module 2: wound care Flashcards
who are prone to ulcers?
- pts confined to bed for long periods of time
- motor or sensory dysfunction
- pt who may experience muscular atrophy
what are pressure ulcers?
localized areas of infarcted soft tissue that occur when pressure is applied to the skin over time is greater than normal capillary closure pressure (about 25-32mmHg)
critically ill pt have lower capillary closure pressure thus?
are at greater risks of pressure ulcers
initial sign of pressure ulcers
-erythema caused by hypermia
unrelieved pressure results in?
further skin breakdown
assessment of pressure ulcers/skin breakdown?
- immobility
- impaired sensory perception or congition
- decreased tissue perfusion
- decreased nutritional status
- friction and shear forces
- increased moisture
geriatric and skin breakdown?
- older adults have a number of age-related chances that increase the risk (reduced skin elasticity, decreased collagen, muscle/tissue atrophy
- decreased inflm response
- little subcutaneous padding over bony prominences
definition of would?
any disruption to the layers of the skin and underlying tissues
types of wound healing?
primary intention
secondary intention: left to close with scar tissue
tertiary intention: left open for a long period of time
trajectory of wound healing?
- hemostasis: 1-4 days, sending cells to site, want it to stop bleeding
- inflammation: up to 4 days, trying to get bacteria out of the wound
- proliferation: longer stage, 4-21 days, affected by inadequate nutrition
- remodelling: can take up to 2 years until all scar tissue is completely formed and healed
all wounds start as?
acute
acute wound=
wound that heals within an expected time frame (within 21 days_
what is a chronic wound?
one that in which the normal process of wound healing is disrupted at one or more points in the phases of wound healing, long duration reoccurs frequently
stage 1 pressure ulcer?
- redness, skin still intact
- only affecting top layer, no dermis yet, no breakage
stage 2 pressure ulcer?
goes into dermis layer, skin starting to break
-primary prevention now gone,risk to infection
stage 3 pressure ulcer?
- damage of subcutaneous layer, may see some subcutaneous fat
- drainage, open- note the colour, surrounding skin
stage 4 pressure ulcer?
all the way through to muscle, bone, tendons
-definite drainage
unstageable pressure ulcer?
- ulcer is covered by slough or eschar
- usually requires advanced interventions
what is wound dehiscence?
distressing but common occurrence among patients who have received sutures. The condition involves thewoundopening up either partially or completely along the sutures – thewoundreopens to create a newwound.
risk factors for pressure ulcers?
- prolonged pressure on tissue
- immobility
- loss of protective reflexes
- poor skin perfusion
- malnutrition, hypoproteinemia, anemia, vit def., friction, incontinence, alterred skin moisture, advanced age, equipment (casts), critcally ill patients
arterial disorder?
arteriosclerosis
atherosclerosis
what is arteriosclerosis?
- most common disease of the arteries “hardening of the arteries”
- muscle fibers and walls of small arteries and arterioles become thickened
what is atherosclerosis?
-affects the intima of large and medium sized arteries
-change consists of accumulation of lipids, calcium, blood components, carbs, fibres on intimal layer
(referred to as atheromas or plaques)
most common result of atherosclerosis?
narrowing (stenosis) of the lumen, obstruction by thrombosis, aneurysm, ulceration
indirect result of atherosclerosis?
-malnutrition, subsequent fibrosis
risk factors to atherosclerosis?
- tobacco
- nicotine
- carbon monoxide
- obesity, stress, lack of exercise
- elevated BP, family history
prevention of atherosclerosis?
- dont eat high fat diet
- diet modifiation
- measure cholesterol
- LDL below 2mmol per L
nursing management for atherosclerosis: improving peripheral arterial circulation
- applying warmth
- avoid exposure to cold temp
- adequate clothing to maintain warmth
- warm bath or drink
- hot water bottle or pad on abdomen
relieving pain from atherosclerosis?
oxycodone plus aspirin and acetaminophen may be helpful
pressure ulcer interventions?
- maintain good skin hygiene, avoid skin trauma
- provide supporting devices
- frequent positioning
- multidisciplinary approach
- provide local wound care
what are lower limb ulcers? caused by?
- distinct from pressure ulcers
- caused by diabetes or arterial or venous insufficiency
- assessment and treatment: aided by doppler ultrasounds, compression dressings, interdisciplinary approach
characteristics of venous ulcers?
- 75% caused by chronic venous insufficency
- dull aching or heavy
- edema
- typically large
- irregular ulcer border
- highly exudative
- pulses present
- bleeds easily
- location: gaiter area
venous ulcer prevention?
-compression of extremity, protect from trauma, keep clean, dry, soft, wound management
arterial ulcer characteristics?
- 20% of leg ulcers due to arterial insufficency
- claudication
- 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
- location: toes, heels, skin, medial side of hallux
arterial ulcer intervention?
eliminate restrictive clothing
- protect extremities from cold and trauma
- apply warmth
- elevate head of bed to maintain lower leg position below level of heart
- support client to supervised exercise program
diabetic foot ulcers? why?
-hyperglycemia, motor neuropathy, sensory neuropathy, PVD
what is chronic venous insufficency
results from obstruction of venous valves in the legs or a reflux of blood through the valves
-walls of veins are thinner and more elastic, distend readily when pressure elevated
