Week 8- Pressure ulcers/ dressing Flashcards Preview

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Flashcards in Week 8- Pressure ulcers/ dressing Deck (72):

Who experiences a loss of skin integrity?

Patients confined to bed for long periods, patients with motor or sensory dysfunction, and patients who experience muscular atrophy and reduction of padding between the overlying skin and the underlying bone are prone to pressure ulcers.


What is a pressure ulcer (related to cap closure pressure)?
Who is at risk for this?
What is the initial sign of pressure?

localized areas of infarcted soft tissue that occur when pressure applied to the skin over time is greater than normal capillary closure pressure (25 to 32 mm Hg)

Critically ill patients= lower capillary closure pressure and are at greater risk for pressure ulcers.

The initial sign of pressure is erythema caused by reactive hyperemia, which normally resolves in less than 1 hour.


What contributes to the development of pressure ulcers (list)?

Immobility, impaired sensory perception or cognition, decreased tissue perfusion, decreased nutritional status, friction and shear forces, increased moisture, and age-related skin changes all contribute to the development of pressure ulcers.


Of the 7 contributing factors to pressure ulcers, how does Immobility contribute to development? Where are the most susceptible areas?

Weight-bearing bony prominences are most susceptible to pressure ulcer development because they are covered only by skin and small amounts of subcutaneous tissue.

Susceptible areas:
sacrum and coccygeal areas
ischial tuberosities
greater trochanter
medial condyle of the tibia
fibular head


Of the 7 contributing factors to pressure ulcers, how does Sensory Perception or Cognition contribute to development?

Patients with sensory loss, impaired level of consciousness, or paralysis may not be aware of the discomfort associated with prolonged pressure on the skin and therefore may not change their position themselves to relieve the pressure.

Also... I THINK they may not be able to say when they're wet and may have less control of bladder


How does Decreased Tissue Perfusion contribute to the development of pressure ulcers? What three types of patients are at higher risk and why?

Any condition that reduces the circulation and nourishment of the skin and subcutaneous tissue increases the risk of pressure ulcer development.
Patients with diabetes mellitus experience an alteration in microcirculation.
Similarly, patients with edema have impaired circulation and poor nourishment of the skin tissue.
Patients who are obese have large amounts of poorly vascularized adipose tissue.


How does Altered Nutritional Status contribute to the development of pressure ulcers? Which vitamin and other nutritional elements are especially important?

Nutritional deficiencies, anemias, and metabolic disorders.
Anemia decreases the blood’s oxygen-carrying ability and predisposes a patient to pressure ulcer formation.
Patients who have low protein levels or who are in a negative nitrogen balance experience tissue wasting and inhibited tissue repair.
Serum albumin is a sensitive indicator of protein deficiency; lowered serum albumin levels are associated with hypoalbuminemic tissue edema and increased risk of pressure ulcers.
Vitamin C and trace minerals, are needed for tissue maintenance and repair


How does friction and shear contribute to development of pressure ulcers? What are f and s? and what area is the most susceptible to this type of skin damage?

Friction is the resistance to movement that occurs when two surfaces are moved across each other.
Shear is created by the interplay of gravitational forces and friction.
When shear occurs, tissue layers slide over one another, blood vessels stretch and twist, and the microcirculation of the skin and subcutaneous tissue is disrupted.
The sacrum and heels are most susceptible to the effects of shear.


How does increased moisture contribute to development of pressure ulcers? What is a complication?

Prolonged contact with moisture from perspiration, urine, feces, or drainage produces maceration (softening) of the skin.
The lesion may continue to enlarge and extend deep into the fascia, muscle, and bone, with multiple sinus tracts radiating from the pressure ulcer.
May result in sepsis.


What are Gerontological Considerations of development of pressure ulcers?

Older adults: reduced skin elasticity, decreased collagen, and muscle/tissue atrophy.
Polypharmacy and concomitant medical conditions may affect wound healing.
Decreased inflammatory response, little subcutaneous padding over bony prominences and decreased nutritional intake


How does the nurse assess a patient's risk for pressure ulcers?

The nurse assesses the patient’s mobility, sensory perception, cognitive abilities, tissue perfusion, nutritional status, friction and shear forces, sources of moisture on the skin, and age.
The nurse performs the following:
• Assesses the total skin condition at least twice a day
• Inspects each pressure site for erythema
• Assesses areas of erythema for a blanching response
• Inspects for dry skin, moist skin, and breaks in skin
• Determines the presence of incontinence
• Notes any drainage and odour
• Evaluates the level of mobility
• Notes restrictive devices (e.g., restraints, splints)
Evaluates circulatory status (e.g., peripheral pulses, edema)
• Assesses the neurovascular status
• Evaluates the nutritional and hydration status
• Reviews the patient’s record for laboratory studies, including hematocrit, hemoglobin, electrolytes, albumin, transferrin, and creatinine
• Notes any present health problems
• Reviews current medications
Spinal Cord Injury Pressure Ulcer Scale (SCIPUS): is used to measure the risk for pressure ulcer development for individuals with a spinal cord injury who are in a rehabilitation centre


How can the nurse help a patient improve Peripheral Arterial Circulation ?

