Exam 2: pressure ulcers and wound healing Flashcards
Risk factors for pressure ulcers
- decreased mobility
- dehydration
- co-morbidities
- drugs
- impaired blood flow (arterial insufficiency)
- exposure to urinary/fecal incontinence
nutrition related risk factors
- significant, unintentional weight loss
- appetite changes
- poor dental health (dentures don’t fit)
- GI symptoms
- ability to self feed
- med/surg interventions
- alcohol and substance abuse (nutrient replacement)
Braden scale
Risk assessment tool
- scale from 0-18; higher score = lower risk
- assesses activity, mobility, friction/shear, nutrition, not responding to pressure related discomfort
Define: pressure ulcer
- Localized skin and underlying tissue injury, usually over a bony prominence
- stages: 1-4, SDTI, unstageable
- Caused by pressure OR pressure + friction/shear
define: suspected deep tissue injury (SDTI)
- 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
stage 1 pressure ulcer
- 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
stage 2 pressure ulcer
- 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
stage 3 pressure ulcer
- full thickness tissue loss
- subcutaneous fat may be visible
- may include tunneling
- depth may vary by location
stage 4 pressure ulcer
- full thickness tissue loss
- exposed bone, muscle, tendon
- often includes tunneling
unstageable pressure ulcer
- 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
Assessing risk for developing pressure ulcer
- Assessment tools (braden scale)
- > 50 years old
- over/underweight
- poor skin condition
- surgery
- friction/sheer
- confined to bed
- poor dietary intake
Energy needs for SDTI
30 kcal/kg
Energy needs for Stage 1 and 2
30-35 kcal/kg
energy needs for stage 3, stage 4 and unstageable
35-40 kcal/kg
protein needs
- 25-1.5 g/kg/d
- arginine + glutamine
importance of arginine and glutamine
preserves lean body mass; fuel for enterocytes
arginine increases collagen production
factors to consider when determining fluid needs
- draining wounds
- fever
- other fluid losses (vomiting, diarrhea)
- CHF
- renal disease
Vitamin A importance
stimulates epithelium
Vitamin C importance
cofactor w/ iron; helps with collagen production
deficiency = longer healing time
smokers automatically need supplementation
Vitamin E importance
antioxidant, helps w/ normal fat metabolism
Zinc importance
cofactor for collagen, removes vitamin A from liver, can interfere w/ copper absorption
intervention goals
- 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
monitor/evaluate
- weight and anthropometrics
- lab tests
- nutrient intake, quantity, quality (eating > 75% po?)
- wound stage/healing
- hydration status
phases of wound healing
- inflammatory stage
- proliferation/repair phase
- maturation/remodeling phase
