wounds (art and ven insuff, p ulcers, lower extrem ulcers, diabetic food and leg) Flashcards
wht is a pressure ulcer
what is the initial sig of P ulcer
how does this progress to P ulcer
- P ulcers are localized areas of infracted soft tissue that occur when P applied to skin over time is greater than normal capillary closure P (25-32mm Hg. Critically ill pts have lower cap closure P and are more at risk)
- Initial sign is erythema d/t reactive hyperaemia (normally gone in an hr)
- First cutaneous tissue destr, then destr and necrosis of underlying soft tissueP ulcer thats painful and slow to heal
because immoblity is risk of P ulcer and If P occurs long enough small vein thrombosis and tissue necrosis occur
…this is most likely to occur where?
Bony prominences most likely site as only covered by skin and sm amounts of subcut tissue eg sacrum, coccygeal area, ischial tuberosistis, greater trochanter, heel, knee, malleolus, medial condyle of tibia, fibular head, scapula, elbow
how is adipose risk of P ulcer
Obese have lg amounts of poory vascularised adipose which is susceptibe to breakdown
what nutritional def could promote wound dev
what is good ndicator of protein levels?
which vit and minerals nec for repair
- Pts with nutrional def of low protein (good indicator is albumin. Low levels assoc with hypoalbuminemic tissue edema and inc risk of P ulcer) or negative nitrogen balance have tissue wasting and inhibited tissue repair.
- Anemic pts have dec O2 carrying capacity. Metb disorders canP ulcers. Vitamin c and trace minerals like zinc nec for tissue maint and repair
what is shear and what parts of body are most at risk of it
what is friction
- Shear is created by gravitational forces and friction. When it occurs, tissue layers slide over one another, blood vessels stretch and twist and microcirc to skin and subcut tissue is disrupted. Sacrum and heals are most at risk of shear
- Friction=resistance to movement that occurs when two surfaces are moved across each other
what is maceration and how does this affect ehaling
• Prolonged contact w moisture leads to maceration (softening) of skin
why are elderly so at risk of P ulcer dev
o Dec elasticity, dec collagen, muscle/tissue atrophy, polypharmacy, comorbidities all affect wound healing and inc risk of breakdown. Dec inflm response, decsubcut padding, dec intake
what factors do you assess for risk of pt dev P ulcer
o To assess risk of P ulcer dev assess: Mobility, sensory perception, cog abilities, tissue perfusion, nutritional, friction and shear, sources of moisture on skin, age
how often do you assess someones skin if they have risk of P ulcer
what do if pt has erythema
what labs are you checking
2x daily
check erythema for blanching
hgb, hct, lytes, albumin, transferrin, creatinine),
!! you have a pt with a stage 2 ulcer but it is healing. how do you document this
what if you had a stage 1 that is getting worse
o Ulcers can be upgraded eg stage 1 to 3 but not downgraded. Instead we say it is healing stage 3 ulcer or healed.
how many stages of P ulcers are there
I-IV
stage I P ulcer
these are NPUAP american ulcer categories..not sure what we use.. we need to know assessments of chronic wounds…
• Area of erythema that doesn’t blanch with P
• Inc skin temp
• Tissue swollen and congested
• Pt complains of discomfort
• Erythema progresses to dusky blue-grey
o Darkly pigmented skin may not have visibe blanching but colour may be different than surrounding area. Can be warmer or cooler than surrounding area.
stage II P ulcer
Stage II: skin breaks, abrasion, blister, or shallow crater, edema persists, ulcer drains, infect may dev
-Partial thickness loss of dermis.
-Presents as shallow open ulcer with red pink wound bed with no slough or
-as open/ruptured serum-filled or serosanguineous filled blister.
Presents as shiny or dry shallow ulcer without slough or bruising (bruising indicates deep tissue injury).
Dont use to describe skin tears, tape burns, incontinence assoc dermatitis, maceration or excoriation.
stage III P ulcer
Stage III: ulcer extends to subcut, infection dev, necrosis and drainage continue
o Full thickness tissue loss.
Subcut fat can be visible but no tendon muscle bone. Can have slough that doesn’t obscure depth of tissue loss.
May have undermining and tunnelling.
Depth varies
stage IV P ulcer
Stage IV: ulcer extends to muscle and bone, deep pockets of infect dev, necrosis and drainage continue
o Full thickness tissue loss. Osteomyelitis or osteitis likely.
o The bridge of nose, occiput and malleolus have no subcut adipose. These areas can have shallow ulcers
which stage can you first have tunneling
when can bruising appear
when tendon appears what stage is it
III=tunneling
not until III=bruising
tendon=IV
pt has nonblanching erythema and the skin is broken, which stage
you can see bridge of pts nose (bone) what stage
II ( one is nonblanching erythema but broken skin=2)
since theres little subcut tissue it is stage IV
!!do you want to have venous insufficiency raised above heart or arterial and why
venous to promote VR.
