what are some intrinsic risk factors for wounds
- nutrition/hydration
- medication
- infection
- incontinence
- immobility (calf mm)
- co morbid disease
what are some extrinsic risk factors for wounds
mechanical forces
- pressure
- shear
- friction
- moisture
how do you classify an acute wound
- surgical/non surgical
- burn first-fourth
how do you classify a chronic wound
- venous ulcer
- arterial ulcer
- diabetic ulcer
- pressure ulcer
what is the location of diabetic foot ulcer
- plantar forefoot
- plantar toes/heel
- DIP/PIP (dorsal)
what are characteristics of a diabetic foot ulcer
- high bacterial load
- painless
why is a diabetic foot ulcer painless
due to neuropathy
how is a diabetic foot ulcer graded
Wagner Grade
Wagner 0
- pre ulceration
- healed ulcer
- bony deformity
Wagner 1
Superficial ulcer w/o subcutaneous involvement
Wagner 2
- thru subcutaneous
- may expose bone, tendon, ligament, joint capsule
Wagner 3
osteitis, abscess or osteomyelitis
Wagner 4
digit gangrene
Wagner 5
foot gangrene
where are pressure ulcers located
wound over bony prominence
how do you determine the severity of pressure ulcer
Stage I - IV
deep tissue injuries
Pressure Ulcer Stage 1
unblanchable erythema
Pressure Ulcer Stage 2
- partial thickness
- thru epidermis
- 100% pink
- intact blister
Pressure Ulcer Stage 3
- full thickness
- into dermis
- damage/necrosis of tissue
Pressure Ulcer Stage 4
- extensive destruction
- exposed mm, tendon, bone
when do you determine a pressure ulcer is unstageable
covered by black eschar
Deep tissue injury is identified as
discoloration
partial thickness is defined as
loss of epidermis and down into but not thru the dermis
examples of partial thickness wound
- abrasions
- skin tears
- blisters
- skin graft
characteristics of partial thickness wound
100% pink
NO NECROSIS
full thickness is defined as
thru the dermis, into the subcutaneous tissue
may have exposed structures
arterial and venous ulcers are graded as
partial and full thickness
what is the location of arterial ulcers
- wound on dorsal foot/toes
- lateral leg
how do you determine the severity of arterial ulcer
partial or full thickness
what are some characteristics of arterial ulcer
- dry
- painful
- ischemic LE
what position should you place a arterial ulcer in
let it dangle to promote blood flow
what is the location of venous ulcer
- b/w the knee and ankle
- medial is more common
how do you determine the severity of venous ulcer
partial or full thickness
what are some characteristics of venous ulcer
- irregular border
- heavily draining
- edematous LE
what techniques help determine wound dimension
- two dimensional (L x W)
- three dimensional (LxWxD)
- tracings
- planimetry: visual imaging
how do you describe the depth of a wound
- undermining
- tunneling
undermining
tissue loss parallel to skin surface
tunneling/sinus tracts
tissue loss into depths of the wound
Epibole
Wound edges are rolled
exudate
wound drainage containing dead cells and debris
how do you describe the amount of drainage
- none
- scant/small
- moderate
- large
- copious
how do you describe the color of drainage
- serous
- serosanguineous
- sanguineous
- purulent
serous
clear
serosanguineous
blood tinged
sanguineous
bloody drainage
purulent
brown, green, white
sweet odor
pseudomonas
foul odor
anaerobic bacteria
periwound erythema
red and warm
periwound induration
firmness to tissue
Periwound maceration
too moist
Periwound echymotic
bruised
periwound cyanotic
bluish skin indicative of ischemia
what is edema
the presence of fluid in the intracellular tissue space
how do you describe edema
- pitting
- non pitting
how to grade pitting edema
0= not present 1 = minimal 2+= moderate 3+= severe
how do you measure edema
- volumetric
- girth
volumetric
water displacement
girth
measurements at determined intervals
what does LOPS stand for
Loss of protective sensation
how do you check if sensory loss is suspected
monofilament
what size monofilament is used as an indicator for risk of DFU
5.07 monofilament
describe the categories for LOPS
0= no loss
1= loss of protective
2= loss of protective w/ high pressure, poor circulation
3= hx of plantar ulceration, neuropathetic fx, amputation
neuropathic fx
charcot foot
what is the relationship b/w temp and ulceration
change in temp greater than 4 deg = risk of ulcer
a pulse grade of 1+
barely felt
a pulse grade of 2+
diminished
when she you address and document pain
when pain is rated > 3
the plan of care must include
procedure location parameters duration frequency
what indicates if pressure, diabetic foot, and venous ulcer is unlikely to progress to healing
if it does not reduce in size 30-50% in 2-4 weeks
