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105 Cards in this Set
- Front
- Back
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Where are common locations for pressure ulcers?
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bony prominences
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Where are common locations of venous ulcers?
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above the ankle
on the medial lower leg |
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Where are common locations for arterial ulcers
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lower leg, dorsum of the foot, malleolus, toe joints, lateral border of the foot
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What are common locations for diabetic/neuropathic ulcers?
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plantar surface of foot, metatarsal heads, heels, lateral border of foot
(many of the same places as arterial) |
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What is a pressure ulcer
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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
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Pressure Ulcer: Stage I
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nonblanchable erythema
intact skin with non-blanchable redness of a localized area usually over a bony prominence darkly pigmented skin may not have visible blanching, but its color may differ from the surrounding tissues |
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What may a pressure ulcer stage I feel like?
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may be painful, firm, warmer or cooler as compared to adjacent tissue
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What do you do to check if there's a stage I pressure ulcer?
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change position and if it still has a nonblanchable reddness, then it's a stage one
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What is the best time to treat a pressure ulcer?
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stage one
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Pressure Ulcer: Stage II
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partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough
May present as an intact or open/ruptured serum-filled blister |
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Do you have an open area in stage II?
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yes
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What is the depth of a stage II pressure ulcer?
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nothing beyond 0.2 cm
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Can you use stage II to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation?
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no
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What do you do if you can't see the bottom of the wound (wound base)
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you cannot stage it
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What is a maceration from?
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sitting in a wet environment
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Do you have an open area in stage II?
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yes
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What is the depth of a stage II pressure ulcer?
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nothing beyond 0.2 cm
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Can you use stage II to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation?
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no
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What do you do if you can't see the bottom of the wound (wound base)
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you cannot stage it
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What is a maceration from?
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sitting in a wet environment
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What is an excoriation from?
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moisture site
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Pressure Ulcer: Stage III
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*full thickness tissue loss
*subQ fat may be visible but bone, tendon, or muscle are not exposed *slough may be present but does not obscure the depth of tissue loss *may include undermining and tunneling *bone-tendon is not visible or directly palpable |
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What stage is bone/tendon visible and directly palpable?
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stage IV
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What is the depth of a Stage III?
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greater than 0.2 cm, but you are not able to see bone/tendon
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Pressure Ulcer: Stage IV
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*full thickness tissue loss with exposed bone, tendon, or muscle
*sloud or eschar may be present on some parts of the wound bed *often includes undermining or tunneling *exposed bone/tendon is visible or directly palpable |
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Pressure Ulcer: Unstageable
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full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, black) in thewound bed
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What colors are slough?
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yellow, tan, gray, green or brown
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What colors are eschar?
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tan, brown, or black
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What must you do in order to stage an unstageable pressure ulcer?
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remove enough slough and/or eschar to expose the base of the wound, as well as the true depth
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What stages must be reported to the state?
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stage 3, 4, or unstageable
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Pressure Ulcer: Suspected Deep Tissue Injury
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purple or maroon localized area of discolored intact skin or blood-filled blister due to damange of underlying sotft tissue from pressure and/or shear
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What may precede a suspected deep tissue injury?
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tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue
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What must be done with a suspected deep tissue injury?
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it MUST be caught early, then it may be able to be reversed
otherwise, it may break open and cause death |
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What may occur with pressure ulcers (tip of the iceberg)
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may get worse before it gets better
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What is reverse staging of pressure ulcers?
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once the ulcer is staged, that remains the stage and would severity diagnosis
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What would you call a pressure ulcer that was staged as a stage III and now appears to be a stage II after it has begun healting?
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a healing Stage III pressure ulcer
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What is a venous ulcer?
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lesion caused by insufficient backflow of blood into the venous system, failure of calf muscle pump to improve venous return, and bacflow causes capillary distenstion, fluid extravasation, tissue ischemia leading to ulceration and decreased delivery of oxygen and nutrients to the skin caused by capillary fibrin cuffing and white cell trapping
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What can be done to support venous blood flow?
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compression therapy
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What is the main cause of a venous ulcer?
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valve incompetence in perforating veins
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What will you feel like with a venous ulcer?
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tired when active and resting makes it better
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What will you feel like with an arterial ulcer?
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better when feet are down and active; hate resting
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Arterial ulcer
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lesion caused by narrowing and eventual occlusion of the extremity artery
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What do a lot of arterial ulcers look like?
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precise lesions
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What is neuropathy
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a chronic complication fo diabetes in which the nerves have been damaged so the person's foot is primarily insensate and does not feel pressure, injuries, or infection
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What are partial-thickness wounds?
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shallow, involves the epidermins and dermis, moist, painful, pink-red color, up to 0.2 cm
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Full-Thickness wound
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*extends to subcutaneous layer or deeper: over 0.2 cm depth
*may include necrotic tissue or infection *often extensive tissue damage |
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When is pressure ulcer documented?
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on admission
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What length of the ulcer do you measure
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the longest length in cm measured from head to toe (12:00-6:00)
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What width of the ulcer to you measure?
