wound care (M 10-13: pressure injuries, debridement, infection and edges, support) Flashcards
(62 cards)
1
Q
pressure injury definition
A
a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction
* can also be due to medical or other device
2
Q
pressure injuries - hospital acquired
A
- HAPI affect about 2.5 million patients/year in US – about 60,000 patients die
- report of data from 2016 – HAPI in US cost > $26.8 billion
3
Q
pressure injury stages
A
- boggy, non-blanchable, warm, red
- skin opening, partial thickness, might not look like much, just abrasion
- full thickness, epibole likely, subcutaneous with no muscle, bone, tendon, tunneling and undermining
- full thickness, can see muscle, bone, tendon, see all the gross things
4
Q
once a pressure injury has been staged
A
- once a pressure injury has been staged, teh stage cannot be reversed
- a stage 4 becomes a healing stage 4
- a stage 3 gets worse and become a stage four and then become a healing stage 4
with the exception of unstageable or DTI pressure injuries
5
Q
pressure injuries and bed rest
A
- pressure injury (decubitus ulcer) is consequence of ischemia and anoxia to tissue
- tissues are compressed, blood vessels are compressed and blood flow is diverted by continual pressure on the skin and underlying structures
- cellular respiration is impaired and cells die
- pressure injuries in hospitalized patients are “never events” (stage 3-4)
6
Q
pressure injuries - where and why
A
- over bony landmarks
- causeative factors
- shear forces
- friction forces
- pressure forces
- moisture
7
Q
pressure forces
A
- intensity versus duration
- prolonged exposure to mild-moderate increase in forces
- short exposure to moderate-severe increase in forces
- but can change patient to patient
8
Q
friction
A
- mechanical force exerted when two surfaces move (rub) against another
9
Q
shear
A
- stress resulting from applied forces which cause two objects to deform in the transverse plane
- invovles both friction and gravity
- body layers are laterally shifted in relation to each other
- skeleton sliding while skin in place
10
Q
pressure areas
A
11
Q
head of bed at [ ] is best for sacrum and heel pressure
A
less than 30 degrees
12
Q
arterial ulcers
A
- location: distal to ankle, usually foot, toes, lateral malleolus
- edges: punched out, well defined
- wound bed: pale or rubor of dependence, skin shiny and thin, hair loss, nail changes common
- periwound: thin and shiny, hair loss and nail chages common
- possible PMH: diabetes, hypertension, smoking, previous vascular disease
- other characteristics: typically dry
- management goals: keep it dry and reduce bioburden
13
Q
venous ulcers
A
- location: lower leg or above ankle, near medial malleolus, feet unlikely
- edges: irregularly shaped
- wound bed: often granulating, with cellular debris and/or crust, usually shallow
- periwound: scaly, dry, hemosiderin staining
- possible PMH: varicose veins, obesity, pregnancy, previous DVT
- other characteristics: typically wet
- management goals: manage moisture
14
Q
pressure ulcers
A
- location: bony prominences, especially sacrum, ischial tuberosity, greater trochanter, heels
- edges: circular or teardrop, well defined
- wound bed: can be pale, granulating, necrotic, or eschar
- periwound: health or red/purple due to pressure
- possible PMH: immobility, SCI, dementia, progressive neurologic disorder, dependent with moblity, bed or WC bound
- management goals: offloading, nutrition, consider stool/urine contamination, debridement
15
Q
neuropathic ulcer
A
- location: plantar surface of foot, toes, heels, metatarsal heads
- edges: callused, well defined
- wound bed: deep and often granulating
- periwound: thick, dry, callused
- possible PMH: diabetes, neuropathy/loss of protective sensation, possible Charcot foot
- management goals: promote granulation and reduce infection
16
Q
skin tears
A
- common in extremes of age (young or old), critically or chronically ill
- may experience increased pain, decreased mobility, decreased quality of life
- particularly problematic in elderly: global prevalence studies show 10-54% in LTC
- caused by shear, friction, and/or blunt force trauma: forces separation of skin layers, can be partial or full-thickness, slow to heal, susceptible to secondary infection
- preventable wounds with high propensity to develop into chronic wounds
17
Q
grading skin tears
