Week 4 - Pressure Ulcers Flashcards
(119 cards)
1
Q
- An injury to living tissue caused by a cut, blow, or other impact, typically one in which the skin is cut or broken.
- Costly to treat
- Impact on quality of life
A
WOUND
2
Q
A type of ulcer in which localized areas of prolonged ischemia of soft tissue that occur when pressure applied to the skin over time greater than the normal capillary closure pressure.
A
Pressure Ulcers (Decubitus Ulcer)
3
Q
An open sore on an external or internal surface of the body, caused by a break in the skin or mucous membrane that fails to heal.
A
Ulcer
4
Q
How often should a client’s skin be assessed?(4)
A
All clients should be assessed for skin integrity: – On admission – On a weekly basis – Following a change in health status – Before transfer or discharge
5
Q
What are some risk factors in developing a wound?
A
- Immobility
- Friction and shear
- Increased moisture (I.e. Incontinence, perspiration)
- Altered nutritional status (I.e. Deficiencies, anemia)
- Motor/sensory dysfunction
- Impaired cognition
- Decreased tissue perfusion (I.e. DM, obese)
- Splints, restraints etc.
- Critically ill
- Advanced age
- Medications
6
Q
What is the goal for promoting skin integrity?
A
Goal is to reverse risk factors and causes; to prevent and treat wounds
7
Q
What is a example of a susceptible area in developing a pressure ulcer?
A
Weight bearing prominences at risk due to small amount of subcutaneous tissue
8
Q
Resistance to movement that occurs when two surfaces are moved across each other
A
Friction
9
Q
An applied force or pressure exerted against the surface and layers of the skin as tissues slide in opposite but parallel planes.
- Created by interplay of gravitational forces & friction
A
Shear
10
Q
Where in the body are friction and shear most susceptible?
A
Sacrum and heels most susceptible
11
Q
Likely or liable to be influenced or harmed by a particular thing.
A
Susceptible
12
Q
An assessment tool for determining a patient’s risk level for incurring skin breakdown.Braden Scale
A
Braden Scale
13
Q
- Areas assessed in the Bradn Scale. (7) include:
A
sensory perception moisture activity mobility nutrition friction and shear (SMAMNFS)
14
Q
Braden Scale Score indicates level of risk of skin breakdown:
- 9 or less- ______
A
very high risk
15
Q
Braden Scale Score indicates level of risk of skin breakdown:
- 10-12 – _______
A
high risk
16
Q
Braden Scale Score indicates level of risk of skin breakdown:
- 13-14- _______
A
moderate risk
17
Q
Braden Scale Score indicates level of risk of skin breakdown:
- 15-16 _____
A
mild risk
18
Q
Assess the pressure ulcer(s) initially for: (8)
A
- Stage/Depth
- Location
- Surface Area (length x width)
- Odour
- Sinus tracts/Undermining/Tunneling
- Exudate
- Appearance of the wound bed
- Condition of the surrounding skin (periwound) and wound edges
19
Q
- when a wound diameter is wider at its base (deep in the wound) than at the wound’s skin edge.
- the wound is spread out underneath the skin that surrounds the visible part of the sore.
A
Undermining
20
Q
- when the wound tracks under the skin to another opening in the skin OR to a deeper cavity.
- Sometimes referred to as a “sinus” or “tract”.
A
Tunneling
21
Q
Redness or inflammation of the skin
A
Erythema
22
Q
Breakdown of tissue as a result of moisture
A
Maceration
23
Q
Healing by the growth of epithelium
A
Epithelization
24
Q
Draining or oozing of fluid
A
Exudate
25
Containing pus
Purulent
26
Tissue that is being shed
Slough
27
Dead tissue
Necrotic
28
Scab or dry crust
Eschar
29
Pink fleshy projections that form during the healing process
Granulation
30
- Pressure Ulcer Stage?
•Area of erythema on intact skin
•Erythema does not whiten with pressure
•Skin temperature elevated (because of the increased vasodilation)
•Tissue swollen and congested
•Patient complains of discomfort
•Erythema progresses to dusky blue-gray (the result of skin capillary occlusion and subcutaneous weakening)
Stage I
31
- Pressure Ulcer Stage?
