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MODULE 2 NDNQI WOUNDS COMPLETE
EXAM NEW UPDATE 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. Lower Extremity Venous Disease Risks - Family history Older age Obesity History of venous disease or thromboembolism Trauma to the legs Female Pregnancy Occupation that involves standing for a long period
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. Common sources of moisture include urine and stool, perspiration, wound exudate, and effluent from an ostomy. Incontinence-Associated Dermatitis Perineal Dermatitis, Diaper/Napkin/Nappy Dermatitis or Rash, Irritant Dermatitis and Moisture Lesions - From prolonged exposure to urinary and fecal incontinence irritates the skin leading to erosion. Urine overhydrates exposed skin increasing the risk for friction injury Ammonia in urine elevates skin pH impairing its barrier function Fecal enzymes weaken epidermal integrity. Liquid stool is particularly irritating to the skin. Incontinence Associated Dermatitis Risk - Incontinence Frequent episodes of incontinences (especially fecal) Use of occlusive containment products Poor skin condition (due to age, steroids, diabetes) Compromised mobility Diminished cognitive awareness Inability to perform personal hygiene Pain Elevated body temperature Medications (antibiotic, immunosuppressant) Poor nutritional status Critical illness IAD Location - Buttocks, perineum, perianal area - may extend to inner and posterior thighs IAD Skin Assessment - Diffuse erythema of the skin surface
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) location: upper/lower extremities, head, trunk Skin Tear Causes - Blunt trauma from accidently bumping into objects Friction/shear injury or mechanical trauma during provision of ADLs Transfers and falls Equipment related injury Skin Tear Risk Factors Intrinsic - Very young (neonate) or very old (> 75 years of age) Immobility Dependence in ADLs
Compromised nutrition or hydration status Cognitive impairment and/or decreased sensation Visual impairment History of skin tears Existing skin conditions: ecchymosis, senile purpura, hematoma, frail fragile skin Multiple chronic conditions Skin Tear Risk Factors Extrinsic - Long-term corticosteroid use Polypharmacy Dry skin from frequent bathing and/or use of skin cleansers that reduce natural skin oils Medical equipment and assistive devices Removal of tape or dressings Skin Tear Prediction Hospitalized Patients - Ecchymosis (bruising) Senile purpura Hematoma Evidence of previously healed skin tear 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
