LEC 2: Wound Care Continued Flashcards
What are the four steps to treating a chronic wound?
- Identify and control the underlying causes
- Support patient centred concerns
- Optimize local wound care; providing an environment to heal
- Provide organizational support
What is the function of the Braden Scale?
Helps to identifie patients that are at risk for pressure ulcers
What are the six characteristics used to predicting pressure ulcers?
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction/ shear
Braden Scale: Sensory Perception
Ability to respond meaningfully to pressure-related discomfort
Braden Scale: Moisture
Degree to which skin is exposed to moisture
Braden Scale: Activity
Degree of physical activity
Breden Scale: Mobility
Ability to change and control body position
Braden Scale: Nutrition
Usual food intake pattern
When should a Braden Scale assessment be done on a patient in acute care?
Every 24 hours in acute care
How does the Braden Scale work?
The total score ranges from 6 to 23, and a lower total score indicates a higher risk of pressure ulcer development
What are the three pressure-related factors that contribute to pressure ulcer development?
- Pressure intensity
- Pressure duration
- Tissue tolerance
Suspected Deep Tissue Injury
Purple or maroon localized area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure or shear or both. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue
What are the five guidlines for staging pressure ulcers?
- Stage I
- Stage II
- Stage III
- Stave IV
- Unstageable
Pressure Injury: Stage I
- Intact skin with nonblanchable redness of a localized area usually over a bony prominence
- Epidermis and dermis are still in-tacked
- When you put pressure on pressure injury, it does not turn white
Pressure Injury: Stage II
- Partial thickness loss of dermis
- Looks like shallow ulcer
- Has a red/pink wound bed
- Could be intact or open blister
Pressure Injury: Stage III
- Full thickness tissue loss
- Subcutaneous fat may be visible
- Bone, tendon, muscle not visible
- May include undermining and tunnelling
- Possible odour and drainage
Pressure Injury: Stage IV
- Fill thickness tissue loss
- Exposed bone , tendon, or muscle
- Slough or eschar may be present
- Often undermining and tunnelling
- Possible odour and drainage
Pressure Injury: Unstageable
- Full thickness loss
- Base of ulcer covered by slough or eschar
- Extent of tissue damage can’t be confirmed
Slough
Decaying tissue/ collagen, looks yellow
Eschar
Dead tissue, looks black/dark
Best Practice Guidelines for Interdisciplinary Management
- Wound cleansing
- Debridement of healable wound
- Moisture balance
- Elimination of dead space; packing
- Thermal insulation; good circulation
- Protection of periwound skin
Why do we pack a wound?
To eliminate dead space, which allows the wound to heal from bottom up
What acronym is used for complex wound assessment?
MEASURE
What dose MEASURE stand for?
- Measure
- Exudate
- Appearance of wound base
- Suffering
- Undermining
- Re-evaluate
- Edge
MEASURE: Measure
- Length
- Width
- Depth
How do you measure the length of the wound?
The longest dimension of the wound bed (regardless of direction)
How do you measure the width of the wound?
Measured at the widest portion of the wound, perpendicular to the length
How do you measure the depth of the wound?
With a sterile wet, cotton-tip applicator, measure the greatest distance 90 degrees from the skin surface to the base of the wound
MEASURE: Exudate
- Amount and type
- Is there an odour
MEASURE: Appearance of Wound Base
Estimate percentage of each tissue type
- Black wound
- Yellow wound
- Pink wound
Black Wound Base
Devitalized tissue May be grey, brown or black Necrosis can by moist or dry
Yellow Wound Base
Decaying collagen (slough) of fibrin
Pink Wound Base
- Moist granulation tissue and indicates profiling wounds
- May be shades of pink or red
- Pink indicated new epithelialization
*What we want the wound to look like
MEASURE: Suffering
What is the patient’s pain level
MEASUR: Undermining
Evaluate the undermining and tunneling of the wound
Undermining
Tissue destruction extending under intact skin along the wound margin
Tunneling
(sinus tract) course or path of tissue destruction occurring in any direction from the wound bed
MEASURE: Re-Evaluate
All wound should be reassessed regularly
- Done every time you change the dressing
MEASURE: Edge
Appearance of wound edge and surrounding (periwound) skin
When talking about wounds, how do we indicate the direction of tunneling and undermining?
When talking about wound use a clockwise direction