A
- type 1: no skin loss – linear or flap tear that can be repositioned over wound bed
- type 2: partial flap loss – partial flap loss that cannot be repositioned to cover the wound bed
- type 3: total flap loss – total flap loss exposing entire wound bed
18
Q
braden scale
A
- risk assessment outcome to determine a patient’s risk of developing pressure ulcers
- common in acute and rehab settings (SNF, IRF, etc)
- most commonly used for patients who are bed- or chair-bound, as well as those with an impaired ability to reposition
- scored on a variety of categories: sensory perception, moisture, acitivity, mobility, nutrition, friction and shear
- scored on a 1-3 or 1-4 scale
- higher score is lower risk of pressure injury development
19
Q
acute vs chronic wounds
A
20
Q
PT roles in wound care
A
- skills and roles to be familiar with: infection, arterial, venous, diabetic/neuropathic ulcer, pressure injury, lymphedema
- populations: post-op, trauma, acute care/ICU, elderly, medically fragile, wheelchair bound, diabetic, frequent falls, high fall risk
21
Q
basic wound assessment
A
- full or partial thickness
- wound type
- location
- stage
- measurements
- wound bed
- wound edges
- drainage
- periwound - general integumentary exam/screening
22
Q
DIMES
A
23
Q
DIMES debridement
A
- purpose: remove necrotic tissue (slough, eschar), remove bacteria to prevent infection, increase ability to assess wound bed
- goal: 100% granulation tissue
24
Q
types of debridement
A
- non-slective/mechanical: wet-to-dry, irrigation, hydrotherapy, abraded technique
- for moderate to extensive necrotic tissue: more potential to bleed, more potential to be dry or add maceration
- selective: autolytic, enzymatic, biosurgical, sharp/surgical
25
wet-to-dry debridement
* non-preferred method
* wet gauze, stick to wound, gauze dries, rip it off
26
irrigation debridement
* use spray to spray high pressure on wound
27
hydrotherapy debridement
* submerge affected body part, jet stream
* hard to clean, requires dependent position, takes a long time
* not super clean
28
abraded technique debridement
* rub wound
* can irritate healthy, intact tissue
29
autolytic debridement
* assists body's cells in digesting necrotic tissue
* most conservative
* for non-infected wounds
* need a good immune system
* stays damp
* occlusive (hydrocolloid): denser material, non-permeable
* transparent (non-occlusive): allows for gas exchange
* hydrogel: wet, put into wound
* medihoney: specific honey from NZ, high osmolarity - bringes water from lower tissues, lowers wound pH
30
enzymatic debridement
* patients can be very sensitive to it
* racts with silver products
* expensive
* santyl
31
biosurgical debridement
* maggots bred specifically for medical use
* eat necrotic tissue, painless for patient, produce ammonia that lowers pH of wound, get rid of biofilm
* can be in bag or "free range" -- works 2x faster when free-range
32
conservative sharp debridement
* what we do as PTs
* scissors, tweezers, scalpel, scraping tools
* need specific orders from MD for sharp debridement -- not just wound care orders
* goal: 100% granulation tissue, eventually over multiple sessions
* no PTAs -- PTAs can do dressing changes, technically non-selective debridement
33
surgical debridement
* MD only
* more aggressive
34
debridement comparisons
35
selective debridement contraindications
* stable heel eschar: if no signs of infection, to protect wound
* gangrene: requires surgical debridement
* unidentified structures: if you don't know, don't touch it
* terminally ill -- is it worth it
* arterial insufficiency (ABI <0.8): debriding something that has no chance to recover
* coagulopathy: INR, PT, PTT, platelets, hemoglobin
36
silver nitrate stick
* cauterizing tissue
* needs prescription
* not the silver that reacts with enzymes
37
what do you need before sharp debridement
| in order
* physician's order
* chart review
* check labs
* gather tools
* pre-medicate as needed
* comfortable positioning for patient and you
* adquate lighting
* cleanse
* measure: paper tape measure, cotton tip applicator
38
before selective debridement, you should
cleanse
* angiocatheter methods: end of IV connected to syinge to spray saline
* skin/wound cleanser
* bulb syringe
39
selective debridement
* cross-hatching: increases surface area for enzymatic debridement -- creating damage to promote growth
* silver nitrate