Arterial blood supply to a body part can be enhanced by positioning the part below the level of the heart.
For the lower extremities: elevating the head of the patient’s bed or by having the patient use a reclining chair or sit with the feet resting on the floor.
The nurse instructs the patient to walk to the point of pain, rest until the pain subsides, and then resume walking
The onset of pain indicates that the tissues are not receiving adequate oxygen, signalling the patient to rest before continuing activity.
Not all patients with peripheral vascular disease should exercise.
Conditions that worsen with exercise include leg ulcers, cellulitis, gangrene, or acute thrombotic occlusions.


Which patients are at risk for vascular compression?

If the arteries are severely sclerosed, inelastic, or damaged, dilation is not possible.


What are some nursing interventions for vascular compression? What is some teaching the nurse can do?

Nursing interventions may involve applications of warmth to promote arterial flow and instructions to the patient to avoid exposure to cold temperatures, which causes vasoconstriction.
A hot water bottle or heating pad may be applied to the patient’s abdomen, causing vasodilation throughout the lower extremities.
Nicotine from tobacco products causes vasospasm, reduces circulation to the extremities.
Emotional upsets stimulate the sympathetic nervous system, resulting in peripheral vasoconstriction.
Crossing the legs for more than 15 minutes at a time should be discouraged because it compresses vessels in the legs.


How can the nurse help to relieve pain associated with reduced perfusion, vascular compression, ulcers?

Analgesic agents such as oxycodone (OxyContin) plus acetylsalicylic acid (Aspirin), or oxycodone plus acetaminophen (Tylenol) may be helpful in reducing pain so that the patient can participate in therapies that can increase circulation and ultimately relieve pain more effectively.


What teaching can the nurse do to help the patient maintain tissue integrity?

Poorly perfused tissues= susceptible to damage and infection. When lesions develop, healing may be delayed or inhibited because of the poor blood supply to the area.
Advising the patient to wear sturdy, well-fitting shoes or slippers to prevent foot injury and blisters may be helpful, and recommending neutral soaps and body lotions may prevent drying and cracking of skin.
Instruct the patient not to apply lotion between the toes because the increased moisture can lead to maceration of tissue.
Feet should be patted dry. Stockings should be clean and dry.
Fingernails and toenails should be carefully trimmed straight across and sharp corners filed to follow the contour of the nail.
Good nutrition promotes healing and prevents tissue breakdown (adequate protein and vitamins is necessary for patients with arterial insufficiency)
Vitamin C is essential for collagen synthesis and capillary development.
Vitamin A enhances epithelialization.
Zinc is necessary for cell mitosis and cell proliferation.
Weight reduction: Obesity strains the heart, increases venous congestion, and reduces circulation


What causes venous insufficiency? What are the clinical manifestations?

Venous insufficiency results from obstruction of the venous valves in the legs or a reflux of blood through the valves.

Clinical Manifestations
Postthrombotic syndrome: by chronic venous stasis, resulting in edema, altered pigmentation, pain, and stasis dermatitis.
symptoms less in the morning and more in the evening.
Stasis ulcers develop as a result of the rupture of small skin veins and subsequent ulcerations.
When these vessels rupture, red blood cells escape into surrounding tissues and then degenerate, leaving a brownish discolouration
The pigmentation and ulcerations usually occur in the lower part of the extremity(medial malleolus of the ankle).


What are Postthrombotic syndrome? Stasis ulcers?

Manifestations of venous stasis
Postthrombotic syndrome: by chronic venous stasis, resulting in edema, altered pigmentation, pain, and stasis dermatitis.
symptoms less in the morning and more in the evening.
Stasis ulcers develop as a result of the rupture of small skin veins and subsequent ulcerations.
When these vessels rupture, red blood cells escape into surrounding tissues and then degenerate, leaving a brownish discolouration


Where do ulcers and pigmentation usually occur in a venous ulcer?

The pigmentation and ulcerations usually occur in the lower part of the extremity(medial malleolus of the ankle)


what are the complications of venous stasis?

Venous ulceration is the most serious complication
Cellulitis or dermatitis


what are the interventions of venous stasis?

