Wound Care and Treatment Flashcards
Evaluation and Management of Wounds
Wound Assessment
Pressure Injury/Device related pressure injury
Moisture associated dermatitis, skin tears, other
Leg Ulcers
Diabetic Foot Ulcers
Update on Covid Wounds
Not all Wounds are the Same
- There are core treatment modalities that cross all wound types
- Treatment of inf_____
- Topical dressings
- De______ of necrotic or non-healing, well-perfused wounds
- N______
- _____ cessation
- Treatment of medical co_____ that affect healing
- How old is the wound? Is it greater than ___days?
- But for each wound type, patient also needs evaluation and treatment targeting un_____ etiologies of the wound
- There are core treatment modalities that cross all wound types
- Treatment of infection
- Topical dressings
- Debridement of necrotic or non-healing, well-perfused wounds
- Nutrition
- Smoking cessation
- Treatment of medical comorbidities that affect healing
- How old is the wound? Is it greater than 90 days?
- But for each wound type, patient also needs evaluation and treatment targeting underlying etiologies of the wound
Wound Assessment
★ Staging only for?
★ M_______
★ Ex____
★ Wound B__ Characteristics
★ T______ (Sinus Tract)/Under_____
★ ____wound/Surrounding Skin
★ Distinguish _____ Ulcers from other Wounds
★ P____
★ Staging
★ Measurement
★ Exudate
★ Wound Bed Characteristics
★ Tunneling (Sinus Tract)/Undermining
★ Periwound/Surrounding Skin
★ Distinguish Pressure Ulcers from other Wounds
★ Pain
Measurement
Measure the greatest length (___to ___) and the greatest width (___to ___) using a ____meter ruler.
Measure depth by?
Measure the greatest length (head to toe) and the greatest width (side to side) using a centimeter ruler.
Measure depth of the ulcer by gently placing a cotton tipped applicator to the deepest portion of the wound, and placing a mark on the applicator at the level of the skin. The cotton tipped applicator is then held against a centimeter ruler to the determine the depth.
Dimensions/Size
Document in (1)
- _____ (head to toe)
- ____ (perpendicular to length or side to side)
- ____ (at deepest point)
- Describe undermining or tunneling in relation to ____
- Length (head to toe)
- Width (perpendicular to length or side to side)
- Depth (at deepest point)
- Describe undermining or tunneling in relation to clock
Wound Exudate
- Exudate (drainage) is the accumulation of fluids in a wound that may contain (4).
- The characteristics of wound exudate that should be assessed include (3).
- The characteristics of the exudate will vary depending on the level of moisture, organisms, and amount of non-viable tissue, if present.
- Individual health and healing stages affect the makeup of the wound exudate
- Exudate (drainage) is the accumulation of fluids in a wound that may contain serum, cellular debris, bacteria, and leukocytes.
- The characteristics of wound exudate that should be assessed include amount, type, and odor.
- The characteristics of the exudate will vary depending on the level of moisture, organisms, and amount of non-viable tissue, if present.
- Individual health and healing stages affect the makeup of the wound exudate
Significance of Wound Drainage
- The volume and type of wound drainage determines the dressing selection for the wound.
- Dry wounds require a ______ dressing and exudative wounds require an ______ dressing.
- Containment of the exudate is crucial to protect the surr______ intact skin, reduce b_____load, and control od__.
- The volume and type of wound drainage determines the dressing selection for the wound.
- Dry wounds require a hydrating dressing and exudative wounds require an absorptive dressing.
- Containment of the exudate is crucial to protect the surrounding intact skin, reduce bacterial load, and control odor.
Dressing Categories to be used with all types of wounds
- H____fibers cellulose and absorptive
- F____ absorptive
- Hydrog___ provides moisture
- Hydroco_____ (duoderm)
- Al_____ seaweed
- Gauze products
- S_____ products is antimicrobial
- Com_______ especially important for leg ulcers/with edema
- Hydrofibers cellulose and absorptive
- Foams absorptive
- Hydrogels provides moisture
- Hydrocolloids (duoderm)
- Alginates seaweed
- Gauze products
- Silver products silver is antimicrobial
- Compression especially important for leg ulcers/with edema
Wound Bed Characteristics
(5)
Epithelialization
Granulation
Necrotic Tissue (Slough and Eschar)
Tunneling and Undermining
Periwound (Maceration and Erythema)
(1)
The process of becoming covered with or converted to epithelium. The new epithelial cells advance across the wound until they eventually meet epithelial cells moving in from the opposite direction.
