Pressure Ulcers + Wounds

Unit 2 Questions

Define: Bony prominence, necrosis, shear, and pressure ulcer

-(aka a pressure point where the bone sticks out or projects from the flat surface of the body (rubs against skin) E.g. shoulder blades, hips, knees, etc.

-death of most or all of cells in an organ or tissue due to disease, injury or failure of the blood supply (would begin as skin breakdown).

-when layers of the skin rub against each other or when skin remains in place and underlying tissues move and stretch which tear underlying capillaries and blood vessels.

-any lesion caused by unrelieved pressure that results in damage to underlying tissues, usually over a bony prominence,

Common causes of skin breakdown:

Age related skin changes, breaks in skin, loss of fatty layer under skin, poor circulation to an area, poor hydration, pressure on bony parts, friction and shearing, edema

5 risk factors in a person with limited mobility which makes it more likely that the person will develop a pressure ulcer

are bedfast or chairfast, need some or total help moving, are agitated or have muscle spasms or involuntary muscle movements, are incontinent, are exposed to moisture (e.g. sweat, saliva, wound drainage), have poor nutrition or fluid balance, have limited awareness, have problems sensing pain or pressure, have circulatory problems, have weight loss and are very thin, are obese, have medical devices, have a healed pressure ulcer.

Explain what happens in the 4 stages of development of a pressure ulcer.

Stage 1 – intact skin with redness over a bony prominence, colour does not fade with pressure.

Stage 2 – partial thickness skin loss – wound may involve a blister or shallow ulcer, ulcer may be reddish-pink.

Stage 3 – full-thickness tissue loss – skin is gone, subcutaneous fat is exposed, slough (dead skin) may be present.

Stage 4 – Full thickness tissue loss with muscle, tendon and bone exposure

– slough and eschar (thick, leathery dead tissue that may be loose or adhered to the skin often black or brown) may be present. (Necrosis)

Explain different ways of preventing pressure ulcers.

Have the person on a repositioning schedule and follow it (e.g. every 1-2 hours if bedfast or chairfast (15 mins every)

-using props e.g. pillows, foam wedges as needed.

-Do not position on a pressure ulcer, reddened area or on tubes or medical devices.

-Prevent shearing and friction during moving and transfer.

-Provide good skin care – all areas are clean and free of moisture, urine, feces, sweat, etc.

-Follow measures to prevent incontinence

What is a wound?

A break in the skin or mucous membrane.

DEFINE: abrasions, excoriation, contusion, incision, laceration,

penetrating wound, puncture wound and ulcer.

Abrasions – a partial thickness wound caused by scraping.

Excoriation –loss of the epidermis caused by scratching or when skin rubs against skin, clothing or material.

Contusion – a closed wound caused by a blow to the body (a bruise).

Incision –a cut produced surgically by a sharp instrument creating an opening in the body or into an organ.

Laceration – an open wound with torn tissues and jagged edges.

Penetrating wound – an open wound that breaks the skin and enters a body area, organ or cavity.

Puncture wound – an open wound made by a sharp object (knife, nail, metal, wood, glass).

Ulcer – a shallow or deep crater-like sore of the skin or mucous

membrane.

Explain the difference between an intentional wound and unintentional wound.

Intentional wound is created for therapy e.g. surgical incision,

venipuncture.

Unintentional wound is created by trauma.

4. What must happen for a wound to heal properly?

In order for a wound to heal it must be clean/free of microbes, good nutrition is needed (protein needed for tissue growth and repair), must not irritate or further aggravate it, dressings must not be too tight and changed properly.

DEFINE: edema, gangrene, venous ulcers, arterial ulcers, diabetic foot ulcers.

Edema - swelling caused by fluid collecting in tissues.

Gangrene – condition in which there is death of tissue.

Venous ulcers – open sores on the lower legs or feet caused by poor

venous blood flow.

Arterial ulcers – open wounds on the lower legs or feet caused by poor

arterial blood flow.

Diabetic foot ulcers – an open wound on the foot caused by complications

from diabetes.

Describe the 3 phases of wound healing.

Inflammatory phase – (3 days), bleeding stops and a scab forms (no

microbes in), increased blood supply to the wound.

Proliferative phase – (day 3 -21) cells multiply rapidly to repair the wound.

Maturation phase – (day 21 – 2 years) scar gains strength and becomes

thin and pale.

Explain the difference between first-intention, second-intention and third-intention wound

healing.

First intention – wound is closed – sutures, stitches, staples, clips, glue or

adhesive strips are used.

Second intention – contaminated/infected wounds are cleaned and dead

tissue is removed. Wound edges are not brought together, wound gapes,

healing takes longer, leaving a large scar, greater risk of infection.

Third intention – wound is left open and closed later. Combines first and

second. Infection and poor circulation are reasons for 3 rd intention.

What are wound drains?

Wound drains are fluids and cells escaping from tissues – it is observed in

measured.

What are wound dressings and why are they applied to wounds?

Wound dressings are gauze, absorbent pads, band-aids that can be applied to wounds. They are applied to protect from injury and microbes, absorb drainage, remove dead tissue, promote comfort, cover unsightly wounds, provide a moist environment for healing, apply pressure to

control bleeding