Pressure Ulcers: Causes, Symptoms, and Treatment, Exams of Nursing

Download Pressure Ulcers: Causes, Symptoms, and Treatment and more Exams Nursing in PDF only on Docsity! Wound certification exam -with 100% verified solutions 2024-2025 tutor verified what are 6 risk factor components of Braden Scale for pressure ulcer? sensory perception, moisture, mobility, activity, nutrition, and shear/friction What is the name of the organization that developed the pressure ulcer staging? NPUAP (national pressure ulcer advisory panel) pathological effect of excessive pressure on soft tissue can be attributed by 3 factors? what are they? tissue tolerance, duration of pressure, and intensity of pressure what are the extrinsic factors that impact pressure ulcers? increase in moisture, friction and shearing how does friction play a role in shearing which eventually leads to pressure ulcer? friction alone causes only superfical abrasion, but with gravity it plays a synergistic effect leading to shearing. When gravity pushes down on the body and resistance (friction) between the patient and surface is exerted, shearing occurs. because skin does not freely move, primary effect of shearing occurs at the deeper fascial level. what are the intrisinc factors of pressur ulcers? nutritional debilitation, advanced age, low BP, stress, smoking, elevated body temperature Aging skin undergoes what elements affecting risk for pressure ulcer? dermoepidermal junction flattens, less nutrient exchange occurs, less resistance to shearing, changes in sensory perception, loss of dermal thickness, increased vascular fragility; ability of soft tisuse to distribute mechanical load w/out comprosing blood flow is impaired What does nonblanching erythema indicate in the skin r/t PU? when pressure is applied to the erythematic area skin becomes white (blanched), but once relieved, erythema returns -indicating blood flow; however in nonblanching erythema, skin does not blanche-indicating impaired blood flow-suggesting tissue destructon why does sitting in a chair pose more of a risk in skin break down than lying? deep tissue injury or PU is likely to occur sooner sitting down because tissue offloading over boney prominences is higher Describe what you will see in deep tissue injury? purple or maroon localized area of discolored intact skin skinor blood filled blister; may be preceded by painful, firm, mushy, or boggy; skin may be warmer to cooler in adjacent tissue. In dark skin, thin blister or eschar over a dark wound bed may bee seen Describe stage I pressure ulcer? Intact skin with nonblanchable redness of localized area. Will not see blanching in dark skin, but changes in skin tissue consistency (firm vs boggy when palpated), sensation (pain), and warmer or cooler temperature may differ from surrounding area Describe stage II pressure ulcer? When are active support surfaces appropriate? when manual frequent repositioning is not possible when are reactive support surfaces appropriate? for pressure ulcer prevention what is a benefit in low air loss feature and when is it contraindicated? low air loss assists in managing mositure. It is contraindicated in patients with unstable spine and it puts patients at risk for entrapment when is an air fluidized feature integrated in bed systems appropriate? for patients with multiple stage III or Iv pressure ulcers, burns, myocutaneous skin flap for what kind of patients are traditional air-fluidized bed not recommended? pulmonary diseases or unstable spine patients what are some general guidelines for caring for patients on a support surface? support surfaces alone doe snot prevent or heal PUs, fuctions best with minimal linens and pads under patients, must be able to assume variety of positions to prevent bottoming out, patients should be turned regardless of support surfaces, patients who sit with a risk for PU should have a sitting plan- duration, position, and posture what type of patient is a lateral rotation feature in a supportive surface beneficial? for patients with acute respiratory conditions- requiring pulmonary hygience what are the 3 essential physical properties for normal venous function? competent valves, venous wall, and calf muscle pump what are the classical characteristic traits seen in venous ulcers? shallow, irregular wound eges, with moderate to heavy exudate, dark red or "ruddy" wound base or thin layer of yellow slough, macerated periwound, crusting, scaling and /or hemosiderin staining Define hemosiderin staining? leakage of RBCs which have been broken down appears as a purple to brown staining Define lipodermatosclerosis? hardening of soft tissue where hemosiderin staining evolves into lipodermatosclerosis- found on gaiter and sock areas and has appearance of inverted champagne bottle Define atrophie blanche? smooth, white plaques of think speckled atrophic tissue with tortous vessels on ankle or foot with hemosiderin pigmented border Define venous dermatitis? characterized by