Elevating the leg, and compression of superficial veins with graduated compression stockings.
The legs should be elevated frequently throughout the day (at least 15 to 30 minutes every 2 hours).
At night, the patient should sleep with the foot of the bed elevated about 15 cm.
Compression of the legs with graduated compression stockings reduces the pooling of venous blood, enhances venous return to the heart, and is recommended for people with venous insufficiency.
It is recommended that stockings with 30 to 40 mm Hg pressure be used during the first year post-DVT
Each stocking should fit so that pressure is greater at the foot and ankle and then gradually declines to a lesser pressure at the knee or groin.
Stockings should be applied after the legs have been elevated for a period, when the amount of blood in the leg veins is at its lowest.
skin is kept clean, dry, and soft.


What is a leg ulcer and what are the manifestations?

Leg Ulcers
A leg ulcer is an excavation of the skin surface that occurs when inflamed necrotic tissue sloughs off.
Clinical Manifestations
The symptoms depend on arterial or venous in origin
The severity of the symptoms depends on the extent and duration of the vascular insufficiency. The ulcer itself appears as an open, inflamed sore. The area may be draining or covered by eschar (dark, hard crust).


What are arterial ulcers?

Arterial Ulcers
Chronic arterial disease is characterized by intermittent claudication (a condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries.)
If the onset of arterial occlusion is acute, ischemic pain is unrelenting and rarely relieved even with opioids.
Arterial ulcers are small, circular, deep ulcerations on the tips of toes or in the web spaces between the toes.
Ulcers often occur on the medial side of the hallux or lateral fifth toe and may be caused by a combination of ischemia and pressure
Arterial insufficiency may result in gangrene of the toe (digital gangrene), which usually is caused by trauma.
Débridement is contraindicated in these instances.
Managing dry gangrene is preferable to débriding the toe and causing an open wound that will not heal because of insufficient circulation.
Dry gangrene of the toe in an elderly person with poor circulation is usually left undisturbed.


Where do arterial ulcers usually occur?

Arterial ulcers are small, circular, deep ulcerations on the tips of toes or in the web spaces between the toes.
Ulcers often occur on the medial side of the hallux or lateral fifth toe and may be caused by a combination of ischemia and pressure


What are venous ulcers?

Chronic venous insufficiency is characterized by pain described as aching or heavy.
The foot and ankle may be edematous.
Ulcerations are in the area of the medial or lateral malleolus (gaiter area)
Typically large, superficial, and highly exudative.
Patients with neuropathy frequently have ulcerations on the side of the foot over the metatarsal
Heads (painless).


What type of pain is associated with arterial ulcers?

Chronic arterial disease is characterized by intermittent claudication (a condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries.)
If the onset of arterial occlusion is acute, ischemic pain is unrelenting and rarely relieved even with opioids.


What type of pain is associated with venous ulcers?

Chronic venous insufficiency is characterized by pain described as aching or heavy.


Where do venous ulcers usually appear and what is their general appearance?

Ulcerations are in the area of the medial or lateral malleolus (gaiter area)
Typically large, superficial, and highly exudative.


What are the assessment and diagnostics for ulcers?

The pulses of the lower extremities (femoral, popliteal, posterior tibial, and dorsalis pedis) examined.
Conclusive: Doppler and duplex ultrasound studies, arteriography, and venography.
Cultures of the ulcer bed may be necessary to determine whether an infecting agent is the primary cause of the ulcer.


What are the therapies for ulcers? (pharmacological, compression, debridement)

Pharmacologic Therapy
Antibiotic therapy is prescribed when the ulcer is infected
Oral antibiotics usually are prescribed because topical antibiotics have not proven to be effective for leg ulcers.
Compression Therapy
The patient should be instructed to wear the stockings at all times except at night and to reapply the stockings in the morning before getting out of bed.
Short stretch elastic wraps, Unna boots, and CircAids may be other effective options.
Flush the area with normal saline solution or clean it with a noncytotoxic wound-cleansing agent (Saf-Clens, Biolex, Restore).
If this is unsuccessful, débridement may be necessary.
Débridement: removal of nonviable tissue from wounds.
Removing the dead tissue is important, particularly in instances of infection.


what are the different types of debridement?