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longest width in cm measured from side to side (9:00-3:00)
the widest portion that is still perpendicular |
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What is the wound depth
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distance from visible skin surface to wound bed
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How can you assess wound depth
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by using a clean cotton-tipped applicator or a cm measuring device placed in the deepest part of the wound, marking it, and then measuring it upon removal
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What is a sinus tract/tunnel?
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channel that extends from any part of the wound through subcutaenous tissue or muscle
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How do you document a tunnel?
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measuring depth and noting location using face of clock as a guide
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Undermining
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Tissue destruction that occurs under intact skin around the wound perimeter
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How do you document/measure undermining?
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measure depth and note location using face of the clock as a guide
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Necrotic tissue
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tissue that has died and lost is physical properties and biologic activity
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Eschar
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black or brown necrotic, devitalized tissue
*can be loose or firmly adherence, hard, soft or boggy |
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If eschar is one the heels and hard, firm, well attached and has no sign of infection, what do you do?
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leave it
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If the heel is boggy, draining and has infection what do you do?
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remove it
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Slough
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soft, moist, avascular (necrotic or devitalized) tissue
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What may slough look/feel like?
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white, yellow, tan or green
loose or firmly adherent slippery |
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Granulation tissue
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deep pink/ red moist tissue comprised of new blood vessels, connective tissue, fibroblasts, and inflammatory cells that fill an open wound when it starts to heal
*surface is granular, berry like or cobblestone in appearance |
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Clean, non granulating tissue
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absence of granulation on wound surface
*appears smooth and red but not granular, berry like or cobblestone appearing |
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Epithelial tissue
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regenerated epidermis across the wound surface
*pink color and dry appearance |
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How do you describe hte amount of tissue in the wound bedd
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a transparent measuring guide with concentric circles dividing into four pie shaped quadrants that can help to determine percentage of wound involved
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Exudate
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drainage of the wound
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Blood exudate
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thin, bright red
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serous exudate
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thin, watery, clear
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Serosanguineous exudate
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think, watery, pale red to pink
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purulent exudate
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thin or thick and opaque tan to yellow
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foul purulent exudate
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thick, opaque yellow to green with offensive odor
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No exudate
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wound tissues dry
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Scant exudate
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wound tissues moist; no measurable exudate
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Small exudate
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wound tissues wet; moisture evenly distributed in wound; wound drainage invovles less than or equal to 25% of the dressing
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Moderate exudate
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wound tissues saturated; drainage may or may not be evenly distribuated in wound
drainage involves great than 25% to less than or equal to 75% of dressing |
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Large exudate
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wound tissues bathed in fluid; drainage freely expressed; may or may not be evenly distributed in wound; drainage involves over 75% of dressing
**get moisture off of the wound! |
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What is amount of exudate important?
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when choosing dressing and what compression therapy to use
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What do you do before assessing a wound?
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clean it first, use deodorizer in the air and then smell clean wound to see if it smells
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What do you do if you think the wound smells
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ensure that its the wound and not the dressing that smells
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What is induration
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firm skin that goes in
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What are some conditions that may happen to the periwound skin?
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callus, maceration, edema, skin color surrounding wound, peripheral tissue induration, temperature
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What do you do for venous insufficiency ulcers?
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compress
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What do you do for arterial ulcers?
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open up circulation
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What is important for diabetic ulcers?
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get the right footwear! Find a place that measures and fits the foot!
get footwear as seamless as possible where you're able to move the toes |
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What should you do before debridement?
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make sure the patient has been provided pain relief
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What are some conditions that may happen to the periwound skin?
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callus, maceration, edema, skin color surrounding wound, peripheral tissue induration, temperature
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What do you do for venous insufficiency ulcers?
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compress
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What do you do for arterial ulcers?
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open up circulation
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What is important for diabetic ulcers?
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get the right footwear! Find a place that measures and fits the foot!
get footwear as seamless as possible where you're able to move the toes |
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What should you do before debridement?
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make sure the patient has been provided pain relief
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What do you check in wound before healing?
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dead tissue
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How do you remove necrotic tissue?
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pulse lavage, soften tissue, ultrasound mist, debride
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What are local factors?
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presence of devitalized tissue, moistness of the wound bed (not wet but moist), presence of bacterial infection
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What are some systemic factors
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age, bodybuild, stress, diabetes, previous medical history, oxygen, nutrition, steroids, prealbumin
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What can build up protein/albumin?
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whey protein
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What do you do before getting a would culture?
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clean the would with saline, then once clean, twirl applicator along wound and into depth/ tunnel to get a good sample
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What are some objectives to treatment
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protect from further trauma, optimal and moist environment, remove devitalized tissue, optimal systemic conditions
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What can you do to protect pressure ulcers?
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pressure relief and patient movement
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What can do you do protect venous ulcers?
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compression
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What can you do to protect arterial ulcers?
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restore circulation
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What can you do to protect diabetic ulcers?
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offload
wear shoes any time out of bed |
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What are some ways to maintain optimal moist healing environment?
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wound hydration and dressing selection
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What can you do for debridement?
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surgical, sharp, enzymes, polyurethane dressings, irrigations, wet to moist dressings
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What are some optimal systemic conditions for healing?
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nutritional status, diabetes control, stress, patient and family involvement, oxygen, sterois
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What is the most effective treatment for pressure ulcers?
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PREVENTION
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