Pressure and Diabetic Injuries - Class 4 Flashcards
pressure wounds occur from
compression of soft tissues b/w bony prominence and a support surface
capillary closing pressure of 32 mm Hg exceeded
pressure wounds –> relationship
time/pressure
–> the long you’re on it the more likely you are to sustain a wound
contributory factors of pressure injuries
shear
friction
moisture
heat
extrinsic physical factors
intrinsic factors
shear
tears capillary beds perpendicular to skin
accounts for undermining
friction
causes blisters exposing dermal structures
moisture
macerates and erodes skin
heat
raises tissue metabolism but compressed capillaries cannot dilate leading to tissue hypoxia
extrinsic physical factors
support surfaces
orthotic devices
tight fitting clothes/shoes
tight dressings
intrinsic factors
muscle atrophy
medications
malnutrition
medical co-morbidities
pressure injury shape
rounded, craterlike, shape with regular edges
pressure injuries may have
tunneling or undermining
what is the shape of pressure wounds caused by
shearing forces and the round, pointed shape of bony prominences
how are pressure injuries classified
by stage
by thickness
classification by thickness
partial thickness
full thickness
partial thickness classification
wound extends to dermis only
may heal by epithelialization
full thickness classification
wound extends through dermis
may involve subcutaneous tissues, muscle and possibly bone
classification by stage
suspected deep tissue injury
stage 1
stage 2
stage 3
stage 4
unstageable
suspected deep tissue injury –> presentation
purple or maroon
localized area of discolored intact skin
blood-filled blister
–> d/t damage to of underlying soft tissue from pressure or shear
suspected deep tissue injury –> proceeded by
tissue that is painful, firm, mushy, boggy, warmer or cooler
as compared to adjacent tissue
stage 1 –> presentation
non blanchable erythema of intact skin
usually over a bony prominence
stage 1 –> darker skin tones
non-blanchable redness may not be visible
presents w/ discoloration, warmth or coolness, edema, indurations (firmness) and pain
stage 1 –> lesion
heralding lesion of skin ulceration
stage 2 involves
partial thickness skin loss
involving epidermis and/or dermis
does not go through the dermis
stage 2 clinical presentation
presents as a blister (in tact or open/ruptured serum filled), abrasion, or shallow crater
stage 2 color
wound bed is red/pink and moist
stage 2 is differentiated from
skin tears
tape burns
dermatitis
maceration or excoriation
stage 3 is a
full thickness skin loss
involving damage to subcutaneous tissue
stage 3 may extend
to fascia
but not through it
stage 3 may have
undermining or tunneling
stage 4 is a
full thickness skin loss w/ extensive tissue destruction
stage 4 has damage that
extends to muscle, bone, tendons, and joint capsule
unstageable is
full thickness tissue loss
unstageable wound bed is covered in
slough (yellow, tan, gray, green, brown)
and/or
eschar (tan, brown or black)
interventions for pressure wounds
minimize risk factors
off load pressure areas
pressure relieving devices
therapeutic positioning
wound care
interventions –> minimize risk factors
nutrition
mobility
skin moisture
mechanical forces
metabolic psychosocial
interventions –> therapeutic positioning
equipment and support
pressure interventions –> wound care
debride necrotic tissue (sharps, enzymatic, autolytic)
control infection
control wound exudate (alignates, foams, hydrocolloids)
protect granulation tissue (alignates, foams, hydrocolloids)
interventions for pressure injuries cont.
pressure relieving devices (PRDs)
think prevention
watch for false sense of security
mobility is key
reduce, redistribute or alternate pressures
interventions –> reduce, redistribute or alternate pressures
foam PRD
high density foam PRD
water PRD
gel PRD
static air PRD
static PRD
dynamic air PRD
low air loss PRD
primary cause of diabetic ulcers
insensitivity from peripheral neuropathy and abnormal pressures from structural deformities
diabetic ulcers have
loss of protective sensation
other causes of diabetic ulcers
repetitive mechanical stress
foot deformities
compromised skin barrier
arterial insufficiency
uncontrolled blood glucose level
other causes of diabetic ulcers –> foot deformities
form muscle weakness
secondary to motor neuropathy
other causes of diabetic ulcers –> compromised skin barrier
secondary to autonomic neuropathy
other causes of diabetic ulcers –> arterial insufficiency
a contributor but not the primary cause
other causes of diabetic ulcers –> uncontrollable blood glucose levels
effects on inflammatory response
those with diabetes
are in a nasty cycle that increases uncontrolled hyperglycemia
pts w/ diabetic ulcers will have
diminished sensation
foot deformities
palpable pulses
warm foot
may have PVD
where are diabetic ulcers found
plantar surface of foot
MTP heads
under heel
diabetic ulcer wound bed
deep
diabetic ulcer wound margins
even
there is granulation tissue with diabetic ulcers unless they have
PVD
diabetic ulcer is accompanied by
no pain
diabetic ulcer drainage
low to moderate drainage
diabetic ulcer may also have
cellulitis or osteomyelitis
diabetic management
strict maintenance of blood glucose
control of hypertension, cholesterol and triglyceride levels
stop smoking
preventive care
preventative care diabetic ulcers
foot screening and risk identification
pt education
proper foot hygiene and self education
appropriate foot wear
ROM exercises and joint mobility
diabetic wound care
off-load the wound
debride necrotic tissue and protection of wound
scrape calluses
control of wound infection
wound care –> off load the wound
NWB of foot
total contact casting
appropriate foot wear to accommodate for dressing and wound location (local pressure relief)