arterial should be below heart to use gravity to promote flow to extremities
you have pt with arterial insuff how can you inc their blood flow
o Moderate + isometric exercises to help blood flow + dev of collateral circ
o Enc moderate amount of walking until the point of pain, rest until pains gone, then walk again to inc endurance (and increases collateral circ). The pain shows lack of O2 to tissue.
interventions to promote vasodilation and prevent vascular compression
\:maint warm temp and avoid chilling. Discourage tobacco (causes vasospasm). Counsel to have stress mgmt and avoid emotional upset. Discourage constrictive clothes. Enc not to cross legs (venous stasis and compression) for >15min. Admin vasodilators (relax sm muscle) and adrenergic blocking agents (block SNS response and circulating catecholamines)
considerations with using heat on extremities of pt with arterial insufficiency
o A hot water bottle can be applied to pts abdm causing reflex vasodilation through lower extrem if pt is chilled (avoid hot water bottles and heating pads on extrem). Test temp of bath water. Even at low temps, trauma to the tissues can ocur in ischemic extrem. If pt has vasospastic disorder egRaynauds, heat that doesn’t exceed body temp can be applied to extrem.
o Excess heat may inc the metb rate of the extreme and inc need for O2 beyond that provided by dec arterial flow through diseased artery
if pt has severe art insuff is dilation possible
o Goal is to inc vasodilation in extremities but these patients, if arteries are severlysclerosed, inelastic or damaged, dilation is not possible
what is venous insuff
what veins can be involved
o Venous insuff results from obstr of venous valves in the legs or reflux of blood through the valves
o Both superficial and deep veins may be involved
o Resultant venous HTN can occur whenever theres been prolonged inc in venous P eg with DVT
o The thin walls of veins distend easily when venous P inc consistently. This stretches the valves and doesn’t let them close allt he way, causing backflow or reflux of blood in veins
maybe too specific of a wound not sure…
20-50% of pts post DVT get postthrombotic syndrome what is this
what kind of wound can result
how can it look
where is it
qaulity of the skin
risks
o PTS is characterized by chronic venous stasis, resulting in edem, alt pigmentation, pain, and stasis dermatitis
o Stasis ulcers dev d/t rupture of small skin veins and seubseq ulcerations. The RBCs degranulate in surrounding tissue which leaves brownish discolouration of the tissues. This pigmentation and ulceration usually occurs in lower parts of the extrem, in the area of malleolus of ankle. The skin gets dry, cracks and itches, subcut tissues fibrose and atrophy. The risk of injury and infect of the extreme is inc.
what are complications of venous insuff
o Venous ulceration is most serious
o Cellulitis or dermatitis may complic the care of chornic vonous insuff and venous ulcerations
mgmt of venous insuff maybe not imp
o Mgmt aims to dec venous stasis and prevent ulcerations
o To inc blood flow (venous): antigravity activiteseg elevate legs, graduated compression stocking
o elevating legs decedema, promote VR and give symptomatic relief. Do freq (min 15-30min/2hrs)
o at night sleep with foot of bed inc 15cm
o enc walking ad discourage sitting/standing in one pos. If sitting avoid putting P on ppliteal spaces
o compression w stockings dec pooling, inc VR, is recommended for pt with venous insufficiency. Use stockings with 30-40mmhg P for 1yr post DVT. P should be greater at foot and ankle then decline as it goes up leg. Apply stockings after legs have been elevated for awhile
o protect venous insufficient extrem from trauma, keep skin dry, clean, soft
what is more common leg ulcers due to venous or art insuff
o leg ulcer is excavation of the skin surface that occurs when inflm necrotic tissue sloughs off. 75% are d/t chronic venous insufficiency, 20% arterial insuff, 5% burns, sickle cell anemia and other.
!!! which type of ulcers are small, circular, deep ulcerations on tips of toes or in web spaces bet the toes
arterial
!! venous or art: pain is aching or heavy
vnous
!! edematous v or art
venous
!! intermittent claudication is what
v or a
what other kind of pain would they complain of with this form of insuff
o chronic arterial disease is characterized by intermittent claudication (pain caused by acitivity and relieved after rest).
