Ulcers/wound Dressings Flashcards
What is the presentation of an arterial ulcer?
-Anywhere on legs or dorsum of foot, toes, LATERAL MALLEOLOUS
-round, punched out, WELL DEFINED
-Color: white, pale, not granulating
-Appearance: shallow in early stages, skin thin, smooth, later has hair loss, dry, trophic changes, brittle nails
-Exudate: minimal, dry
-Pain: relieved in dependent position / very painful
-Pulse/temp: pulse indistinguishabintermittent claudication, cold to touch
Presentation of a venous ulcer?
-ABOVE medial malleolus, distal LE
-size: shallow, large and irregular , dark pigmentation
-Color: ruddy red with granular tissue, discolored with yellow slogh, if its chronic it has hemosiderian stain, SCALY AND SHINY
-exudate: moderate to heavy/ wet
-pain: dull ache pain more related to venous HTN, comfortable with legs elevated
-Normal arterial pulses, warm
What is stage 0 of the Wagner Scale?
What is stage 1 of the Wagner Scale?
What is stage 2 of the Wagner Scale?
What is stage 3 of the Wagner Scale?
What is 4 of the Wagner Scale?
What is stage 5 injury of the Wagner Scale?
Diabetic ulcer presentation?
-Caused by loss of protective sensation, coordination
-associated with peripheral artery disease and peripheral neuropathy
-Occurs where arterial ulcers appear or neuropathy areas (Plantar aspect of foot - usually big toe)
-typically not painful 2’ sensory loss
-pulse may or may not be present
-infection, sepsis, gangrene may present
What do we use transparent films for?
-Stage 1 and II pressure ulcer
-Is an adhesive
-For autolytic debridement
-Visual evaluation of wound without removal*****
-Impermeable to external fluids and bacteria
What do we use hydrocolloid dressings for?
-Protection of partial thickness wounds
-Also used for autolytic debridement*** of necrosis or slough
-Used for MILD EXUDATE
-They are adhesive wafers containing absorptive particles that interact with wound fluid to make gelatinous mass over wound bed
What are hydrogel dressings used for?
-Partial and full thickness, wounds with necrosis and slough, BURNS AND TISSUE DAMAGE BY RADIATION
(Remember colloids are used AFTER autolytic debridement of slough and necrosis)
-These are water or glycerine based gels
-Rehydrate dry wound beds
What are foam dressings used for?
-Partial and full thickness wounds with MINIMAL TO MOD EXUDATE
-Secondary dressing for wounds with packing to provide absorption
-Made of semipermeable membranes that are hydrophobic
-Insulate wounds
What are alginate dressings used for?
-Wounds with mod- large amounts of exudate
-Wounds with combination exudate and necrosis, that require packing and absorption
-Infected and noninfected exuding wounds
-Soft, absorbent, nonwoven dressings from seaweed
When is gauze used for dressing?
-Exudateive wounds, wounds with dead space, tunneling or sinus tracts, exudate or necrotic tissue
-Wet to dry: mechanical debridement of necrotic tissue and slough
-Continuous dry: heavily exudating wounds
-Continuous moist: protection of clean wounds, autolytic debridement of slough or eschar, delivery of topical needs
What is stage I pressure ulcer?
-Non-blancheable erythema of intact skin (redness, irritation) EPIDERMIS
-May include changes in skin temperature, tissue consistency and sensation
-Redness may not be visible in darker skin (dark blue/purple print)
What is stage II pressure injury?
-Partial-thickness skin loss
-Epidermis, dermis or both
-Ulcer is superficial and presents as an abrasion, blister, or shallow crater
Stage III pressure injury?
-Full-thickness skin loss
-Involves damage to or necrosis of subcutaneous tissue
-May extend to underlying fascia but not through
-Presents as a deep crater
What is a stage IV pressure injury?
-Full thickness skin loss (MUSCLE, BONE, TENDONS)
-Undermining and sinus tracts may be present
What is an unstageable ulcer?
Tissue depth is obscured due to slough or eschar and extent of damage cannot be determined
What is the stage of “deep tissue injury” for a pressure ulcer?