•Skin breaks- involves epidermis, dermis or both
•Abrasion, blister or shallow crater (superficial)
•Edema
•Ulcer may drain
•Infection may occur
•Pressure off loading by positioning
Stage II
32
```
- Pressure Ulcer Stage?
•Full thickness skin loss involving ulcer extending into subcutaneous tissue
•Necrosis and drainage
•Infection often develops
•Deep crater with no undermining
•Specialty beds often required
```
Stage III
33
- Pressure Ulcer Stage?
•Ulcer extends to underlying muscle and bone
•Extensive destruction, tissue necrosis or damage to muscle, bone and supporting structures (tendons etc.)
•Deep pockets of infection develop
•Necrosis and drainage develop
•Goal of treatment
Stage IV
34
- Pressure Ulcer Stage?
•If you can’t see the wound base the wound is labeled stage X in your documentation
•Once the eschar is removed, it can be properly staged
•If healing is not the goal, keep eschar dry and intact; it is done by painting with betadine solution and frequent incontinence care.
•If healing is the goal, skin grafts are usually done after debridement and stabilizing patient and wound.
Stage X
35
If you can’t see the wound base the wound is labeled stage ___ in your documentation
X
36
Once the ___ is removed in a stage X pressure ulcer, it can be properly staged.
eschar
37
If healing is not the goal, keep eschar dry and intact; it is done by painting with _____ and frequent incontinence care.
betadine solution
38
If healing is the goal, skin grafts are usually done after ____ and stabilizing patient and wound.
Debridement
39
- refers to a surgical procedure to move tissue from one site to another on the body, or from another person, without bringing its own blood supply with it.
Grafting
40
Open area or tunneling under the edge of a wound
Undermining
41
Types of Exudates
* Serous:
* Sanguineous:
* Serosanguineous:
* Purulent:
42
Type of Exudate
- Clear ,watery plasma with visual
absence of pus, blood and debris
Serous
43
Type of Exudate
- Bloody drainage, appears entirely
composed of blood
Sanguineous
44
Type of Exudate
| - Blood mixed with clear fluid
Serosanguineous
45
Type of Exudate
- Pus-like appearance,
cloudy, thick
Purulent
46
Wound base assessment - Color (3)
A) Black - eschar/ necrotic - cleanse & debride
B) Yellow - fibrin or slough - cleanse & debride
C) Pink/Red - granulation - protect
47
The wound base is "Black" what does it mean? What should the nurse do?
eschar/ necrotic - cleanse & debride
48
The wound base is "Yellow" what does it mean? What should the nurse do?
fibrin or slough - cleanse & debride
49
The wound base is "Pink/Red" what does it mean? What should the nurse do?
granulation - protect
50
Nursing Diagnosis for Pressure Ulcer.
| r/t (6)
```
Risk for impaired skin integrity
R/T:
•Immobility
•Decreased sensory perception
•Decreased tissue perfusion
•Decreased nutritional status
•Friction and shear forces
•Increased moisture etc.
```
51
Nursing Interventions for Pressure relief: (2)
–Frequent position changes and turning Q1-2H
| –Teach patient to reposition self regularly and to shift weight Q15min
52
Nursing Interventions for Positioning:(3)
–Q2H, 30 degree lateral preferred
–Avoid positioning on bony prominences
–Pillows and cushions may be needed
53
Nursing Interventions for Skin Care (4)
–Never massage reddened areas
–Minimize irritating moisture
–Wash skin with mild soap
–Barrier ointments/creams may be helpful
54
Nursing Interventions for Nutritional Status
* Select foods high in Protein, Zinc, Vitamin A, C & E
* Nutritional supplements may be required
* Administer multivitamin as ordered
* Consult dietician
55
In pt with risk for skin impairment, what nutrients are needed?
