Wounds Flashcards
What stage of wound healing occurs immediately after injury? What skills are involved? What clinical observation is noted? What occurs during this stage?
Coagulation
- Platelets
- Bleeding stops
- Hemostasis; formation of fibrin clot
- Messengers that bring on the inflammatory process
What stage of wound healing occurs immediately after injury until day 4? What skills are involved? What clinical observation is noted? What occurs during this stage?
Inflammation
- Platelets, macrophages, neutrophils
- Erythema, warmth, edema, pain
- Prepares wound bed for healing by removing dead tissue and bacteria
What stage of wound healing occurs from day 4 - day 21? What skills are involved? What clinical observation is noted? What occurs during this stage?
Migratory/proliferative
- Macrophages, lymphocytes, fibroblasts, epithelial cells, endothelial cells
- Beefy red tissue
(newly formed collagen and blood vessels) which is covered by migrating epithelial cells
- Fills the defect and covers it as quickly as possible
What stage of wound healing occurs from day 21 - 1-2 years? What skills are involved? What clinical observation is noted? What occurs during this stage?
Remodeling/maturation
- Fibroblasts
- Shrinking, thinning, paling of scar
- Reworks the new tissue to make it stronger
What factors impede wound healing?
Diabetes Malnutrition Smoking Anemia Ischemia Edema Over-colonization Infection -sepsis -osteomyelitis Radiation MOF Medications -Steroids -Immunosuppressants -Chemotherapy -Vasopressors Incontinence -Fecal -Urinary
Skin Changes with Aging?
- drier, less elastic, and less well perfused
- Epithelial and fatty layers become thinner
- Skin vascularity diminishes, inc atherosclerotic changes
- Inflammatory response decreases and tissue regeneration slows
What is the most costly hospital acquired condition?
Pressure injuries
What is a pressure injury?
- Localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device.
- Can present as intact skin or an open ulcer and may be painful.
- Occurs as a result of intense and/or prolonged pressure or pressure in combination with shear.
- The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue
What characteristics are assessed in the Braden scale?
Sensory Perception Moisture Activity Mobility Nutrition Friction & Shear
What consists of the SKIN CARE bundle?
S upport Surfaces
K eep Repositioning
I ncontinence Care
N utrition & Hydration
C heck devices
A ssess risk and skin daily
R educe HOB < 30 degrees
E levate heels
When would you use a low air loss bed?
If Braden < 12, moisture is a significant problem or patient has PIs on multiple turning
When would use an air fluidized bed or dynamic immersion therapy?
If multiple large, truncal stage 3 or 4 PIs
What is the best position for generating low-pressure?
30 degree semi Fowler position
What does of albumin measure? Prealbumin? Which is the most reliable indicator?
- Albumin: picture of past nutrition
- Pre- albumin: monitored for success of current therapy - Most reliable indicator
(Normal: 16-30 mg/100mL)
What are the four different types of moisture associated skin?
- Incontinence associated dermatitis
- Intertriginous dermatitis
- Peri wound moisture associated dermatitis
- Peristomal moisture associated dermatitis
What type of ulcer would you most likely see on the medial aspect of the lower legs? Lateral aspect?
Medial = Venous Lateral = Arterial
What are some characteristics that would put someone at risk for developing arterial ulcers?
Predisposing Factors:
PVD
Diabetes
Advanced age
Assessment: Thin, shiny, dry skin Loss of hair on ankle and foot Thickened toenails Pallor on elevation & dependent rubor Cyanosis Decreased temp Absent or diminished pulses
What are some characteristics of arterial ulcers?
Location: Between toes or tips of toes Over phalangeal heads Around lateral malleolus Where subjected to trauma or rubbing of footwear
Characteristics: Even wound margins Gangrene or necrosis Deep, pale wound bed Painful Cellulitis
What is the treatment for arterial ulcers?
Conservative Treatment: Bedrest as feasible Treat any cellulitis Topical care Patient ed & support
Surgical Treatment:
Revascularization
Angioplasty
What are some characteristics that would put someone at risk for developing venous ulcers?
Predisposing factors: Valve incompetence in perforating veins H/O deep vein thrombophlebitis & thrombosis Advanced age Obesity
Assessment: Firm (“brawny”) edema Dilated superficial veins Dry, thin Skin Evidence of healed ulcers Lipodermatosclerosis
What are some characteristics of venous ulcers?
Location:
Medial aspect of lower leg and ankle
May extend into malleolar area
Characteristics: Irregular wound margins Superficial (into dermis) Ruddy, granular tissue Usually painless Exudate may be present
What is the treatment for venous ulcers?
Conservative Treatment: Elevate extremity as feasible Therapeutic vascular compression Unna boots, high compression wraps, stockings Topical care Absorption dressings Debridement as needed
Surgical Treatment:
Skin Grafting
What are some characteristics that would put someone at risk for developing neuropathic (diabetic) ulcers?
Predisposing Factors:
Diabetic with peripheral neuropathy
Assessment: Diminished or no sensation in foot Foot deformities Palpable pulses Warm foot If pt has PVD, same assessments as arterial
What are some characteristics of neuropathic (diabetic) ulcers?
Location:
Plantar aspect of foot
Over metatarsal heads
Under heel
Characteristics: Painless Even wound margins Deep Cellulitis or underlying osteomyelitis Granular tissue present unless coexisting PVD
What is the treatment for neuropathic (diabetic) ulcers?
Conservative Treatment: Treat cellulitis R/O osteomyelitis Metabolic diabetic control No weight bearing Contact casting Topical Care Orthotics Patient Ed & support
Surgical Treatment:
Aggressive debridement
Revascularization (if
coexisting PVD)
When not to debride?
Intact, stable heel eschar -No odor -No pain -No drainage -No cellulitis Severe PVD Dry gangrene *Know the vascular status
When to Debride?
Open wound edges
Drainage, odor
Fever, other signs of cellulitis, sepsis
Debridement may need to be sharp for cellulitic wounds
Types of Debridement?
Autolytic -Uses body’s own processes to remove devitalized tissue -Occlusive dressings Mechanical -Wet-to-dry dressings Enzymatic -Collagenase Surgical or Sharp
What are the criteria for determining if a wound is critically colonized?
Nerds
- Nonhealing wound
- Exudative
- Red and bleeding
- Debris
- Smell
What are the criteria for determining if a wound has a deep tissue infection?
Stonees
- Size is bigger
- Temperature increase
- Os (Probes to or exposed bone)
- New area of breakdown
- Erythema/edema
- Exudate
- Smell
What topical therapy would you use for a wound in order to:
Add moisture to dry wound bed?
Hydrogel
What topical therapy would you use for a wound in order to:
Maintain moist wound bed/absorb drainage?
- Hydrocolloid
- Calcium alginate
What topical therapy would you use for a wound in order to:
Absorb drainage/decrease bioburden?
Hydro fiber with AG
What topical therapy would you use for a wound in order to:
Debride?
- Collagenase (Chemical)
- Medihoney (Autolytic and mechanical)
What topical therapy would you use for a wound in order to:
Gentle adhesive/absorb drainage?
Foam dressings
What topical therapy would you use for a wound in order to:
Promote granulation tissue/control exudate?
NPWT (wound vac)
What topical therapy would you use for a wound in order to:
Stalled wounds?
Promogran Prisma
