Wound Care Modules Flashcards
Components of Braden Scale
- Sensory Perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and Shear
Braden scale scoring
High: 28
18 or lower: risk of pressure ulcers
Repositioning in bed
change position every 2 hours
Repositioning in chair
change position every hour
shift weight every 15 min if possible
Pressure reduction surfaces
- Redistribute
- Inner spring mattress
- foam core mattress
- thick foam overlay (eggcrate)
- low air loss overly
- low air loss replacement
- alternating air cell
Goal for offloading diabetic foot ulcers
control, limit or remove all intrinsic and extrinsic factors that increase plantar pressures.
Diabetic foot ulcers:
Non-surgical trx
contact casting, orthotics, cast walkers, therapeutic footwear
Diabetic foot ulcers:
curative surgery
- exostectomy
- digital arthroplasty
- bone and joint resection
- partial calcanectomy
Venous stasis ulcer treatment
- elevate the leg
2. compression therapy (rigid or elastic) when you can’t elevate
Benefits of compression therapy
- improves rate as ulcer healing
- reduces incidences of recurrence
- prolongs the time to the first recurrence
- improves lymphatic drainage
- reduces superficial venous pressure
- improves blood flow velocity through unoccluded deep and superficial veins
- reduces reflux in the deep veins
Arterial Ulcers:
Goal of treatment
revascularization procedures
Arterial Ulcers:
Revascularization procedures
- arterial bypass
- angioplasty
- stents
Arterial Ulcers:
Arterial bypass
most common
graft may be autogenous or synthetic
Arterial Ulcers:
Angioplasty
catheter with balloon inserted into artery portion with plaque.
balloon crushes plaque against arterial wall
Arterial Ulcers:
Stents
holds the artery open
Perfusion:
effects of impaired blood flow and tissue perfusion
- ischemia
2. affects scarring, and can lead to increased risk of infection
Nutritional Assessment components
- Nutrition
- Hydration
- Education
Nutritional Assessment:
Protein
- Initial assessment provides baseline data about a patient’s nutritional status
- Subsequent assessments reflect changes in status and effects of interventions
Nutritional Assessment:
Nitrogen-balance study
- Nitrogen input determined by eval of 24 hour intake of nitrogen
- Nitrogen output from 24 hr urine collection
- Nitrogen input minus output (want=0)
- Retained nitrogen available for protein synthesis
Nutritional Assessment:
physical signs of dehydration
- dry skin
- cracked lips
- thirst
- poor skin turgor
- fever
- appetite loss
- nausea
- dizziness
- increased confusion
Nutritional Assessment:
clinical signs of dehydration
- Increased lab values for serum creatinine, HCT, BUN, K+, Cl-, osmolarity, and Na+
- Decreased BP
- increased pulse rate
- constipation
- concentrated urine
Pressure ulcer Do’s and Don’ts
Do:
- change position every 2 hours
- check skin for signs of pressure ulcers 2/day
- use mirror to check difficult areas
- follow HEP
- well balanced diet, hydrate, maintain recommended weight
Don’ts:
- use commercial soaps that dry skin
- sleep on wrinkled bed sheet or tuck corners tight into EOB
Colonization:
Group of organisms living together in or on the body prior to tissue invasion not causing infection
Infection:
invasion of tissues by microorganisms resulting in systemic reaction
Local signs of infection
- edema
- erythema
- drainage
- warmth
- tenderness
- crepitus
Systemic signs of infection
- fever
- leukocytosis
- confusion
- tachycardia
- HTN
- malaise
autolytic debridement
allows body to lysis necrotic tissue using its own moisture to dissolve tissue.
(don’t do if infected)
chemical debridement
enzymes applied topically to necrotic tissue. digests.
allows for moist wound healing
mechanical debridement
use of physical forces to remove necrotic tissue
wet-to-dry dressings
wound irrigation
whirlpool
sharp debridement
removing necrotic tissue with cutting tool
sharp debridement:
conservative vs surgical
conservative: removes necrotic tissue only
surgical: removes necrotic and healthy tissue
Cleansing:
normal saline
- provides a moist environment
- promotes granulation tissue formation
- causes minimal fluid shifts in healthy cells
Cleansing:
commercial wound cleansers
used to remove containments, foreign debris, and exudate from wound surface
or
used to irrigate deep cavity wound
Cleansing:
antiseptic solutions
may damage tissue and delay healing
Wound environment:
Moist wound bed provides
- communication amongst cells
- communication with growth factors
- construction of collagen
- migration of new epithelium
Wound environment:
Benefit for moist wound bed
- enhances epidermal migration
- promotes new blood vessel growth
- promotes development of collagen/CT
Wound environment:
Dry wound bed effects
- WBCs can’t fight infection
- enzymes can’t break down dead material
- macrophages can’t carry away debris
- epithelial cells burrow underneath wound bed preventing re-epitheliazation
Components of a wound environment
Moist environment
protection from heat and cold
Wound environment:
heat
- some benefit, too much detriment.
- excessive heat can cause increase in bacteria
- increase of temp combined with pressure =susceptibility to injury
Wound environment:
Cold
- may cause hypoxia
- may have AE on immune function
- decreased subcut O2
Considerations for packing
- wound size
- depth
- drainage
- type of dressing
- solution to maintain moist environment
Impact of frequency of dressing changes:
- prevent washing away of growth factors and other beneficial proteins
- protect fragile wound bed from damage
Most susceptible areas for pressure ulcers
sacrum and coccyx (65%)
trochanter (9%)
heel and ankle (15%)
Most common areas for venous ulcers
anywhere between ankle and midcalf. medial aspect above malleolus most common
Venous ulcer appearance
shaggy, irregular borders. usually shallow
Venous ulcer pathophysiology
- vein becomes dilated
- blood vessel congestion
- fluid leaks out and congests immediate tissue area
- tissue becomes poorly perfused, dies, ulcer results
Arterial ulcer pathophysiology
caused by damaged arteries that decrease blood flow to tissue
leads to cell death
PVD, DM, smoking
Arterial ulcer assessment
- weak or absent pulse
- absence of leg hair
- thickened nails
- pain
- cold feet
Ulcers:
minimal drainage, often occurs on the toes or dorsum of the foot, and is accompanied by a weak or absent pulse?
arterial
Ulcers:
heavy drainage, irregular wound borders, and often results in hemosiderin stains around the lower leg/ankle?
venous ulcers
Microscopic biochemical environment
metabolic control, nutritional status, immune status, presence of inflammation, and tissue perfusion
Macroscopic biochemical environment
levels of tissue proteases, high levels of cytokines, low levels of growth factors,
tissue hypoxia,
decreased proliferative capacity of the key cells,
increased levels and types of bacteria.