- In _____ thickness wounds, epithelialization occurs throughout the wound bed as well as from the wound edges.
- In ___ thickness wounds, epithelialization usually occurs from the edges only. The tissue appears as pink or red in color
Epithelialization
- In partial thickness wounds, epithelialization occurs throughout the wound bed as well as from the wound edges.
- In full thickness wounds, epithelialization usually occurs from the edges only. The tissue appears as pink or red in color
-(1)
The process of filling in an open wound with new blood vessels, connective tissue, fibroblasts, and inflammatory cells, when an open wound starts to heal.
- In ____thickness wounds, granulation tissue starts at the ______ level of tissue damage and proceeds _____. The wound typically appears deep pink or ____ red with an irregular, gr_____ surface
Granulation
- In full thickness wounds, granulation tissue starts at the deepest level of tissue damage and proceeds irregularly. The wound typically appears deep pink or beefy red with an irregular, granular surface
Necrotic Tissue
(1) is moist, devitalized tissue and may appear in many colors, such as, white, yellow, tan, or green. The tissue may be loose or firmly adherent.
(1) is black or brown, necrotic, devitalized tissue that can be loose or firmly adherent, hard, soft or boggy
Slough is moist, devitalized tissue and may appear in many colors, such as, white, yellow, tan, or green. The tissue may be loose or firmly adherent.
Eschar is black or brown, necrotic, devitalized tissue that can be loose or firmly adherent, hard, soft or boggy
Tunneling and Undermining
(1) (also referred to as Sinus Tract) is a course or path of tissue destruction occurring in any direction from the surface or edge of the wound; results in dead space with potential for abscess formation.
(1) is tissue destruction that occurs under 4 Eschar is black or brown, necrotic, devitalized tissue that can be loose or firmly adherent, hard, soft or boggy. intact skin around the wound perimeter. Shear forces often cause undermining.
Tunneling (also referred to as Sinus Tract) is a course or path of tissue destruction occurring in any direction from the surface or edge of the wound; results in dead space with potential for abscess formation.
Undermining is tissue destruction that occurs under 4 Eschar is black or brown, necrotic, devitalized tissue that can be loose or firmly adherent, hard, soft or boggy. intact skin around the wound perimeter. Shear forces often cause undermining.
Periwound Area/Surrounding Skin
- Routine wound assessment should include the area around the wound. Parameters of the assessment should include; c_____, skin tem_____, texture such as m___, d__, in_____, and the integrity of the surrounding skin including any infection.
- Periwound assessment can offer clues to the effectiveness of ______ options and/or removal techniques. For example, if wound drainage is not contained or a moist dressing is left on intact skin, m______and/or denudement may occur.
- Routine wound assessment should include the area around the wound. Parameters of the assessment should include; color, skin temperature, texture such as moist, dry, indurated, and the integrity of the surrounding skin including any infection.
- Periwound assessment can offer clues to the effectiveness of treatment options and/or removal techniques. For example, if wound drainage is not contained or a moist dressing is left on intact skin, maceration and/or denudement may occur.
Stage 1 Pressure Injury
=
Stage 1 Pressure Injury
Red Non-Blanching epithelium
Intact skin with non-blanchable redness of a localized area over bony prominence
Stage 2 Pressure Injury
=
Epithelium ulcerated, Dermis intact
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister
Stage 3 Pressure Injury
=
Beyond dermis into subcutaneous tissue
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss
May include undermining or tunneling.
Stage 4 Pressure Injury
=
Beyond fascia into muscle, bone
Full thickness tissue loss with exposed tendon or muscle. Slough or eschar may be present on some parts of the wound bed, may include undermining or tunneling.
(1)
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft from pressure and/or shear. The area may be preceded tissue that is painful, firm, ushy, boggy, warmer or cooler as compared to adjacent tissue
Deep Tissue Injury
(1)
Full thickness tissue loss in which the base of the ulcer is covered by (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed
Unstageable
Pressure Causes Ischemia
Pressure, Friction, Shear
>__mmHg closes ______
What areas should you exam, at least (4) sites (minimum exam)
Pressure, Friction, Shear
>30mmHg closes capillaries
(capillaries can close with only a little bit of pressure)
- Sacrum
- Ischia
- Greater Trochanter
- Heels
Braden Score
Max score =
Risk indicated by score =
- _____ perception (“ability to respond meaningfully to pressure-related discomfort”) >
- M_____
- A_____ (OOB, walking)
- M_____ (position change in bed)
- N_____
- Fr____/ Sh_____
Max Score = 23
Risk indicated by score <18
- Sensory perception (“ability to respond meaningfully to pressure-related discomfort”) >
- Moisture
- Activity (OOB, walking)
- Mobility (position change in bed)
- Nutrition
- Friction/ Shear
What type of pressure injury is shown in these pictures?