Débridement can be accomplished by several different methods:
• Surgical débridement is the fastest method and can be performed by a physician, skilled advanced practice nurse, or wound–ostomy–continence nurse in collaboration with the physician.
• Nonselective debridement can be accomplished by applying isotonic saline dressings of fine-mesh gauze to the ulcer. When the dressing dries, it is removed (dry), along with the debris adhering to the gauze. Pain management is usually necessary.
• Enzymatic debridement with the application of enzyme ointments may be prescribed to treat the ulcer.
The ointment is applied to the lesion but not to normal surrounding skin. Most enzymatic ointments are covered with saline-soaked gauze that has been thoroughly wrung out. A dry gauze dressing and a loose bandage are then applied. The enzymatic ointment is discontinued when the necrotic tissue has been débrided, and appropriate wound dressing is applied.
• Calcium alginate dressings may be used for débridement when absorption of exudate is needed.
These dressings are changed when the exudate seeps through the cover dressing or at least every 7 days. The dressing can also be used on areas that are bleeding, because the material helps stop the bleeding. As the dry fibres absorb exudate, they become a gel that can be painlessly removed from the ulcer bed. Calcium alginate dressings should not be used on dry or nonexudative wounds.
Foam dressings may be an option for exudative wounds because they absorb exudate into the foam, keeping the wound moist.


When can the nurse start using dressings on an ulcer?

After the circulatory status has been assessed and determined to be adequate for healing (ABI of more than 0.5), surgical dressings can be used to promote a moist environment.


What are Semiocclusive or occlusive wound dressings good for?

Semiocclusive or occlusive wound dressings prevent evaporative water loss from the wound and retain warmth


When determining the appropriate dressing to apply, the following should be considered: 1, 2, 3, 4, 5 ?

simplicity of application,
frequency of required dressing changes,
ability to absorb wound drainage,
expense, and
patient comfort.


What are some different types of wound therapy (dressings)? *warning the answer is very long... don't suspect to get them all ;) *

Available options that promote the growth of granulation tissue and reepithelialization include the hydrocolloid
These materials also provide a barrier for protection because they adhere to the wound bed and surrounding tissue.

Semipermeable film dressings (e.g., Bioclusive,OpSite, Tegaderm) may be selected because they keep the wound moist and don’t let bacteria pass while allowing some gas exchange. may not be effective treatment for deep wounds and infected wounds.

Stimulated Healing
Tissue-engineered human skin equivalent (e.g., Apligraf [Graftskin]) is a skin product cultured from human dermal fibroblasts and keratinocytes used in combination with therapeutic compression. It interacts with the patient’s cells within the wound to stimulate the production of growth factors. Application is not difficult, no suturing is involved, and the procedure is painless.

Hyperbaric oxygenation (HBO) may be beneficial as an adjunct treatment in patients with diabetes with no signs of wound healing after 30 days of standard wound treatment.
HBO is accomplished by 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.
The two most common adverse effects of HBO are middle ear barotrauma and confinement anxiety

Negative Pressure Wound Therapy
Research findings suggest that negative pressure wound therapy using vacuum-assisted closure (VAC) devices decreases time to healing in complex wounds that have not healed in a 3-week period
Ambulatory patients may be given the small, portable VAC devices that can be strapped around the waist, giving patients the freedom to perform their ADLs.


What does the assessment include for patients with leg ulcers?

The extent and type of pain
appearance and temperature of the skin of both legs.
The quality of all peripheral pulses is assessed, compared.
edema, degree of edema
limitation of mobility and activity
nutritional status is assessed
history of diabetes, collagen disease, or varicose veins?


What are potential complications for leg ulcers?

Potential Complications
• Infection
• Gangrene


What are the nursing interventions for leg ulcers?

Restoring Skin Integrity
Cleansing: a mild soap, and lukewarm water.
Dependent edema can be avoided by elevating the lower extremities.
Protective boots may be used (e.g., Rooke Vascular boot); they are soft and provide warmth and protection from injury and displace tissue pressure to prevent ulcer formation.
relieve pressure on the heels
a bed cradle can be used to relieve pressure from bed linens and to prevent anything from touching the legs.
Heating pads, hot water bottles, or hot baths are avoided

Improving Physical Mobility
physical activity is initially restricted to promote healing.
When infection resolves: ambulation should resume
If pain limits the patient’s activity, analgesic agents may be prescribed.

Promoting Adequate Nutrition
A diet that is high in protein, vitamins C and A, iron, and zinc I

Promoting Home and Community-Based Care
The self-care program is planned with the patient so that activities that promote arterial and venous circulation, relieve pain, and promote tissue integrity are encouraged.


What are the expected outcomes for a patient with leg ulcers?

Expected patient outcomes may include:
1. Demonstrates restored skin integrity
a. Exhibits absence of inflammation
b. Exhibits absence of drainage; negative wound culture
c. Avoids trauma to the legs
2. Increases physical mobility
a. Progresses gradually to optimal level of activity
b. Reports that pain does not impede activity
3. Attains adequate nutrition
a. Selects foods high in protein, vitamins, iron, and zinc
b. Discusses with family members dietary modifications that need to be made at home
c. Plans, with the family, a diet that is nutritionally sound


Which population comprises 50-75% of lower extremity amputations?

people with diabetes :(


What are the complications of diabetes that contribute to the increased risk of foot infections ?

