Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
88 Cards in this Set
- Front
- Back
|
List the goals of wound care |
Identify underlying injury Decrease incident of infection Promote optimal healing Minimize scarring Manage pain |
|
|
What are the steps to wound care |
1. Manage patient 2.Focus on general area 3. Address specific wound |
|
|
What’s your first steps to manage a patient with a wound? |
1.standard safety precautions 2. Airway and Breathing 3. Control bleeding with pressure, elevation, topical hemostatics, surgery 4. Treat hemorrhagic shock( earliest signs tachycardia and tachypnea 5.Assess and monitor for hypothermia especially in mass skin loss 6.Expose pt to assess other wounds 7. Assess Tetanus Status |
|
|
List your steps to manage the injured area in a wound Pt after managing the patient |
1. Assess distal pulses, cap refill, color and temp as well as motor and sensory function distal to wound 2. Splint Fractures 3.Remove restrictive jewelry clothing or objects 4. Assess and identify open fractures for extensive irrigation and IV antibiotics. Possible surgical debridement |
|
|
List your steps to manage a wound after managing the pt and the injured area |
1. Remove current dressings. Place dressings where drains can be seen 2.Radiograph fractures and suspected foreign bodies 3.Monitor any wound with copious or pulsatile bleeding 4.Remove visible foreign matter |
|
|
According to institutional protocol what will you perform or assist with in a wound pt? |
1. Flush abrasions and wounds containing obvious debris 2.Irrigate puncture wounds and lacerations 3. Explore wounds for foreign bodies and damage to underlying structures. Suspect open fractures when skin disruption near to fracture. Bone splinters can pierce skin and retract. 4. Debride devitalized tissue 5. Approximate edges or bandage prepare to pack for packable wounds 6. Notify health authorities of reportable events 7.Collect forensic evidence per institutional policy |
|
|
When does a wound begin healing? |
Immediately after injury. Immediate vasodilation and edema promotes epithelial cell migration within 24 hrs |
|
|
How long does it take for an approximated wound to close |
48-72hrs |
|
|
What are some conditions that can cause ulcers and chronic wounds or poor healing? |
Poor nutrition, compromised vascular supply, meds that slow collagen formation such as corticosteroids or phenytoin, wounds on lower legs and feet,advanced age, low tissue oxygen levels,pressure on skin |
|
|
When is natural wound contracture a concern? |
When it inhibits movement such as hands, joints, massive circumferential wounds |
|
|
When is secondary closure of a wound needed? |
When unable to approximate the edges or wound has a great chance of infection. |
|
|
What are some options for secondary wound closing? |
Wound packing to allow granulation. Also skin grafting if defect exceeds 1cm in diameter |
|
|
What causes keloids and hypertrophic scarring? |
Lack of collagen synthesis such as genetic conditions, wound ischemia, steroid use, reduction in skin tensile strength |
|
|
What is your plan of action if you suspect organic foreign bodies or those silicate to soft tissues? |
Expect order for ultrasound, CT, or MRI |
|
|
What is the first step in wound prep and what are some issues to be considered? |
Surface cleaning is the initial step and issues to be considered are cleanser selection, hair removal, and wound irrigation |
|
|
True or false Tap water from treated sources is as effective as other solutions in cleaning surface of wound? |
True |
|
|
Potential for contamination should be considered in any open wound. How would you determine contamination? |
Historical eval and wound inspection, was wounding implement clean or dirty |
|
|
What are some objects always considered contaminated? |
Kitchen knives, foreign bodies, bites especially human mouths such as knuckle on fist, fungal infections from wood fragments , soil and organic matter |
|
|
What’s the rule for what you cleanse inside a wound with? |
Never put any substance in a wound that you should not put in an eye. |
|
|
What cleansers should you careful about avoiding getting into wounds |
Clorhexidine (hibiclens), 10% povidone-iodine (Betadine) solution, Hydrogen peroxide |
|
|
What is a good solution for infection prone wounds that need surface cleansing that is less toxic to tissue? |
Dilute (1%) povidine-iodine solution |
|
|
What’s the best method of hair removal for wound care |
Moving hair aside and securing with lubricant such as petroleum jelly, topical ointment, or tape |
|
|
When is irrigation of a wound essential ? |
Foreign bodies, soil, bites, fecal contamination |
|
|
What are the indications for wound cleansing and irrigation |
1. Cleanse skin disruption 2. Cleanse before closing, draining, invasive procedures and removal of foreign bodies 3. Promote healing without infection 4. Possible function and appearance |
|
|
What are some injured that require special care |
