Wound Care Flashcards
What are risk factors for pressure injury on a Braden scale?
- Sensory perception (completely limited to no impairment)
- Moisture (constantly to rarely)
- Mobility (completely immobile to no limit in bed)
- Activity (bedfast to walks frequently)
- Nutrition (very poor to excellent intake)
- Friction and shear (problem to no apparent problem)
What are the four stages of wound healing?
- Hemostasis
- Inflammation
- Proliferation
- Remodeling
What is the first step of wound treatment?
Debridement of dead or devitalized tissue
What are the stages of pressure injury?
- Stage 1 - skin intact, non blanchable erythema
- Stage 2 - partial loss of dermis, shallow open ulcer
- Stage 3 - full thickness skin loss, fat exposed
- Stage 4 - full thickness skin loss, exposed bone/muscle/tendon
- Unstageable pressure injury - covered with slough or eschar, depth undetermined
- Deep tissue pressure injury - purplish skin discolouration, potential for deeper tissue damage
What are 4 extrinsic risk factors for pressure injury?
- Friction
- Pressure
- Shear force
- Excessive moisture
What are 7 intrinsic risk factors for pressure injury?
- Dermatitis
- Edema
- Hypoperfusion
- Immobility
- Longterm steroid use
- Circulatory impairment
- Nutritional compromise
- Older age
- Lower body weight
- Cognitive impairment
- Black or Hispanic
- Loss of sensation
- DM
- Urinary or fecal incontinence
What are two risk assessment tools for pressure injury and briefly summarize their evidence
Braden
Norton
Waterlow
Evidence suggests poor Sn and Sp
No better than clinical judgement alone
Can be used to support clinical judgement
What are 5 pressure ulcer prevention strategies and what are their mechanism of action?
- Heel supports: protects against sheer force, evenly distributes pressure
- Repositioning: change position to prevent constant contact
- Nutritional supplement: improves wound healing
- Creams and cleansers: prevents cracking, soiling
- Alternating air beds: change distribution of pressure by inflating cells
What are the total score ranges on the Braden scale that indicate higher risk for pressure injury?
Mild 15-18
Moderate 13-14
High 10-12
Severe <9
Name 3 forces that contribute to pressure ulcers.
- Sheer stress
- Friction
- Pressure
What’re are 4 chronic diseases associated with pressure ulcers?
- Diabetes
- Alzheimer’s
- Parkinson’s disease
- Stroke
What are normal changes to the skin with aging that can be related to pressure ulcers?
- Decreased rate of skin turnover = rougher skin = dec barrier function
- Flattening of dermal-epidermal junction = less contact = separate more easily
- Reduced blood flow to skin
- Decreased collagen synthesis = impaired wound healing
- Decreased skin elasticity
What are components to a multimodal approach to pressure injury management?
- Off loading - turning
- Pressure redistribution devices - mattress
- Moisture management - barrier cream, dressing, drying powder
- Nutritional management - high protein diet
- Optimize comorbidities
- Avoid friction/shear injuries
- Control symptoms - pain, anxiety
