Module 2: Acute and Chronic wounds

Question 1

Acute wound:

Answer 1

Wound that heals within an expected time frame (within 21 days)

Question 2

Chronic wound:

Answer 2

A wound in which the normal processes of wound healing is disrupted at one or more points of wound healing (stalling in the healing process).
o Long duration
o Reoccurs frequently
o Examples: Pressure ulcers, venous ulcers, arterial ulcers, diabetic foot ulcers

Question 3

what does tx of chronic wound depend on?

Answer 3

type of ulcer

Question 4

What is the general nursing care for pt with chronic wound?

Answer 4

· Thorough assessment/history
· Treatment depends on type of ulcer
· Assess for presence of infection
· Assess nutrition

Question 5

Risk factors for pressure injury?

Answer 5

o Prolonged pressure on tissue
o Immobility, compromised mobility
o Loss of protective reflexes, sensory deficit/loss
o Poor skin perfusion, edema
o Malnutrition, hypoproteinemia, anemia, vitamin deficiency, over/under weight
o Friction, shearing, forces, trauma
o Incontinence of urine or feces
o Altered skin moisture, excessively dry, excessively moist
o Advanced age, debilitation
o Equipment: Casts, traction, restraints

Question 6

What nursing assessments can be done in the prevention of pressure ulcers?

Answer 6

o Assess the total skin condition at least twice a day
o Inspect each pressure site for erythema
o Assess areas of erythema for a balancing response
o Inspect for dry skin, moist skin, and breaks in skin
o Determine the presence of incontinence – good hygiene
o Note any drainage and colour
o Evaluate level of mobility
o Note restrictive devices (restraints, splints)
o Evaluate circulatory status (peripheral pulses, edema)
o Assess the neurovascular status
o Evaluate nutritional and hydration status
o Review patient record for lab studies (Hg, Hct, electrolytes, albumin, iron, creatinine)
o Note any present health problems
o Review current medications
o Complete the Braden scale on admission and review as per policy and procedure

Question 7

What are lower limb ulcers generally caused by?

Answer 7

o Diabetes

o Arterial or venous insufficiency

Question 8

Characteristics of venous ulcer?

Answer 8

·  	75% of leg ulcers are caused by chronic venous insufficiency
·  	Dull aching or heavy
·  	Edema
·  	Typically, large, superficial
·  	Highly exudative
·  	Irregular ulcer border
·  	Pulses present
·  	Bleeds easily
·  	Location: Gaiter area, especially medial malleolus

Question 9

Prevention of venous ulcer?

Answer 9

·  	Major goals include restoration of skin integrity, improved physical mobility, adequate nutrition, and absence of complications
·  	Compression of the extremity
·  	Elevation
·  	Protect from trauma
·  	Skin kept clean, dry, and soft
·  	Wound management

Question 10

risk factors for venous ulceR?

Answer 10

Arterial Insufficiency to Extremities – Risk Factors

Atherosclerosis and Peripheral Arterial Disease

Question 11

Arterial Ulcer Characteristics?

Answer 11

·  	20% of leg ulcers are due to arterial insufficiency
·  	Claudication - a condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries.
·  	Digital or forefoot pain at rest
·  	Smooth/regular shaped borders
·  	Typically small, circular, deep
·  	Minimal drainage
·  	Non-bleeding
·  	Pulse weak or not palpable
·  	Pale or black

Question 12

What is the typical location for arterial ulcers?

Answer 12

On or between toes, heel, shin, medial side of hallux (big toe)

Question 13

Interventions for arterial ulcer interventions?

Answer 13

· Eliminate restrictive clothing
· Protect extremities from cold and trauma
· Apply warmth to promote arterial flow
· Elevate head of bed 10-15cm (4-6 inches) to maintain lower beg position below the level of the heart (position extremity flat)
· Support client to access supervised exercise program as tolerated: consult with a PT if needed
· Provide support surfaces and wound management

Question 14

Why are diabetes at risk for foot ulcers?

Answer 14

o Hyperglycemia
o Motor neuropathy
o Sensory neuropathy
o Peripheral vascular disease

Question 15

What assessments would you do for someone with a diabetic foot ulcer?

Answer 15

· Extent and type of pain, appearance and temp of skin in both legs
· Quality of all peripheral pulses compare bilaterally
· Check for edema and degree of
· Check limitations in mobility and activity
· Check moisture of
· Nutritional status
· History of diabetes, collagen disease, varicose veins

Question 16

What is the trajectory for wound healing?

Answer 16

• hemostasis (anticoagulants may prevent this, low calcium, low platelets)
• Inflm (immunodeficiency, chronic irritation)
• proliferation (nutrition, hydration
• remodelling
• what each impacts each stage?

Question 17

Stage 1 pressure:

Answer 17

• intact
• rednes
• not affecting the dermis
• Can happen in just a few hrs
  • Area of erythema
  • Erythema does not blanch with pressure • Skin temperature elevated
  • Tissue swollen and congested
  • Patient complains of discomfort
  • Erythema progresses to dusky blue-grey

Question 18

Stage 2:

Answer 18

• Skin breaks
• Abrasion, blister, or shallow crater • Edema persists
• Ulcer drains
• Infection may develop

Question 19

stage 3:

Answer 19

• Ulcer extends into subcutaneous tissue • Necrosis and drainage continue
• Infection develops

Question 20

Stage 4:

Answer 20

• Ulcer extends to underlying muscle and bone • Deep pockets of infection develop
• Necrosis and drainage continue

Question 21

how often should a nurse reposition pt?

Answer 21

• Turned and repositioned at 1- to 2-hour intervals

* Encouragedtoshiftweightactivelyevery15minutes

Question 22

How often should a pt shift thier weight?

Answer 22

The patient should be reminded to shift weight frequently and to rise for a few seconds every 15 minutes while sitting in a chair (Fig. 12-5).

Question 23

To avoid fritcion and shear what angle should the head of th ebed be at?

Answer 23

t is important to keep the head of the bed at less than 30 degrees whenever possible.

Question 24

Arteriosclerosis?

Answer 24

Arteriosclerosis is the most common disease of the arter- ies; the term means “hardening of the arteries.

Question 25

Atherosclerosis

Answer 25

Atherosclerosis is a generalized disease of the arteries, and when it is present in the extremities, it is usually present elsewhere in the body.

Question 26

Modifieable/modifieable risk factors for Arteriosclerosis and peripheral disease

Answer 26

• Nicotine use (i.e., tobacco smoking or chewing)
• Diet (contributing to hyperlipidemia)
• Hypertension
• Diabetes mellitus (speeds the atherosclerotic process by
thickening the basement membranes of both large and
small vessels)
• Obesity
• Stress
• Sedentary lifestyle
• Elevated C-reactive protein
• Hyperhomocysteinemia

• Age
• Gender
• Familial predisposition/genetics

Question 27

Arterial vs venous ulcers?

Answer 27

Arterial: Chronic arterial disease is characterized by intermittent claudication, which is pain caused by activity and relieved after a few minutes of rest. The patient may also complain of digital or forefoot pain at rest. If the onset of arterial occlu- sion is acute, ischemic pain is unrelenting and rarely relieved even with opioids. Typically, arterial ulcers are small, circu- lar, deep ulcerations

Venous: Chronic venous insufficiency is characterized by pain described as aching or heavy. The foot and ankle may be edematous. Ulcerations are in the area of the medial or lateral malleolus (gaiter area) and are typically large, superficial, and highly exudative.

Question 28

special considerations for arterial ulcer

Answer 28

Arterial to be higher than the heart and no compression

Question 29

Dehiss?

Answer 29

wound comes apart