Day 2 Flashcards
Pressure wound -At risk pts
Elderly Immobile Very sick, hypotension SCI CVA
Main causative factor of pressure sores
Immobility
Pathology of pressure due to
Intensity of pressure
Duration of pressure
Tissue tolerance
Capillary closing pressure
12-32 mmHG
Duration of pressure in conductivity w/ intensity
Long/low = damage Short/high = damage
Tissue tolerance
Skin and tissue ability to transmit load
-reduced by shear, friction , moisture, malnutrition, low BP, impaired perfusion, stress, smoking, fever, anemia
Deep tissue pressure injury
Persistent non-blanchable deep red, maroon or purple discoloration
Unstageable pressure injury
Obscured full thickness skin and tissue loss
Look at slides
Stage 1 pressure injury
Non blanchable erythema of intact skin
Stage 2 pressure injury
Partial thickness skin loss w/ exposed dermis
Stage 3 pressure injury
Full thickness skin loss
Stage 4 pressure injury
Full thickness and tissue loss
Wounds that are classified differently than pressure injury
Moisture associated w/ skin damage
Medical device related pressure injury
Mucosal membrane pressure injury
Tx cause of pressure injury
Help nursing ed and reposition every 2 hours
Keep pt off existing pressure injuries
Increase mobility and independence
Monitor skin closely during tax
Place decides on properly
Help w/ preventative measures and support surface adherence
Aging skin - physiological changes
Decrease in keratinocyte proliferation Decrease in keratinocyte renewal rate Drop in melanocyte levels Decline in Langherhans cell count Reduced vascularity Subcutaneous tissue flattens Collagen, elastin, and glycosaminoglycans are altered, reducing skin strength and flexibility Reduced sebaceous gland output
Aging skin results of cellular changes
Dry skin (xerosis)
More susceptible to blisters
More susceptible to skin and deep tissue injury
Increased rate of skin cancers
Slow healing of wounds, whether simple or complex
Increased risk for wound infections Pro-inflammatory environment
Urinary and fecal incontinence may lead to
Dermatitis
Fungal infection
Colliculitis
Wound bed prep
DIME Debridement Infection/inflammation Moisture balance Epithelialization advancement (edge)
Debridement removes
Non vascular tissue
Bacteria
Cells that impede healing process
Stimulates healthy tissue formation
Faster wound closure
Benefits of debridement
Reduce risk of infection
Reduce abscess formation risk
Reduce odor
Reduce inflammation
Sharp debridement done by
Performed by PT,PTA,MD,PA,RN
RNs must be signed off by MD initially
Types of debridement
Sharp Sx Mechanical Autolysis Enzymatic Biosx Low frequency US
Normal BUN
8-25 mg/dL
Elevated = delayed wound healing
Glucose normal
70-120 mg/dL
Hemoglobin norm
13-18 men
12-16 women
Decreased = less O2 carried to tissues, slower healing
INR norm
0.9-1.2
>2 =relative contraindication to debridement
Protime norm
11-13.5 seconds
Elevated = impaired clotting if bleeding occurs
Platelets norm
130-400
Decreased impaired clotting if bleeding occurs
Lab values for debridement
Hemoglobin <12
IRN >2
Platelets <130
Sharp debridement precuations
Low RBC, Hct, Hgb Marginal platelet levels Poor med status/prognosis On Coumadin w/ marginal INR Near deep structures Hands, genital areas
Sharp debridement contras
Stable eschar Poor med status/poor prognosis Patient on IV heparin Low platelet count IRN above 2.0 Gangrene of toes or fingers
Mechanical debridement
Non-discriminatory physical force to remove necrotic tissue
Gauze, whirlpool, pulsatilla lovage
May slow wound healing process
Autolytic debridement
Promotes phagocytic activity and formation of granulation tissue
Achieved by a moist wound enviro, use of impermeable, semipermeable, or most dressings
Enzymatic debridement
Active enzyme therapy that continuously removes necrotic tissue form wound
Collagenase selectively target collagen strands that hold cellular debris to wound bed
Collagenase saintly
May be used in conjunction w/ sharp debridement
Biosx debridement
Rapid but selective Reduces bacterial burden Possible control of MRSA Stimulates granulation tissue formation No reported toxicity