Protein, Zinc, Vitamin A, C & E (PZACE)
56
Choice of Dressing Balances: (4)
–Moisture
–Bacterial load
–Temperature
–Protection
57
Signs too Little Moisture(5)
* Base non glistening
* Grey in colour
* Dressing sticks to base
* Some products are still dry
* No break through outer dressing
58
Signs of too Much Moisture(5)
* Base spongy
* Base after dressing removed - floods
* Maceration
* Dressing changed two to three times a day
* Can’t see base when using transparent film
59
Factors in Choosing a Product(Dressing) - (7)
* Stage of wound
* Appearance of wound base and borders
* Exudate and odour
* Sinus tract/infection
* Necrotic tissue
* Age of wound
* Type of skin of patient
60
Dressing Types (6)
* Transparent dressing
* Gauze
* Telfa
* Hydrocolloidal
* Hydrogel
* Calcium Alginates
61
Type of Dressing
–E.g. Op-site, Tegaderm
– Reduces risk of infection by providing a protective barrier, waterproof
– Protects from friction injury and is a barrier to bacteria
– Allows the skin to breathe
– Allows direct visualization
– Stays in place, easy to remove
– Molds to awkward places
– Can be left in place up to 7 days
– Stage I
– Never used on open wounds as a primary dressing
Transparent dressing
62
Type of Dressing
| - loosely woven or synthetic
Gauze
63
Type of Dressing
| - nonadherent sterile plastic coated gauze
Telfa
64
Type of Dressing
- dressing for moderate amounts of exudate
- Interacts with wound fluid to provide a moist environment (Venous ulcers, pressure ulcers, diabetic ulcers, 1st and 2nd degree burns)
- Absorbency and film dressing (Highly absorbent gel (polyurethane), Oxygen and water vapor permeable)
- Adhesion and elasticity
- Bacterial barrier
- Allows for autolytic debridement
- Can stay in place for up to 3-5 days or until seal broken
Hydrocolloidal
65
Type of Dressing
| - dehydrates necrotic tissue in order to debride it
Hydrogel
66
Type of Dressing
- hydrophilic
- a sterile or non-sterile device intended to cover a wound and to absorb exudate.
- Indicated for bleeding and/or exudating wounds
- Helps stop bleeding after debridement
- Absorbs exudate
- Put in dry; should come out as gel
- Packed lightly into a wound since it expands in size
- Protect periwound
- Flush out well
Calcium Alginates
67
Removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue.
Debridement
68
Examples of Hydrocolloidal Wound Dressing
* Replicare, Cutinova hydro (Smith & Nephew)
* Comfeel (Coloplast)
* Tegasorb (3M)
* DuoDERM (ConvaTec/CVL)
* NU-DERM (J&J)
69
```
Type of Wound Dressing
•Indications:
–Mildly exudating wounds, clean wounds, partial thickness wounds; it applies pressure and removes scabs
•Absorbs 5 times own weight
–Hydrophilic polysaccharide particles
•Cooling soothing effect
•Facilitates autolytic debridement
•Delivered in many forms
–Amorphous gel, Sheets
•Can stay in place for 24 hours
•Need to protect peri-wound to reduce maceration
```
Hydrogel
70
Debridement Methods (6)
* Selective debridement
* Nonselective
* Autolytic
* Enzymatic
* Mechanical
* Sharp/surgical
71
Debridement Method
| • removal of only nonviable tissue.
Selective debridement
72
Debridement Method
| • removal of both nonviable and viable tissue and may prolong healing.
Nonselective debridement
73
not able to develop, grow, or survive.
Nonviable
74
Debridement Method
- process by which the body’s leukocytes and proteolytic enzymes digest nonviable tissue and debris from the wound bed. Selective process.
Autolytic
75
Debridement Method
| - application of prescriptive topical enzymes to nonviable tissue to breakdown devitalized collagen.
Enzymatic
76
Debridement Method
- removal of devitalized tissue by physical forces that are nonselective and maybe painful .
–E.g. wet-to-dry dressings and high pressure wound irrigation.
Mechanical
77
Debridement Method
| - Removal of nonviable selective tissue by a physician or specially trained or certified wound care nurse.
