Wounds Flashcards
What phase is a non-healing wound stuck in?
Stuck in the inflammation phase
What is a chronic wound?
An injury to the integument that has failed to heal by the generally predictable events that occur through the phases of wound healing
What are common barriers to wound healing (memorize!!)?
Inadequate microcirculation
Prolonged pressure from interstitial edema
Bacterial infection
Absence of adequate electrical potential
What are common barriers to wound healing (2)?
Tissue perfusion/oxygenation Nutrition Presence/abscence of infection DM steriod administration Immunosupression Aging Topical Therapy
What is a pressure ulcer?
Localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure (with or without shear and friction)
What are some common sites for pressure ulcers?
Sacrum Heel Ischium Lateral Malleolus Greater trochanter
What happens when an external load is placed on a tissue?
Shear/pressure closes the microcirculation and lymphatic systems when pressure is exceeded
What is tunneling?
Not sure yet
What is a stage 1 pressure ulcer?
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. color may differ from surrounding area
What is a stage 2 pressure ulcer?
A 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
What is a stage 3 pressure ulcer?
- Full thickness tissue loss.
- Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.
- Slough may be present but does not obscure depth of tissue loss
- May include undermining and tunneling
What is a stage 4 pressure ulcer?
- Full thickness tissue loss with exposed bone, tendon or muscle.
- Slough or eschar may be present on some parts of the wound bed
- Often include undermining and tunneling
What is a (suspected) deep tissue injury (DTI)?
Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear.
What is an unstageable pressure ulcer?
A full thickness loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.
What are the two classifications of Chronic wound?
Partial thickness and full thickness
What is a partial thickness wound?
Breakdown of the epidermis and possibly penetrating into but not through dermis.
What is a full thickness wound?
Breakdown of the dermis into the subcutaneous tissue through fascia, may involve muscle, tendon and/or bone.
What are several causes of venous insufficent ulcers?
Muscle pump failure
Pericapillary fibrin deposits
What are some characteristics of venous insufficient ulcers?
Superficial Highly exudative minimal pain, relieved with elevation Irregular edge Hyperpigmentation Medial side of ankle Red wound base Dermatitis Hemosiderin staining
What are arterial insufficient Ulcers the result of?
Inadequate blood supply
may also have venous insufficiency
Below what ABI are arterial insufficient ulcers not likely to heal?
below 0.5
What are some characteristics of Arterial insufficient ulcers?
very painful Pain decreases with dependency Associated trophic changes in the skin Minimal exudate with dry eschar/necrosis Located on toes, fingers or interdigital spaces Blanched wound base and periwound tissue
What are some characteristics of post surgical wounds?
Closed by primary intention Treatment usually uneventful Healing occurs with protective dressing Generally well-defined Straight wound margins
What are some characteristics of traumatic wounds?
generally irregular wound margins
Visible inflammatory response margin
indurated wound margin
What are the major contributory factors in the pathogenesis of a diabetic foot ulceration?
Combination of peripheral neuropathy, peripheral vascular disease and biomechanical abnormalities with PN being the most important complication
What are some biomechanical abnormalities that can lead to diabetic foot ulcerations?
Foot deformities and limited joint mobility
What are different scales for classifying diabetic/neuropathic ulcers?
Wagner scale, and University of Texas scale
What are the different scales for risk assessment of a diabetic foot ulceration?
Norton scale and braden scale
What is the range for the Wegner scale and what is it measuring?
0-5 (5 being the worst), used for classifying diabetic/neuropathic ulcers
What is the range for the University of Texas scale and what is it used for?
Stages A-Stage D (measuring the amt of infection present with D being the worst)
Grades 0-3 (Measuring the depth of the wound with 3 being the worst)
What different risk factors does the norton scale look at?
Physical Condition Mental condition Activity Mobility Incontinent
What different risk factors does the Braden scale look at?
Sensory perception Moisture Activity Mobility Nutrition Friction and Shear
What are some preventative skin care methods?
Keeps skin clean and dry Daily personal hygiene Clean skin with warm/tepid water Moisturize skin Reduce exposure to irritants
How can you reduce your exposure to irritants?
Clean immediately after incontinence Apply skin protectants Keep linens clean/wrinkle free Check fit of splints/braces/medical devices Maintain environmental humidity
What should you avoid with incontinent patients?
Diapers so the excrement doesn’t pool and create an ulceration. Use incontinence pads/briefs instead
Where should you avoid massage with incontinent patients/patients with DM?
Red areas, may decrease rather than increase blood flow
What does shear do to the skin blood supply?
Reduces supply of blood to the skin
How can you minimize shear and friction injuries?
Use positioning, transferring and turning techniques
What layers of skin do friction involve?
Superficial skin layers
When does friction occur?
When the pt is moving across a coarse surface
Who is at a high risk for frictional injuries?
Agitated pts
spastic pts
When pt’s slide down in bed
What are some methods for preventing frictional injuries?
Heel protectors, elevation of heels, stockings, skin protectors
How often should you reposition bed bound patients?
@ least every 2 hours
How often should you reposition chair bound individuals?
Reposition @ least every hour and encourage weight shift every 15 minutes
How many degrees must a person be turned to remove pressure on their sacrum?
Must be turned at least 40 degrees
What are some positioning devices?
Trapeze for self positioning
Lift devices for those who cannot assist
Pillows and wedges for knees and ankles
Who should you limit elevating the head of the bed?
To reduce friction and shear if the patient slides down the bed
Unless medically necessary, what should be the limit of head-of-bed elevation?
30 Degrees
What bony prominence should you avoid in the side lying position?
The greater trochanters
What position should you use for side lying?
The 30 degree lateral inclined position
What should you do to the heels?
MUST elevate
When elevating the heels, what must you be aware of at the knee?
Make sure the knee is not hyperextended
What device should you not use for pressure relief?
Do not use donuts or plastic rings. They can cause a larger area of tissue injury because of intense pressure along the device
What are more effective; standard hospital mattresses or pressure reducing devices?
Pressure reducing devices
What is a DMERC Category 1?
Static overlays and mattresses
-foam, air, gel
What is a DMERC Category 2?
Alternating pressure and air floatation
What is a Category 3 support surface?
Air fluidized
Low air loss bed/mattress
What should wheelchair bound pt’s use?
Pressure reducing cushions