Device-Related Pressure Injury
Core Measures for Prevention and Treatment of pressure injuries
(1)
- Group 2 surface (mattress, chair cushion)
- Avoid linen layering
- Heel protectors, offloading boots, redistributing pillows
- Correctly sized wheelchair
(1)
- Devices as needed
- Head of bed <30 degrees
(1)
- Assess, reassess, maximize PO’s, if failing PO’s then make another plan
(1)
- Underpads NOT diapers
- Condom catheter
Preventing _____ related pressure injury
Pressure redistribution surfaces
- Group 2 surface (mattress, chair cushion)
- Avoid linen layering
- Heel protectors, offloading boots, redistributing pillows
- Correctly sized wheelchair
Repositioning q2h
- Devices as needed
- Head of bed <30 degrees
Nutritional intake adequacy
- Assess, reassess, maximize PO’s, if failing PO’s then make another plan
Incontinence management
- Underpads NOT diapers
- Condom catheter
Preventing device related pressure injury
Moisture associated dermatitis, skin tears, other
Distinguish Pressure Ulcers from other Wounds
Wound etiology other than from pressure:
- A_____ Ulcer
- V____ Stasis Ulcer
- Neuropathic Wounds-D_____ Ulcer
- Skin T_____
- C____ Dermatitis
- F_______
Not to be documented as a pressure ulcer
- Arterial Ulcer
- Venous Stasis Ulcer
- Neuropathic Wounds-Diabetic Ulcer
- Skin Tears
- Contact Dermatitis
- Fungus
Causative Factors for Skin Breakdown
What non-pressure wounds are shown in these pictures?
Skin tears- ISTAP skin tear classification
Type 1 =
Type 2 =
Type 3 =
Type 1: No skin loss
Type 2: Partial flap loss
Type 3: Total flap loss
Leg Ulcers
Key Points
- Are Venous stasis ulcers common?
- A_____ disease should always be suspected/ ruled out
- Not every leg ulcer is a venous stasis ulcer
- Pursue a specific diagnosis
- Ulcers can be m____factorial
- Monitor area and aim for healing
- Venous stasis ulcers are common
- Arterial disease should always be suspected/ ruled out
- Not every leg ulcer is a venous stasis ulcer
- Pursue a specific diagnosis
- Ulcers can be multifactorial
- Monitor area and aim for healing
Venous Stasis Ulcers
- P____
- S_____
- Dr_____
- Dis____
- Social is______
- Psychological dis_____
- In______
- Pain
- Smell
- Drainage
- Disability
- Social isolation
- Psychological distress
- Infections
What is Venous Stasis?
- ____ veins
- Iliac, femoral, popliteal, tibial veins
- V____ create directional flow ‘Muscle ____’ pushes blood towards heart
- _______/ perforating veins
- Drain into deep veins during ‘muscle ____’
- _____ valves > flow from deep to superficial veins
- Increased pressure -> ____ capillaries
- Ed____
- Inf_____
- Hemosiderin deposition causes (1)
- Lipodermatosclerosis causes (1)
- Deep veins
- Iliac, femoral, popliteal, tibial veins
- Valves create directional flow ○ ‘Muscle systole’ pushes blood towards heart
- Superficial/ perforating veins
- Drain into deep veins during ‘muscle diastole’
- Faulty valves > flow from deep to superficial veins
- Increased pressure -> leaky capillaries
- Edema
- Inflammation
- Hemosiderin deposition → dark discoloration
- Lipodermatosclerosis → white tissue
Risk factors for Venous Stasis
- F_____ history
- Gender (1)
- Pr_____
- Height (1)
- Weight (1)
- St______ for extended periods
- Family history
- Female
- Pregnancy
- Tall
- Obese
- Standing for extended periods
Venous Stasis Ulcers Prevention
- (1) stockings
- Vascular surgery (superficial vein ab_____, valvulo____)
- Treat ‘venous ec_____’
- Compression stockings
- Vascular surgery (superficial vein ablation, valvuloplasty)
- Treat ‘venous eczema common form of eczema/dermatitis that affects one or both lower legs in association with venous insufficiency.
