Pressure Ulcer and Wound Management, Exams of Nursing

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what are 6 risk factor components of Braden Scale for pressure ulcer? - Answer- sensory perception, moisture, mobility, activity, nutrition, and shear/friction What is the name of the organization that developed the pressure ulcer staging? - Answer-NPUAP (national pressure ulcer advisory panel) pathological effect of excessive pressure on soft tissue can be attributed by 3 factors? what are they? - Answer-tissue tolerance, duration of pressure, and intensity of pressure what are the extrinsic factors that impact pressure ulcers? - Answer-increase in moisture, friction and shearing how does friction play a role in shearing which eventually leads to pressure ulcer? - Answer-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? - Answer- nutritional debilitation, advanced age, low BP, stress, smoking, elevated body temperature Aging skin undergoes what elements affecting risk for pressure ulcer?

• Answer- 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? - Answer-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? - Answer-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? - Answer-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? - Answer-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? - Answer-partial-thickness wound where epidermis and tip of dermis is lost with red-pink wound bed w/out slough. may also present as intact or open/ruptured serum - filled blister Describe stage III pressure ulcer? - Answer-full-thickness wound where both epidermis and dermis is lost and subcutaneous tissue may be visible, but deeper structures such as muscle, bone, and tendon are not exposed; slough my be present but it doesn't

obscure depth and tunneling and undermining may be present

Describe stage IV pressure ulcer? - Answer-full-thickness wound with exposed bone,tendon, and muscle; slough or eschar may be seen in some parts of the wound bed. you will often see tunneling and undermining. Osteomyelitis may be dxed at this stage, since bone is palpable Describe unstageble ulcers? - Answer-full-thickness wound where base of the ulcer is covered by slough and/or eschar, obscuring depth When should eschars not be removed? - Answer-when it's stable with dry, adherent, and intact w/out erythema on the heel; this serves as the body's natural cover and should not be removed. Therapeutic function of pressure distribution is accomplised by what 2 factors? - Answer-immersion and envelopement Define immersion? - Answer-depth of penetration or skining into surgace allowing pressure to be spread out over surrounding area rather than directly over boney prominence Define envelopement? - Answer-is the ability of support surface to conform to irregularities without causing substantial increase in pressure what is bottoming out? - Answer-this occurs when depth of penetration or sinking is excessive, allowing increased pressure to concentrate over boney prominences what factors contribute to bottoming out? - Answer-weight, disproportion of weight and size such as amputation, tendency to keep HOB >30 degrees, inappropriate support surface settings When should you consider reactive support surface with features and components such as low air loss, alternating pressure, viscous or air fluids? - Answer-for patients who cannot effectively position

off their wound, have PUs in multiple turning

surfaces, or have PUs that fail to improve despite optimal comprehensive management When should active support surface be considered? - Answer- when effective positioning is determined by an MD to be medically contraindicated What is the difference between an active and reactive support surfaces/ - Answer- active support surface is a powered mattress or overlay that changes it's load- distribution with or without applied load; pressure is redistributed across the body by inflating and deflating the cells of alternating zones. conversely a reactive support surface moves or changes load-distribution properties only in response to applied load, such as the patient's body. When are active support surfaces appropriate? - Answer-when manual frequent repositioning is not possible when are reactive support surfaces appropriate? - Answer-for pressure ulcer prevention what is a benefit in low air loss feature and when is it contraindicated? - Answer-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? - Answer-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? - Answer-pulmonary diseases or unstable spine patients what are some general guidelines for caring for patients on a support surface? - Answer-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? - Answer-for patients with acute respiratory conditions- requiring pulmonary hygience what are the 3 essential physical properties for normal venous function? - Answer- competent valves, venous wall, and calf muscle pump what are the classical characteristic traits seen in venous ulcers? - Answer-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? - Answer-leakage of RBCs which have been broken down appears as a purple to brown staining Define lipodermatosclerosis? - Answer-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? - Answer-smooth, white plaques of think speckled atrophic tissue with tortous vessels on ankle or foot with hemosiderin pigmented border Define venous dermatitis? - Answer-characterized by scaling, crusting, weeping, erythema, erosions, and intense itching. Differentiate dermatitis from cellulitis? - Answer-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? - Answer-DM, tobacco, malnutrition, umplanned weight loss, and meds (corticosteroids) What is the most effective managment of CVI? - Answer- therapeutic compressions (30-40mmHg) What should you do before deciding to tx with compressions? - Answer-rule out LEAD, by obtaing an ABI What are the interpretations of ABI? - Answer-ABI of 1. is pure LEVD ABI of 0.9 or less is LEAD ABI of 0.5 or less is ischemia When should you obtain an TBI? - Answer-when ABI is >1. indicating calcification of vessels which in turn reflects invalid data. A TBI of < 0.7 indicates LEAD What is the gold standard for evaluating valve failure and extent of reflux? - Answer- duplex ultra sound What are some methods for manaing venous ulcers and CVI - Answer- limb elevation-