40
review of debridement types
41
patient's core body temperate for wound healing
* 91.4-107.6
* moisture loss = cooling
* decrease of 2 degrees affects healing: increases risk of infection, inhibited platelet activation, reduction in wound strength due to declining colalgen deposition
42
why would wound temperature decrease
* dressing changes
* wound cleansing
* loose dressing
* inappropriate dressings
* things to consider: decreased frequency of dressing changes -- if possible, consider types of dressing, how long, order of operations of performing dressing change
43
inflammation vs infection
44
infection and cleansing for non-infected wounds vs for infected wounds
* for non-infected wounds: soap and water
* for infected wounds: antiseptic x2 weeks, then wash with water -- for limited use, basically like bleach
* hydrogen peroxide: very limited use, cytotoxic, kills healthy cells
* iodine: very limited use, cytotoxic, not a long-term option
45
why not neosporin
* good when used appropriately
* not for chronic wounds
* allergies to neomycin
* can develop dermatitis
46
moisture in wounds
* complex wounds shouldn't be left open to air
* they require the proper moisture balance and temperature
* if you "leave to open air," it's pretty much done healing
47
moisture associated skin damage (MASD)
maceration, excoriation, denuded
48
periwound and subcutaneous extensions
tunneling
undermining
bogginess
induration
epibole
maceration
49
maceration
* like wet tissue paper
* softening and breaking down of skin due to prolonged exposure to moisture
50
excoriation
* chafing, raw irritated lesion
* linear erosion of the skin by mechanical means (scratching, rubbing)
51
denuded
* loss of epidermis due to exposure to urine, feces, body fluids, wound exudate or friction
52
things to avoid and needs with moisture
* avoid: depends, extra layers (sheets, bed pads)
* needs: toileting schedule, rectal tube
53
passive drains
* air or fluid moves from an area of high pressure to low pressure (often just "gravity assisted")
* penrose, pigtail catheter (typically into a body cavity), gastrostomy, cystostomy, nephrostomy, T-tube
54
active drains
* negative pressure is used
* connected to a collecton device
* Jackson-pratt: longer use, can be bulb or long suction
* hemovac: compressed, usually post-op, 1-3 days
55
tubes
* used to remove air and fluids
* provides decompression
* maintains patency of a lumen
56
adding collagen to a stalled wound
* can be topical
* hyperbaric oxygen -- if non-healing or stalled for 30 days, expensive, try and fail others, for Wagner 3 or higher, non-healing osteomyolitis, crush injuries, non-healing skin flaps
57
PT involvement in DIMES support
* risk assessment
* functional mobility training
* positioning
* pressure redistribution
* exercise
* application of biophysical agents for pain reduction and tissue healing
* direct management of open wounds
58
e-stim in wound care
* 1-125 PPS, 100-300 microsec
59
support for venous wounds
* compression hosiery
* elevation -- higher than heart
* exercise to activate venous pump
* avoid prolonged sitting or standing
* avoid crossing the legs
* skin lubrication
* patients who receive supervised LE exercise programs, counseling on compression adherence and elevation, tend to be more active, achieve faster wound closure, improved venous hemodynamics
* TEDs are for bed: DVT prevention, not edema
60
support for arterial wounds
* critical limb ischemia requires vascular surgery before the wound can heal
* gait training (often NWB)
* education on footwear
* if presenting with dry gangrene: need protection and offleading
* walking programs
* for high compression (40-50 mmHg) or moderate pressure compression (30-40 mmHg) --> ABI > 0.8
* for low to moderate-pressure compression (25-33 mmHg) --> ABI 0.5-0.8
* for low pressure compression (18-24 mmHg) --> ABI > 0.5
* never apply compression if ABI < 0.5
61
support for neuropathic wounds
* gait trianing, equipment, prevention, education (keep toes dry, look at feet every day)
* exercise: exercise at least 5x a week for 30 minutes per session or 150 minutes/week -- strength training 2x/week
* footwear
62
supporting pressure injuries
* causative factors: shear forces, friction forces, pressure forces, moisture
* risk assessment within 6 hours of admission
* skin assessment performed with each repositioning
* strict Q2 turning with clocks
