wound care (M 10-13: pressure injuries, debridement, infection and edges, support) Flashcards
1
Q
pressure injury definition
A
a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction
* can also be due to medical or other device
2
Q
pressure injuries - hospital acquired
A
- HAPI affect about 2.5 million patients/year in US – about 60,000 patients die
- report of data from 2016 – HAPI in US cost > $26.8 billion
3
Q
pressure injury stages
A
- boggy, non-blanchable, warm, red
- skin opening, partial thickness, might not look like much, just abrasion
- full thickness, epibole likely, subcutaneous with no muscle, bone, tendon, tunneling and undermining
- full thickness, can see muscle, bone, tendon, see all the gross things
4
Q
once a pressure injury has been staged
A
- once a pressure injury has been staged, teh stage cannot be reversed
- a stage 4 becomes a healing stage 4
- a stage 3 gets worse and become a stage four and then become a healing stage 4
with the exception of unstageable or DTI pressure injuries
5
Q
pressure injuries and bed rest
A
- pressure injury (decubitus ulcer) is consequence of ischemia and anoxia to tissue
- tissues are compressed, blood vessels are compressed and blood flow is diverted by continual pressure on the skin and underlying structures
- cellular respiration is impaired and cells die
- pressure injuries in hospitalized patients are “never events” (stage 3-4)
6
Q
pressure injuries - where and why
A
- over bony landmarks
- causeative factors
- shear forces
- friction forces
- pressure forces
- moisture
7
Q
pressure forces
A
- intensity versus duration
- prolonged exposure to mild-moderate increase in forces
- short exposure to moderate-severe increase in forces
- but can change patient to patient
8
Q
friction
A
- mechanical force exerted when two surfaces move (rub) against another
9
Q
shear
A
- stress resulting from applied forces which cause two objects to deform in the transverse plane
- invovles both friction and gravity
- body layers are laterally shifted in relation to each other
- skeleton sliding while skin in place
10
Q
pressure areas
A
11
Q
head of bed at [ ] is best for sacrum and heel pressure
A
less than 30 degrees
12
Q
arterial ulcers
A
- location: distal to ankle, usually foot, toes, lateral malleolus
- edges: punched out, well defined
- wound bed: pale or rubor of dependence, skin shiny and thin, hair loss, nail changes common
- periwound: thin and shiny, hair loss and nail chages common
- possible PMH: diabetes, hypertension, smoking, previous vascular disease
- other characteristics: typically dry
- management goals: keep it dry and reduce bioburden
13
Q
venous ulcers
A
- location: lower leg or above ankle, near medial malleolus, feet unlikely
- edges: irregularly shaped
- wound bed: often granulating, with cellular debris and/or crust, usually shallow
- periwound: scaly, dry, hemosiderin staining
- possible PMH: varicose veins, obesity, pregnancy, previous DVT
- other characteristics: typically wet
- management goals: manage moisture
14
Q
pressure ulcers
A
- location: bony prominences, especially sacrum, ischial tuberosity, greater trochanter, heels
- edges: circular or teardrop, well defined
- wound bed: can be pale, granulating, necrotic, or eschar
- periwound: health or red/purple due to pressure
- possible PMH: immobility, SCI, dementia, progressive neurologic disorder, dependent with moblity, bed or WC bound
- management goals: offloading, nutrition, consider stool/urine contamination, debridement
15
Q
neuropathic ulcer
A
- location: plantar surface of foot, toes, heels, metatarsal heads
- edges: callused, well defined
- wound bed: deep and often granulating
- periwound: thick, dry, callused
- possible PMH: diabetes, neuropathy/loss of protective sensation, possible Charcot foot
- management goals: promote granulation and reduce infection
16
Q
skin tears
A
- common in extremes of age (young or old), critically or chronically ill
- may experience increased pain, decreased mobility, decreased quality of life
- particularly problematic in elderly: global prevalence studies show 10-54% in LTC
- caused by shear, friction, and/or blunt force trauma: forces separation of skin layers, can be partial or full-thickness, slow to heal, susceptible to secondary infection
- preventable wounds with high propensity to develop into chronic wounds
17
Q
grading skin tears
A
- type 1: no skin loss – linear or flap tear that can be repositioned over wound bed