heart level for 1-2 hours/daily and during sleep, calf pump exercises or referral to PT for shuffling gait, weight control, medications (diuretics, topical corticosteroids, Pentoxifylline (Trental), and compression therapy How does Pentoxifylline work and when is it appropriate? - Answer-reduces aggregation of platelets and WBC, reducing capillary plugging and enhances blood flow. ordered when standard therapy is not effective When are elastic or inelastic compressions indicated? - Answer- elastic for patients who are sedenatary vs. inelastic for patients

who are amublatory

When are high pressure compressions (30-40mmgHg) indicated, when assessing ABI?

• Answer-ABI>0.8 can use high compressions when are compressions contraindicated? - Answer-venous thrombosis in LE w/ulcers and uncompensated heart failure when is sustained (continuous) compression contraindicated? - Answer-in the presene of PVD with an ABI that is < or =0.6 or when ABI is >0.5 but <0.8 is more appropriate when is IPC (intermittent pneumatic compression)-dynamic compression indicated? - Answer-for patients with venous insufficiency and ABI< or =0.5, for those who cannot tolerate sustained compression, as an adjunct therapy to sustained therapy, those who are immobile when is modified or lower compressions appropriate (23-30mmHg)?
• Answer-when coexisting arterial disease is present all patients with leg uclers should be screened for arterial disease using what, initially?
• Answer-doppler which measures ABI; takes BP in the arm and ankle and compares ratio What are the attributes of short-stretch compression? - Answer- it's inelastic, sustained compression and provides a modified to therapeutic level of pressure- reusable What are the attributes of long-stretch compression? - Answer-same as short stretch except it's elastic (ex. Surepress) what are the attributes of multi-layer compression? - Answer- 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? - Answer-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? - Answer-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? - Answer-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?

• Answer-bypass graft what are the 6 P's in assessing for acute limb ischemia? - Answer- pulse, pallor, polar (cool), pain, paresthesia(burning and tingling sensation), and paralysis What is the general appearance of LEAD? - Answer-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?
• Answer-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? - Answer-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?

• Answer-tobacco: stop smoking diabetes: HbA1c <7.0 and if possible for high risk patients, <6. 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? - Answer-will take > 2-3 seconds. what are the ABI values and its indicator? - Answer->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)? - Answer- 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? - Answer-40 mmHg or greater=normal <40mmHg=hypoxia w/impaired wound healing When do you use SLP (segmental leg pressure)? - Answer-used to determine location of occlusion for surgical intervention. a 30mmHg decrease in pressure between two adjacent levels indicate occlusion