Discolored area of tissue that is not reversible and will likely progress to a full thickness injury
What is autolytic debridement?
-SELECTIVE method of natural debridement promoted under occlusive or semi occlusive moisture retentive dressing that results in solubilization of necrotic tissue -Uses the body’s own enzymes and moisture beneath dressing
-Hydrocolloids, hydrogels and transparent films
-Promotes fast healing time with less pain **
What are the indications for autolytic debridement?
-Individuals on anticoagulant therapy
-Individuals who cannot tolerate other foams
-ALL NECROTIC WOUNDS in people medically stable
What are the contraindications for autolytic debridement?
-infection
-immunosuppressed individuals
-Dry gangrene or dry ischemic wounds
What is enzymatic debridement?
A SELECTIVE method of chemical debridement that promotes liquefaction of necrotic tissue by applying topical preparation of collagenolytic enzymes to those tissues
-Involves the application of a topical agent that liquefies necrotic tissue
What are the indications for enzymatic debridement?
-All moist necrotic wounds
-Eschar after cross-hatching
-homebound individuals
-People who cannot tolerate surgical debridement
What are the contraindications of enzymatic debridement?
-Ischemic wounds unless adequate vascular status has been determined
- Dry gangrene
-Clean granulated wounds
What is mechanical debridement?
NONSELECTIVE method of debridement that removes foreign material and devitalized or contaminated tissue by physical forces (Wet to dry gauze, dextranomers, pulsation lavage with suction)
-involves irrigation/wet to dry dressings
What are the indications for mechanical debridement?
Wounds with moist necrotic tissue or foreign material present
What are the contraindications for mechanical debridement?
Clean, granulated wounds
What is sharp debridement?
-SELECTIVE method of debridement using sterile instruments (scissors, scalpel, forces, silver nitrate stick) that removes the necrotic wound without anesthesia and little bleeding
What are the indications for sharp debridement?
-Scoring/excision of leathery eschar
-Excision of moist necrotic tissue
-Biofilm removal
What are the contraindications for sharp debridement?
-Clean wounds
-Advancing cellulitis with sepsis
-Individuals on anticoagulants
What is surgical debridement?
For deep (stage III or IV) or complicated pressure ulcer
-most efficient method of debridement
-SELECTIVE and performed by physician or surgeon with sterile instruments (scissors, scalpel, forceps, etc…)
-The individual may require anesthesia for pain
What are the indications for surgical debridement?
-Advancing cellulitis with sepsis
-Immunocompromised individuals
-When infection threatens the individuals life
-Granulation and scar tissue may be excised
-Biofilm removal
What are the contraindications for surgical debridement?
Cardiac disease, pulmonary disease, diabetes, severe spasticity, individuals who cannot tolerate surgery, individuals with a short life expectancy, QOL cannot be improved
What is biological debridement?
-use of maggots grown in a sterile environment to debridement nonviable tissue. They produce enzymes and phagocytize necrotic tissue and bacteria (MRSA). They may stimulate granulation formation and epithelialization
What are the indications for biological debridement?
-rarely used
-Individuals who cannot tolerate other forms of debridement
-All non-healing necrotic wounds in people who are medically stable
What are the contraindications for biological debridement?
-Psychological stress arises from having living creatures in wounds
-Reports of pain increasing
-poor perfusion or exposed blood vessels
What does >1.2 indicate for ABI?
Falsely elevated, calcified
What does 0.95-1.19 indicate for ABI?
NORMAL
What does 0.75-0.94 indicate for ABI?
Mild, intermittent claudication
What does 0.50-0.74 indicate on the ABI scale?
Mod, pain at rest
What does <0.5 indicate for ABI?
Severe arterial disease
What is a grade I on the subjective ratings of p! With intermittent claudication?
Minimal discomfort or pain
What is a grade II on the subjective ratings of p! With intermittent claudication?
Moderate discomfort or pain; patients attention can be diverted
What is a grade III on the subjective ratings of p! With intermittent claudication?
Intense pain; patients attention cannot be diverted
What is a grade IV on the subjective ratings of p! With intermittent claudication?
Excruciating or unbearable pain
