gauze dressings

question

what type of dressing should be used for deep wounds?

answer

light filling to prevent abscess formation

question

what type of dressing should be used for tunneling wounds?

answer

gauze dressings or alginate rope (if significant wound drainage) and frequent dressing changes

question

What types of dressings should you avoid for fragile skin?

answer

adhesives and adherent dressings

question

What should the optimal dressing for an uninfected wound require?

answer

the least frequent dressing changes

question

When should adhesive, moisture-retentive dressings be used?

answer

only if intended for three days or more

question

What is best for wounds in a highly mobile area or in an area not conducive to wrapping?

answer

adherent moisture-retentive dressing

question

What is the clinical implication for a granular wound bed?

answer

debride necrotic tissue; protect granular tissue

question

What is the clinical implication for a moist wound bed?

answer

add moisture to dry wound bed; absorb moisture from wet wound bed; keep wound covered

question

What is the clinical implication for a warm wound environment?

answer

cover with wound dressing

question

What is the clinical implication for managing an infection?

answer

prevent contamination; keep wounds covered; use universal precautions; use sterile technique when indicated; if infected, use topical antimicrobials and systemic antibiotics as directed by physician

question

What is the clinical implication to eliminate dead space?

answer

lightly fill wound cavity, tunnels, and undermining

question

what is the clinical implication for healthy periwound and intact skin?

answer

apply moisturizers to anhydrous or calloused intact skin; apply skin sealant to protect from maceration

question

What is the clinical implication for managing tissue loads?

answer

prevent trauma (pressure, friction, and shear) to wound bed; unload affected areas - positioning, cushions, supports, assistive devices

question

What is the clinical implication for controlling contributing factors?

answer

educate pt and caregivers; involve appropriate health care professionals to address factors known to delay wound healing

question

What factors are known to delay wound healing?

answer

malnutrition; impaired circulation; impaired oxygenation; immunocompromise; activity/mobility limitations; behavioral risk taking

question

How do we enhance the patient's ability to heal?

answer

stimulate healing of recalcitrant wounds - serial instrumented debridement, electrotherapeutic modalities, physical agents, mechanical modalities, growth factors, skin substitutes

question

How do you properly remove adhesive dressings?

answer

lift up corner and stretch dressing longitudinally to decrease dressing's adhesion to the skin's surface

question

How do you properly remove a gauze dressing that is adhered to the wound bed?

answer

moisten with saline prior to removal unless performing wet-to-dry dressing on a wound that is 100% necrotic

question

What types of dressings are communal used on small to medium-sized uninfected wounds with good surrounding skin integrity?

answer

semipermeable films, adherent semipermeable foams, hydrocolloids, and composite dressings

question

what types of dressings are ideal for hands, arms, legs, and trunk wounds?

answer

adherent occlusive dressings

question

what should the clinician do after applying the dressing?

answer

initial and date it

question

What should be avoided whenever possible for nonadherent dressings? What should you use if necessary?

answer

tape; if tape must be used, choose foam, cloh, or hypoallergenic paper tape

question

What are the preferred methods of securing dressings?

answer

roll gauze, self-adherent elastic wraps (Coban or Co-flex), elastic netting (Surgiflex)

question

What should you do with wounds with dead space and why?

answer

should be filled to prevent premature wound closure and abscess formation

question

What should you use to fill wounds with dead space?

answer

alginate ropes for moderate to heavy drainage; gauze packing strips may also be considered

question

What might large wounds with extensive cavities require?

answer

filling with small-weave roll gauze or gauze sponges

question

What should the packing material be confined to?

answer

the wound bed

question

What should you use to fill the wound?

answer

sterile instruments and packing materials

question

Why should you use alginate-tipped applicators?

answer

because of potential for cotton to remain in wound bed

question

What should you do outside the wound cavity tunnel?