Sharp/surgical
78
```
Device that uses negative pressure to
pull edges of wounds together
• Creates healing by:
–Promotes granular tissue formation
–Removes fluid
–Improves circulation
–Decreases bacterial burden
• Requires airtight seal
• Changed 3x a week
• Used in highly exudating wounds
```
Vacuum Assisted Closure Device (VACD)
79
Second most common type of nosocomial infection
Wound Infection
80
All ______ are considered contaminated with bacteria and infection inhibits wound healing
Chronic skin wounds
81
_______ often have deep pockets of infection
Extensive pressure ulcers
82
Wound infections can progress to infection in (4)
- bone (osteomyelitis), joints (pyarthrosis), sepsis and septic shock
83
Infection in the bone.
Osteomyelitis
84
Infection in the joints
Pyarthrosis
85
Infection in the whole body
Sepsis
86
Signs of wound infection (7)
```
• Delayed healing/dehisence
• Increased wound pain
• Malodour
• Abscess/sinus formation
• Localized swelling/ redness/ heat
• Increased exudates/ purulent discharge
• Pyrexia/Fever
• C&S swab (but may test negative if not taken properly)
• Appearance of infection:
–Contaminated or traumatic wound: 2-3 days
–Surgical wound: 4-5 days post-op
```
87
Prevention of Wound Infections (5)
* Ongoing wound assessment
* Proper wound cleansing and dressing technique
* Removal of non-viable tissue, debris etc.
* Application of topical antimicrobial agents if ordered
* Use of dressing material that changes wound pH (I.e. Silver or iodine based products)
88
Improvement of host factors that contribute to infection: (5)
1. Poor tissue perfusion
2. Poor nutritional status
3. Local edema
4. Immunocompromising drug/conditions
5. Smoking and alcohol use
89
The process of a body delivering blood to a capillary bed in its biological tissue.
Perfusion
90
Ulcers that result from rupture of small skin veins and subsequent ulcerations related to arterial or venous disease
- Occur when inflamed necrotic tissue sloughs off
- Inadequate oxygen and nutrient delivery to tissue is factor that leads to cell death
- Ulcers are often chronic and difficult to heal.
- May recur
Stasis Ulcers
91
Manifestations of Arterial Stasis Ulcers (5)
```
–Intermittent claudication
–Continuous acute pain
–Small, circular, deep ulcerations
–Location- tips of toes, lateral 5th toe, medial side of hallux
–Gangrene may be present
```
92
Muscle pain caused by too little blood flow during exercise.
Intermittent Claudication
93
occurring at irregular intervals; not continuous or steady.
Intermittent
94
occurs when tissue dies (necrosis) because its blood supply is interrupted.
Gangrene
95
Manifestations of Venous Stasis Ulcers (6)
```
–Pain- aching, heaviness
–Ankle/foot edema
–Location-medial or lateral malleolous
–Superficial, irregular shape
–Heavy drainage
–Discoloration of ulcer area
```
96
Assessment & Diagnostics for Stasis Ulcers: (4)
```
•Need to identify cause of ulcer
•Pulse of lower extremities
•Wound assessment
•Diagnostic tests:
–Doppler and duplex ultrasound studies
–Arteriography
–Venography
–Cultures of ulcer bed for infection
–If not healing in 12 weeks, biopsy of wound edge
```
97
Diagnostic tests for Stasis Ulcers
```
– Doppler and duplex ultrasound studies
– Arteriography
– Venography
– Cultures of ulcer bed for infection
– If not healing in 12 weeks, biopsy of wound edge
```
98
* Device used to detect a weak peripheral pulse by magnifying pulsatile sounds from the heart and blood vessels
* Position the person supine
* Legs externally rotated
* A couple drops of gel is used.
* Apply light pressure
Doppler Ultrasonic Stethoscope
99
- the ratio of the blood pressure in the lower legs to the blood pressure in the arms.
•Use Doppler stethoscope to determine the extent of peripheral vascular disease.
•Apply a regular arm blood pressure cuff above the ankle and determine the systolic pressure in either the posterior tibial or dorsalis pedis artery.