1. Eyelids- check visual acuity 2.neck wounds- don’t underestimate superficial appearing injuries that could be deeper and interfere with airway 3.spray gun injuries: extensive tissue injury despite benign appearance injected chemicals and foreign bodies may require surgical exploration 4. Scalp lacs: disguise skull fractures, may have lost a lot of blood, may be difficult to assess completely, check carefully in peds for skull fractures 5. Crush\avulsion : increase risk of infection and delayed healing 6. Facial: care for cosmetic reasons 7.hand: disability 8.associated fractures: open at high risk of infection and specialty consult 9. Puncture: be aware of penetrating object causing infection be aware of foreign bodies esp if punctured through clothes 10. Bites: evaluate for rabies exposure dc with antibiotics and return in 24-48 hrs for follow up. Increase infection risk careful in peds in head for skull fractures
|
|
|
What would you expect to use on tar wounds |
Petroleum jelly, topical antibiotic ointment, or mineral oil |
|
|
How long til bacterial growth in wounds? |
3 hours |
|
|
What is some patient teaching for wounds |
High risk pts return for re-eval 24-48 hrs Keep dry for first 24 hrs may then shower but don’t soak in tub change wet dressings ASAP Clean wound 4x a day with remove crust gently with cotton swab Apply light layer of antibiotic ointment after cleanings apply gauze dressing esp first 48 hours Watch for reopening bleeding infection circulatory compromise Elevate Do not expose to sun for 6 months Complete healing and scar reduction may not be evident for 1 yr |
|
|
What do you expect to treat to prevent in plantar punctures through shoes? |
Pseudomonas |
|
|
T/F punctures near joints are high risk infection. |
True |
|
|
How would you expect to treat puncture wound |
CBC BMP xRay Remove foreign body Assist with opening debriding irrigating and packing Antibiotics tetanus pain meds Elevate limit use Home care: warm soapy water wound follow up |
|
|
Where is tetanus found |
Soil gardens farms anywhere human and animal excrement found |
|
|
What is tetanus incubation period |
2days -2 weeks |
|
|
What type of tetanus is recommended from CDC |
Tetanus vaccine containing diphtheria toxin dT(Td) 0.5mL IM |
|
|
Describe properly vaccinated children |
Tetanus diphtheria pertussis at 2,4,6,8,18mths 4,6 yrs and booster at 16 |
|
|
How often adults vaccinated for tetanus |
Initial childhood series and every 10 years Minimal contamination assure 10yrs gross contamination assure 5yrs |
|
|
What if a patient has received no initial or part of initial series |
Give 0.5 dTTd if grossly contaminated 250units of IM antitoxin recommended |
|
|
If ped >6 that have not completed immunization |
Refer to primary or health dept for second dTTd 0.5 dose in 4-6 weeks then in 6-12mths recommend first dose be Tdap |
|
|
How to help pain with lidocaine injection |
Warm to 37C 98.6F |
|
|
Where should you careful injecting lidocaine with epi |
Heavily contaminated wounds tentative blood supply like avulsions, ears nose digits or penis due to ischemia risk |
|
|
What would be used for closures that need more than 2 hours |
Bupivacaine(marcaine sensorcaine) last 4x longer than lidocaine |
|
|
What size needle would you anticipate for infiltration anesthesia |
30g or smaller |
|
|
What are some benefits to topical anesthesia |
Reduce pain assoc with injection, prevent tissue swelling, vasoconstriction which limits bleeding |
|
|
What are some benefits to topical anesthesia |
Reduce pain assoc with injection, prevent tissue swelling, vasoconstriction which limits bleeding |
|
|
How do you know a topical anesthesia agent is caused complete anesthesia? |
Skin blanching around application site. Usually takes around 20 min |
|
|
Name some topical anesthesia agents you may see ordered |
TAC (0.5%tetracaine, 0.5% epinephrine, 11.8% cocaine (old med) LET (4%lidocaine, 0.1%epinephrine, 0.5%tetracaine) XAP (xylocaine-adrenaline-pontocaine) |
|
|
What is EMLA how long do you leave it and what should you consider |
EMLA is a mixture of 5%lidocaine and prilocaine you apply for 60 min but can only be used on intact skin due to causing inflammation and thus increased infection rates Good for topical intact skin in pediatrics local skin reaction common but generally mild and transient just remove cream Methemoglobinemia can be cause due to prilocaine but rare if used properly Do not use in younger than 3months and 3-12 months who are being treated with methemoglobinemia inducing drugs such as acteaminophen, phenobarbital, nitrites, sulfonamides, and antimalarial agents Patients with anemia respiratory or cardiovascular disease or glucose 6 phosphate dehydrogenase (G6PD) or methemoglobin reductase deficiency are higher risk for untoward effects |
|
|
Name the two general types of local anesthetics and some examples |
Ester compounds( procaine, cocaine, tetracaine) Amide compounds ( bupivacaine, lidocaine, mepivacaine) |
|
|
Name some considerations with epinephrine use in anesthesia |
