Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Wound 2.2 > Lesson 6: Wound Assessment + Pressure Injury Staging > Flashcards

Lesson 6: Wound Assessment + Pressure Injury Staging Flashcards

1
Q

Initial Wound Assessment

A

Etiological factors
- Location of wound
- Depth and contours
- Patient’s history

Assessment of systemic factors
- Nutrition status
— Weight loss? Dehydrated? Malnutrition?
- Perfusion status
- Glucose control
- Medications
- Comorbidities

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Comprehensive Wound Assessment

A
  • location
  • onset and duration
  • prior treatment and response
  • dimensions
  • tunnelling or undermining
  • status of wound bed
  • status of wound edges
  • exudate
  • status of surrounding tissue
  • indicators of infection
  • wound-related pain
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Pressure Injuries

A

Location: over bone or under medical device

Characteristics
- Partial or full thickness
- Round or oval with defined edges

Patient history
- Immobility
- Sliding down in bed
- Medical device in place

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Friction Injury

A

Location: fleshy areas exposed to rubbing

Characteristics
- Superficial
- Round or irregular borders
- Wound bed pink/red with no necrosis

Patient history
- Restlessness
- Rubbing against underlying surface

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Incontinence-Associated Dermatitis

A

Location: areas exposed to urine and stool

Characteristics
- Superficial
- Irregular borders
- Pink/red + moist wound bed

Patient history
- Fecal or urinary incontinence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Intertriginous Dermatitis

A

Location: base of body fold on opposing sides

Characteristics
- Superficial
- Linear crack on opposing sides
- Wound bed pink or red

Patient history
- Diaphoresis
- Trapped moisture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Pressure Injury - Stage 1

A

Non-blanchable erythema

Treatment
- Pressure relief + offloading

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Pressure Injury - Deep Tissue Injury

A

Intact or nonintact skin with localized areas of persistent non-blanchable, deep discolouration
OR
epidermal separation revealing a dark wound bed or blood-filled blister

Caused by intense or prolonged pressure/shear forces

Classify wound as DTI until:
- Wound resolves → no action
- Wound is covered with eschar → now unstageable
- Viable tissue is exposed → stage 1-4, depending on depth

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Pressure Injury - Stage 2

A
  • Partial thickness skin loss with exposed dermis
  • Wound bed is pink/red and moist
  • Superficial with no exposed fat, muscle, granulation, or slough/eschar
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Pressure Injury - Stage 3

A
  • Full thickness skin loss with visible fat in wound base
  • No exposed muscle, bone, or joint
  • Slough/eschar may be present but cannot obscure wound depth
  • Cannot have stage 3 on areas of body with no fat
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Pressure Injury - Stage 4

A
  • Full thickness skin loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone
  • Base has necrotic tissue with tunneling/undermining
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Pressure Injury - Unstageable

A
  • Full thickness skin loss obscured by slough and eschar
  • Cannot confirm depth or injury
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

DIWAMOPI

A

D: debride necrotic tissue
I: identify and treat infection
W: wick fluid from tunneling/undermining
A: absorb excess exudate
M: maintain moist wound surface
O: open wound edges
P: protect healing wound
I: insulate healing wound

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

D: debride necrotic tissue

A

Indications (yes to at least 1)
- When goal is repair
- When wound is already open and necrotic tissue is present
- When wound is clinically infected

Options
- surgical/instrumental
- conservative sharp wound debridement
- enzymatic
- autolytic
- chemical
- hydrotherapy
- ultrasonic
- larval / maggot therapy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Surgical Debridement

A
  • Sterile excision of all necrotic tissue
  • Good for wounds with large amount of necrotic tissue or with bone/joint involvement

Risks of the OR
- Overall patient condition
- Coagulation disorders
- Active infection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Conservative Sharp Wound Debridement (CSWD)

A
  • Removal of loose + avascular tissue at bedside
  • Good for uninfected wounds with loose necrotic tissue
  • Need to identify viable structures to avoid
  • Need to establish plane of dissection between viable and nonviable
17
Q

Enzymatic Debridement

A
  • Collagenase/Santyl
  • Selective + non-invasive but is slow
  • Need to cross-hatch large areas of dry necrosis prior to application
  • Nickel-thick application with moist cover dressing
18
Q

Autolytic Debridement

A
  • Uses patient’s own WBC to debride
  • Requires moist wound bed with adequate perfusion

Indications
- Limited necrotic tissue
- Dry and adherent eschar

Options
- Dry = hydrogel or medihoney
- Wet = alginates or hydrofibers

19
Q

Chemical Debridement

A
  • Antimicrobial, odor elimination, breakdown of necrotic tissue
  • Good choice for infected and necrotic wounds
  • Cheap but must be changed frequently (q12-24h)

Options
- Dakins solution, Anasept

20
Q

Hydrotherapy Debridement

A
  • Used to soften + loosen necrotic tissue via pulsed lavage

Contraindications
- Exposed blood vessels
- Graft sites

21
Q

Ultrasonic Debridement

A
  • Uses ultrasound-powered NS mist
  • Good to remove slough, thin fibrous exudate, and bacteria
22
Q