answer

leave a wick outside for easy identification for next dressing change

question

describe the bandaging procedure for fingers

answer

each digit should be wrapped individually; keep bandaging to a minimum; tubular dressings may be ideal if sterile technique is not required

question

Describe the bandaging procedure for hands

answer

Occlusive dressings for small wounds; if a large wound or infected, roll gauze is required - figure eight wrapping, minimize bandage bulk to allow use of extremity

question

Describe the bandaging procedure for legs and arms

answer

occlusive dressings for uninfected wounds; nonadherent dressings if skin integrity is poor or if significant body hair is present; dressings may be secured with roll gauze, self adherent elastic wraps, or elastic netting

question

Describe the bandaging procedure for the trunk

answer

wounds requiring a secondary dressing may be secured in place with roll gauze, an elastic vest, or both; trunk wounds covering a large area may be best managed with a burn vest

question

Describe what Montgomery straps are used for

answer

used for abdomen; minimally adhesive strips with ties on one side; after placement of primary dressing, straps are tied together creating an external suture

question

Describe the bandaging procedure for the ankle/foot

answer

can be bandaged like hand wounds; because of increased drainage, dressing may require more absorptive capabilities; thick gauze pads, sheet hydrogels, and thick foams may be used on plantar wounds; must ensure adequate room for footwear; temporary footwear (post-op shoe) or assistive device may be appropriate options

question

What is wound irrigation?

answer

use of fluid to remove loosely adherent cellular debris, surface bacteria, wound exudate, dressing residue, and residual topical agents

question

What does wound irrigation do?

answer

facilitates debridement; assists with maintaining a moist wound environment; and enhances wound healing

question

What are the indications for wound irrigation?

answer

acceptable intervention for all types of wounds; indicated for healing, granular wounds

question

what are contraindications/precautions for wound irrigation?

answer

not indicated for active, profuse-bleeding wounds

question

Describe the method for wound irrigation

answer

wound should be irrigated on initial exam and with each dressing change; use saline or tap water; use minimal force, but don't just pour saline over the wound; recommended pressures 4-15 psi; may be performed with soaked gauze, water-pik, syringe, pulsed lavage, whirlpool (irrigate with another method after whirlpool)

question

what are the advantages of wound irrigation?

answer

simple, quick, inexpensive, effective; can be performed on any body location and in any treatment setting

question

What are the disadvantages of wound irrigation?

answer

runoff may soil linens or clothing; may not use adequate amount of irrigant

question

What are alternative interventions for wound irrigation?

answer

soaking, whirlpool, and pulsed lavage

question

What are the purposes of whirlpool?

answer

debrides loosely adherent devitalized tissues, debris, and surface bacteria; softens necrotic tissue and eschar; hydrates wound bed and promotes healing; promotes circulation; decreases pt pain complaints; eases ROM for pts with burn injuries; helps soak off adherent wound dressings

question

What are the indications for whirlpool?

answer

use on infected wounds to reduce bacterial load; use on nondraining wounds to rehydrate wound bed; rehydrates wounds with eschar, adherent necrotic tissue, or thick exudate

question

What can inappropriate use of the whirlpool do?

answer

can prolong or prevent wound closure

question

What are the contraindications/precautions of whirlpool?

answer

contraindicated for ulcers due to venous insufficiency, edema, or lymphedema; dependent positioning and warm water can cause increased peripheral edema; contraindicated for wounds with active, profuse bleeding; pts who are confused, combative, or with uncontrolled seizures should not receive whirlpool treatments; should not be used if multiple wounds are present and if not all wounds are believed to be infected, for risk of cross-contamination; tunneling wounds, wounds with significant undermining, and wound in areas of skin folds will not be sufficiently irrigated; do not use in incontinent pts; wounds due to arterial insufficiency should be treated at lower temperatures

question

What are the methods for whirlpool?

answer

immersion technique; shower technique

question

Describe the immersion technique for whirlpool

answer

water should be between 92-98oF, never exceeding 102oF; clinician must don appropriate barrier devices; should be completed in 10-20 min; pts are encouraged to perform ROM exercises unless contraindicated; after whirlpool, irrigate wound, assess treatment results, perform debridement if indicated, and bandage

question

How often are whirlpool treatments performed?