o Pt may complain of digital or forefoot pain at rest
!! pt has acute arterial occlusion is pain easily relieved
o If onset of arterial occlusion is acute, ischemic pain ir unrelenting and rarely relieved even with opioids
!! where are arterial ulcers typically
what do they look like
what is their likely cause
o Typically arterial ulcers are small, circular, deep ulcerations on tips of toes or in web spaces bet the toes
o Ulcers often on medial side of hallux or fifth lateral toe. May be caused by combo of P and ischemia
!! arterial vs venous whih wound is gen larger
venous
!! a or V which is gen superficial which is deep
V=superficial
!! is gangrene more likely from V or A
t or f this necessitates debridemet. what else to do for care of gangrenous foot
art insuff Maygangrene of toe (digital gangrene) usually caused by trauma. The toe is stubbed and then turns black. Pts with this problem are generally elderly without adequate circ to provide revascularzation. Debridement is contraindicated
The gangrenous toe is dry and you don’t want to open the skin and cause a wound that cant heal d/t insuff circ. If amputated the insuff circ would prevent healing and might mean more amputation is nec. Dry gangrene of the toe in o adult w poor circ is usually left alone. Keep the toe clean and dry until it separates without causing an open wound
!! where are vnous ulcerations generally
o Ulcerations are in area of medial and lateral malleolus (gaiter area) and are typically lg, superficial and highyexudative
!! v or a is gen discoloured area around wound and why
o Venous HTN causes extravasation of blood which discolours the area
there is wound with purulent exudate what kind of things to assess
o As ulcers have many causes, det the cause. Hx of the condition will give info for venous or arterial
o Periph pulses (femoral, popliteal, posterior tibial, and dorsalispedis) are carefully examined
o Diagnostic aids are Doppler and duplex u/s, arteriography, venography
o May need to culture the ulcer to det whether an infecting agent is the primary cause of the ulcer
my point was kind of that it might not be art or v insuff and instead an infection
do we do debridenment not sure…
what is debridement and when is it nec
o To inc wound healing wound is kept clean of drainage and necrotic tissue. Usual method is flush area with NS or clean w noncytotoxic wound cleansing agent. If none of this works, debridement is nec. Debridement is removal of nonviable tissue from wounds. Removing the dead tissue is imp, esp with infect
methods of debridement
surgical nonselective debridement enzymatic debridement calcium alginate drsg foam drsg
nonselective dbridement (which marilyn says we dont do so much because it reopens the wound)
o Nonselective debridement: by application of isotonic saline drsg of fine mesh gauze to the ulcer. When dry its removed along with debris. Pain mgmt generally nec
what kind of wound should you NOT use calciu alginate drsg on. when should you use it
how does it work
o Calcium alginate dressing: can be used when absorption of exudates is nec (don’t use on enonexudative wound. Drsgs changes when exudates seeps through the cover drsg or at least every 7 days. Can also be used on bleeding as material helps stop the bleeding. As the dry fibers absorb exudates, they become a gel that can be painlessly removed fromt he ulcer bed.
pt has ulcer should you enc or restrict mobility in acute phase
o Generally restricted initially to promote healing and then enc after acute phase of ulcer
o When infection resolves and healing begins ambulation should resume gradually and progressively. Enc bed exercises, position changes.
now info starts from kozier lower extremitiy ulcers
!! pt has ankle flares A or V
(appear near or on the ankle and are assoc w venous HTN or varicose veins),
what is lipodermatosclerosis
(occurs in gaiter area and caused by areas of connective tissue int he dep dermis and fat and produces a woody hardening of tissue),
atrophie blanche is assoc with
what does it have in centre of wound
(appears as white, atophic lesions and is often assoc w venous disease)
tiny visible blood vessels called teleangiectasia often seen in centre
what is assessed in BRaden scale for risk of P ulcers
how are these categories scored
o Assess sensory perception(ability to respond meaningfully to pressure related discomfort),
moisture,
activity,
mobility(ability to change and control body position), nutrition,
friction and shear (F&S are one category)
o Scored from 1 (being worst) to 4 (best) on all categories except friction and shear which is out of 3.
what is best score in braden scale.
what is very high risk
what is no risk
best=23
v high risk= less than 9
no risk=19-23
Very High Risk: Total Score 9 or less High Risk: Total Score 10-12 Moderate Risk: Total Score 13-14 Mild Risk: Total Score 15-18 No Risk: Total Score 19-23
!!which type A or V
has Ulcers with punched out appearance
arterial disease
!! art or v Pale or blue feet
arterial
!! art or v Shiny, taut skin
art
!! a or v Eczema
venous
!! art or ven Usually shallow moist ulcers
vnous
!! art or ven Base of wound poorly perfused, pale, dry
art
!! art or ven who has red legs
venous, blood is pooling
what kind of issue is mot likley to lead to amputation
DM
what 3 reasons lead to inc infection rate in DM wound
- neuropathy
2) Peripheral Vascular disease: poor circ in extrem = poor wound healing + gangrene
3) Immuno-compromised: hyperglycemiaimapires WBC’s to destroy bacteria
3 types of DM neuropathy and what they cause
a. Sensory neuropathy loss of pain + pressure sensation
b. Autonomic neuropathy inc dryness + fissuring of skin (secondary to dec sweating)
c. Motor neuropathy causes muscular atrophy changes in shape of foot
progression and signs of DM ulcer
tx of DM ulcer
- Begins with soft tissue injury, fissure between toes or area of dry skin, callus
- Not felt by patient – undetected if not daily inspection
- Drainage, swelling, redness (from cellulitis) or gangrene may be first noticed signs
bed rest, abx, debridement, control glucose levels