• Neuropathy: Sensory neuropathy leads to loss of pain and pressure sensation, and autonomic neuropathy leads to increased dryness and fissuring of the skin (secondary to decreased sweating). Motor neuropathy results in muscular atrophy, which may lead to changes in the shape of the foot.
• Peripheral vascular disease: Poor circulation of the lower extremities contributes to poor wound healing and the development of gangrene.
• Immunocompromise: Hyperglycemia impairs the ability of specialized leukocytes to destroy bacteria, lowered resistance to certain infections.


For a diabetic ulcer, what is the typical series of events that lead to it? What types of injury often occur?

The typical sequence of events in the development of a diabetic foot ulcer begins with a soft tissue injury of the
foot, formation of a fissure between the toes or in an area of dry skin, or formation of a callus.

Injuries may be:
thermal (e.g., from using heating pads, walking barefoot on hot concrete, or testing bath water with the foot),

chemical (e.g., burning the foot while using caustic agents on calluses, corns, or bunions),

traumatic (e.g., injuring skin while cutting nails, walking with an undetected foreign object in the shoe, or wearing ill-fitting shoes and socks).


What is typically the first sign of a foot ulcer the diabetic patient notices? What are some treatments (brief)?

Drainage swelling, redness (from cellulitis) of the leg or gangrene may be the first sign of foot problems that the patient notices.

Treatment of foot ulcers involves bed rest, antibiotics, and débridement.
Controlling glucose levels which increase when infections


What are some high risk characteristics of developing diabetic ulcers?

Some of the high-risk characteristics include the following:
• Duration of diabetes more than 10 years
• Age older than 40 years
• History of smoking
• Decreased peripheral pulses
• Decreased sensation
• Anatomic deformities or pressure areas (e.g., bunions, calluses, hammertoes)
• History of previous foot ulcers or amputation


What is the nursing management for diabetic ulcers? patient teaching?

Pt teaching
The feet must be inspected on a daily basis for any redness, blisters, fissures, calluses, ulcerations, changes in skin temperature, and the development of foot deformities (i.e., hammertoes, bunions).
Patients with neuropathy should also undergo evaluation of neurologic status using a monofilament
device by an experienced examiner
Patients with pressure areas, such as calluses, or thick toenails
should see the podiatrist routinely for treatment of calluses
and trimming of nails.
Additional aspects of preventive foot care that are taught to the patient and family include the following:
• Properly bathing, drying, and lubricating the feet, taking care not to allow moisture (water or lotion) to accumulate between the toes
• Wearing closed-toe shoes that fit well.


What are occlusive dressings? (types of dressings card set)

Occlusive Dressings
Occlusive dressings may be commercially produced or made inexpensively from sterile or nonsterile gauze squares or wrap.
Occlusive dressings cover topical medication that is applied to a skin lesion.
Plastic surgical tape containing a corticosteroid in the adhesive layer can be cut to size and applied to individual lesions.
Generally, plastic wrap should be used for no more than 12 hours each day.


What are wet dressings?

Wet Dressings
Wet dressings (i.e., wet compresses applied to the skin) were traditionally used for acute, weeping, inflammatory lesions.
Almost obsolete in light of the many newer products available for wound care.


What are moisture-retentive dressings? Some types? **warning lots of information on answer**

Moisture-retentive dressings can perform the same functions as wet compresses but are more efficient at removing exudate because of their higher moisture-vapour transmission rate
A number of moisture- retentive dressings are already impregnated with saline solution, petrolatum, zinc-saline solution, hydrogel, or antimicrobial agents, thereby eliminating the need to coat the skin to avoid maceration.
The main advantages of moisture-retentive dressings over wet compresses are improved fibrinolysis, accelerated epidermal resurfacing, reduced pain, fewer infections, less scar tissue, gentle autolytic débridement, and decreased frequency of dressing changes.
Most moisture retentive dressings remain in place from 12 to 24 hours; some can remain in place as long as a week.

Types of Moisture-retentive dressings:

Hydrogels are polymers with a 90% to 95% water content.
They are available in impregnated sheets or as gel in a tube.
Their high moisture content makes them ideal for autolytic débridement of wounds.
Semitransparent, allowing for wound inspection without dressing removal.
Hydrogels are appropriate for superficial wounds with high serous output, such as abrasions, skin graft sites, and draining venous ulcers.