answer

twice daily to 3x/week

question

When should you discontinue whirlpool?

answer

when the wound is clean and granular

question

describe the showering technique for whirlpool

answer

affected area is positioned over the empty whirlpool and sprayed with water

question

Describe the use of chemical additives for whirlpool

answer

clinicians must weight potential benefits of antimicrobial application with known risks of delayed wound healing; should not be used on chemical wounds - could lead to chemical reaction; contraindicated in young, elderly and those with sensitivities to these agents; use is not recommended except in isolated cases

question

What are the advantages of whirlpool?

answer

comfortable; promotes moist wound healing; available in most clinical settings; simple, effective

question

What are the disadvantages of whirlpool?

answer

cannot calibrate irrigation pressure; potential for maceration, edema, cross-contamination; requires time for set-up/cleanup; expensive

question

Describe pulsed lavage with concurrent suction

answer

involves regular, automatic interruption of fluid flow with handheld device to regulate irrigation pressure; applies negative pressure to wound bed which removes irritant, pathogens, and enhance granulation tissue formation, epithelialization, and local tissue perfusion

question

What are the indications for pulsed lavage with concurrent suction?

answer

cleansing or debriding wounds due to arterial insufficiency, venous insufficiency, diabetes, pressure, small burns, surgery, or trauma; appropriate for tunneling or undermining wounds

question

What are the contraindications/precautions for pulsed lavage with concurrent suction?

answer

contraindicated near exposed arteries, tendons, nerves, capsules, or bones; should not be used in body cavities, facial wounds, on recent grafts or surgical procedures, or on actively bleeding wounds; should not be used on pts with latex sensitivities or allergies; used with caution on pts taking anticoagulants, insensate patients, and deep tunneling wounds; irrigation >15 psi is contraindicated - may drive bacteria deeper into tissues

question

Describe the method for pulsed lavage with concurrent suction

answer

pt should wear mask due to aerosolization; clinician should wear appropriate barrier devices; irrigant reservoir (saline) should be warmed to 102-106oF; 1000-3000 mL of irrigant required; pressure adjusted between 4-15 psi or lower pressure used initially or with tunneling or undermining wounds; average treatment time is 15-30 min; infection control guidelines must be followed; treatment frequency varies between twice daily for severely infected or necrotic wounds or wounds with heavy exudate and three times per week for granular wounds

question

What is the purpose/effects of pulsed lavage?

answer

irrigates wound bed with precisely calibrated pressure; assists with obtaining and maintaining a moist wound environment; facilitates debridement; may enhance granulation tissue formation, epithelialization, and tissue perfusion

question

What are the advantages of pulsed lavage?

answer

encourages thorough irrigation; can be used in any setting; quick; less expensive than whirlpool; low risk of cross-contamination; can be used for any wound location; can be used in any setting; ergonomical

question

What are the disadvantages of pulsed lavage?

answer

messy; more expensive than wound irrigation; not appropriate for large wounds

question

Describe research for electrical stimulation and wound healing

answer

extensive research supports use as adjunct to enhance wound healing

question

How does electrical stimulation facilitate wound healing?

answer

restores current of injury which is thought to speed healing (epidermis normally has a (-) charge and a wound breaks that normal charge; causes galvanotaxis; stimulates cell proliferation; increases blood flow; increases bactericidal abilities; reduces edema; facilitates autolytic debridement - use (-) polarity

question

What is galvanotaxis?

answer

stimulation of cells to move along an electrical gradient

question

What are the indications for electrical stimulation?

answer

adjunct for chronic or recalcitrant wounds that are clean or infected, granular, or necrotic; pressure ulcers, neuropathic ulcers, venous ulcers, arterial ulcers, traumatic and surgical wounds, and burns

question

What are the contraindications/precautions for electrical stimulation?

