Pressure and Diabetic Injuries - Class 4

Question 1

pressure wounds occur from

Answer 1

compression of soft tissues b/w bony prominence and a support surface

capillary closing pressure of 32 mm Hg exceeded

Question 2

pressure wounds –> relationship

Answer 2

time/pressure

–> the long you’re on it the more likely you are to sustain a wound

Question 3

contributory factors of pressure injuries

Answer 3

shear

friction

moisture

heat

extrinsic physical factors

intrinsic factors

Question 4

shear

Answer 4

tears capillary beds perpendicular to skin

accounts for undermining

Question 5

friction

Answer 5

causes blisters exposing dermal structures

Question 6

moisture

Answer 6

macerates and erodes skin

Question 7

heat

Answer 7

raises tissue metabolism but compressed capillaries cannot dilate leading to tissue hypoxia

Question 8

extrinsic physical factors

Answer 8

support surfaces

orthotic devices

tight fitting clothes/shoes

tight dressings

Question 9

intrinsic factors

Answer 9

muscle atrophy

medications

malnutrition

medical co-morbidities

Question 10

pressure injury shape

Answer 10

rounded, craterlike, shape with regular edges

Question 11

pressure injuries may have

Answer 11

tunneling or undermining

Question 12

what is the shape of pressure wounds caused by

Answer 12

shearing forces and the round, pointed shape of bony prominences

Question 13

how are pressure injuries classified

Answer 13

by stage

by thickness

Question 14

classification by thickness

Answer 14

partial thickness

full thickness

Question 15

partial thickness classification

Answer 15

wound extends to dermis only

may heal by epithelialization

Question 16

full thickness classification

Answer 16

wound extends through dermis

may involve subcutaneous tissues, muscle and possibly bone

Question 17

classification by stage

Answer 17

suspected deep tissue injury

stage 1

stage 2

stage 3

stage 4

unstageable

Question 18

suspected deep tissue injury –> presentation

Answer 18

purple or maroon

localized area of discolored intact skin

blood-filled blister
–> d/t damage to of underlying soft tissue from pressure or shear

Question 19

suspected deep tissue injury –> proceeded by

Answer 19

tissue that is painful, firm, mushy, boggy, warmer or cooler

as compared to adjacent tissue

Question 20

stage 1 –> presentation

Answer 20

non blanchable erythema of intact skin

usually over a bony prominence

Question 21

stage 1 –> darker skin tones

Answer 21

non-blanchable redness may not be visible

presents w/ discoloration, warmth or coolness, edema, indurations (firmness) and pain

Question 22

stage 1 –> lesion

Answer 22

heralding lesion of skin ulceration

Question 23

stage 2 involves

Answer 23

partial thickness skin loss

involving epidermis and/or dermis

does not go through the dermis

Question 24

stage 2 clinical presentation

Answer 24

presents as a blister (in tact or open/ruptured serum filled), abrasion, or shallow crater

Question 25

stage 2 color

Answer 25

wound bed is red/pink and moist

Question 26

stage 2 is differentiated from

Answer 26

skin tears tape burns dermatitis maceration or excoriation

Question 27

stage 3 is a

Answer 27

full thickness skin loss involving damage to subcutaneous tissue

Question 28

stage 3 may extend

Answer 28

to fascia but not through it

Question 29

stage 3 may have

Answer 29

undermining or tunneling

Question 30

stage 4 is a

Answer 30

full thickness skin loss w/ extensive tissue destruction

Question 31

stage 4 has damage that

Answer 31

extends to muscle, bone, tendons, and joint capsule

Question 32

unstageable is

Answer 32

full thickness tissue loss

Question 33

unstageable wound bed is covered in

Answer 33

slough (yellow, tan, gray, green, brown) and/or eschar (tan, brown or black)

Question 34

interventions for pressure wounds

Answer 34

minimize risk factors off load pressure areas pressure relieving devices therapeutic positioning wound care

Question 35

interventions --> minimize risk factors

Answer 35

nutrition mobility skin moisture mechanical forces metabolic psychosocial

Question 36

interventions --> therapeutic positioning

Answer 36

equipment and support

Question 37

pressure interventions --> wound care

Answer 37

debride necrotic tissue (sharps, enzymatic, autolytic) control infection control wound exudate (alignates, foams, hydrocolloids) protect granulation tissue (alignates, foams, hydrocolloids)

Question 38

interventions for pressure injuries cont.

Answer 38

pressure relieving devices (PRDs) think prevention watch for false sense of security mobility is key reduce, redistribute or alternate pressures

Question 39

interventions --> reduce, redistribute or alternate pressures

Answer 39

foam PRD high density foam PRD water PRD gel PRD static air PRD static PRD dynamic air PRD low air loss PRD

Question 40

primary cause of diabetic ulcers

Answer 40

insensitivity from peripheral neuropathy and abnormal pressures from structural deformities

Question 41

diabetic ulcers have

Answer 41

loss of protective sensation

Question 42

other causes of diabetic ulcers

Answer 42

repetitive mechanical stress foot deformities compromised skin barrier arterial insufficiency uncontrolled blood glucose level

Question 43

other causes of diabetic ulcers --> foot deformities

Answer 43

form muscle weakness secondary to motor neuropathy

Question 44

other causes of diabetic ulcers --> compromised skin barrier

Answer 44

secondary to autonomic neuropathy

Question 45

other causes of diabetic ulcers --> arterial insufficiency

Answer 45

a contributor but not the primary cause

Question 46

other causes of diabetic ulcers --> uncontrollable blood glucose levels

Answer 46

effects on inflammatory response

Question 47

those with diabetes

Answer 47

are in a nasty cycle that increases uncontrolled hyperglycemia

Question 48

pts w/ diabetic ulcers will have

Answer 48

diminished sensation foot deformities palpable pulses warm foot may have PVD

Question 49

where are diabetic ulcers found

Answer 49

plantar surface of foot MTP heads under heel

Question 50

diabetic ulcer wound bed

Answer 50

deep

Question 51

diabetic ulcer wound margins

Answer 51

even

Question 52

there is granulation tissue with diabetic ulcers unless they have

Answer 52

PVD

Question 53

diabetic ulcer is accompanied by

Answer 53

no pain

Question 54

diabetic ulcer drainage

Answer 54

low to moderate drainage

Question 55

diabetic ulcer may also have

Answer 55

cellulitis or osteomyelitis

Question 56

diabetic management

Answer 56

strict maintenance of blood glucose control of hypertension, cholesterol and triglyceride levels stop smoking preventive care

Question 57

preventative care diabetic ulcers

Answer 57

foot screening and risk identification pt education proper foot hygiene and self education appropriate foot wear ROM exercises and joint mobility

Question 58

diabetic wound care

Answer 58

off-load the wound debride necrotic tissue and protection of wound scrape calluses control of wound infection

Question 59

wound care --> off load the wound

Answer 59

NWB of foot total contact casting appropriate foot wear to accommodate for dressing and wound location (local pressure relief)