Hydrocolloids are composed of a water-impermeable, polyurethane outer covering separated from the wound by a hydrocolloid material.
They are adherent and nonpermeable to water vapour and oxygen.
As water evaporates over the wound, water is absorbed into the dressing, which softens and discolours with the increased water content.
can be removed without damage to the wound.
As the dressing absorbs water, it produces a foul-smelling, yellowish covering over the wound.
This is a normal chemical interaction between the dressing and wound exudate and should not be confused with purulent drainage from the wound.
Hydrocolloid dressings are opaque, limiting inspection of the wound without removal of the dressing.
Available in sheets and in gels, hydrocolloids are a good choice for exudative wounds and for acute wounds.
Easy to use and comfortable
Promote débridement and formation of granulation tissue.
They do not have to be removed for bathing.
Most can be left in place for up to 7 days.
Foam Dressings
Foam dressings consist of microporous polyurethane with an absorptive hydrophilic (water-absorbing) surface that covers the wound and a hydrophobic (water-resistant) backing to block leakage of exudate.
They are nonadherent, require a secondary dressing to keep them in place.
Moisture is absorbed into the foam layer, decreasing maceration of surrounding tissue.
A moist environment is maintained, and removal of the dressing does not damage the wound.
The foams are opaque and must be removed for wound inspection.

Foams are a good choice for exudative wounds.
especially helpful over bony prominences, provide contoured cushioning.

Calcium Alginates
Calcium alginates are derived from seaweed and consist of tremendously absorbent calcium alginate fibres.
They are hemostatic and bioabsorbable and can be used as sheets, mats, or ropes of absorbent material.
As the exudate is absorbed, the fibres turn into a viscous hydrogel.
They are quite useful in areas where the tissue is more irritated or macerated.
The alginate dressing forms a moist pocket over the wound while the surrounding skin stays dry.
The dressing also reacts with wound fluid to form a foul-smelling coating.
Alginates work well when packed into a deep cavity, wound, or sinus tract with heavy drainage.
They are nonadherent and require a secondary dressing.


How do you treat pressure ulcers (this is related to the red, yellow, black system)

Treating pressure ulcers:
Complete vascular assessment to determine appropriate therapy
Universal classification for wounds is RYB (red, yellow, black)
Surface appearance
Red is granulation tissue (protect)
Yellow is slough (cleanse)
Black is necrotic (debride)

Red is usually late regeneration phase of tissue repair and need to be protected to avoid disturbance ( gentle cleansing, protect with alcohol free barrier film, fill dead space with hydrogel and cover with appropriate dressing and change infrequently)

Yellow are usually liquid slough that is accompanied with purulent drainage (cleanse to remove non-viable tissue and exudate (wet to damp dressing), irrigate , abs dressings antimicrobial, if cant remove with cleansing move to debridement)

Black are thick necrotic tissue (debride except with foot ulcers with dry schar, must be removed before wound can heal)


What are the four types of debridement?

4 types of debridement:
Sharp (scalpel)
Mechanical (manual)
Chemical (enzymes )
Autolytic (dressings to promote self digestion)


What are the reasons for dressing a wound? (8 listed)

Protect wound form mechanical injury

Protect from MO contamination

Provide or maintain moist wound healing

Provide thermal insulation

Absorb drainage or debride

Prevent hemorrhage

Splint or immobilize

Psychological comfort


What are transparent films (uses, when to avoid)? (types of dressings)

Superficial wounds and skin breaks with minimal damage to maintain moist healing

Non porous, self adhesive UP to 7 DAYS

Can assess wound thru them

Wound remains moist and retains serous exudate to support epithelial growth and also supports autolytic debrid.

Reduces risk of infection

Do not use with yeast infection will make it worse!

only adhere to skin around wound

Can shower it

Can be removed without damage


What are hydrocolloid dressings (uses, when to use, etc)?

Provide wound hydration and are frequently used with wounds with minimal drainage and not needing debridement
Can fit difficult areas
Do not need cover dressing
Can shower them
3-7 days
Mold to uneven surfaces
Abs moderate drainage
Temporary skin/ block MO
Decrease pain
Contain wound odor
Occlusive and opaque
Characteristic odor
Facilitate anaerobic bact growth do not use with any kind of infection
Difficult to remove, residue on skin


What are the steps of a wound assessment?

Steps of a wound assessment:

Location: Note the anatomic position of the wound on the body.

Type of wound: If possible, note the etiology of the wound (i.e., surgical, pressure, trauma).

Extent of tissue involvement: Full-thickness wound involves both the dermis and epidermis. Partial-thickness wound involves only the epidermal layer.

Type and percentage of tissue in wound base: Describe the type of tissue (i.e., granulation, slough, eschar) and the approximate amount.

Wound size: Follow agency policy to measure wound dimensions, which includes width, length, and depth.

Wound exudate: Describe the amount, color, and consistency. Serous drainage is clear like plasma; sanguineous or bright red drainage indicates fresh bleeding; serosanguineous drainage is pink; and purulent drainage is thick and yellow, pale green, or white.