Contraindicated in known peripheral vascular disease due to vasoconstriction action May be useful in vascular areas such as face and scalp to slow absorption and lower peak blood levels of anesthesia as well as decrease bleeding at site. Contraindicated in cartilaginous areas of ears and nares and areas served by end arteries (fingers, toes, penis) Distorts lip borders and contraindicated in lip lacs that extend through lip border Be careful not to use in flap repairs Can potentiate cardiac toxicity |
|
|
Talk about cocaine containing topicals and a safe alternative |
Drugs like TAC no longer recommended due to adverse effects and cost. LET is a good option. Can be used as a liquid or mixed with methylcellulose to form a gel |
|
|
What is a contraindication for LET |
Do not use on mucous membranes,noses, pinna of ear, fingers, toes, penis |
|
|
Benzocaine is found in many over the counter meds name a caution to watch for |
Toxic and allergic reactions are cannon and can cause methemoglobinemia |
|
|
Discuss aquired methymoglobinemia |
Methemoglobin takes over hemeglobin and causes s/s of hypoxia such as SOB tachycardia, HA, changes in LOC, dyspnea, lethargy, cynanosis, coma Caused by nitrates in young age, meds like benzocaine, lidocaine, prilocaine, aczone, antimalarial drugs Diagnose with CBC liver enzymes, chocolate blood, nitrate levels, pulse ox (will show 95-100% but pt show signs of hypoxia), DNA sequencing Treat with Methylene blue (note: monitor for rebound effect after administration). If congenital treat with blood transfusion Those at risk asthma, bronchitis, emphysema, heart disease |
|
|
Discuss Cetacaine |
Made of benzocaine and tetracaine Tetracaine is rapidly absorbed by pharynx and tracheobronchial tree and is long acting Do not spray longer than 2 sec because of rapid mucosal absorption and potential toxicity of benzocaine and tetracaine |
|
|
What do you need for a digital block |
Local anesthetic without epi (lidocaine1-2% or bupivacaine 0.25-0.5%) 5ml syringe 18g and 25 or 27 g needle Povidone iodine or alcohol wipe |
|
|
What is some patient teaching following a digital block |
Teach how to assess for circulatory and motor/nerve impairment return if compromised Consider immobilizing adjoining digits Begin analgesia after anesthesia wears off return of sensation for if lidocaine 1-2 hours bupivacaine 4-8 hrs if last longer than 24 hrs return or contact physician Provide wound or fracture instructions as indicated |
|
|
Name some max doses in topical Lidocaine HCL Mepivacaine HCL Bupivacaine HCL |
Lidocaine s epi 3-5mg/kg c epi 7mg/kg Mepivacaine s epi 8mg/kg c epi 7 mg/kg Bupivacaine s epi 1.5mg/kg c epi 3mg/kg |
|
|
What topical anesthetics should you use carefully in liver patients |
Amide compounds like bupivacaine, lidocaine, mepivacaine |
|
|
How is cocaine excreted |
It is an ester compounds excreted unchanged in urine |
|
|
True or false systemic absorption of a topical agent is more rapid than that of infiltrated thus achieving a higher peak blood level than the same dose given by infiltration |
True |
|
|
When you carefully ask about medication allergies to topical agents what should you be aware of |
True allergy is rare but may include urticaria, bronchospasm, changes in neuro status, fatal cardiac collapse Allergic reaction is more common with ester preps like cocaine, benzocaine, tetracaine, and procaine Can be caused by preservatives in multi dose vials If epinephrine was used may experience pallor, anxiety, palpitations, tachycardia, hypertension, and tachypnea |
|
|
How do you make buffered lidocaine |
1ml of sodium bicarbonate (8.4%) to 10 ml of lidocaine Effect for 1 week before precipitates |
|
|
What are some considerations in local anethsetics for peds population |
Calculate dose very carefully for local and topical anesthesia For extensive wound repair consider sedation Do not use viscous lidocaine in infants for oral irritation or anyone who cannot expectorate well Use distraction |
|
|
What are some complications for local and topical anesthesia |
Local reactions may include irritation burning erythema skin sloughing Major cause of systemic reactions is high serum levels most common after topical applications to trachea and upper airway passages Signs of central nervous system toxicity are apprehension, nausea, vomiting, tremor, lightheaded, muscle twitch, incoherent speech, seizures, severe leads to prolonged PR and QRS interval bradycardia hypotension and asystole Factors influencing toxicity include quantity, vascularity of site, rate of absorption, rate of destruction, hypersensitivity, age, physical status, weight |
|
|
What is some patient teaching after use of local and topical anesthesia |
Instruct when to expect return of sensation Protect area until sensation returns Provide analgesia when local wears off Oral topicals can cause difficulty swallowing. Use at appropriate intervals swish and expectorate 1-2 min do not swallow avoid food or drink 1 hr after application to prevent aspiration |
|
