Wounds Flashcards
Risk factors for wound
Bed bound
Low/high body weight adds pressure
Bony prominences
Poor w/c positioning
Decreased sensation
Decreased mobility
Common areas for wounds
Heels, sacral, low back and skin folds
Pressure/bed sore
Prolonged pressure on skin, bony prominence
Stages of pressure ulcer: stage 1
Skin looks red/pink, darker skin shiny might feel warmer or cooler
Stages of pressure ulcer: stage 2
Wound with pink red base, may see skin loss, blisters, changes in skin
Stages of pressure ulcer: stage 3
Into the hypodermis
Stages of pressure ulcer: stage 4
Penetrate all 3 layers, exposing muscle, tendon, bone
Non-blanchable redness
Trigger pressure ulcer plan secondary to increase likelihood of new pressure ulcers, consent obtained for skin check
Skin assessment: Best Shot
Buttocks
Elbows/ears
Sacrum
Trochanters
Spine/shoulder
Heels
Occipital
Toes
Norton Pressure Score Risk Assessment
Scaled scoring system 1-4
Physical condition, mental condition, activity, mobility, incontinence
>18 low risk
14-18 medium risk
10-14 high risk
<10 very high risk
Braden Scale
Used for predicting pressure sore risk
Sensory perception, moisture, activity, mobility, nutrition, friction/shear
Less than or equal to 9 severe
10-12 high risk
13-14 moderate risk
14-18 mild
Adverse events
Occur secondary to error or failure to apply accepted strategy for prevention 25% SNF, 29% SNF+IRF, 25% of that t/f to hospital
Pressure ulcer intervention
Strong evidence in mattress/cushion choice, positioning education, family
Education, regular screening, patient education
Fall prevention, infection mgmt, pressure injury prevention, feeding/swallowing techniques, med mgmt, self mgmt of conditions
Alternating air mattresses= decreased pressure ulcer, mod evidence
More than 3” foam cushoon f
Multi-component pressure ulcer prevention programs
Standardized positioning plan
Algorithm for mattress selection in set up
Agency for healthcare research and quality guidelines
Intensive training
Interdisciplinary leadership team, protocol to reduce pressure ulcer
Eval support surfaces
Skin/wound producs
Simplification of clinical process (EMR, simplified wound care protocol)
Saves $24,000 to facility
Medline Pressure Ulcer prevention program
Caregiver education
Provider training in best program
New skin care products
Standardized algorithm
Specialized wound care team
Mod evidence for facility wide oressurew reduction program
Wounds
Abrasions, punctures, bites, surgical wound, diabetic ulcer, pressure injuries, traumatic wounds, venous stasis ulcers, arterial ulcers
Diabetes
Group of conditions that impact bod’s ability to process/use glucose
DMII
Most common develops in 40s
Body doesnt produce enough insulin or resists it
DMI
Lifelong, comorbidities depend on glucose control
Sx: frequent urination, vision changes, poor wound healing, irritability, mood changes, peripheral neuropathy
Chronic condition where pancrease produces little or no insulin
Interventions for diabetes
Llifestyle mgmt techniques
Healthy eating
Being active
Monitoring glucose levels
Med mgmt
Problem solving/routines
Decrease risk with preventative care
Healthy coping skills
AADE 7 self care behaviors
Framework for assessment/intervention/outcome eval for pre diabetes and diabetes
Shift content for outcome driven based on client centered goals
AADE7 outcome continuum
Immediate (skill acquisition) to intermediate (behavior change) to post intermediate (improved clinical indicators A1c, BP, lipids, BMI) to long term (improved health status)
Multimodal group intervention for diabetes
Strong evidence x 1 month or short duration 1-3
Includes education, group discussion, goal setting, plan development, relaxation strategies
8 week group focused on identifying barriers, CBT for problem solving, behavior change and lifestyle development=improved glucose self
Monitoring
Strong evidence for group/individual combo
Individual intervention for diabetes
Strong for 1:1 in person treatment for
Self mgmt
Moderate evidence for telephone based 1:1 multimodal interventions