Presence of odor: Note the presence or absence of odor, which may indicate infection.

Periwound area: Assess the color, temperature, and integrity of the skin.

Pain: Use a validated pain assessment scale to evaluate pain.


What are signs that the patient may have a wound infection?

If there is an increase in the amount and consistency of the drainage and if there is new presence of odor, these factors may indicate a wound infection; and a wound culture is often necessary to support appropriate antibiotics


What are the procedural steps to a wound assessment? (warning LONNNNNG)

Procedural steps:
1.) Determine agency-approved wound assessment tool and review the frequency of assessment. Examine the last wound assessment to use as comparison for this assessment.
2 Assess comfort level or pain on a scale of 0 to 10 and identify symptoms of anxiety.
3 Explain procedure of wound assessment to patient.
4 Close room door or bed curtains and position patient.
a Position comfortably to permit observation of wound in well-lighted room.
b Expose only the wound.
5 Perform hand hygiene and form a cuff on waterproof biohazard bag and place near bed.
6 Apply clean gloves and remove soiled dressings.
7 Examine dressings for quality of drainage (color, consistency), presence or absence of odor, and quantity of drainage (note if dressings were saturated, slightly moist, or had no drainage). Discard dressings in waterproof biohazard bag. Discard gloves.
8 Perform hand hygiene and apply clean gloves. Inspect wound and determine type of wound healing (e.g., primary or secondary intention). A partial-thickness wound heals by reepithelialization, whereas a full-thickness wound heals by the creation of scar tissue and will take longer to heal
10 Use agency-approved assessment tool and assess the following:
a  Wound healing by primary intention (surgical wound):
(1) Assess anatomic location of wound on body.
(2)  Note if incisional wound margins are approximated or closed together. The wound edges should be together with no gaps.
(3)  Observe for presence of drainage. A closed incision should not have any drainage.
(4)  Look for evidence of infection (presence of erythema, odor, or wound drainage).
(5)  Lightly palpate along incision to feel a healing ridge.
The ridge will appear as an accumulation of new tissue presenting as firmness beneath the skin, extending to about 1 cm ( 1 2 inch) on each side of the wound between 5 and 9 days after wounding. This is an expected positive sign
b  Wound healing by secondary intention (e.g., pressure ulcer or contaminated surgical or traumatic wound):
(1) Assess anatomic location of wound.
(2) Assess wound dimensions: Measure size of wound (including length, width, and depth) using a centimeter measuring guide. Measure length by placing a ruler over wound at the point of greatest length (or head to foot). Measure width from side to side. Measure depth by inserting cotton-tipped applicator in area of greatest depth and placing a mark on applicator at skin level. Discard measuring guide and cotton-tipped applicator in a biohazard bag.
(3)  Assess for undermining: Use cotton-tipped applicator to gently probe wound edges. Measure depth and note location using the face of a clock as a guide. The 12 o’clock position (top of wound) would be head of patient, and the 6 o’clock position would be the bottom of the wound toward patient’s feet. Document the number of centimeters that area extends from wound edge (e.g., underneath intact skin).
(4)  Assess extent of tissue loss: If wound is a pressure ulcer, determine the deepest viable tissue layer in wound bed. If necrotic tissue does not allow visualization of base of wound, the stage cannot be determined.
(5)  Notice tissue type, including percentage of tissue intact and presence of granulation, slough, and necrotic tissue.
(6) Note presence of exudate: Amount, color, consistency and odor. Indicate amount of exudate by using part of dressing saturated or in terms of quantity (e.g., scant, moderate, or copious).
(7) Note if any wound edges are rounded toward wound bed; this may be an indication of delayed wound healing. Describe presence of epithelialization at wound edges (if present) because this indicates move- ment toward healing.
(8) Inspect periwound skin: Include color, texture, temperature, and description of integrity (e.g., open mac- erated areas). Periwound assessment gives clues about the effectiveness of the wound treatment and possible wound extension
11Reapply dressings per order. Place time, date, and initials on new dressing.
12 Reassess patient’s pain and level of comfort, including pain at wound site, using a scale of 0 to 10, after dressing is applied.
13 Discard biohazard bag, soiled supplies, and gloves per agency
policy; perform hand hygiene.
14 Record wound assessment findings and compare assessment
with previous wound assessments to monitor wound healing.


What are the four stages of wound healing and why are they important?

Wound Healing 4 stages:
•Homeostasis – first 24hours
•Inflammation – 1-4 days
•Proliferation or granulation – 4-21 days
•Remodeling or maturation – up to 2 years

Why it is important to identify ?•To create the appropriate care plan to promote wound healing•To use the appropriate wound care product that correspond with the treatment plan goal >is it to Heal, To Maintain, To absorb ...) .


