Positioning and Wound Care

Question 1

what are the 3 goals of patient positioning?

Answer 1

• pt comfort
• skin hygiene
• joint mobility

Question 2

what are the 4 “dos” of pillows?

Answer 2

float heels, elevate UE, use for S/L, prevent hip ER in supine

Question 3

what are the 2 “don’ts” of pillows?

Answer 3

place under knees, keep neck flexed

Question 4

what is the gold standard for offloading with diabetic ulcers, and what does it allow the pt to do?

Answer 4

• total contact cast

- allows pt to be ambulatory

Question 5

define eschar

Answer 5

black and crusty stuff

Question 6

define desiccated

Answer 6

dried out

Question 7

define epibole

Answer 7

rolled or curled under wound edges

Question 8

what are the 3 main characteristics of skin?

Answer 8

waterproof, protective, adaptive

Question 9

arterial insufficiency is associated with a(n) ____ pedal pulse (increased/decreased)

Answer 9

decreased (might be absent)

Question 10

describe intermittent claudication

Answer 10

O2 not meeting muscle demand → ischemia → pain

Question 11

what body parts are most affected by arterial insufficiency?

Answer 11

• Anterolateral foot/ankle and toes

- Dorsum of the foot

Question 12

how will wounds due to arterial insufficiency appear?

Answer 12

• full thickness with well-defined borders
• minimal drainage
• often with eschar
• shiny, anhydrous, pale to cyanotic skin

Question 13

what causes venous insufficiency?

Answer 13

vales aren’t working and there is backflow of fluid

Question 14

is the pedal pulse present with venous insufficiency?

Answer 14

yes, unless there is a concomitant arterial disease

Question 15

what makes the lower limb discomfort and edema with venous insufficiency worse?

Answer 15

being in a dependent position

Question 16

what makes the lower limb discomfort and edema with venous insufficiency better?

Answer 16

being more raised up

Question 17

what part of the foot is most affected by venous insufficiency?

Answer 17

anteromedial

Question 18

how will wounds due to venous insufficiency appear?

Answer 18

• Irregularly shaped, shallow wound
• Typically located on the medial lower leg and malleolus
• Moderate to copious drainage

Question 19

is the pedal pulse present with diabetic foot ulcers?

Answer 19

not usually, it is often absent with arterial disease (but it may be present)

Question 20

diabetic foot ulcers are often ____ with decreased ____

Answer 20

painless; temperature

Question 21

what body part is most commonly affected by diabetic foot ulcers?

Answer 21

plantar surface of foot/toes

Question 22

what are some other body parts impacted by diabetic foot ulcers?

Answer 22

• dorsum of foot/toes
• ends of toes
• metatarsals

Question 23

how do diabetic foot ulcers appear?

Answer 23

pale wound bed often with nonviable tissue and minimal drainage

Question 24

what kinds of changes happen to the skin/hair/nails in pts with diabetic foot ulcers?

Answer 24

• trophic changes

- skin will be shiny and hairless

Question 25

are pulses intact with pressure injuries?

Answer 25

yes, unless there is vascular compromise

Question 26

where are pressure injuries typically found?

Answer 26

pressure areas/bony prominences

Question 27

pressure injuries are ____ if sensation is still intact

Answer 27

painful

Question 28

describe a superficial wound

Answer 28

- damage to epithelium | - heals rapidly through regeneration of epithelial cells

Question 29

describe a partial thickness wound

Answer 29

- involves the dermal layers | - vessel damage

Question 30

describe a full thickness wound

Answer 30

- involves subcutaneous fat and deeper - takes longest time to heal bc new CT needs to regenerate - contraction occurs during healing

Question 31

describe a stage 1 pressure injury

Answer 31

Intact, reddened skin that does not lighten when palpated

Question 32

describe a stage 2 pressure injury

Answer 32

- Partial thickness w exposed, viable dermis | - No slough or eschar

Question 33

describe a stage 3 pressure injury

Answer 33

- Full-thickness w exposed subcutaneous layer - May include epibole, tunneling, undermining - Slough and eschar can be present

Question 34

describe a stage 4 pressure injury

Answer 34

- Full-thickness with exposed muscle, tendon, ligament, fascia, cartilage, and/or bone - Often with epibole, tunneling, undermining - Slough and eschar may be present

Question 35

what does it mean for a pressure injury to be "unstageable"?

Answer 35

- slough/eschar covers full-thickness wound | - unable to detect depth

Question 36

what is a deep tissue pressure injury (DTPI)?

Answer 36

intact or non-intact skin appearing as non-blanchable red, maroon, or purple in color

Question 37

what is the most common type of chronic wound?

Answer 37

diabetic ulcer

Question 38

what factors can delay wound healing (VAL NM MBA)?

Answer 38

- vascular status - age - lifestyle - nutrition - medical status - medications - bioburden and infections - appropriate care and pt compliance

Question 39

what are 4 PT considerations with wound healing?

Answer 39

- prevention - pain management - ROM, strength, functional mobility - edema management