|
How long do non absorbable sutures retain their strength? |
60 days should be removed as soon as epithelialization occurs. Shortest time in face and longest in feet |
|
|
What are some guidelines for suture removal |
Face 3-5 days Eyebrow 4-5 days Ear 4-6 days Scalp 5-8 days Trunk arms 7-10 days Legs feet 10-14 days |
|
|
T/Fdue to reduced tensile strength you should place tape stripes across newly removed suture sites to reduce tension |
True |
|
|
Should you put antibiotic ointment on steroid strips |
No |
|
|
How long til wound glue sloughs off |
5-10 days but can be removed with antibiotic ointment |
|
|
Howling should use sunscreen after wound |
6 months |
|
|
What are some aftercare instructions for wounds |
Follow up dates for removal Activity restrictions Signs of infection or circulatory compromise Specific reasons to return to ED or primary Use sunscreen 6 months Elevate to prevent edema |
|
|
Discuss care for abrasions |
Same physiologic effect as a partial thickness burn. Large areas can effect fluid balance and thermoregulation Pain control Cleanse with irrigation and gentle scrubbing Remove all foreign material Apply antibiotic ointment and sterile dressing |
|
|
Discuss care for abscesses |
Antibiotic therapy for those with cellulitis,immunosuppression, endocarditis, or facial abbesses draining into sinuses Local anethestic Drain Pack |
|
|
Discuss care for avulsions |
Clean irrigate and debride Avoid lidocaine with epi due to vasoconstriction If crinkled sometimes can replace and suture Approximate grey or dusky edges may heal debride edges following day Use tegaderm in thin skin form age or corticosteroids |
|
|
Discuss care for contusions |
Turn yellow in about 2 days Be aware of compartment syndrome in large hematoma Ice elevate nsaids |
|
|
Discuss Subungual hematoma |
Ice elevate and analgesia X-ray to rule out tuft fracture May drill hole with electrocautery or scalpel May remove loose nail |
|
|
Discuss incisions and lacerations |
Determine wound age Anethetize Cleanse with irrigation Explore for fractures bone exposure damage to structures Remove foreign bodies Excise necrotic tissue Approximate edges Apply sterile dressing |
|
|
Discuss punctures |
Punctures into joints can lead to septic arthritis punctures into cartilage bone and periosteum can lead to osteomyelitis Radiograph infected punctures for foreign body Explore for contaminants Routine prophylactic antibiotic use such as first generation cephalosporins like Ancef or Kefzol in uncomplicated healthy adults can predispose pt to secondary pseudomonas recommended for plantar punctures immunodeficiency periferal vascular disease diabetes Tetanus status Observe for cellulitis abscess joint infection osteomyelitis Expect osteomyelitis adults or osteochondritis kids if metatarsal-phalangeal puncture with pain 4-7 days after injury with swelling |
|
|
What do you expect to see in plantar punctures |
Pseudomonas if through shoes as well as forgein bodies |
|
|
Discuss gun shot wounds |
Treat pt first manage hypovolemia and shock Be aware of damage caused by bullet ( X-rays bleeding) Bones can become secondary projectiles negative pressure can pull clothes and debris inside wound High velocity causes shock waves and more damage Notify law enforcement as required Document location photos Record number of wounds Bags over hands Cut around holes/evidence not through it in clothes Follow chain of command procedure
|
|
|
Discuss high pressure injures |
Serious and require immediate surgical intervention to remove paint or grease |
|
|
When would you consider osteomyelitis in a pressure ulcer? |
By bone fever high white blood cell count high sedimentation rate |
|
|
Discuss venous ulcers |
Elevation Improve mobility Improve nutrition Simple low adherence dressing under compression bandage Refer to skilled personnel for compression bandaging Compression heals ulcer at 12-15 weeks |
|
|
Discuss bites |
Assess tetanus rabies and hepatitis status Most hand wounds closed after 3-5 days or packed left open Document circumstances provoked or not source infection signs number and wound type location depth Assess for underlying damage Irrigate and debride Expect staphylococcus aureus and pateurella multocidea from dog bites expect augmentin Cat bites show infection within 12 hrs and carry pasteurella multocida treat with penicillin and or augmentin |
|
|
How long do you observe suspect rabid animal |
2 weeks |
|
|
Discuss rabies prophylaxis |
Vaccinated animals or animals that can be observed for 2 weeks usually do not need prophylaxis. If animal dies autopsy and treat if neccessary Prophylaxis must be administered before symptoms begin |
|
|
Discuss passive immunity Rabies immune globulin( RIG) and active immunity human diploid cell vaccine (HDCV) |
RIG given til HDCV can initiate active body immunity response RIG 20units/kg half IM and other locally in wound felt in adult anterolateral thigh in peds HDCV 1mL IM days 0 3 7 14 and 28 1mL IM days 0 3 if immunized preexposure |