Treatment Options for Venous Stasis Ulcers
- Treatment options
- De________
- _______ (if not ischemic) heals 80%
- Elastic vs. inelastic
- T_____ therapy, treat maceration and dermatitis in surrounding skin
- Human s____ equivalent
- Consider vascular ______ referral
- Subfascial endoscopic perforator surgery
- Consider _____ surgery referral for skin graft (may break down)
- Pentoxifylline? As_____?
- _\_-__ months average healing time
- Most will have re______
- Treatment options
- Debridement
- Compression (if not ischemic) heals 80%
- Elastic vs. inelastic
- Topical therapy, treat maceration and dermatitis in surrounding skin
- Human skin equivalent
- Consider vascular surgery referral
- Subfascial endoscopic perforator surgery
- Consider plastic surgery referral for skin graft (may break down)
- Pentoxifylline? Aspirin?
- 4-5 months average healing time
- Most will have recurrence
ALWAYS screen for arterial disease in ANY lower extremity ulcer
- Consider ___ in any lower extremity wound
- Remember that wounds are often multifactorial
- Symptoms: pain during ____, cl______
- Signs: decreased h____, dependent r___, ____ capillary refill; distal, multiple, painful, or ___-healing wounds
- Pulse exam may not be adequate
- ______ blood flow can maintain pulses although inadequate flow for healing
- Wounds with PAD should not be (2)
- Consider PAD in any lower extremity wound
- Remember that wounds are often multifactorial
- Symptoms: rest pain, claudication
- Signs: decreased hair, dependent rubor, poor capillary refill; distal, multiple, painful, or non-healing wounds
- Pulse exam may not be adequate
- Collateral blood flow can maintain pulses although inadequate flow for healing
- Wounds with PAD should not be debrided or tightly compressed
Screening for PAD noninvasive vascular test in which blood pressure cuffs and a hand-held ultrasound device (called a Doppler or transducer) are used to obtain information about arterial blood flow in the arms and legs
Pulse Volume Recording
What type of wound is this?
Lymphedema
What types of wounds are these?
Diabetic Foot Ulcers
How do diabetics end up as amputees?
- Patients who do NOT have _____ do NOT get diabetic foot ulcers. ** though PAD patients can get ischemic ulcers
- Increased risk for ulceration: n_____ PLUS ____ disease, foot de____, pre-ulcerative callus, prior ulcers
- Patients who do NOT have neuropathy do NOT get diabetic foot ulcers. ** though PAD patients can get ischemic ulcers
- Increased risk for ulceration: neuropathy PLUS arterial disease, foot deformity, pre-ulcerative callus, prior ulcers
Sensory Neuropathy Assessment
- 10 g Semmes-Weinstein (1) to evaluate pressure sensation on the first, third, and fifth metatarsal heads, and on the plantar surface of the great toe +
- v______ testing
- p_______ sensation proximal to the nail bed of the first toe
- a_____ reflex at the Achilles tendon
- vibration perception threshold testing
- 10 g Semmes-Weinstein monofilament to evaluate pressure sensation on the first, third, and fifth metatarsal heads, and on the plantar surface of the great toe +
- vibration testing
- pinprick sensation proximal to the nail bed of the first toe
- ankle reflex at the Achilles tendon
- vibration perception threshold testing
Foot Deformity
-
Increases _____ -> ul_____ risk
- Prominent metatarsal heads
- Claw or hammer toes
- Distal displacement of submetatarsal fat pads
- Hallux valgus
- Charcot neuroarthropathy
- Can have acute presentation
- Mid-plantar pressure
- Can have acute presentation
- Limited joint mobility
- Ankle, 1st MP join
-
Increases pressure -> ulceration risk
- Prominent metatarsal heads
- Claw or hammer toes
- Distal displacement of submetatarsal fat pads
- Hallux valgus
- Charcot neuroarthropathy
- Can have acute presentation
- Mid-plantar pressure
- Can have acute presentation
- Limited joint mobility
- Ankle, 1st MP join
Update on Covid Wounds
- The Covid-19 pandemic presented us with a host of new maladies that affected every body system
- The hyperc_______ and in______ reactions gave way to multiple wounds and skin conditions
- Covid ____, a condition similar in appearance to chilblains has been noted
