4.2 - Integumentary PPT - Wounds Flashcards
Week 3, Wednesday
Describe the staging of pressure injuries
Stage 1 - nonblanchable erythema o fintact skin
Stage 2 - partial thickness skin loss (exposed dermis); WITHOUT slough; red or pink wound bed
Stage 3 - full thickness skin loss
Stage 4 - Full thickness w/ exposed bone, tendon, or muscle
Unstageable - slough or eschar obscure the extent of tissue loss
How is the staging of a pressure injury referred to as it heals?
Staging never goes in reverse
ex: once a stage 4, always a stage 4
If healed, referred to as a “healed stage 4”
Describe a Deep Tissue Pressure Injury
Persistent non-blanchable, deep red, maroon, or purple localized area of intact skin
“Dark wound bed” or “blood-filled blister”
Color is BLACK or PURPLE
Evolves into a stage 3 or 4 ulcer w/in days
What is the Braden scale used for?
Describe the scoring
To determine risk of pressure injury
Lower score = higher risk
Total score possible = 23
Low risk = 15-16
Moderate risk = 13-14
High risk = <12
Describe the management of a pressure injury
Positional
- Turning schedule (every 2 hours)
- Offload bony prominences
- Float the heels
Prevent or limit friction / shearing
- Lift, don’t drag
- Keep head of bed low
- Use draw sheet
- Bed mobility training
Address incontinence
- Keep skin clean and dry
Which type of vascular ulcers have the highest incidence?
Venous 75-80%
Arterial 15-20%
Neuropathic 5%
Describe the staging for vascular & neuropathic ulcers
Uses partial- & full-thickness classifications
NOT the same staging as pressure injuries
Venous Ulcers
Etiology / pathophysiology
Risk factors
Clinical presentation
Treatment / management
Etiology:
- Chronic venous insufficiency
- Valvular incompetence
- Venous HTN
Venous insufficiency → back up of blood in veins → fluid overload → capillary rupture; excessive edema
○ “Only so much fluid the skin can hold until it bursts”
Risk Factors:
- HF
- LE muscle weakness
- Prolonged standing
- Obesity
- Immobility
Clinical Presentation:
- Location: MEDIAL MALLEOLUS, can occur anywhere on leg
- WET wound (large amount of exudate, macerated borders)
- Irregular borders
- Normal pulses
- Aching / throbbing in dependent position
- Marked edema
- Hemosiderin staining
Treatment:
- Optimize venous return - elevate LEs, avoid prolonged standing & sitting, ambulate to tolerance several time per day
- Control edema - elevation, intermittent compression
- Control exudate (highly absorptive dressing - calcium alignate)
- Bandages, pressure garments, Unna boot
Arterial Ulcers
Etiology
Risk Factors
Clinical presentation
Etiology:
- Chronic arterial insufficiency (Peripheral arterial disease)
- Arteriosclerosis obliterans
- History of minor non-healing trauma
Risk Factors:
- Smoking
- HTN
- Hyperlipidemia
- Diabetes
- Advanced age
Clinical Presentation:
- Location:
○ Most common in SMALL TOES, FEET, & BONY AREAS of trauma (ex: shin)
- Poor / absent pulses
- Severe pain
○ Intermittent claudication
- Color: pale w/ elevation, dusky rubor on dependency
- Cool temp (bc ↓ BF)
- Trophic skin changes
○ Thin, shiny, loss of hair
Gangrene may be present
○ Necrosis due to lack of BF
Worrisome because of threat of limb loss!
Treatment:
- Prevent / patient education
- Proper fitting footwear (AVOID walking barefoot)
- Control underlying medical problem
- Topical therapy
At what ABI is LE compression contraindicated?
ABI <0.8
Describe how to calculate the ABI
Describe the normal vs abnormal ABI ranges
ABI = ankle SBP / higher brachial SBP (of either side)
1.0-1.4 = norma;
> 1.4 = vessel calcification / hardening (refer to vascular specialist)
0.8-0.9 = some arterial disease (treat risk factors)
0.5-0.8 = moderate arterial disease (refer to vascular specialist)
<0.5 = severe arterial disease (refer to vascular specialist)
Where do diabetic neuropathic ulcers typically form?
Plantar surface of the foot
Describe the pathophysiology that causes diabetic neuropathic ulcers
Excessive blood glucose damages capillaries, nerves
Ulcers result fromt:
- Decreased BF to capillaries
- Lack of perspiration; dry, cracking skin
- Deterioration of bones, muscles, joints
- Lack of protective sensation
What is used to determine protective sensation?
5.07 monofilament (10 grams)
Describe the clinical presentation of a neuropathic ulcer
Location: plantar aspect of foot; toes; feet
Surrounding calluses
Typically not painful (due to sensory loss)
Sepsis common (gangrene may develop)