scaling, crusting, weeping, erythema, erosions, and intense itching. Differentiate dermatitis from cellulitis? In cellulitis, patients will often exhibit pain, fever, tenderness, one or few bullae, no relevent history, no crusting, blood cxs usually negative, no lesions anywhere else other than localized area, and high WBC count What factors impede healing in venous ulcers? DM, tobacco, malnutrition, umplanned weight loss, and meds (corticosteroids) What is the most effective managment of CVI? therapeutic compressions (30-40mmHg) What should you do before deciding to tx with compressions? rule out LEAD, by obtaing an ABI What are the interpretations of ABI? ABI of 1.0 is pure LEVD ABI of 0.9 or less is LEAD ABI of 0.5 or less is ischemia What are the attributes of long-stretch compression? same as short stretch except it's elastic (ex. Surepress) what are the attributes of multi-layer compression? sustained, elastic, disposable, and provides therapeutic to modified pressure (ex. 3M w/coban) what are the attributes of paste compression and problems associated with it? sustained, inelastic, disposable, and provides modified level of pressure;lacks absorptive property so skin has tendency to macerate, patients are sensitive to calamine paste, slippage, poor fit, and inablity to bathe. When are compression stockings indicated? only when venous insufficiency is stable and used as maintenace therapy, since compressions are for "life" to prevent venous ulcers what are the goals in treating LEAD? maximizing perfusion, minimizing risk of infection, using evidence-based wound care, and ongoing assessment and managment of ischemic pain What is the gold standard for revascularization of sapenous veins? bypass graft what are the 6 P's in assessing for acute limb ischemia? pulse, pallor, polar (cool), pain, paresthesia(burning and tingling sensation), and paralysis What is the general appearance of LEAD? thin, shiny epidermis, loss of hair growth, thickened nails, edema is variable depending on positioning and coexisting disease; pale or ischemic (purpura and petechiae secondary to blood thinners) What vacular symptoms or perfusion status will you see in LEAD during assessment? diminished ABI and TBI; dimished or absent pulse; delayed capillary refill time; abnormal turbulence of blood flow (aka bruit), depedent rubor or elevational pallor, cool skin What kinds of pain will the patient with LEAD experience and what is the interpretation? patient experiences intermittent claudication with moderate-heavy activity which is relieved by 10 minutes of rest=50% vessel occlusion; experiences nocturnal pain during sleep which is caused by leg elevation and decreased cardiac output- this is relieved by placing limb in dependent position; rest pain occurs in the absence of activity and with legs in dependent position=90% occlusion What are modifiable risk factors for LEAD? what are the lab goals for managing them? tobacco: stop smoking diabetes: HbA1c <7.0 and if possible for high risk patients, <6.0 dyslipidemia (elevation of cholesterol and triglycerides): HDL >40, LDL<100, TG <150 HTN: <140/90 (for DM, <130/80) In presence of arterial occlusion, refill time will be longer than what? in seconds? will take > 2-3 seconds. what are the ABI values and its indicator? >1.3=invalid 1.0-1.3=normal range 0.9 or less=LEAD 0.8-0.6=borderline 0.5 or less=severe ischemia and revascularization needed When should you obtain TcPO2 (transcutaneous partial pressure of O2)? when ABI or TBI cannot be performed d/t calcification or amputation of ankles or toes What are the values of TcPO2 and its interpretation? 40 mmHg or greater=normal <40mmHg=hypoxia w/impaired wound healing When do you use SLP (segmental leg pressure)? used to determine location of occlusion for surgical intervention. a 30mmHg decrease in pressure between two adjacent levels indicate occlusion what happens in motor neuropathy and what do you typically observe? foot muscles atrophy resulting in deformities of toes and foot structure which leads to eneven weight distribution and pressure points ( hammer and claw toes, charcot foot) what happens in sensory neuropathy and what do you typically observe? protective sensation is lost and patients lack awareness of pain and temperature which leads to injury and infection what happens in autonomic neuropathy and what do you typically observe? an involuntary nervous system resulting in loss of sweating and oil production causing skin to be dry. Xerosis leads to fissures, cracks, callus, and ulceration Under the foot risk classification system, what signs connote low risk diabetes and how should you manage the condition to prevent neuropathic ulcers? intact sensation(neuropathy), intact pulse (vasularity), no foot deformities (motor fx). management includes: education r/t disease control, daily inspection of foot, proper shoe wear, early report of foot injuries; annual foot exam and callus removal and nail care prn Under the foot risk classification system, what signs