- type 2: partial flap loss – partial flap loss that cannot be repositioned to cover the wound bed
- type 3: total flap loss – total flap loss exposing entire wound bed
18
Q
braden scale
A
- risk assessment outcome to determine a patient’s risk of developing pressure ulcers
- common in acute and rehab settings (SNF, IRF, etc)
- most commonly used for patients who are bed- or chair-bound, as well as those with an impaired ability to reposition
- scored on a variety of categories: sensory perception, moisture, acitivity, mobility, nutrition, friction and shear
- scored on a 1-3 or 1-4 scale
- higher score is lower risk of pressure injury development
19
Q
acute vs chronic wounds
A
20
Q
PT roles in wound care
A
- skills and roles to be familiar with: infection, arterial, venous, diabetic/neuropathic ulcer, pressure injury, lymphedema
- populations: post-op, trauma, acute care/ICU, elderly, medically fragile, wheelchair bound, diabetic, frequent falls, high fall risk
21
Q
basic wound assessment
A
- full or partial thickness
- wound type
- location
- stage
- measurements
- wound bed
- wound edges
- drainage
- periwound - general integumentary exam/screening
22
Q
DIMES
A
23
Q
DIMES debridement
A
- purpose: remove necrotic tissue (slough, eschar), remove bacteria to prevent infection, increase ability to assess wound bed
- goal: 100% granulation tissue
24
Q
types of debridement
A
- non-slective/mechanical: wet-to-dry, irrigation, hydrotherapy, abraded technique
- for moderate to extensive necrotic tissue: more potential to bleed, more potential to be dry or add maceration
- selective: autolytic, enzymatic, biosurgical, sharp/surgical
25
Q
wet-to-dry debridement
A
- non-preferred method
- wet gauze, stick to wound, gauze dries, rip it off
26
Q
irrigation debridement
A
- use spray to spray high pressure on wound
27
Q
hydrotherapy debridement
A
- submerge affected body part, jet stream
- hard to clean, requires dependent position, takes a long time
- not super clean
28
Q
abraded technique debridement
A
- rub wound
- can irritate healthy, intact tissue
29
Q
autolytic debridement
A
- assists body’s cells in digesting necrotic tissue
- most conservative
- for non-infected wounds
- need a good immune system
- stays damp
- occlusive (hydrocolloid): denser material, non-permeable
- transparent (non-occlusive): allows for gas exchange
- hydrogel: wet, put into wound
- medihoney: specific honey from NZ, high osmolarity - bringes water from lower tissues, lowers wound pH
30
Q
enzymatic debridement
A
- patients can be very sensitive to it
- racts with silver products
- expensive
- santyl
31
Q
biosurgical debridement
A
- maggots bred specifically for medical use
- eat necrotic tissue, painless for patient, produce ammonia that lowers pH of wound, get rid of biofilm
- can be in bag or “free range” – works 2x faster when free-range
32
Q
conservative sharp debridement
A
- what we do as PTs
- scissors, tweezers, scalpel, scraping tools
- need specific orders from MD for sharp debridement – not just wound care orders
- goal: 100% granulation tissue, eventually over multiple sessions
- no PTAs – PTAs can do dressing changes, technically non-selective debridement
33
Q
surgical debridement
A
- MD only
- more aggressive
34
Q
debridement comparisons
A
35
Q
selective debridement contraindications
A
- stable heel eschar: if no signs of infection, to protect wound
- gangrene: requires surgical debridement
- unidentified structures: if you don’t know, don’t touch it
- terminally ill – is it worth it
- arterial insufficiency (ABI <0.8): debriding something that has no chance to recover
- coagulopathy: INR, PT, PTT, platelets, hemoglobin
36
Q
silver nitrate stick
A
- cauterizing tissue
- needs prescription
- not the silver that reacts with enzymes
37
Q
what do you need before sharp debridement
in order
A
- physician’s order
- chart review
- check labs
- gather tools
- pre-medicate as needed
- comfortable positioning for patient and you
- adquate lighting
- cleanse
- measure: paper tape measure, cotton tip applicator
38
Q
before selective debridement, you should
A
cleanse
* angiocatheter methods: end of IV connected to syinge to spray saline
* skin/wound cleanser
* bulb syringe
39
Q
selective debridement
A
- cross-hatching: increases surface area for enzymatic debridement – creating damage to promote growth
- silver nitrate
40
Q
review of debridement types
A
41
Q
