Positioning and Wound Care Flashcards
what are the 3 goals of patient positioning?
- pt comfort
- skin hygiene
- joint mobility
what are the 4 “dos” of pillows?
float heels, elevate UE, use for S/L, prevent hip ER in supine
what are the 2 “don’ts” of pillows?
place under knees, keep neck flexed
what is the gold standard for offloading with diabetic ulcers, and what does it allow the pt to do?
- total contact cast
- allows pt to be ambulatory
define eschar
black and crusty stuff
define desiccated
dried out
define epibole
rolled or curled under wound edges
what are the 3 main characteristics of skin?
waterproof, protective, adaptive
arterial insufficiency is associated with a(n) ____ pedal pulse (increased/decreased)
decreased (might be absent)
describe intermittent claudication
O2 not meeting muscle demand → ischemia → pain
what body parts are most affected by arterial insufficiency?
- Anterolateral foot/ankle and toes
- Dorsum of the foot
how will wounds due to arterial insufficiency appear?
- full thickness with well-defined borders
- minimal drainage
- often with eschar
- shiny, anhydrous, pale to cyanotic skin
what causes venous insufficiency?
vales aren’t working and there is backflow of fluid
is the pedal pulse present with venous insufficiency?
yes, unless there is a concomitant arterial disease
what makes the lower limb discomfort and edema with venous insufficiency worse?
being in a dependent position
what makes the lower limb discomfort and edema with venous insufficiency better?
being more raised up
what part of the foot is most affected by venous insufficiency?
anteromedial
how will wounds due to venous insufficiency appear?
- Irregularly shaped, shallow wound
- Typically located on the medial lower leg and malleolus
- Moderate to copious drainage
is the pedal pulse present with diabetic foot ulcers?
not usually, it is often absent with arterial disease (but it may be present)
diabetic foot ulcers are often ____ with decreased ____
painless; temperature
what body part is most commonly affected by diabetic foot ulcers?
plantar surface of foot/toes
what are some other body parts impacted by diabetic foot ulcers?
- dorsum of foot/toes
- ends of toes
- metatarsals
how do diabetic foot ulcers appear?
pale wound bed often with nonviable tissue and minimal drainage
what kinds of changes happen to the skin/hair/nails in pts with diabetic foot ulcers?
- trophic changes
- skin will be shiny and hairless
are pulses intact with pressure injuries?
yes, unless there is vascular compromise
where are pressure injuries typically found?
pressure areas/bony prominences
pressure injuries are ____ if sensation is still intact
painful
describe a superficial wound
- damage to epithelium
- heals rapidly through regeneration of epithelial cells
describe a partial thickness wound
- involves the dermal layers
- vessel damage
describe a full thickness wound
- involves subcutaneous fat and deeper
- takes longest time to heal bc new CT needs to regenerate
- contraction occurs during healing
describe a stage 1 pressure injury
Intact, reddened skin that does not lighten when palpated
describe a stage 2 pressure injury
- Partial thickness w exposed, viable dermis
- No slough or eschar
describe a stage 3 pressure injury
- Full-thickness w exposed subcutaneous layer
- May include epibole, tunneling, undermining
- Slough and eschar can be present
describe a stage 4 pressure injury
- Full-thickness with exposed muscle, tendon, ligament, fascia, cartilage, and/or bone
- Often with epibole, tunneling, undermining
- Slough and eschar may be present
what does it mean for a pressure injury to be “unstageable”?
- slough/eschar covers full-thickness wound
- unable to detect depth
what is a deep tissue pressure injury (DTPI)?
intact or non-intact skin appearing as non-blanchable red, maroon, or purple in color
what is the most common type of chronic wound?
diabetic ulcer
what factors can delay wound healing (VAL NM MBA)?
- vascular status
- age
- lifestyle
- nutrition
- medical status
- medications
- bioburden and infections
- appropriate care and pt compliance
what are 4 PT considerations with wound healing?
- prevention
- pain management
- ROM, strength, functional mobility
- edema management
