Wound Care

Question 1

Wound Stages

Answer 1

_Stage 1 _

• Non-blanchable erythema of intact skin The heralding lesion of skin ulceration.
• Darker skin: red, blue, purple

_Stage 2 _

• Partial thickness loss of dermis
• presenting as a shallow open ulcer with a red pink wound bed,
• without slough Superficial ulcer that may clinically

_Stage 3 _

• Full thickness tissue loss Subcutaneous tissue may be visible
• bone, tendon or muscle are not exposed.
• Slough may be present but does not obscure the depth of tissue loss.
• May include undermining and tunneling

_Stage 4 _

• Full thickness tissue loss with exposed bone, tendon or muscle.
• Slough or eschar may be present on some parts of the wound bed.
• Often includes undermining and tunneling.

Unstageable

• Full thickness tissue loss in which the base of the ulcer is covered by slough (tellow,tan,gray, green, brown) and/or eschar (tan, brown, black) in the wound bed
• Often eschar is not mobile and may be firm/soft making it difficult to assess the tissue below

_Suspected Deep Tissue Injury _

• Purple/maroon localized area of discoloured intact skin or blood filled blister due to damage underlying tissue from pressure and/or shear.
• The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer/clooer as compared to adjacent tissue.

_Mucosal Pressure Ulcer _

• PU found on mucous membranes with a hx of a medical device in use at the location of the ulcer such as O2 tubing, endotracheal tubes, bite blocks, oro-gastric/nasogastric tubes, urinary catheters and fecal containment devices

Question 2

Positionig and supporting

Answer 2

• Use positioning devices such as pillows/foam to prevent direct contact between bony prominences (knees/ankles)
• Never use donut type devices
• Maintain HOB at lowest degree of elevation (30) Limit the amount of time the head of the bed is elevated
• Recommended positions: side lying degree 30 degree, heels off bed
• Establish a written repositioning schedule. If you have no help/pt unstable, use small shift changes to decrease risk
• Individuals who are able should be taught to shift their weight q 15 mins. reposition the sitting individual so that points under pressure are shifted at least q1h. consider the use of wheelchair with a tilt mechanism
• Therapeutic support surface does not imply that you do not need to turn position (use of scales)

Question 3

Diabetic Foot Ulcers: Risk Factors, Triad, Assessment

Answer 3

Risk Factors

• Loss of sensation r/t periphera neuropathy
• Arterial insufficiency
• obesity
• impaired vision
• poor glucose control
• limited joint mobility

_Triad _

1. Neuropathy
2. Deformity
3. Minor Trauma (improperly fitting shoes, foreign bodies, imprper trimming of nails, burn)

_Assessment _

1. Neurological Exam: vibration, ankle flex, thermal testing
2. Musculoskeletal Exam: muscle strengtht, deformities, x ray
3. Dermatolic Exam: callus, dryness, ulcers
4. Vascular Exam: hair loss, pain, eschar, gangrene

Question 4

Diabetic Foot Ulcers: Prevention

Answer 4

Hollistic approach

• glycemic control, smoking cessation, diligent foot care
• educate regarding foot hygiene, nail care
• daily food inspection
• gentle cleansing with soap and water
• avoid hot soaks, heating pands and harsh topical agents

Question 5

Offloading vs Download Devices

Answer 5

Offloading: Many devices aim to redistribute pressure points by dispersing weight over the entire surface of the foot and/or the leg. Pt’s lifestyle and physical ability must be considered when choosing the offloading device

• short term and therapeutic

1. Total contact cast*
2. Ankle foot orthotic
3. Heel offloading
4. Pneumatic Walker
5. Heeling Sandal Rockers

Downloading: pressure reductiong, long term, preventative look for shoes with solid heel counters, deep toes box, forgiving materl

Question 6

Leg ulcers: Venous VS Arterial Insufficiency

Answer 6

_Venous Insufficiency: Pooling of blood / increase in pressure _

• Pitting edema
• Reddish brown discoloration
• skin thick and tough
• dull ache/heaviness
• distetion of superficial veins

_Arterial Insufficiency: Insufficient blood supply _

• Pain on elevation
• Pulselessness
• Pallor: blanching on elevation red/blue limb, skin is shiny or dry
• Paresthesia
• Paralysis
• Polykilothermia
  *

Question 7

Interventions of Leg Ulcers

Answer 7

Venous

1. Compression: bandages, stockings, ABPI must be done first
2. Non invasive therapy: elevating feet, avoid long periods of siting and standing, flex and extend feet and akles 10xq30mins
3. Meds: Lovenox, heparin

Arterial

1. Restore blood suply by sugery stents/bypass
2. Control of HTN, hyperlipidemia, diabetes, smoking cessatoing, excercise
3. Meds: antiplatelets

Question 8

Lymphedema and Tx

Answer 8

Abnormal swelling caused by accumulation of excess high protein lympathic fluid

• Skin care: moisturization/hydration
• Manual Lymphatic Drainage
• Elevation

Question 9

MEASURE providing local wound care

Answer 9

M : measure

E: exudate

A: appearance

S: suffering pain

U: undermining

R: reevaluate

E: edge condition