Larval + Maggot Debridement

A
  • Used for complex + difficult wounds
  • Action is restricted to necrotic tissue
  • Very fast acting; in 1-2 dressing changes
23
Q

Contamination

A

bacteria present on wound surface but not replicating and not impairing wound healing

24
Q

Colonization

A

bacteria present, are reproducing slowly, but low numbers so not interfering with repair process

25
Q

Critical Colonization

A

number of bacteria are high enough to interfere with wound repair →now WOCN intervenes topically

26
Q

Invasive Infection

A

bacteria numbers are so high that they migrate into the periwound skin and triggers a systemic response

27
Q

Antiseptic Solutions

A
  • Dakins or Anasept (both sodium hypochlorite) 0.025-0.0125%)
  • Iodine 1%
  • Acetic Acid 0.25 %
28
Q

AMD Dressings

A
  • Cadexomer iodine (ie. Iodosorb)
  • Intended for exudative wounds
  • May penetrate biofilm
  • Be mindful if patient has a shellfish allergy
29
Q

Sustained-Release Silver

A
  • Aquacel or Urgotul
  • Some donate silver to wound bed
  • Some kill bacteria within the dressing
30
Q

Broad-Spectrum AMD

A

Methylene blue, crystal violet, polyvinyl alcohol, polyurethane foam (ie. Hydrofera blue)

AMD and anti-inflammatory effects

AMD Gauze and Packing
- Active agent = PHMB (polyhexamethylene biguanide)

Manuka honey dressing
- Effective autolytic debridement with AMD effects

Dialkylcarbomoyl chloride (DACC)
- Attracts bacteria to dressing surface

31
Q

Creating Environment to Promote Wound Healing

A
  • Wick fluid from tunneling//undermining
  • Absorb exudate
  • Maintain moist wound surface
  • Provide waterproof bacterial barrier
  • Contribute to insulation
  • Provide atraumatic removal
32
Q

Deep + Wet Wound

A

> 0.25 cm deep OR tunnels/undermining + moderate-large amounts of exudate

Goals
- Wick fluid from tunnels/undermining
- Absorb excess exudate
- Provide bacterial barrier
- Provide AMD if indicated

Wicking dressings
- Ribbon gauze (plain or AMD)
- Hypertonic ribbon gauze (Mesalt)
- Foam strips (Hydrofera blue)
- Hydrofiber strips (Aquacel)

Filler/Contact Layer
- Alginates (Silvercel or Kaltostat)
— Can absorb 20x weight in exudate
- Hydrofibers (Aquacel)
— Interact with wound to become a gel
- Polymer absorptive dressing
- Gauze
— Can be woven or unwoven
— Woven = Kerlix or standard 4x4
— Unwoven = Kling or packing strips
— Plain or AMD

Cover/Secondary Layer
- Select based on volume of exudate + location of wound
- Gauze + tape/Tegaderm
- Gauze/foam + roll gauze
- Adhesive bordered foam (Mepilex)

33
Q

Deep + Dry Wounds

A

> 0.25 cm deep OR tunnels/undermining + minimal exudate

Goals
- Wick fluid from tunneled/undermined areas
- Maintain moist wound surface
- Provide bacterial barrier
- AMD PRN

Wicking dressings
- Ribbon gauze (plain or AMD)
- Hypertonic ribbon gauze (Mesalt)
- Foam strips (Hydrofera blue)
- Hydrofiber strips (Aquacel)

Filler/contact layer
- Layer of wound gel + dampened, fluffed gauze
- Gel-impregnated gauze

Cover/secondary layer
- Gauze + Tegaderm
- Adhesive bordered foam dressing (Mepilex)

34
Q

Shallow + Wet Wounds

A

<0.25 cm with no tunnels/undermining + moderate-large amounts of exudate

Goals
- Absorb excess exudate
- Maintain moist wound surface
- Provide bacterial barrier
- AMD PRN

Options
- Alginate/hydrofiber with adhesive foam
- Alginate/hydrofiber + porous foam gauze + roll gauze
- Nonadherent contact layer + gauze + roll gauze
- Adhesive foam only

Foam dressing
- Commonly is Mepilex or Melipex with border
- Can be primary or secondary

Contact layer
- Commonly Jelonet or Adaptic
- Porous and nonadherent
- Protects wound bed and permits exudate through
— 1st generation
—— Petrolatum based
—— Initially non-adherent but can dry out
—— Ie. Adaptic, Jelonet
— 2nd generation
—— Silicone based
—— Does not dry out
—— Ie. Mepitel

35
Q

Shallow + Dry Wounds

A

<0.25 cm deep with no tunnels/undermining + minimal exudate

Goals
- Create/maintain wound edge
- Protect healing wound

Options
- Solid Gel dressing
— Hydrocolloid dressings
— Ie. Duoderm
— Provides minimal absorption
- Nonadherent contact layer
— Mepitel/Adaptic with roll gauze
- Transparent adhesive
— Ie. Tegaderm
— Only if wound has ZERO exudate

Wound 2.2 (9 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions