NURSING 1: Wounds and Pressure Ulcers – Flashcards
Unlock all answers in this set
Unlock answersquestion
pressure ulcer
answer
-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 -a number of confounding factors are also associated with pressure ulcers -the significance of these factors is yet to be elucidated (made clear)
question
cost of treating the deepest pressure ulcers
answer
$130,000 per ulcer
question
pressure ulcers etiology
answer
-pressure ulcers arise from prolonged tissue ischemia caused by pressure that exceeds tissue capillary pressure
question
baseline arterial skin capillary pressure needed for perfusion
answer
25-30 mmHg
question
venous pressure
answer
5-10 mmHg
question
sacral pressures can reach up to ____mmHg after short periods
answer
70 mmHg
question
if pressure is relieved before a critical time period is reached, tissue perfusion is restored by _______.
answer
vasodilation
question
the bright red flush after extra blood flows to the area to compensate for the ischemia caused by the pressure is called.....
answer
reactive hyperemia
question
The physiological responses to the pressure injury are demonstrated by:
answer
-erythema -heat -edema -pain
question
tissue necrosis
answer
following the initial response to pressure begins to die
question
autolytic debridement
answer
the process initiated by the body to remove the necrotic tissue
question
symptoms of autolytic debridement
answer
-the area of pressure injury becomes cool to touch -may feel boggy or sponge-like -eventually the necrotic tissue liquifies -the ischemic tissue sloughs away
question
anatomical regions prone to pressure injury
answer
-occiput (back of head) -scapula (back of shoulders) -coccyx (butt area) -ischium(butt area) -trochanter (hips) -posterior superior iliac spine(back) -calcaneus (heel) -lateral malleolus (outer ankle)
question
pressure ulcer risk factors
answer
-friction/shear -immobility -inadequate nutrition -moisture (fecal and urinary incontinence) -decreased mental status -diminished sensation -excessive body heat -advanced age -chronic medical conditions
question
pressure ulcers common risk assessment tools
answer
-braden's scale for predicting pressure risk -norton's pressure area assessment form scale
question
what is staging?
answer
staging is an assessment system that classifies pressure ulcers based on anatomic depth of soft tissue damage
question
stages
answer
stage I stage II stage III stage IV unstageable deep tissue injury
question
cutoff score for braden scale at u of m
answer
17
question
stage I
answer
-discoloration -intact skin -non-blanchable redness -area may be painful, firm, soft, warner, cooler than surrounding tissue
question
stage II
answer
-dermis, epidermis -presents as a shallow open ulcer/ red pink wound bed -lack of slough -may also present with a serum filled blister
question
stage III
answer
-subcutaneous -full thickness tissue loss -subQ fat may be visible/ bone, tendon or muscle NOT exposed -slough may be present -may include tunneling/undermining
question
stage IV
answer
-exposed muscle, bone, tendons -full thickness tissue loss -slough or eschar may be present on some parts of wound bed -often include undermining or tunneling
question
unstageable
answer
-has necrotic tissue in it -full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar
question
suspected deep tissue injury
answer
-purple/maroon localized area of discolored intact skin or blood-filled blister -may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler -area where there has been tissue necrosis and the blood vessels have been compromised or dead and then blood leaks out of the damaged capillaries and looks like a deep purple/ red bruise
question
NPUAP's position on reverse staging
answer
DON'T REVERSE STAGE (once a stage IV always a stage IV)
question
undermining
answer
-"Undermining" refers to overhanging skin edges at the margin of the wound, so the pressure ulcer is larger in area at its base than at the skin surface -It is caused by bacterial infection and commonly associated with osteomyelitis -Surgical debridement is absolutely necessary in the presence of undermining
question
maceration
answer
Caused by excessive moisture, Tissue loses its pigmentation (appears lucid or turns white) and becomes soft and friable.
question
epithelialization
answer
healing by the growth of epithelium over a denuded surface.
question
slough
answer
-moist devitalized tissue -necrotic - may be white, yellow, gray, or tan -intervention, debride
question
eschar
answer
-necrotic tissue -leathery black, brown, or gray -debride
question
Pressure ulcers lab data
answer
-albumin/ pre albumin (protein) -Hgb/HHT (hemoglobin/ blood vessels disease) -INR (prothrombin and international normalized ratio) -cultures
question
pressure ulcers documentation
answer
-anatomical location -size of ulcer -stage of ulcer -color of wound bed -presence of eschar -drainage -odor -perimeters of skin
question
how do you document anatomical location?
answer
head to toe
question
how do you document size of ulcer?
answer
length x width x depth in cm
question
how do you document color of wound bed?
answer
% of each color
question
how do you document drainage?
answer
amount and color, type
question
how do you document perimeters of skin?
answer
is it clear, excoriated(damaged), pink, bruised, etc.
question
devices for removing pressure
answer
-gel floatation pads -pillows and wedges -heel protectors -memory foam mattress/chair pad -alternating pressure mattress -static low air loss bed - LAL bed -air fluidized (AF) bed (static high-air loss bed)
question
intentional wounds
answer
trauma that occurs during therapy (surgery)
question
unintentional wounds
answer
-accidental (trauma) -closed or open
question
closed unintentional wound
answer
tissue trauma without break in skin
question
open unintentional wound
answer
skin or mucous membrane open
question
incision
answer
sharp instrument (knife or scalpel)
question
contusion
answer
blow from blunt instrument
question
puncture
answer
penetration by a sharp instrument
question
abrasion
answer
surface scrape, either intentional or unintentional
question
laceration
answer
tissues are torn apart
question
penetrating
answer
penetration of skin and underlying tissue (bullet, metal fragment)
question
clean wounds
answer
-uninfected wounds -minimal inflammation -respiratory, GI, genital, urinary tracts not entered -mostly closed
question
clean-contaminated wound
answer
-surgical wounds in which respiratory, GI, urinary tract has been entered -no evidence of infection
question
contaminated wound
answer
-open, fresh, accidental wounds and surgical wounds involving major break in sterile technique, or large spillage form GI tract -no evidence of inflammation
question
dirty or infected wounds
answer
-wounds containing dead tissue -wounds with clinical infection such as purulent (pus-like)drainage
question
depth: superficial wound
answer
-epidermal area only -usually from shearing, friction
question
depth: partial thickness
answer
-confined to skin -ex. the dermis and epidermis -heal by regeneration
question
depth: full thickness
answer
-involves dermis, epidermis, subQ tissue, possibly muscle and bone -require connective tissue repair
question
depth: penetrating
answer
-wound depth impacts healing time -involves internal organs
question
venous stasis ulcers
answer
-open lesions -damage to valves of vein -usually between knee and ankle
question
arterial wound
answer
-nonpressure related blockage of arterial flow -necrosis -usually over lower leg -wound dry -pale -little drainage
question
diabetic ulcers
answer
-tissue damage -neuropathies -usually plantar surface - ball of foot, or toes
question
wound healing: primary intention
answer
-occurs where the tissue surface have been approximated (closed) -there is minimal or no tissue loss -(ex. surgical incision)
question
wound healing: secondary intention
answer
-extensive and involves considerable tissue loss -edges cannot be approximated - (ex. pressure ulcer)
question
wound healing: tertiary intention
answer
-wounds that are left open for 3 to 5 days to allow edema or infection to resolve or exudate to drain and then are closed
question
phases of wound healing: inflammatory phase
answer
-imitated immediately -lasts 3-5 days -two processes occur during this phase: hemostasis and phagocytosis
question
hemostasis
answer
cessation(ending) of bleeding
question
phagocytosis
answer
the macrophages engulf microorganisms and debris
question
phases of wound healing: proliferative phase
answer
-the second phase -extends from day 3 or 4 to day 21 post-injury
question
phases of wound healing: maturation phase
answer
-begins on about day 21 and can extend to 1 or 2 years
question
fibrin
answer
involved in clotting of blood
question
granulation
answer
-pink to red moist, new blood vessels and connective tissue -protect
question
keloid
answer
a growth of extra scar tissue where the sin has healed after an injury
question
complications of wound healing: hemorrhage
answer
massive bleeding
question
complications of wound healing: infection
answer
-surgery involving intestines -trauma -pt who are immunosuppressed
question
complications of wound healing: dehiscence with possible evisceration
answer
-partial or total rupturing of a sutured wound
question
evisceration
answer
extrusion of viscera outside the body
question
dehiscence
answer
splitting open of wound
question
wound assessment
answer
-anatomical location -size of ulcer -character/color of wound bed -presence of necrotic tissue -exudate -surgical drains
question
exudate
answer
A fluid rich in protein and cellular elements that oozes out of blood vessels due to inflammation and is deposited in nearby tissues
question
surgical drains
answer
-jackson-pratt -hemovac -penrose
question
during measurement of wounds, look for...
answer
undermining and sinus tracts
question
wound exudate: serous
answer
clear serum derived from the blood (fluid in blister)
question
wound exudate: purulent
answer
-thicker -presence of pus or necrotic tissue
question
wound exudate: sanguineous
answer
-frank red blood
question
wound exudate: serosanguineous
answer
clear and blood tinged
question
goals for topical therapy
answer
-remove necrotic tissue -identify and eliminate infection -obliterate dead space -absorb excess exudate -maintain moist wound surface -provide thermal insulation -protect the healing wound
question
debridement
answer
-surgical -mechanical -chemical/ enzymatic -autolysis -biological- maggots, leeches
question
topical treatments
answer
-transparent -hydrocolloid -securing -hydrogels -impregnated -polyurethane foams -alginites -collagen
question
irrigation and packing
answer
-sterile technique used -use piston type syringes -safe, effective pressure -gauze packing: lightly pack wound, used for debridement, absorption
question
additional therapies
answer
-collagen products -silver products -biological agents (skin replacements) -growth factors -keratinocytes -hyperbaric oxygen -electromagnetic therapy -electric stimulation
question
NPWT
answer
negative pressure wound therapy
question
NPWT benefits
answer
-helps promote perfusion -applies controlled, localized, negative pressure to help pull wound edges together -provides a closed, moist wound healing environment -removes excess exudate -helps control bioburden -can be applied to many types of wounds
question
indications for NPWT
answer
-acute or chronic wounds -traumatic wounds -diabetic ulcers -pressure ulcers -flaps, skin grafts