connote moderate risk diabetes and how should you manage the condition to prevent neuropathic ulcers? intact sensation(neuropathy), intact pulse (vasularity), foot deformities present (motor fx). management includes: education r/t disease control, daily inspection of foot, proper shoe wear, early report of foot injuries; depth in-lay footwear, foot exam every 6 months; referral to foot/ankle specialist if deformity is causing pressure and conservative measures failed Under the foot risk classification system, what signs connote high risk diabetes and how should you manage the condition to prevent neuropathic ulcers? absent sensation(neuropathy), absent pulse (vasularity), foot deformities present (motor fx). management includes: education r/t disease control, daily inspection of foot, proper shoe wear, early report of foot injuries; custom footwear, foot exam every 3months; callus maintenance; referral to foot/ankle specialist if deformity is causing pressure and conservative measures failed what are some key things to remember when caring for diabetic foot? daily inspections of foot and shoes, don't soak in water for prolonged period to avoid maceration, avoid nylon socks bc they don't breathe, avoid chemicals for removing corns, never use razor blades, change shoes often to reduce hotspots, see a professional for trimming nails Describe SSSS (staphylococcal scaled skin syndrome)? infectious wound caused by toxins from staph and usually affects healthy children 6 yrs or younger. primary lesion: superficial bullae secondary lesion: superficial scales looks like a burn; avoid adhesive dressings Describe necrotizing fasciitis (aka flesh eating infection)? rapidly progressive and fatal infection of the SQ tissue and fascia accompanied by pain, erythema, crepitous, and sysemic toxicity (bullae, sloughing, gangrene aslo noted). Aggressive surgical debridement and IV abx is required Describe pyoderma granulosum? inflammatory condition of the skin characterized by painful necrosis, ulceration, and vasculitis. Associated with RA and IBS (Crohn's disease) and often occurs on the LE or trunk of the body. wound edges are violaceous w/ undermining and surrounding wound is erythematous and indurated. Tx includes topical steroid ointment, systemic corticosteroids, and Ciclosporin (immunosuppressant); mainstay of tx is immunosuppression; may start out as a pimple and progress to crater Describe phemphigus vulgaris? painful autoimmune disorder that causes blisters on the skin and mucous membranes. blistera are flaccid and ruptures.Mainstay tx is systemic corticosteroids Describe fungating neoplastic wound? mass of malignant cells which have infiltrated the epithelium and surrounding blood vessels and lymph vessels-ulcerating necrois and slough. most frequently reported symptoms are malodour, exudate, bleeding and pain. Tx is usually palliative and may require catuerization w/silver nitrate d/t bleeding or use of charcoal dressing, Chloromycetion solution or metronidazole to control odor. surgical or sharp debridement is not recommended bc of excessive bleeding; instead autolytic or enzymatic debridement is preferred. avoid adhesive dressings and cont to keep wound moist. Describe Calciphylaxis? What are the clinical manifestations of Herpes Simplex? viral condition affecting the genitalia areas (perianal, buttocks, genitals); isolated vesicles rupture and crusts over Differentiate IAD, Cutaneous Candidiasis, and Herpes Simplex from pressure ulcer? types of lesions, medical hx and location of the conditions assist in diagnosing. Whereas IAD and Cadidiasis occurs in skin fold areas, Herpes is found in genitalia while PUs occur over boney prominences. IAD is incontinence related, Candidiasis is associated with moisture issues and Herpes is a STD. Uniqueness of lesions also depicts type of condition. IAD is irregular, denuded, blistering; Candidiasis is confluent, patchy, papular, pustular, cheesy-like exudate; Herpes is isolated blister which eventually ruptures into crust; PUs in stage II may be confused with the alluded conditions in that it's superficial, partial thickness wound that's red w/serous blister whys is albumin and prealbumin an important lab value to know in wound management and healing? lab values indicate potential risk for malnutrition. Protein is needed in growth factors to promote healing. Becasue albumin has a long half life, it foretells muscle wasting/malnourishement which has been chronic. Albumin level <3.5 is malnourished (normal is 3.5-5). Conversely, prealbumin has a short half life of 2 days and indicates acute stage. <19.5 is malnourished (19.5-35.8 normal). What does transferrin lab value a good indicator of? iron deficiency Are the the interpretations of BMI for underweight, normal, overweight, and obesity? > 18.5kg =underweight 18.5-24.9=normal 25-29.9=overweight 30 and > is obesity What % of body weight is considered significant weight loss? 5 % or greater w/in 30 days (1 month) or 10% or greater w/in 180 days (6 months) Which nutritional element is needed for angeogenesis, collagen synthesis/remodeling, immune fx and serves as precursor to nitric oxide and wound contraction? protein How much protein is necessary per kg, for wound healing? 