- Pressure ulcers from pr_____ with the ventilator have been noted on the face and s_____ pressure ulcers from prolonged immobility in ICU have been noted
- New wounds of the f____ have also been noted
- The Covid-19 pandemic presented us with a host of new maladies that affected every body system
- The hypercoagulability and inflammatory reactions gave way to multiple wounds and skin conditions
- Covid toes, a condition similar in appearance to chilblains has been noted
- Pressure ulcers from proning with the ventilator have been noted on the face and sacral pressure ulcers from prolonged immobility in ICU have been noted
- New wounds of the feet have also been noted
(1)
At Montefiore Medical Center, Bronx, NY during the height of the pandemic we were called to see a number of uncommon wounds that presented as extensive skin lesion of the plantar aspect of foot and the ankle
All of the patients tested positive for Covid-19
Comorbidities such as obesity, Diabetes Mellitus, Hispanic or African American ethnicity were present
Immunocompromised states such as HIV and Heart Transplant on immunosupressants were present in two patients
Unusual Bullae
(1)
- By far the most common leg ulcer, up to 80%, but there are other ulcers
- Generally associated with edema
- Can be chronic and recurring
- Estimated annual cost $ 1.9 to 2.5 billion
- Note hyperpigmentation, lipodermatosclerosis, edema, eczema
Venous Ulcer
(1)
- Due to (1)–formed red blood cell clots along with venous valve incompetence, vasoconstriction related autonomic control, lead to decreased tissue perfusion and ulceration
- Located at the medial or lateral malleolus, pretibial area or the dorsum of the foot
- Surrounding skin with –hyperpigmented, atrophy of subcutaneous fat, absence of hair follicles
Sickle Cell Ulcers
(1)
Condition associated with high levels of calcium phosphate ; leading to calcification of the small arteries; leading to intimal fibrosis and thrombus formation
- Associated with end stage renal disease
- Hyperparathyroidism
- If associated cardiac involvement , high mortality
- Distribution of peripheral locations on the body including fingers, toes, tongue, penis and torso
- Can be very painful
- Start as localized tender lesions with violaceous mottling and progress to purpuric patches and placques , and to eschar
- Elevated calcium and phosphorus levels
Calciphylllaxis
(1)
Uncommon noninfectious neutrophilic dermatosis that is of uncertain etiology
- Starts as small painful papule, pustule or nodule surrounded by an erythematous bawe, The lesion enlarges and ulcerates
- Most commonly seen in middle aged women
- Associated with various arthritides, inflammatory bowel disease, hepatitis, myeloproliferative disorders, SLE, PBC, PAPA
- _____ for diagnosis
- Diagnosis of _____
- Can be very painful
Pyoderma Gangrenosum
Uncommon noninfectious neutrophilic dermatosis that is of uncertain etiology
- Starts as small painful papule, pustule or nodule surrounded by an erythematous bawe, The lesion enlarges and ulcerates
- Most commonly seen in middle aged women
- Associated with various arthritides, inflammatory bowel disease, hepatitis, myeloproliferative disorders, SLE, PBC, PAPA
- _____ for diagnosis
- Diagnosis of _____
- Can be very painful
(1)
Systemic autoimmune disorders/ collagen vascular disorders
Autoimmune processes make pathologic changes in involved blood vessels
- Begins as palpable purpura and ecchymosis
- Located on pressure points or lower extremities w/ livedo reticularis
- Extremely painful
Rheumatoid Arthritis
Other Atypical Ulcers
- C____ induced
- Anticoagulant induced –(1)
- Drain cleaner only 2 drops (similar to pressor effect)
- Cocaine induced
- Anticoagulant induced –Enoxaparin, Heparin
- Drain cleaner only 2 drops (similar to pressor effect)
Warfarin- Induced Skin Necrosis
- Ischemia-related skin necrosis
- 1 in 10,000 patients
- Secondary to rapid decline in Protein __ when warfarin is initiated
- Risk Factors
- _____ warfarin dose
- Ob_____
- F______ gender
- Manifestation
- Pl_____, hemorrhagic bl____ or scar
- Ischemia-related skin necrosis
- 1 in 10,000 patients
- Secondary to rapid decline in Protein C when warfarin is initiated
- Risk Factors
- High warfarin dose
- Obesity
- Female gender
- Manifestation
- Plaques, hemorrhagic blisters or scar