patient’s core body temperate for wound healing
A
- 91.4-107.6
- moisture loss = cooling
- decrease of 2 degrees affects healing: increases risk of infection, inhibited platelet activation, reduction in wound strength due to declining colalgen deposition
42
Q
why would wound temperature decrease
A
- dressing changes
- wound cleansing
- loose dressing
- inappropriate dressings
- things to consider: decreased frequency of dressing changes – if possible, consider types of dressing, how long, order of operations of performing dressing change
43
Q
inflammation vs infection
A
44
Q
infection and cleansing for non-infected wounds vs for infected wounds
A
- for non-infected wounds: soap and water
- for infected wounds: antiseptic x2 weeks, then wash with water – for limited use, basically like bleach
- hydrogen peroxide: very limited use, cytotoxic, kills healthy cells
- iodine: very limited use, cytotoxic, not a long-term option
45
Q
why not neosporin
A
- good when used appropriately
- not for chronic wounds
- allergies to neomycin
- can develop dermatitis
46
Q
moisture in wounds
A
- complex wounds shouldn’t be left open to air
- they require the proper moisture balance and temperature
- if you “leave to open air,” it’s pretty much done healing
47
Q
moisture associated skin damage (MASD)
A
maceration, excoriation, denuded
48
Q
periwound and subcutaneous extensions
A
tunneling
undermining
bogginess
induration
epibole
maceration
49
Q
maceration
A
- like wet tissue paper
- softening and breaking down of skin due to prolonged exposure to moisture
50
Q
excoriation
A
- chafing, raw irritated lesion
- linear erosion of the skin by mechanical means (scratching, rubbing)
51
Q
denuded
A
- loss of epidermis due to exposure to urine, feces, body fluids, wound exudate or friction
52
Q
things to avoid and needs with moisture
A
- avoid: depends, extra layers (sheets, bed pads)
- needs: toileting schedule, rectal tube
53
Q
passive drains
A
- air or fluid moves from an area of high pressure to low pressure (often just “gravity assisted”)
- penrose, pigtail catheter (typically into a body cavity), gastrostomy, cystostomy, nephrostomy, T-tube
54
Q
active drains
A
- negative pressure is used
- connected to a collecton device
- Jackson-pratt: longer use, can be bulb or long suction
- hemovac: compressed, usually post-op, 1-3 days
55
Q
tubes
A
- used to remove air and fluids
- provides decompression
- maintains patency of a lumen
56
Q
adding collagen to a stalled wound
A
- can be topical
- hyperbaric oxygen – if non-healing or stalled for 30 days, expensive, try and fail others, for Wagner 3 or higher, non-healing osteomyolitis, crush injuries, non-healing skin flaps
57
Q
PT involvement in DIMES support
A
- risk assessment
- functional mobility training
- positioning
- pressure redistribution
- exercise
- application of biophysical agents for pain reduction and tissue healing
- direct management of open wounds
58
Q
e-stim in wound care
A
- 1-125 PPS, 100-300 microsec
59
Q
support for venous wounds
A
- compression hosiery
- elevation – higher than heart
- exercise to activate venous pump
- avoid prolonged sitting or standing
- avoid crossing the legs
- skin lubrication
- patients who receive supervised LE exercise programs, counseling on compression adherence and elevation, tend to be more active, achieve faster wound closure, improved venous hemodynamics
- TEDs are for bed: DVT prevention, not edema
60
Q
support for arterial wounds
A
- critical limb ischemia requires vascular surgery before the wound can heal
- gait training (often NWB)
- education on footwear
- if presenting with dry gangrene: need protection and offleading
- walking programs
- for high compression (40-50 mmHg) or moderate pressure compression (30-40 mmHg) –> ABI > 0.8
- for low to moderate-pressure compression (25-33 mmHg) –> ABI 0.5-0.8
- for low pressure compression (18-24 mmHg) –> ABI > 0.5
- never apply compression if ABI < 0.5
61
Q
support for neuropathic wounds
A
- gait trianing, equipment, prevention, education (keep toes dry, look at feet every day)
- exercise: exercise at least 5x a week for 30 minutes per session or 150 minutes/week – strength training 2x/week
- footwear
62
Q
supporting pressure injuries
A
- causative factors: shear forces, friction forces, pressure forces, moisture
- risk assessment within 6 hours of admission
- skin assessment performed with each repositioning
- strict Q2 turning with clocks