What are some wound care products/ examples (7)? (ppt) Note i think the powerpoint might be better than the textbook notes for this week!!

1.Wound Care Cleansers: Examples: normal saline land other antiseptic solutions
2.Wound Hydration Products: Example: Hydrogel 3.Wound Moisture Retention Products: Example Hydrocolloid
4.Exudate Management Products :Example: calcium alginate dressing
5.Anti-Microbial Products: Examples Inadine & Iodosorb
6.Foam Dressing Products :Example : Allevyn Gentle Border
7.Other Special Dressings: odor control, compression therapy. Examples Actisorb Silver 220,Coban wrap & NPWT


What is an acute wound versus a chronic wound?

All wounds start out as acute
Acute wound: wound that heals within an expected time frame ( within 21 days).

Chronic wound : is one in which the normal process of wound healing is disrupted at one or more points in the phases of wound healing (stalling in the healing process).Long duration Recurs frequently. Examples : Pressure ulcers ,Venous ulcers ,Arterial ulcers, Diabetic foot ulcers


What is a stage one pressure ulcer?

Nonblanchable erythema signals potential ulceration
Skin intact


What is a stage 2 ulcer?

Partial-thickness skin loss


What is a stage 3 ulcer?

Full-thickness skin loss to subcutaneous tissue


What is a stage 4 ulcer?

Full-thickness skin loss
Exposed muscle, tendon, or bone


What is an unstageable ulcer?

Ulcer is covered by slough or eschar
Usually requires advanced interventions


Are pressure injuries preventable? How? (PPT)

Most Pressure Ulcers Are Preventable, How ?
Acknowledging the contributing factors:
mechanical loads (friction and shear )
Inadequate nutrition
Fecal and urinary incontinence
Decreased mental status
Diminished sensation
Excessive body heat
Age and the presence of chronic medical issues
Complete the Braden scale on admission and review as needed
HTT on admission/Focus integumentary assessment
Thorough History &Identifying patients with Poor Blood Circulation (Venous Insufficiency, Arterial Insufficiency/ Atherosclerosis & Diabetes)
Assess &Monitor Lab work(Leukocyte count,Hemoglobin level,Blood coagulation studies,Serum protein analysis (albumin level), Results of wound culture and sensitivities


What are lower limb ulcers?

Distinct from pressure ulcers
Can be caused by:
Arterial or venous insufficiency

Assessment and Treatment:
Aided by Doppler ultrasounds
Compression Dressings?
Interdisciplinary Approach


Venous ulcer characteristics ? (ppt)

81% of leg ulcers caused by venous diseases
Dull ache to moderate pain
Irregular ulcer border
May be copious drainage
Pulses present
Bleeds easily
Location: Gaiter area, especially medial malleolus
Why do they happen


What are venous ulcer interventions (ppt)?

Major goals include restoration of skin integrity, improved physical mobility, adequate nutrition, and absence of complications.
Compression of the extremity
Wound Management


What are the characteristics of arterial ulcers? (PPT)

Claudication, painful
Smooth/regular shaped borders
“Punched out”
Minimal drainage
Non bleeding
Pulse weak or not palpable
Pale or black
Location :On or between toes
Heel, Shin, Medial side of hallux


What are interventions for arterial ulcers? (ppt)

Eliminate restrictive clothing.
Protect extremities from cold, heat and trauma.
Elevate head of bed 10-15 cms (4-6 inches) to maintain lower leg position below the level of the heart (Position extremity flat)
Support client to access a supervised exercise program as tolerated; consult with a physiotherapist as needed
Provide proper support surfaces and Wound management


What are the general guidelines for caring for a wound?

Use an Aseptic technique: (When each can be used and why)
Sterile technique
none touch technique
Clean technique
Know hat type of wound you are caring for and what is the goal of the treatment plan
Adhere to the care plan and involve wound care specialist as needed
Use a sterile probe or sterile moistened cotton tipped applicator to measure the depth and determine the direction of cavity wounds, undermining, sinuses/tunnels
As wound heals the products used will change accordingly
Assess the whole patient and not just the hole in the patient
Importance of documentation and patient teaching


What are the principles to maintain a healthy wound bed?

Protect healthy granulation tissue
Provide moist environment
Remove excess exudate and debris and dead tissue
Cleanse with non cytotoxic agents
Prevent infection
Maintain normothermia
Address pain (Patient-Centered Care)
Protect intact surrounding tissue
No “one fits all” treatment or dressing
The dressing changes with the wound
Nursing assessment is “ key”
Thorough documentation is essential