Wounds and Vascular 1-8

  1. OBJ 1:Define and describe PHASES of wound healing
    normal: Myers p.12-16; O'Sullivan p.645-647

    problematic: Myers p.20-23; O'Sullivan p.649-650

    Inflammatory (reactive), proliferative (regenerative), maturation (remodeling)
  2. OBJ 2: Decribe Suspected Deep Tissue Injury (DTI)
    • -worse than the non-blanching erythema of a Stage 1 pressure ulcer
    • -purplish, but has not yet "declared" itself to the superficial layer
    • -injury is severe and also presents as intact skin or with a blister
    • -may evolve (rapidly) with a thin layer of eschar
    • -different from other stages in terms of time
  3. OBJ 2: Testing for non-blanching erythema (Stage 1)
    press on the area then remove finger and look

    if it stays red/angry=Stage 1 pressure ulcer
  4. OBJ 3: Primary Intention (closed) wound healing and secondary intention (open)

    Delayed primary closure:
    Closed: the surgical or lacerated edges can be approximated by suture, staple or steri strip

    Delayed primary closure: occurs when there is doubt that all debris (road rash) has been cleaned out of the wound. Waiting a few days
  5. OBJ 3: Primary Intention (closed) wound healing and secondary intention (open)

    • Dehiscene: splitting open of a closed wound d/t external trauma or suture failure or may occur from a post closure infection that causes increased internal pressure. Monitor for redness, warmth, swelling, excessive or foul smelling drainage and fever.
    • Open: Healing occurs from the bottom up. After wound is cleared from necrotic tissue and slough (still moist) vascular building cover it within granulation tissue. Epithelial cells begin to migrate from perimeter and eventually stops the process once they reach the center
  6. OBJ 4: Describe different etiologies of chronic wounds
    • APPENDIX: Wound management table 4
    • 1. venous insufficiency ulcer
    • 2. arterial " "
    • 3. neuropathic ulcer
    • 4. pressure ulcer

    Effect of supine elevation on venous insuff. vs. arterial insuff.

    arterial and neuropathic ulcers shar many same characteristics
  7. OBJ 5: Perform examinations of LE vascular health and describe normal/abnormal findings

    Pedal Pulse palpation:
    Other tests and measures
    Sensation: 5.07 Semmes Weinstein= PROTECTIVE sensation (4.17 is normal sensation)

    • Pedal Pulse: dorsalis pedis & posterior tibial
    • 0=absent, 1+= barely palpable, 2+ =diminished, 3+= normal, 4+=bounding

    • Other: Capillary Refill, Rubor of Dependency, Venous Filling Time,
    • ABI, Claudication: time and distance
  8. OBJ 5: Perform examinations of LE vascular health and describe normal/abnormal findings

    pitting edema measurement:
    Edema measurement
    pitting edema: 1+=barely perceptible, 2+= pitting rebounds in <15secs, 3+= rebound in 15-30secs, 4+=rebound >30secs

    • DVT: Well's Clinical Decision Rule (CDR)
    • Autar DVT risk assessment scale

    Just measure that edema...
  9. OBJ 5: Perform examinations of LE vascular health and describe normal/abnormal findings


    Calculate an ABI using dopler US and apply results accordingly to prognosis, POC, or referral
    Lymphedema: Stemmer's Sign

    Calculate that sh!t
  10. OBJ 5: Perform examinations of LE vascular health and describe normal/abnormal findings

    ABI values
    • Watchie
    • >0.9: PAD
    • 0.8-0.5: claudication
    • <.5: limb ischemia
    • O'Sullivan
    • >1.2: arteriosclerosis, DM
    • 0.95-1.2: normal
    • 0.75-0.95: mild arterial disease
    • .05-0.75: moderate " "
    • <0.5: severe " "
  11. OBJ 6 Detail an evaluation of a patient with an open wound: appearance, size, depth, stage, edema, sensation, pain; also ROM, strength, functional mobility, and cognition

    1. Size
    2. "Depth"
    3. Edges
    4. Undermining or Tunneling?
    5. Wound Bed
    6. Exudate
    7. Periwound area

    Sample Goals from McCulloch
    • 1. Size- ruler (longest x widest)
    • 2. "Depth"- NPUAP Stage #___ (deep use cm)
    • 3. Edges- ragged, eroded, sharply defined, or rolled
    • 4. Undermining or Tunneling?- probe with moist cotton tipped swab
    • 5. Wound Bed- type of tissue and relative % must add up to %100
    • -Non viable tissue to get rid of: slough & necrotic
    • -What you want: granulation and epithelial
    • 6. Exudate
    • -Description: serosanguinous, serous purulent
    • -Quantity: none...small...large
    • 7. Periwound area- may be red, swollen, indurated (hard), painful. Cellulitis or infection present?

    • Sample Goals: Decrease coverage of necrotic tissue to ___% of wound bed in __wks
    • Increase granulation tissue to __% of wound bed to ___wks
    • decrease edema...decrease erythema...decrease drainage
  12. OBJ 7 Classify wound beds
    If the wound bed is other than clearly and completely visible, it is described as being covered with non-viable tissue which can be either:
    whats the optimal color for granulation tissue?
    • Transudate: serous, thin, "weepy"
    • Exudate/Pus: thick, cellular debris, contains growth factors important for healing. If infected it will be green, brown, malodorous. Note any odors

    3rd question: Slough-fibrin and pus with a yellow or tan color that is stringy, either adherent or loose Eschar- definitions vary. include brown, black which is soft or hard as well as leathery and dry

    optimal color for granulation? "beefy red"

    When epithelial cells migrate and begin to adhere to gran. tissue the appearance will be paler pink for white people and darker for black people. No longer "wound bed"=new skin and cont. to heal
  13. OBJ 8 Define undermining, tunneling, and fistula formation.

    Most common cause?

    How do you measure depth?

    Dressings considerations:
    Pressure Ulcer is most common and fistula of the uretha or colon is possible. Diabetic ulcers can tunnel through foot. Probe with a wet cotton tipped swab

    Depth: fill it with saline and then measure what you can push out. Or cover wound with thin film and pierce it with a graduated syringe.

    Dressings: Fill all voids with moist medicated or unmedicated ribbon. Don't pack to firmly or tight. NEVER use more than ONE ribbon.
Card Set
Wounds and Vascular 1-8
Wounds and Vascular 1-8