answer

standard precautions for e-stim; not indicated for simple wounds; wounds with osteomyelitis should not be treated with e-stim; should not be used in combination with topical agents containing heavy metal ions; actively bleeding wounds should not be treated with e-stim; use with caution on pts with sensory neuropathy

question

Describe the direct technique for e-stim

answer

applied directly to wound bed; after performing any necessary debridement and irrigation, a saline- or hydrogel moistened gauze is placed within the wound bed and covered with carbon electrode; return electrode is placed in any convenient location, 15-20 cm proximally or can be opposite size of extremity

question

What are the parameters for e-stim of wound healing

answer

stimulation frequency 80-125 Hz; interpulse interval 50-100 microseconds; stimulation intensity 75-200 v and should produce comfortable paresthesia

question

How long is treatment time for e-stim for wound healing?

answer

30-60 min

question

What is the frequency for e-stim of wound healing?

answer

twice daily to 3x/week

question

What does cathodal stimulation do?

answer

decrease wound infection

question

what does anodal stimulation do?

answer

restore normal current of injury, promote granulation tissue, and enhance epithelialization

question

What are the advantages of e-stim for wound healing?

answer

research supports efficacy; can be used in any setting; does not cause pain; less setup and cleanup time than whirlpool

question

what are the disadvantages of e-stim for wound healing?

answer

more time consuming than irrigation and whirlpool; risk of contamination; cannot be used on extensive wounds

question

Describe the evidence for using US for wound healing

answer

appears to have sufficient evidence to support use of US for facilitating healing in recalcitrant wounds; recent studies support use of low frequency (25-40 kHz) in combination with saline mist (mist therapy); further controlled studies are needed to determine most effective treatment parameters

question

What phases of wound healing does US enhance?

answer

all 3 phases

question

What are the therapeutic effects of US a result of?

answer

from changes in cell membrane permeability due to nonthermal processes

question

what are the indications for US?

answer

chronic or recalcitrant wounds that are clean or infected; pressure wounds, venous insufficiency, acute trauma, and recent surgery

question

What are the contraindications/precautions for US?

answer

standard precautions for US; presence of osteomyelitis, active bleeding, severe arterial insufficiency, and acute DVT; should not be used on untreated acute infections; in presence of large amounts of necrosis, deliver treatment to intact periwound; not indicated for simple wounds

question

Describe the direct technique method for US

answer

apply directly to wound bed; wound should be irrigated and debrided (if necessary); deep wounds should be filled with amorphous hydrogel or saline; wound must be covered with barrier (sheet hydrogels or bacteriostatic gel pads) to prevent contamination from conductive gel; barrier is not used for scar remodeling; applied over wound, periwound, and scar

question

Describe the periwound technique for US

answer

applied to periwound tissues to facilitate wound healing; may be beneficial for chronic leg ulcers and tunneling, necrotic, or painful wounds; leave wound dressing in place which lower risk of contamination

question

Describe the immersion technique for US

answer

same as underwater US for nonwound injuries; moving sound head is kept 0.5-1.0 cm away from wound surface; intensity should be increased by 50% due to dispersion of energy within basin

question

What is the US immersion technique advantageous for?

answer

painful wounds, wounds at bony areas

question

What are the disadvantages of the US immersion technique?

answer

need for dependent positioning; potential of contamination from sound head, potential for maceration, and hyperhydration

question

What are the parameters for US?

answer

superficial wounds - 3.0 MHz, deeper wounds - 1.0 MHz; pulsed at 20-25% with low intensity (0.5-1.0 W/cm2); acute wounds should be treated with lower intensities compared to chronic wounds; treatment area should be divided into zones equal to 1.5x the area of the sound head with each zone treated for 3 min each

question

What is the frequency for US?

answer

varies from twice daily to 3x/week

question

What do you need for US to remodel scar tissue, reduce contractures, or improve ROM?

answer

a thermal effect is desired with intensities up to 1.5 W/cm2

question

what might be unresponsive to US?