1.25-1.5kg/body weight which vitamin assists in angiogenesis and epithealization? Vitamin A; this also helps with collagen synthesis which vitamin assists in collagen synthesis, immune function, fibroblast function, and enchances activation of leukocytes and macrophages and essential in cell wall integrity? Vitamin C which mineral is needed for protein synthesis? zinc how many calories are needed per kg for sufficiency? 30-35kcal/body weight what lab values help identify patients who are malnourished and need nutritional support for wound healing? weight(<18.5 is underweight, need 30-35kcal/weight, significant weight loss =5% w/in 30 days or 10% w/in 180 days); prealbumin (<19.5=malnourished and 19.5-35.8=normal), and albumin(<3.5 =malnourished and 3.5-5=normal) What the the acroynm TIME used for? used as principle for wound bed preparation What does TIME stand for? tissue, nonviable; infection/inflammation; moisture balance; edge of wound Explain the pathophysiology of moisture balance? dessication slows epithelial cell migration, excessive fluid causes maceration of wound margins; application of moisture-balance dressing, compressions; edema is controlled, epithelial cell migration is restored, maceration avoided what is the difference between selective and nonselective debridement? in selective, only necrotic tissue is removed what are some things to consider when using Dakin's solution? It is used for cleaning, debriding, and controling odor; but it should be used short-term; stop use when infection and odor is under control; viable tissue exposed; used 2x/day; use barrier ointment over periwound what caution should you take in considering conservative sharp or surgical sharp wound debridement? there is potential for transient bacteremia after debridement, particularly wounds that are infected; risk for bleeding, pain what are the 3 general parameter guides for selecting appropriate wound debridement? overall condition and goal of patient; status of wound and urgency in need of debridment; skill level of care provider what product is used for tx of very dry, scaly skin? hyaluronic acid cream when should petrolatum jelly-based products not be used? for prevention or treatment of radiation dermatitis what are some ways to manage radiation dermatitis? use lanolin-free hydrophillic moisturizer, normal saline soaks to provide cooling sensation and loosen crusting, nonadherent dressings What are the characteristic manifestation of Herpes Zoster? begins w/buring pain, followed by erythema that evolves into a grouped unilateral vesicular rash along one or two dermatomes. Pustules form, rupture, and then becomes crusty. Of note, dermatomes are specific skin surface areas innervated by a single spinal nerve group what kind of lesion is an important diagnostic feature in Candidiasis? satellite lesion what are the 2 mechanims for wound healing? regeneration (replacement of damaged or lost tissue with more of the same) or scar formation (replacement of damaged or lost tissue by connective tissue that lacks some fx of original tissue wounds that are confined to epidermal and superficial dermal layers heal by what mechanism and why? regeneration; epithelial, endothelial, and connective tissue can be reproduced wounds that occur deep in the dermal structures, SQ tissue, muscle, tendon, ligaments, and bone heal by what mechanism and why? scar formation; these layers lack capacity to regenerate and therefore loss of these structures are permanent Explain wound healing by primary intention and give an example? In primary intention, wound edges are well approximated and heals by epithealization and connective tissue deposition. surgical incision secured w/staples, surtures, or adhesive tape explain wound healing by secondary intention and give and example? wound edges are not approximated and healing occurs by granulation tissue formation, contraction of wound edges, and epithelialization. chronic wounds such as PU and dehisced incisions explain wound healing by tertiary intentions and give examples? aka delayed primary intention. wound is kept open for several days. superficial wound eges then are approximated, and center of wound heals by granulation tissue formation. abdominla incision complicated by significant infection (deep tissue is healing by graulation and superficial layer of skin is sutured) "red islets" represent what part of the skin layer? basement membrance of the epidermis, which projects deep into the dermis to line the epidermal appendages. Each islets serves as a source of new epithelium why is migration in wound healing delayed when wound is covered w/ a scab? in order to create a moist envinroment, epithelial cells secrete enzymes knwon as MMP (metallproteinases) to lift the scab