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
34
Q
debridement comparisons
A
40
Q
review of debridement types
A
43
Q
inflammation vs infection
A
58
Q
e-stim in wound care
A
- 1-125 PPS, 100-300 microsec
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
