*PTA 200- Wound Management Objectives Flashcards
Discuss wound prevention
Prevention includes:
- repositioning every 2 hours
- pressure reduction with positioning or cushions (example: roho pillow)
- shifting weight
- lifting devices
- pillows
- head of bed elevation. (30 degrees for tube feeds, but never at 45 degrees)
Prevention also includes skin care and early treatment of skin:
- inspection of skin
- bathing
- incontinence
- moisturization
Discuss factors that contribute to a patient’s risk of developing a wound
- Malnutrition
- Immobility
- Chronic Illness
- Advanced age
- Incontinence
- Altered Mental Status
- Diminished Sensation
Why is wound prevention a multidisciplinary team effort?
Prevention is a multidisciplinary team effort because it is part of best practices. The collective wisdom of the team results in shorter wound healing times, a lower rate of wound related complications, and fewer amputations.
Describe an abrasion wound:
a wound caused by rubbing or scraping the skin or mucous membrane. Examples; road rash, skinned knee, scrapes, carpet burns.
Describe a puncture wound:
a wound caused by a pointed object or instrument. Examples; stab wounds, gunshot wounds, bites.
Describe a laceration wound:
a cut; a wound produced by the tearing of body tissue.
Describe a burn:
caused when the skin contacts dry heat (fire), moist heat (steam), chemicals, electricity, or radiation. Burns are classified according to their depth and size. (superficial, partial thickness, full-thickness).
Describe an incision and explain what kind of surface area is created by an incisional wound.
a cut made by a sharp instrument such as a scalpel.
The surface area will be really small and will be approximated. It will heal by primary intention.
Describe interventions for pressure ulcers
-prevention is the best intervention for pressure ulcers.
The five steps in pressure ulcer prevention includes:
- Education
- Positioning
- Mobility
- Nutrition
- Management of incontinence
Pressure Ulcer Prevention mnemonics; NO ULCERS, SKIN
N-nutrition and fluid status
O- observation of skin
U-up and walking or assist with position changes. L- lift don't drag C-clean skin and continence care E- elevate heels R- risk assessment S- support surfaces
S-surface selection
K-Keep turning
I- incontinence management
N-nutrition
Interventions for Vascular Insufficiency- venous ulcers
- Initiate healthcare team with patient to address co-morbidities
- Educate patient and caregiver
- wound etiology
- intervention strategies
- risk factor modification
- guidelines for patients with venous insufficiency ulcers. - Treat Cause
- Apply compression if appropriate
- instruct patients in methods to decrease edema - Treat Wound
-Inflammation Control- use topical steroids to decrease inflammation or weeping.
-Infection Control- choose absorptive dressings
and use skin sealants.
-Debridement - Treat Periwound
- moisturize dry, scaling skin
- infection control
- absorb drainage
- debridement
Interventions for vascular insufficiency; arterial ulcers
- Protect Surrounding Skin
- moisturize dry skin
- avoid adhesives
- reduce friction between toes
- provide padding to protect ischemic toes - Address wound bed
- choose dressings to moisten wound bed
- debride necrotic tissue if appropriate - Maximize circulation
- avoid compression
- choose footwear to accommodate for bandages and decrease stress to wound. - Educate patient/caregivers
- wound etiology
- intervention strategies
- risk factor modification
- foot care guidelines
Foot care guidelines for patients with arterial ulcers
- Protect your feet and legs from:
- trauma-inspect your feet, wash and dry carefully, trim nails straight across
- chemicals-do not use home remedies
- excessive heat and cold-do not use heating pads, soak feet in hot water, use heavy socks to protect against the cold.
- any open wounds- wear bandages, do not put pressure on open areas when walking. - Live Healthy
- eat a balanced diet
- exercise regularly
- if you smoke, quit
- control medical conditions such as diabetes
Correctly measure a wound and document in objective in a SOAP format
- Length x width as linear distances from wound edge to wound edge and then multiplied for surface area in one of two ways: Clock method - head being 12 o’clock and landmarks would be defined and the corresponding widest and longest areas of the wound is measured and then surface area is calculated.
- Depth - Depth of the wound can be described as the distance from the visible surface to the deepest point in the wound. If the depth varies, you would want to record the deepest site, so you may have to take multiple measurements.Typically, a sterile, cotton-tipped applicator (6”) is used. The applicator is inserted gently into the deepest portion of the wound. The thumb and forefinger grasp the applicator at the point corresponding to the skin surface.
- Tunneling and/or undermining (how deep and time)
- Color
- Slough (% of surface area)
- Any structures such as bone - measure l x w and which bone
- Odor
- Pain if present
- Periwound area (color, epiboly, etc.) (use clock method ex. 3-6 o’clock)
- Drainage- amount, color and consistency (serous-clear, watery plasma, sanguinous- bloody, sero-sanguinous- plasma and red blood cells, purulent- thick, white blood cells may be yellow, green or brown, if infected)
- Which stage (if pressure ulcer) or thickness
- Edema (only if present)
- Maceration (if present)
- Location
Demonstrate the correct application and safe removal of the following dressings on your lab partner’s arm: a dry to dry dressing on an 1 inch imaginary incision area and a semipermeable film dressing to an imaginary ½ inch long superficial skin tear.
Clean skin with “skin prep”, use clean method, make “window pane” with tape, slowly pull tape off to remove or to remove film pull toward you.
When shown a wound picture, identify wound characteristics including but not limited to color, type, stage, infection and etiology.
Color: red, yellow, black, pink, gray, white, etc.
Stage: I, II, III, and VI
Thickness: Superficial, Partial, and Full Thickness
Infection: Necrosis, eschar tissue present
Etiology: Venous insufficiency, DM, burn, poor skin integrity, pressure, etc.
Practice identifying pictures from BB
When shown a wound picture, identify wound characteristics including but not limited to color, type, stage, infection and etiology.
Type: Granular- a collagen matrix which contains different types of cells that contribute to wound healing, such as: endothelial cells, fibroblasts, lymphocytes, platelets, and epidermal cells. This tissue has a red, beefy, shiny, granular appearance.
- Necrotic eschar- a slough produced by gangrene.
- Exudate- a fluid with a high content of protein and cellular debris which has escaped from blood vessels and has been deposited in tissues or on tissue surfaces, usually as a result of inflammation.
- Epithelial tissue- Re-establishment of an epidermis on top of the granulation tissue; epithelial margins will begin to migrate toward the center of the wound; This process is sometimes referred to as a “contraction” of the wound… where the surface area of the wound reduces in size. When epithelialization is complete, a scar results.
- Slough- necrotic fatty tissue in the process of being separated from viable portions of the body.
- Maceration- a term used for moisture saturated skin, usually in the periwound area.