Wound care decision making and pressure ulcers (lecture 5)

what drives treatment

pathophysiology and etiology

what are PT needs to wound care

movement dysfunction, patient education, direct wound care

what is the ideal dressing

one that is a barrier to pathogens, removes exudate, maintains a moist clean warm environment, ensure hydration and gas exchange, fill the cavity with no damage, easy application and painless removal

what do you need to think of when choosing a wound dressing

drainage, necrotic tissue, infection, exposure concerns, and depth

if there is no drainage what type of dressing do you need

moisture adding dressing such as hydrogel

if there is moderate to heavy drainage what type of dressing do you need

moisture absorptive dressings that protect the periwound

if there is minimal necrotic tissue what type of debridement

autolytic

if there is thin mucous necrotic tissue what type of debridement

autolytic or enzymatic

if there is thick mucous necrotic tissue what type of debridement

sharp if blood flow

if there is no necrotic tissue what type of dressing

collagen donating dressing

if there is infection what do you need to consider

referral for culture or antibiotics, avoid occlusive dressings, consider antimicrobial agents or dressing

if there is no exposure concerns what type of dressing

gauze

if there is exposure concerns what type of dressing

hydrocolloid, semi-permeable film, composite dressing with adhesive border

what type of dressing do you use if the wound is deep

fill with gauze or foam

what issues do you need to consider when making dressing decisions

pathophysiology, cost, caregiver education

what is permeable and occlusive

the level in which the wound can interact with outside environment think moisture, oxygen, microorganisms, etc.

permeable dressings allow

passage of air, fluids, etc.

what is good about permeable dressings

it allows gas exchange and oxygen can help healing, it reduces the risk of anaerobic infection, it allows fluids to flow out

what is the most permeable dressing

gauze

what is the least permeable dressing

hydrocolloids, sheet hydrogels, foam

what are occlusive dressings

they prevent passage of air, fluids, bacteria

what is good about occlusive dressings

they maintain a moist wound environment with optimal temperature to facilitate healing, protect against external contaminates, help decrease pain by protecting nerve endings in the wound bed

when can you not use an occlusive dressing

when there is an active infection

what is the least absorptive dressing

film, hydrogel

what is the most absorptive dressing

alginate, hydrofiber, foam, vac

what is a pressure injury

localized areas of tissue necrosis that develop when soft tissue is compromised between a firm surface and bony prominence.

the degree of pressure injury is

time and pressure dependent

what are demographic risk factors for pressure injuries

patients with neuromuscular diseases, hospitalized, long term care

what are clinical risk factors for pressure injuries

shear, friction, heat, excessive moisture, maceration, incontinence, impaired mobility, impaired sensation, age, malnutrition, previous ulceration.

how many elderly patients who sustain a femoral fracture have a pressure injury

66%

how much do pressure injuries cost healthcare

3% which is 3.5-7 billion dollars or $152,000 per wound.

what are the features of pressure ulcers

round and crater like, moderate to heavy drainage, can undermine and tunnel

what are the typical locations of pressure ulcers

sacrum, greater trochanter, ischial tuberosity, heels, lateral malleoli

what is the bacteria colony of pressure ulcers

typically colonized

stage 1 pressure injury

non-blanchable erythema of intact skin, "pre-ulcer"

stage 2 pressure injury

partial-thickness skin loss of epidermis and or dermis. Presents clinically as an abrasion, blister, or shallow crater

stage 3 pressure injury

full-thickness skin loss of subcutaneous tissue that may extend down to but not through underlying fascia. Presents clinically as a deep crater with or without undermining.

stage 4 pressure injury

full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or other supporting structures. There is a risk for osteomyelitis and communication with body cavities.

deep tissue injury

purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and or shear. May be painful, firm, mushy, boggy, warmer, or cooler.

unstageable injury

full thickness loss in which the base of the ulcer is covered by slough or eschar in the wound bed.

how do you stage heeling wounds

it remains the initial stage you just document it as healing. You cannot reverse stages.

how many days does it take to fully develop a single episode of pressure

5-7 days

what stages are at very high risk of recurring and can have a significant amount of scar tissue when healed

stage 3 and 4

what are variations in dark skin tone

visual changes may differ, may present as changes in sensation, temp, firmness, and pain, blanch-able test is not reliable

what are the 4 T's assessment framework

tone, temperature, texture, twinge (pain)

what are assessment tools for pressure ulcers

pressure mapping, PSST / BWAT, PUSH tool

what is the PSST / BWAT scored

13-65. high is worse.

what is the PUSH score

0-17. higher is worse.

what is a good indicator that the wound may be healed eventually

substantial decrease in size in the first 2 weeks.

what is important to document / coordinate with others for comprehensive care

nutrition, infection, abscess, minimize sedation, management of incontinence, surgical consult

what is key for patient education

pressure relief

what are some pressure relieving things for sitting

foam, air/fluid filled roho cushion

what are beds / supportive surfaces for pressure relief

alternating pressure mattress, low air loss mattress, fluidized

why is functional training important for procedural interventions

to improve mobility to allow for frequent pressure relief modalities

why is therapeutic exercise important

to alleviate contributing impairments to pressure via positioning / posture or improve mobility

how often should you reposition when laying down

every two hours

how often should you reposition when sitting

every 15 minutes

what is the good position for side lying to reduce pressure

30 degrees lateral position

what is a high risk position when supine

fowlers position where the head of the bed is elevated.

mobility recommendations

positioning schedule, pressure relief, equipment to redistribute pressure, continuous assessment

what is the braden scale

it helps to assess risk of pressure injury

what does the braden scale look at

sensory perception, moisture, activity, mobility, nutrition, friction and shear

with the braden scale when is there a risk for injury

when the score is less than 18

what are strategies for reducing pressure injuries

positioning: decreased head elevation, SL variation, heels elevated. Pressure relief: turn schedule, offloading in chair, redistribution equipment. Management of risk factors: containment of urinary and fecal incontinence, moisture barrier, nutrition, activity, mobility. Education