skin ulcer, and wound care

Dressing Categories / I Hydrotolloids

Adhesive wafers containing hydroactive/ absorptive particles that interact with wound fluid to form a gelatinous mass over the wound bed. adVANTAGES - absorbs minimal to moderate exudate, - protects partial thickness wounds. - maintains a moist wound environment, - nonadhesive - supports autolytic debridement, disadvantages: - not used over infted wounds, - nontransparent, - not for wounds with heavy exudate

summary dressing

DRESSINGS • Very Mild exudate transparent film - • minimal exudate- Hydrogel dressing (amorphous form of hydrogel for infected wounds), hydrocolloid • Moderate to heavy exudate- foam • Heavy exudate- Alginates (max capacity) • Wet to dry gauze- for necrotic tissue and slough • Infected Dressings: Hydrogel, Alginate and gauze. • Non Infected: Hydrocolloid, Films and Gauze.

Deep Tissue Pressure Injury (DTPI)

Deep Tissue Pressure Injury (DTPI) Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4).

Nutritional Considerations

Delayed wound healing associated with malnutrition and poor hydration. Albumin: normal is 3.5-5.5 m/dl; less than 3.5 = malnutrition. BMI - or = 21 with weigh loss increased risk for pressure ulcer. provide adequate hydration. Individuals with wounds require approximately 3 or more liters of water a day. provide adequate nutrition: frequent high-calorie 23- 35kcal/kilo protein 1.5- 2.5 gm/kilo

Alginates

Derived from seaweed and react with exudate to form gel over wound. - with wounds with moderate to large amount of exudate or with combination exudate and necrosis. also, • Infected and noninfected exuding wounds • Absorb up to 20 times their weight in rainage. • Fill dead space I DISADVANTAGES • Not recommended for dry or lightly exudating wounds • Can dry wound bed

Foams

Foams. Cushion and protect the wound. These dressings are hvdrophilic (absorb moisture) on the wound side and hydrophobic on the nonwoundside. • Partial- and full-thickness wounds with minimal to moderate exudate • . Insulate wounds Disadvantages: require secondary dressing, not tor use with dry eschar or wounds with no exudate,

Staging of Pressure Ulcers / Stage 1 Pressure Injury

Stage 1 Pressure Injury Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Nonblanchable erythema is a defined area of redness that persists (does not blanch/become pale) when pressure is applied to the area. type question This 86 year old female has an area of reddened skin on the right heel. The alteration in skin color persists under applied light pressure. - There is no break in the skin surface. - The epidermis remains intact. - No blistering of the skin is observed.

Stage 2 Pressure Injury

Stage 2 Pressure Injury: Partial-Thickness Skin Loss with Exposed Dermis -involves epidermis, dermis or both - ulceris superficial - The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister - presents clinically as an abrasion , blister, or a shallow crater - Adipose (fat) is not visible and deeper tissues are not visible. - Granulation tissue, slough and eschar are not present. type - The pressure injury is approximately 2 cm in length and 1.5 cm in width. - Tissue loss extends into the dermis. - There is no slough in the wound bed. - This wound is shallow. Tissue loss extends into the dermis. The wound bed is reddish. No slough is observed.

Stage 3 Pressure Injury

Stage 3 Pressure Injury: Full-Thickness Skin Loss - involves damage to or necrosis of subcutaneous tissue - may extend down to, but not through, underlying fascia. in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage or bone is not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. type -Tissue loss extends through the dermis to subcutaneous tissue. - Not cartilage or bone is visualized - . The injury is approximately 8.5 cm by 6 cm in size. Subcutaneous tissue is visible in the wound bed. Muscle, tendon, and bone are not evident. A small amount of slough is present.

Stage 4 Pressure Injury

Stage 4 Pressure Injury: Full-Thickness Skin and Tissue Loss Full thickness skin and tissue loss with exposed or directly , involves extensive destruction, palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer - Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. type This pressure injury is located over the left ischial tuberosity. The pressure injury is approximately 3 cm deep. Muscle tissue is exposed. Slough/eschar covers some of the wound bed. Between the areas of slough, muscle tissue is exposed.

Dressing Categories /Transparent Films

Transparent Films Clear, adhesive, semipermeable membrane - Permeable to atmospheric oxygen and moisture vapor but impermeable to water, bacteria, and environmental contaminants. INDICATIONS / ADVANTAGES • Stage I and II pressure ulcers • for cytolytic debridement . excellent bacterial barrier • Promote autolytic debridement • Transparent and comfortable DISADVANTAGES • Nonabsorptive • Not to be used on wounds with fragile surrounding skin or infected wounds

UNDERMINING VS. TUNNELING .

UNDERMINING VS. TUNNELING • Undermining is tissue destruction that occurs under intact skin around the wound perimeter.• Undermining is defined as 1.0 to 1.4 cm,• Undermining is less extensive • A tunnel is a channel that extends from any part of the wound through subcutaneous tissue or muscle.. tunneling penetrates more deeply into tissue.as greater than 1.4 cm.

