Exam 2: pressure ulcers and wound healing

Question 1

Risk factors for pressure ulcers

Answer 1

1. decreased mobility
2. dehydration
3. co-morbidities
4. drugs
5. impaired blood flow (arterial insufficiency)
6. exposure to urinary/fecal incontinence

Question 2

nutrition related risk factors

Answer 2

1. significant, unintentional weight loss
2. appetite changes
3. poor dental health (dentures don’t fit)
4. GI symptoms
5. ability to self feed
6. med/surg interventions
7. alcohol and substance abuse (nutrient replacement)

Question 3

Braden scale

Answer 3

Risk assessment tool

• scale from 0-18; higher score = lower risk
• assesses activity, mobility, friction/shear, nutrition, not responding to pressure related discomfort

Question 4

Define: pressure ulcer

Answer 4

• Localized skin and underlying tissue injury, usually over a bony prominence
• stages: 1-4, SDTI, unstageable
• Caused by pressure OR pressure + friction/shear

Question 5

define: suspected deep tissue injury (SDTI)

Answer 5

• purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue
• from pressure/shear
• may be hard to detect in darker skin tones

Question 6

stage 1 pressure ulcer

Answer 6

• intact skin
• non-blanchable redness of localized area (when you push on it, it won’t turn white)
• usually over bony prominence (heels, elbows, behind ears, top of nose, sacrum)
• may be painful, soft, firm, warmer or cooler than adjacent tissue

Question 7

stage 2 pressure ulcer

Answer 7

• partial thickness loss of dermis
• shallow open ulcer w/ red or pink wound bed
• no slough (skin shedding)
• may also be seen as intact, or open/ruptured serum-filled blister

Question 8

stage 3 pressure ulcer

Answer 8

• full thickness tissue loss
• subcutaneous fat may be visible
• may include tunneling
• depth may vary by location

Question 9

stage 4 pressure ulcer

Answer 9

• full thickness tissue loss
• exposed bone, muscle, tendon
• often includes tunneling

Question 10

unstageable pressure ulcer

Answer 10

• full thickness loss
• base of ulcer is covered by slough/eschar (yellow/tan dead tissue)
• true depth difficult to determine due to skin flap covering wound
• for needs: treat as stage 4

Question 11

Assessing risk for developing pressure ulcer

Answer 11

• Assessment tools (braden scale)
• > 50 years old
• over/underweight
• poor skin condition
• surgery
• friction/sheer
• confined to bed
• poor dietary intake

Question 12

Energy needs for SDTI

Answer 12

30 kcal/kg

Question 13

Energy needs for Stage 1 and 2

Answer 13

30-35 kcal/kg

Question 14

energy needs for stage 3, stage 4 and unstageable

Answer 14

35-40 kcal/kg

Question 15

protein needs

Answer 15

1. 25-1.5 g/kg/d

- arginine + glutamine

Question 16

importance of arginine and glutamine

Answer 16

preserves lean body mass; fuel for enterocytes

arginine increases collagen production

Question 17

factors to consider when determining fluid needs

Answer 17

• draining wounds
• fever
• other fluid losses (vomiting, diarrhea)
• CHF
• renal disease

Question 18

Vitamin A importance

Answer 18

stimulates epithelium

Question 19

Vitamin C importance

Answer 19

cofactor w/ iron; helps with collagen production
deficiency = longer healing time
smokers automatically need supplementation

Question 20

Vitamin E importance

Answer 20

antioxidant, helps w/ normal fat metabolism

Question 21

Zinc importance

Answer 21

cofactor for collagen, removes vitamin A from liver, can interfere w/ copper absorption

Question 22

intervention goals

Answer 22

• maintain adequate nutritional status
• identify and treat causes of poor nutritional intake
• monitor weight status
• select nutrition interventions to improve/maintain nutrition status
• least restrictive diet possible
• excess protein poses dehydration risk
• Vitamin/min supplement, zinc, glutamine + arginine (juven) usually protocol for wound pts

Question 23

monitor/evaluate

Answer 23

• weight and anthropometrics
• lab tests
• nutrient intake, quantity, quality (eating > 75% po?)
• wound stage/healing
• hydration status

Question 24

phases of wound healing

Answer 24

1. inflammatory stage
2. proliferation/repair phase
3. maturation/remodeling phase

Question 25

characteristics of the inflammatory phase

Answer 25

redness, swelling, pain, loss of function

hemostatic pathways start right after injury occurs

Question 26

characteristics of proliferation/repair phase

Answer 26

wound rebuilt w/ new granulation tissue (collagen, protein matrix)
angiogenesis (new capillaries)

Question 27

characteristics of maturation/remodeling phase

Answer 27

-wound closes, cellular activity begins to return

Question 28

chronic wounds

Answer 28

last longer than 6 weeks; frequent recurrence; stuck in inflammation phase

Question 29

factors affecting nonhealing wounds

Answer 29

• impaired circulation
• immunocompromised (chemo pts)
• older age
• disease state
• dehydration
• immobility
• neuropathy
• spinal cord injuries
• obesity
• malnutrition
• nutrient deficiencies

Question 30

impacts of malnutrition on wound healing

Answer 30

impairs wound healing by affecting collagen synthesis, decreases mechanical strength of skin

Question 31

wound types

Answer 31

1. diabetic ulcers
2. venous ulcers
3. arterial ulcers
4. surgical wounds
5. pressure ulcers

Question 32

diabetic ulcers

Answer 32

neuropathy, arterial insufficiency; caused by diabetes

Question 33

venous ulcers

Answer 33

leg veins not able to return blood back to the heart

causes blood to pool in the area, blocks the veins; can be caused by valve incompetence, hx of DVT, edema

Question 34

arterial ulcers

Answer 34

also called ischemic ulcers; artery disease present; artery narrows, decreases blood flow; leads to tissue death/necrosis –> open wounds

Question 35

venous ulcers are common in the _____ and arterial ulcers are common in the _____

Answer 35

1. legs
2. toes/feet
   (they can be in combination w/ each other)