when should you not use TBI? - Answer-when toes are amputated or toes are col that it's not reliable What conditions cause vasoconstrictive properties which worsens LEAD? - Answer- smoking, pain, dehydration, cold temperature, lack of exercise, constrictive clothing when is pulsve volume recordings (PVR) and doppler waveform studies indicated? - Answer-it is recommended when ABI >1.3; the wave forms reflect severity of occlusion what tests give you an anatomic roadmap, prior to revascularization? - Answer-MRA, angiography, duplex angiography, or computed tomographic angiography when is HBO indicated in arterial ulcers? - Answer-patients w/significant ischemia who are not candidates for revascularization and wound healing is impaired Describe the characteristics of a neuropathic wound and periwound? - Answer- wounds are usually found on the planatar, dorsum of metatarsal, and lateral sides of foot; wounds are usually red , if no ischemia not present; wound edges are well defined; exudate is moderate to large; callus periwound Describe the grading system and its corresponding symptoms of Wagner Ulcer Classification system? - Answer-there are 5 grading categories: 0: intact w/some callus formation, deformities, and redness over pressure point 1: superficial ulcer w/out depth into SQ tissue with or w/out cellulitis 2: full-thickness ulcer exposing tendon and joint w/out abcess or osteomyelitis

3. osteomyelitis, absecess, necrotizing fasciitis
4. gangrene toes, forefoot, and heel
5. amputation, gangrene-unsalvageable

what is a traditional tx of Charcot foot? - Answer-cast mobilization

Why is debridement of callus an important maintenance therapy?

• Answer-better distributes pressure and reveals possible ulerations and undermining of tissues what are the priorities in managment of neuropathic wounds? - Answer-relieve pressure by offloading, aggressively treating infection, revascularization, and improve wound condition what are the 3 kinds of neuropathy? - Answer-motor, sensory, and autonomic neuropathy what happens in motor neuropathy and what do you typically observe? - Answer- 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? - Answer- 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? - Answer-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? - Answer- 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? - Answer- 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? - Answer- 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? - Answer-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)? - Answer- 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)? - Answer-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? - Answer-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? - Answer-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? - Answer-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? - Answer-Painful, burning, and sometimes itchy lesion that's indurated, necrotic w/violacious discoloration. The skin cells die because of lack of blood supply (dry gangrene). This causes deep and often extensive ulcers. Occurs w/ESRD patients with hypercalcemia, hyperphosphatemia, and hyperparathydroidism. A distinct finding w/calciphylaxis is intact peripheral pulses bc bloo flow distal to or deeper than necrosis remains intact. Txed with normalization of calcium and phosphorous. IV Sodium thiosulfate has shown to be beneficial.

What acronym is used to evaluate surgical infections, post-op for 5 days? What does each letter stand for? - Answer-ASPSIS:

A: abx S: serous discharge E: erythema P: purulent drainage S: separation of tissue I: isolation of bacteria S: stay as inpatient prolonger >14 days How are surgical wounds usually closed? - Answer-by primary or secondary intention what solution is usually used in traumatic wounds to decrease contamination? - Answer-Dakin's solution or sodium hypochlorite; should have limited use bc it also kills healthy cells when is TCC contraindicated in treating neuropathic ulcers? - Answer-patient with acute deep infection, sepsis, or gangrene. may not be indicated for those who are noncompliant, would be unstable to stand or walk, exessive edema, fragile skin and who have ulcers that have depth >size of width what is used as an adjunct therapy to surgical shoe, healing shoe, or walking splint and when TCC is not warranted? - Answer-foam felt dressing (FFD) what surgical procedure is used for those with peripheral neuropathy and equinus contractures? - Answer-tedon-achilles lengthening (TAL) what are the clinical manifestations of incontinence associated dermatitis (IAD)? - Answer-areas of body where incontinence will be spread to is observed; risk factors are associated w/urinary or bowel incontinence (abx, carthartics, hypoalbumina, fecal

impaction, IBS, infection, radiation, fat malabsorption); blistering, shallow irregular patches that's red and denuded and/or macerated; painful

what are the clinical manifestations of Candidiasis? - Answer- occurs in skin folds where moisture is bountiful (intertrigo, pendulous breasts, groin, perineum, inner thighs -like IAD); associated w/moisture and immunosuppresion; confluent patchy rash or erythematous papules (raised discoloration) with cheesy- white exudate; pustules and satellite lesions also seen; itchy, burning discomfort; Potassium hydroxide preparation scraping (KOH) done for testing What are the clinical manifestations of Herpes Simplex? - Answer- 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? - Answer-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? - Answer-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? - Answer-iron