answer

scars over one year old

question

Describe the method for low-frequency US with saline mist

answer

low frequency US is thought to produce changes at the protein and cellular level; assists with wound debridement and destruction of biofilms, bacteria, viruses, and fungi; has FDA approval for debridement and wound cleansing; probe is held on or above wound bed for 15-20 sec/cm2, with a minimum of 4 minutes for wounds <15 cm2; clinicians must don appropriate PPE

question

What are the purpose/effects of US?

answer

enhances all three phases of wound healing; increases collagen deposition, granulation tissue formation, angiogenesis; enhances wound contraction; improves scar pliability

question

what are the advantages of US?

answer

can be used in any setting; quick; when compared to whirlpool - less setup/cleanup time, does not require dependency, does not hyperhydrate

question

What are the disadvantages of US?

answer

less research support; not appropriate for medium or large wounds; may be painful or difficult to apply effectively; risk of contamination

question

What is NPWT? What is another name for it?

answer

negative pressure wound therapy; wound vacuum-assisted closure (V.A.C.)

question

What are the effects of NPWT?

answer

enhances healing in chronic, slow-healing, and acute wounds; increases local blood flow, capillary filling, and lymphatic flow; may help approximate wound edges and facilitate contraction and closure; decrease wound/periwound edema; increases granulation tissue formation; increases angiogenisis; decreases wound bioburden; promotes cellular proliferation; maintains moist, warm wound environment

question

What are the indications for NPWT?

answer

used for many types of wounds, including chronic wounds and post-surgical wounds/grafts

question

What are the contraindications/precautions for NPWT?

answer

dry wounds, necrotic wounds, wounds in body cavities, over malignancies, in presence of exposed blood vessels or untreated osteomyelitis; caution should be used with pts on anticoagulants or wounds with active bleeding; should not be applied immediately after an I&D (incision and drainage); exposed blood vessels

question

Describe the method for NPWT

answer

wound must first be debrided to be free of eschar, slough, and nonviable tissue; sterile foam is cut to wound size, moistened and placed in wound bed; any areas of undermining or tunneling should also be filled with foam pieces; use of skin sealant with padding of periwound area to prevent excessive pressure from tubing; wound is covered with film drape to ensure an airtight seal; tube clamps are opened and pump turned on to allow wound fluid and bacteria to travel into collection canister

question

what does black foam and white foam do in NPWT?

answer

black foam - used to increase granulation and wound contraction; white foam - increases epithelialization

question

How long is the dressing for NPWT left in place?

answer

48-72 hours (12-24 hours if infected)

question

What is the pressure used in NPWT?

answer

125 mm Hg

question

What are the advantages of NPWT?

answer

may cost less over time than standard care for small wounds; can be used in any setting; maintains warm, moist wound environment

question

what are the disadvantages of NPWT?

answer

no standard for use; pain with treatment and dressing changes; noisy; may hinder pt mobility; can be difficult to obtain air-tight seal with drape; may cause skin damage; may increase wound care costs

question

What do the partial pressures of tissues need to be for normal healing?

answer

>40 mm Hg

question

How does systemic HBO enhance wound healing?

answer

increases concentration gradient for oxygen; may help reduce bacterial load; increases angiogenesis, collagen synthesis, granulation tissue formation, epithelialization, and wound contraction; may help reduce edema

question

Who does HBO?

answer

topical HBO performed by PTs and PTAs; systemic or chamber HBO performed by specially trained RNs or respiratory therapists

question

True or false: There is significant controversy as to the effectiveness of HBO

answer

True

question

What are the indications for HBO?

answer

chronic or slow-healing hypoxic wounds; has been used successfully on the following - thermal burns, skin grafts/flaps, osteomyelitis, necrotizing fascitis, refractory leg ulcers, pressure ulcers, crush injuries, surgical wounds, and radiation tissue damage

question

Who are the best candidates for HBO?

answer

pts with neuropathic foot ulcers

question

What is TCOM? What is it used for?

answer

transcutaneous oxygen monitoring; can be used to determine if wound needs an intervention such as HBO or revascularization

question

Describe TCOM

answer

O2 levels at the skin are monitored with pt on room air and then on 100% O2; if there is an increase in 10-15 mm Hg, then the pt may respond to tx

question

What are the contraindications/precautions for HBO?