what is an example of expected outcome
- increase granulation
- decrease necrosis
- decrease wound size
STG or LTG
pt will be independent with dressing change in 2 wks for pt. convenience thru reduction of office visit
STG
STG or LTG
secure diabetic offloading footwear to decrease risk of DFU recurrence from high to low in 12 weeks
LTG
according to the article when should a wound be reassessed
- after a pt. returns from operating room
- noticeable deteriorates
- odor or purulent exudate
- any change in condition
- after pt. returned form another facility
granulation tissue
deep pink or red is characterized by an irregular granular surface that resembles raspberries
clean nongranulating tissue
deep pink or red and smooth (nongrannular) or striated (when muscle fibers are exposed)
new epithelial tissue
light pink or slightly lavender and dry
healing wounds are characterized
increasing amounts of granulation tissue and later by epithelialization
what signifies a wound in a inflammatory phase
significant amounts of slough or eschar
according to the article what is epibole
a common complication of chronic wounds that include pre mature closure of the wound edges preventing epithelialization and wound closure
how are closed wound edges characterized
dry, normally pigmented skin that extends to the junction with the wound bed
what are signs of heavy bioburden
- sudden deterioriration in quantity or quality of granulation tissue that is edematous, pale, and nongranular
- persistent high volume wound exudate and increased pain
when are clean but not granulating wounds seen
end of the inflammatory phase, when debridement is complete but granulation tissue has not began forming
are all ulcers staged
only pressure ulcers
not arterial, venous, neuropathy
how long should you delay staging
until the deepest viable tissue layer is exposed
wound healing by primary intention key assessment factors
- approximation by 3rd post op day
- drainage
- evidence of infection
- presence of palpable healing ridge along the incisions
what does the presence of palpable haling ridge indicate
granulation tissue formation
normally palpable by 5th post op day
wound healing by secondary intention key assessment factors
- location
- dimensions/depth
- tunneling/undermining
- stage
- appearance of wound base
- status of wound edges
- evidence of heavy bioburden
- status of surrounding tissue
If your pt is post surgery would their wound be considered acute or chronic?
acute
If your pt has diabetes and suffers from ________________ they may not feel pain, and therefore may not be aware of a wound
neuropathy
If your pt’s wound (pressure ulcer) has exposed tendon and bone w/ extensive destrustion, how would it be staged?
stage 4
When would you stage a pressure ulcer as a Deep Tissue Injury?
If there is discoloration, and clear damage below the wound (no visible)
If your patient presents w/ cool hairless legs w/ a wound on their lateral lower limb you would suspect which type of ulcer?
arterial ulcer
If your patient presents w/ tree trunk legs and LE swelling w/ an ulcer on their medial LE you would suspect which type of ulcer?
venous ulcer
Your pt comes to you with a wound and they report that the wound on their lateral LE is dry and very painful. Which Ulcer do you suspect?
arterial ulcer
Your pt comes to you with a wound and they report large swollen LE, a wound w/ irregular borders, and wound location on their medial LE. Which ulcer do you suspect?
venous
Which wound length and width measurement has the best inter-rater reliability?
longest length x longest width
What is undermining? And what causes it?
When the ulcer perimeter is not the true perimeter of the wound; due to shear forces
What is a common standardized method to measuring wound dimensions?
clock method
What kind of wound are you more likely to find undermining and tunneling?
pressure ulcers
What is tunneling?
Tissue loss into the depths of the wound creating a tunnel
What may need to occur on a wound that has unattached edges? Why?
Surgical Debridement; So keritinocytes can do their job
How would hypergranulation tissue present on a pt?
When the beefy red granulation tissue grows outside the wound boundaries
In order to check exudate/drainage what do we look at?
the bandage
Where do we palpate LE pulses?
dorsalis pedis and post tib
What needs to be included when you photograph a wound?
pt. initial, date, wound location
What factors should be considered for predicting wound healing?
duration, size, comparison to documentation
What are the primary goals for wound healing?
- increase granulation tissue
- decrease necrosis
- decrease wound size
- educate pt./caregiver