Download NDNQI Wounds Module 2 Study Guide: Pressure Injuries, Ulcers, and Skin Damage and more Exams Nursing in PDF only on Docsity!
NDNQI Wounds Module 2 Latest Study Guide
Pressure Injury Classification - ** If the deepest type of tissue is visible (or directly palpable), the pressure injury can be classified as Stage 1, 2, 3 or 4. If the deepest tissue is not visible, the pressure injury is classified as unstageable (i.e. deepest tissue obscured by slough or eschar); Deep Tissue Pressure Injury (DTPI) (i.e. deep red, maroon or purple discoloration); or Non-Visible (a special NDNQI category for pressure injuries under non-removable dressings or devices) Pressure injuries on mucosal membranes are counted, but not staged Wound/Skin Injury etiology - ** disease, moisture and trauma Arterial Ulcers - ** A wound caused by impaired arterial blood flow to the lower leg and foot esp. Toes, dorsum of the foot, lateral malleolus, distal lower leg The impairment in blood flow results in tissue ischemia, necrosis, and loss. Arterial Ulcer causes - ** Atherosclerosis Arteriosclerosis History of arterial insufficiency to lower extremities: Peripheral Arterial Disease (PAD) Lower Extremity Arterial Disease (LEAD)(1) Risks: Age Smoking Diabetes Mellitus Hypertension
Dyslipidemia Obesity Family history of cardiovascular disease(2) Arterial Ulcer Associated Skin Assessment - ** Cooler skin temperature Thin, shiny skin Decreased or absent skin hair Decreased pulse strength in affected extremity Skin pallor on foot elevation; dusky rubor on dependency Dystrophic toenails Low Ankle-Brachial Index (ABI) Arterial Ulcer Characteristics - ** Round and regular in shape Pale wound bed Can be shallow in depth or relatively deep Smooth wound edges Gangrenous/necrotic tissue may cover the wound Minimal drainage Severe pain Venous Ulcer - ** An open skin lesion of the leg or foot that occurs in an area affected by venous hypertension. Prolonged venous hypertension results in vein wall damage. This increases capillary permeability and allows the extravasation of micromolecules and macromolecules into the surrounding tissue. Damage to these tissues leads to venous ulcer development. Venous Ulcer Location - ** Lower calf and ankle (the gaiter area) Pretibial and medial supra-malleolar area of the ankle near perforator veins.
Diabetic Foot Ulcer Causes - ** Lower Extremity Neuropathic Disease (LEND) (peripheral neuropathy)
- Sensory neuropathy leads to loss of protective sensation Motor neuropathy causes an imbalance between flexor and extensor muscles leading to foot deformities that create abnormal bony prominences and pressure points
- Autonomic neuropathy alters blood flow in the foot and sweat and oil gland function leaving skin dry Peripheral vascular disease with poor microvascular circulation Leads to tissue ischemia Repetitive mechanical stress or excessive pressure Less well noticed or not noticed because of sensory neuropathy Poorly controlled blood glucose levels Accelerates the development of arterial disease Risk Factors for Ulceration - ** Visual impairment or retinopathy Peripheral arterial disease Neuropathy Foot deformity Limited ankle range of motion High plantar foot pressures Minor trauma Previous ulceration or amputation. Diabetic Foot Ulcers Skin Assessment - ** Decreased sensation in the foot (Loss of protective sensation with monofilament testing) Warm skin, may be dry Callus formation, skin cracks and fissures
Abnormal toe nail growth Plantar fat pad atrophy Foot deformities such as hammer toe, claw toe, and Charcot's foot> Diabetic Foot Ulcer Characteristics - ** Depth varies from partial thickness to full thickness with bone involvement Regular wound margins OfteOften surrounded by a rim of calloused tissue Low to moderate amount of drainage Assess for signs of inflammation and infection Suspect osteomyelitis if bone is visible or directly palpable. Diabetic Foot Ulcer Classification System - ** Meggit-Wagner Classification System Grade 0 - Healed or pre-ulcerative wound Grade 1 - Superficial ulcer without penetrating to deeper layers Grade 2 - Deeper ulcer extends to tendon, bone or joint Grade 3 - Deep tissues involved with abscess, osteomyelitis or tendinitis Grade 4 - Limited gangrene (part of foot) Grade 5 - Extensive gangrene (whole foot) University of Texas Diabetic Wound Classification System Stage A to D based on infection and ischemia Grade 0 to 3 based on ulcer depth Moisture Associated Skin Damage - ** term used to describe skin conditions that are the result of exposure to moisture. Defined as inflammation of the skin and erosion from prolonged exposure to moisture and its contents.