answer

should only be used on wounds that indicate possible improvement through TCOM testing; contraindicated in pts with DVTs or uncontrolled CHF; relative contraindications include pts with COPD or pregnant pts; pts with severe arterial insufficiency should not be treated with topical HBO; not indicated for simple, uncomplicated wounds

question

Describe the method of HBO

answer

systemic HBO involves application of oxygen in a pressurized chamber at 2.0-2.5 Atm; pt breathes in 100% oxygen for 90-120 min; treatment frequency varies from twice daily to 3x/week; average number of treatments is 37-44

question

What are the advantages of HBO?

answer

TCOM test can help predict treatment efficacy

question

What are the disadvantages of HBO?

answer

extremely high cost; requires extensive treatment time

question

What must be taken into account before choosing an intervention?

answer

patient characteristics, wound location, wound etiology and size, treatment setting, and equipment availability

question

What must the clinician explain?

answer

chosen intervention/procedure including rationale, risks and benefits, and expected outcomes

question

When should the intervention be discontinued?

answer

if no appreciable change in wound status after two weeks of appropriate wound care/adjunctive therapy

question

What nutrients are required for homeostasis, repair, and regeneration?

answer

water, protein, carbohydrates, fat, vitamins, minerals

question

How does severe malnutrition affect the patient?

answer

increases pt's hospital stay, increases risk of infection, sepsis, and even death

question

What should the nutritional screening include?

answer

pt characteristics, recent dietary history, wound characteristics, and pt comorbidities; clinicians should compare pt's BMI to normative values

question

What are the characteristics of malnutrition?

answer

emaciation, petechiae, transparent skin, pallor, dull or thinning hair, pale eye membranes, miss or poor dentition, redness/swelling of mouth, swollen/bleeding gums, mouth sores

question

True or false: obese patients are not at risk for impaired healing

answer

false

question

What wound characteristics may represent impaired nutritional status?

answer

chronic or slow healing wounds; repeat ulcerations; pressure ulcers; neuropathic ulcers; extensive burns

question

What does creatine measure?

answer

kidney function and protein status

question

what will malnutrition do to creatine levels?

answer

decreases creatine levels

question

What are normal values for creatine?

answer

0.8-1.5 mg/dL

question

what is serum albumin?

answer

plasma protein produced by the liver

question

what are normal levels of serum albumin?

answer

at least 3.5-5.5 g/dL

question

what does low serum albumin levels have a positive correlation with?

answer

pressure ulcer severity

question

what will decreased levels of serum albumin lead to?

answer

tissue edema

question

What will elevate serum albumin levels?

answer

dehydration

question

what is prealbumin?

answer

major transport protein

question

what are normal values for prealbumin?

answer

16-40 mg/dL

question

what happens when prealbumin levels drop?

answer

mortality risk increases

question

how is pre albumin unlike albumin?

answer

levels are not affected by pt hydration

question

what is prealbumin sensitive to and why?

answer

sensitive to recent changes in nutritional status due to short half-life

question

what is serum transferrin?

answer

sensitive indicator of protein status

question

at what levels of serum transferrin indicate malnutrition?

answer

levels <170 mg/dL

question

What is BUN?

answer

blood urea nitrogen; urea is a by-product of protein metabolism and is excreted by the kidney; indicator of renal function

question

what are normal BUN values?

answer

5-25 mg/dL

question

what are elevated BUN levels associated with?

answer

decreased wound healing

question

What is TLC?

answer

total lymphocyte count; indirect measure of nutritional status and immune function

question

What is decreased TLC associated with?

answer

delayed wound healing and increased mortality

question

What are normal levels for blood glucose?

answer

70-110 mg/dL

question

what are increased levels of blood glucose associated with?

answer

risk of ulceration and impaired wound healing

question

What is the normal value for TLC?

answer

>1800 cells/mm3

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