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Integumentary 1 - Midterm > Pressure and Diabetic Injuries - Class 4 > Flashcards

Pressure and Diabetic Injuries - Class 4 Flashcards

1
Q

pressure wounds occur from

A

compression of soft tissues b/w bony prominence and a support surface

capillary closing pressure of 32 mm Hg exceeded

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2
Q

pressure wounds –> relationship

A

time/pressure

–> the long you’re on it the more likely you are to sustain a wound

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3
Q

contributory factors of pressure injuries

A

shear

friction

moisture

heat

extrinsic physical factors

intrinsic factors

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4
Q

shear

A

tears capillary beds perpendicular to skin

accounts for undermining

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5
Q

friction

A

causes blisters exposing dermal structures

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6
Q

moisture

A

macerates and erodes skin

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7
Q

heat

A

raises tissue metabolism but compressed capillaries cannot dilate leading to tissue hypoxia

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8
Q

extrinsic physical factors

A

support surfaces

orthotic devices

tight fitting clothes/shoes

tight dressings

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9
Q

intrinsic factors

A

muscle atrophy

medications

malnutrition

medical co-morbidities

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10
Q

pressure injury shape

A

rounded, craterlike, shape with regular edges

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11
Q

pressure injuries may have

A

tunneling or undermining

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12
Q

what is the shape of pressure wounds caused by

A

shearing forces and the round, pointed shape of bony prominences

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13
Q

how are pressure injuries classified

A

by stage

by thickness

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14
Q

classification by thickness

A

partial thickness

full thickness

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15
Q

partial thickness classification

A

wound extends to dermis only

may heal by epithelialization

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16
Q

full thickness classification

A

wound extends through dermis

may involve subcutaneous tissues, muscle and possibly bone

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17
Q

classification by stage

A

suspected deep tissue injury

stage 1

stage 2

stage 3

stage 4

unstageable

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18
Q

suspected deep tissue injury –> presentation

A

purple or maroon

localized area of discolored intact skin

blood-filled blister
–> d/t damage to of underlying soft tissue from pressure or shear

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19
Q

suspected deep tissue injury –> proceeded by

A

tissue that is painful, firm, mushy, boggy, warmer or cooler

as compared to adjacent tissue

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20
Q

stage 1 –> presentation

A

non blanchable erythema of intact skin

usually over a bony prominence

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21
Q

stage 1 –> darker skin tones

A

non-blanchable redness may not be visible

presents w/ discoloration, warmth or coolness, edema, indurations (firmness) and pain

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22
Q

stage 1 –> lesion

A

heralding lesion of skin ulceration

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23
Q

stage 2 involves

A

partial thickness skin loss

involving epidermis and/or dermis

does not go through the dermis

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24
Q

stage 2 clinical presentation

A

presents as a blister (in tact or open/ruptured serum filled), abrasion, or shallow crater

25
Q

stage 2 color

A

wound bed is red/pink and moist

26
Q

stage 2 is differentiated from

A

skin tears

tape burns

dermatitis

maceration or excoriation

27
Q

stage 3 is a

A

full thickness skin loss

involving damage to subcutaneous tissue

28
Q

stage 3 may extend

A

to fascia

but not through it

29
Q

stage 3 may have

A

undermining or tunneling

30
Q

stage 4 is a

A

full thickness skin loss w/ extensive tissue destruction

31
Q

stage 4 has damage that

A

extends to muscle, bone, tendons, and joint capsule

32
Q

unstageable is

A

full thickness tissue loss

33
Q

unstageable wound bed is covered in

A

slough (yellow, tan, gray, green, brown)

and/or

eschar (tan, brown or black)

34
Q

interventions for pressure wounds

A

minimize risk factors

off load pressure areas

pressure relieving devices

therapeutic positioning

wound care

35
Q

interventions –> minimize risk factors

A

nutrition

mobility

skin moisture

mechanical forces

metabolic psychosocial

36
Q

interventions –> therapeutic positioning

A

equipment and support

37
Q

pressure interventions –> wound care

A

debride necrotic tissue (sharps, enzymatic, autolytic)

control infection

control wound exudate (alignates, foams, hydrocolloids)

protect granulation tissue (alignates, foams, hydrocolloids)

38
Q

interventions for pressure injuries cont.

A

pressure relieving devices (PRDs)

think prevention

watch for false sense of security

mobility is key

reduce, redistribute or alternate pressures

39
Q

interventions –> reduce, redistribute or alternate pressures

A

foam PRD

high density foam PRD

water PRD

gel PRD

static air PRD

static PRD

dynamic air PRD

low air loss PRD

40
Q

primary cause of diabetic ulcers

A

insensitivity from peripheral neuropathy and abnormal pressures from structural deformities

41
Q

diabetic ulcers have

A

loss of protective sensation

42
Q

other causes of diabetic ulcers

A

repetitive mechanical stress

foot deformities

compromised skin barrier

arterial insufficiency

uncontrolled blood glucose level

43
Q

other causes of diabetic ulcers –> foot deformities

A

form muscle weakness

secondary to motor neuropathy

44
Q

other causes of diabetic ulcers –> compromised skin barrier

A

secondary to autonomic neuropathy

45
Q

other causes of diabetic ulcers –> arterial insufficiency

A

a contributor but not the primary cause

46
Q

other causes of diabetic ulcers –> uncontrollable blood glucose levels

A

effects on inflammatory response

47
Q

those with diabetes

A

are in a nasty cycle that increases uncontrolled hyperglycemia

48
Q

pts w/ diabetic ulcers will have

A

diminished sensation

foot deformities

palpable pulses

warm foot

may have PVD

49
Q

where are diabetic ulcers found

A

plantar surface of foot

MTP heads

under heel

50
Q

diabetic ulcer wound bed

A

deep

51
Q

diabetic ulcer wound margins

A

even

52
Q

there is granulation tissue with diabetic ulcers unless they have

A

PVD

53
Q

diabetic ulcer is accompanied by

A

no pain

54
Q

diabetic ulcer drainage

A

low to moderate drainage

55
Q

diabetic ulcer may also have

A

cellulitis or osteomyelitis

56
Q

diabetic management

A

strict maintenance of blood glucose

control of hypertension, cholesterol and triglyceride levels

stop smoking

preventive care

57
Q

preventative care diabetic ulcers

A

foot screening and risk identification

pt education

proper foot hygiene and self education

appropriate foot wear

ROM exercises and joint mobility

58
Q

diabetic wound care

A

off-load the wound

debride necrotic tissue and protection of wound

scrape calluses

control of wound infection

59
Q

wound care –> off load the wound

A

NWB of foot

total contact casting

appropriate foot wear to accommodate for dressing and wound location (local pressure relief)

Integumentary 1 - Midterm (23 decks)

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