Erythema is brighter red in persons with lighter skin tones Erythema is subtle red in persons with darker skin tones Edema may be present Areas of skin maceration may be observed Secondary cutaneous infection Irritated/impaired skin is more easily invaded by microorganisms A secondary fungal infection (from Candida Albicans) is seen as a maculopapular rash with satellite lesions IAD Wound Characteristics - ** Usually partial thickness skin loss Ranges from one or more islands of erosion to extensive denudation of the epidermis and dermis Skin breakdown may include, denuded skin, skin erosions, vesicles, bullae Epidermal damage of different depths Red, but skin intact (mild) Red with skin breakdown (moderate to severe) Irregular and indistinct borders/edges No exudate or clear, serous exudate which can cause the skin to glisten No slough or eschar Burning pain, itching IAD Classification - ** Incontinence-Associated Dermatitis Intervention Tool Incontinence-Associated Dermatitis Severity (IADS) Instrument Body location of incontinence-associated dermatitis Magnitude of erythema Presence or absence of skin erosion Presence or absence of skin rash IAD Severity Categorization Tool Intertiginous Dermatitis -
** From prolonged exposure to perspiration in skin folds esp. axillary, inframammary and inguinal skin folds Obese patients are at higher risk with ITD frequently found in neck folds, under pendulous breasts and under the abdominal or pubic panniculi. Secondary infections (especially Candida albicans) may develop. Periwound Moisture-Associated Dermatitis - ** From prolonged exposure to wound exudate Peristomal Moisture Associated Dermatitis - ** Prolongued exposure to effluent from an ostomy Bruises vs. DTPI - ** Bruises: traumatic force DTPI: intense and/or prolonged pressure and shear forces at the bone-muscle interface Bruises may change color from purple to green to yellow as they resolve. DTPI usually retain purple, deep red or maroon color and evolve into various stages of pressure injuries. DTPI may exhibit epidermal separation and loss. Bruises usually do not. Burns/Abrasions vs. DTPI - ** Burns and abrasions may be misdiagnosed as pressure injuries. Whenever possible, determine the etiology of the wound before diagnosing it as a pressure injury Skin Tear - ** A wound caused by shear, friction, and/or blunt force resulting in separation of skin layers. Partial Thickness: (separation of the epidermis from the dermis) Full Thickness: (separation of both epidermis and dermis from underlying structures)
Edema Inability to position oneself independently Skin Tear Skin Assessment Older Adults - ** Thin skin appearance due to changes associated with aging Epidermal thinning Decreased dermal thickness Subcutaneous tissue loss Decreased skin elasticity and tensile strength Surrounding purpura or ecchymosis Skin Tear Classification Systems - ** Payne Martin Classification System for Skin Tears STAR Skin Care Classification System International Skin Tear Advisory Panel (ISTAP) Skin Tear Classification Type 1 - No skin loss: linear tear or flap tear that can be repositioned to cover the 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 Skin Tear Neonate Risk Factors - ** Neonate are at higher risk for skin tears because the skin and underlying tissues are not fully developed. This is especially true for premature infants. At 24 weeks gestation, there is very little stratum corneum (top layer of the epidermis). Subcutaneous tissue has not developed, so the dermis may be directly over muscle. At 30 weeks gestation, the stratum corneum in only 2 to 3 cells thick and there is some subcutaneous tissue. At 33 weeks gestation the epidermis is fully keratinized, but the dermal-epidermal junction is weak. At 36 weeks gestation (full term), the epidermis and dermis are only about 60% as thick as an adult. Cohesion between the dermis and epidermis still diminished.
Medical Adhesive-Related Skin Injury (MARSI) - ** etiology is trauma, not pressure
- Mechanical trauma (Epidermal stripping,Tension injury, or blister, Skin tear)
- Dermatitis (Irritant contact dermatitis, Allergic dermatitis)
- Other (Maceration from trapped moisture, Folliculitis)