•Ankle systolic pressure/Arm systolic pressure = ABI
•Normal ankle pressure is slightly
greater than or equal to brachial
pressure, ABI 1.0 to 1.2
Ankle-Brachial Index (ABI)
100
Formula for ABI
Ankle systolic pressure/Arm systolic pressure = ABI
101
Normal ankle pressure
Slightly greater than or equal to brachial
| pressure, ABI 1.0 to 1.2
102
Management of Stasis Ulcers (6)
* To reduce venous stasis and prevention of ulcerations
* Antigravity measures to improve venous blood return
* Elevation of leg regularly during day
* Activity such as walking
* Compression of superficial veins with TEDs
* Protection of limb from injury
103
Pharmacological Management of Venous Ulcers
•Pharmacological therapy:
–Antibiotics if wound infected
–Oral preferred, topical not proven to be effective
104
Non-pharmacological Management of Venous ulcers (6)
- Wound care, appropriate dressing choice & wound care specialists
- Debridement to promote healing by cleaning & draining necrotic tissue (Types: sharp surgical, nonselective with wet-to-dry dressings, enzymatic ointments, debriding agents, calcium alginate dressings)
- Nutritional therapy
- Compression therapy
105
If there is no decrease in the size of a wound in _____, wound management needs to be reassessed.
3 weeks
106
Factors in the treatment of stasis ulcers?
Wound status and amt of exudate
107
(Brand of compression) may each be left on up to 2 – 3 days if swelling is controlled and there is no slippage creating more pressure.
Comprilan® or Surepress®
108
(Brand of compression) may be changed 2 – 3 times a week, but after a couple of weeks of treatment, it can be left on for 7 days.
Profore®
109
When daily changes are required, ______ will guide the type of bandage being used.
cost effectiveness
110
Profore Compression Bandage has 4 layers.
1. Orthopedic wool
2. Cotton layer
3. Elastic layer
4. Cohesive layer
111
Goals in Venous Ulcers (4)
–Restore skin integrity
–Improve physical mobility
–Adequate nutrition (high in protein, vitamins, iron, zinc)
–Absence of complications (infection, gangrene)
112
Nursing interventions for a patient with impaired skin integrity: (9)
1) Relieving pressure
2) Improving mobility
3) Improving Sensory perception
4) Improving tissue perfusion
5) Improving nutritional status
6) Reducing friction and shear
7) Minimizing irritating moisture
8) Promoting pressure ulcer healing
9) Preventing recurrence
113
Nursing Interventions for promoting wound healing.
Changing the dressing
2. maintaining normal body temperature
3. managing gastrointestinal function
4. resuming nutrition
5. promoting bowel function
6. managing voiding
7. maintaining a safe environment
8. providing emotional support to the patient and family
9. managing potential complications: DVT, Hematoma, Infection, wound dehiscence and evisceration
114
Collection of blood outside the blood vessels
Hematoma
115
_____ is the simplest method to use next to the wound bed and cover it with gauze. It maintains a moist environment can be left in place for several days and does not disrupt the capillary bed when removed.
Tegapore
116
_____are good to promote granulation tissue and re-epithelialization. They also provide a barrier for protection because they adhere to the wound bed and surrounding tissue
Hydrocolloids
117
_______, it is a skin product cultured from human dermal fibroblasts and keratinocytes, it interacts with the patient’s cells to stimulate the production of growth factors
Simulated healing tissue-engineered human skin (SHT-EHS)
118
______ it involves placing the patient into a chamber that increases barometric pressure while the patient is breathing 100% oxygen. The edema in the wound area is decreased because high oxygen tension facilitates vasoconstriction and enhances the ability of leukocytes to phagocytize and kill bacteria. HBO is thought to increase diffusion of oxygen to the hypoxic wound, thereby enhancing epithelial migration and improving collagen production. Common side effects are ear barotraumas and confinement anxiety
Hyperbaric Oxygenation (HBO)
119
Nursing interventions for a patient who has leg ulcers (4)
1) Restoring skin integrity, if it is arterial insufficiency a referral is made, if venous insufficiency dependent edema can be avoided by elevating the lower extremities
2) Improving physical mobility
3) Promoting adequate nutrition
4) Promoting home and community based care