UNDERMINING VS. TUNNELING

Undermining and tunneling are documented by measuring depth and noting the location using the face of the clock as a guide. This wound would be charted as a full-thickness, red wound, 7 cm × 5 cm × 3-cm, with a 3-cm tunnel at7 o'clock and 2 cm undermining from 3 o'clock to 5 o'clock.

Unstageable Pressure Injury: Obscured Full-Thickness Skin and Tissue Loss

Unstageable Pressure Injury: Obscured Full-Thickness Skin and Tissue Loss Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. - If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be softened or removed.

DEBRIDEMENTuvj1

Wound Debridement . Removal of necrotic or infected tissue that interferes with wound healing. Selective: removal of only nonviable tissues from a wound • Sharp debridement - using scalpel, scissors, forceps • Enzymatic debridement - use of a topical application • Autolytic debridement - use of the body's own mechanism to remove nonviable tissue Non selective: removal of both nonviable and viable tissues from a wound • Wet-to-dry dressings- application of a moistened gauze over area of necrotic tissue to be completely dried and removed • Wound irrigation- moves necrotic tissue from wound bed using pressurized fluid • Hydrotherapy- using a whirlpool with agitation directed toward a wound requiring debridement

Examination of Wounds

determine wound exudate (drainage). Type: serous (watery serum), clear , thin purulent (containing pus),yellow or green color sanguineous (containing blood). red color and thin Identify color and tissues involved. Clean red wounds: healthy granulating wounds (in need of protection); absence of necrotic tissue. Yellow wounds: include slough (necrotic or dead tissue), fibrous tissue. c. Black wounds: covered with eschar (dried necrotic tissue).

A PT is treating a patient who was originally diagnosed with a pressure injury stage 3. The patient presents to clinic with ulcer shown in the picture. Which of the following findings is MOST accurate? A. No change has occurred in the pressure injury B. The pressure injury has improved to Stage 1 C. The pressure injury has improved to Stage 2 D. The pressure injury has progressed to Stage 4

option a

A patient has a Stage 3 pressure ulcer with bone visible. The wound has necrotic tissue and moderate exudate present. Which of the following is the BEST wound care option? A. Calcium Alginate B. Enzymatic debridement C. Hydrogel dressings D. Transparent films

option a

A 60-year-old female presented with a diabetic foot ulcer secondary to gout and neuropathy on the lateral side of her right foot great toe. Which of the following statements MOST accurately represents the correct documentation of the defect? A. Undermining at 12 o'clock B. Undermining at 3 o'clock C. Undermining at 6 o'clock D. Undermining at 10 o'clock

option b

An 74-year-old female patient stays alone at home and spends the majority of her day in a bed. During the systems examination, the PT finds an ulcer as shown in the picture below. The BEST diagnosis for this wound is: A. Stage II pressure ulcer B. Deep tissue pressure injury C. An arterial ulcer D. Stage III pressure ulcer

option b

The patient lying in supine has a abscess that travels from left scapulae under the skin toward the right scapula. Which of the following statements MOST accurately represents the correct documentation of the defect? A. Tunneling at 12 o'clock B. Tunneling at 3 o'clock C. Tunneling at 6 o'clock D. Tunneling at 10 o'clock

option b

An 65-year-old obese male (BMI 33kg/m2) presents on an outpatient clinic. During the systems examination, the physical therapist finds an ulcer as shown in the picture below. The BEST long-term management of this patient should include: A. Foot intrinsic muscle training B. Bi-phasic pulsed current C. Total contact cast D. Posterior leaf spring

option c option b would be correct but it is MONOPHASIC PULSED CURRENT

A patient admitted to the hospital 3 days ago presents with moderate to high amounts of drainage and edema of the left lower extremity. Which of the following characteristics BEST describes the patient's symptoms? A. Decrease pulse, no granulation tissue and ulcer on lateral malleolus with smooth edges B. Normal pulse, no granulation tissue and ulcer on lateral malleolus with smooth edges. C. No pulse, good granulation tissue and shallow ulcer on medial malleolus. D. Normal pulse, good granulation tissue and dark pigmented ulcer on medial malleolus

option d

A patient has a superficial partial-thickness wound resulting from an abrasion. The wound bed is red and moist and with minimal exudate and needs autolytic debridement. Which of the following wound dressings is MOST appropriate to use? A. Wet to dry gauze B. Sharp debridement C. Calcium alginate D. Transparent films

option d

Gauze Dressings'

• Exudative wounds • Wound with dead space, tunneling, or sinus tracts • Wounds with combination exudate or necrotic tissue WET TO DRY • Mechanical debridement of necrotic tissue and slough CONTINUOUS DRY • Heavily exudating wounds CONTINUOUS MOIST • Protection of clean wounds • Autolytic debridement of slough or eschar • Can be used on infected wounds • Cost-effective filler (or large wounds