Introduction to Decision-Making in Wound Care Practice + Pressure Injuries

What is the main driving factor for treatment of a wound?

the pathophysiology/etiology AND the risk/predisposing factors

PT management for wounds includes addressing what 3 things?

1. movement dysfunction

2. patient education

3. direct wound care

What are the main purposes of an ideal wound dressing?

1. maintenance of a most/clean/warm environment

2. ensure hydration and proper gas exchange

3. remove exudate

4. barrier for external pathogens

5. easy application and painless removal w/o damage

If a wound has none/minimal drainage, what wound dressing is appropriate?

moisture adding dressings

If a wound has moderate/heavy drainage, what wound dressing is appropriate?

moisture absorptive dressing to protect the peri-wound and maintain the moisture barrier (some dressings can be cut to fit in the wound)

If a wound has necrotic minimal necrotic tissue, what type of healing is appropriate?

autolytic

If a wound has thin/mucinous necrotic tissue, what type of healing is appropriate?

autolytic OR enzymatic if there is an increase in amount or thickness

If a wound has thick/mucinous necrotic tissue, what type of healing is appropriate?

sharp debridement if there is adequate blood flow

If a wound has no necrotic tissue, what type of healing is appropriate?

a collagen donating dressing

If a wound is NOT infection, what do you do?

nothing, you have no constraints but keep it free from infection

If a wound is infection, what are the 3 options to consider to promote healing?

1. consider referral for culture and antibiotics

2. avoid occlusive dressings

3. consider antimicrobial agents/dressings

If a wound does NOT have any exposure concerns to things like urine and feces, what is reccommended?

cover the wound with gauze like a Kerlix wrap, pad secured with net or other types of coverings

If a wound has exposure concerns to urine and feces, what do you cover it with?

- hydrocolloid patch

- semipermeable film

- composite dressing with adhesive border

If a wound has NO depth, what do you do?

nothing, there are no constraints

If a wound has depth, what is appropriate?

fill the wound with gauze or foam

When dressing a wound appropriately, what other 3 issues much be addressed?

1. the pathophysiology

2. cost

3. care giver education

What are the 4 moist adding/least absorptive dressings in order of LEAST to MOST?

1. semipermeable foam (LEAST ABSORPTIVE)

2. hydrogel and hydrogel sheets

3. pre-moistened hydrogel OR alginate w/ saline

4. hydrocolloid

In the absorptive continuum, what dressing is in the middle?

gauze

What are the 4 most absorptive dressings starting from LEAST to MOST?

1. calcium alginate

2. hydrofiber

3. semipermeable film

4. VAC/NPWT (MOST ABSORPTIVE)

What are 3 reasons why permeable dressings are important?

1. passage of air for healing

2. decreases risk of anaerobic infection d/t O2

3. lets fluids flow out

What are 3 reasons why occlusive dressings are important?

1. maintains moist environment (for autolytic debridement and healing)

2. protect against external contaminates

3. can help decrease pain by protecting nerve endings and wound bed

DON'T USE WITH ACTIVE INFECTION (traps bacteria)

How much money each year does health care cost the hospital due to ulcers?

3.5-7 billion (152k/ulcer)

What is the etiology of pressure injuries?

pressure! the more pressure there is for a longer period of time, the less time required for ischemia and necrosis to ensue

What are 3 demographic risk factors for pressure ulcers?

- pts with neuromuscular diseases (SCI**)

- hospitalized pts

- pts in long-term care facilities (SNF)

last two categories are a lot of ppl!!

What are clinical risk factors for pressure injuries? (long list)

- shear

- friction

- heat

- excessive moisture/maceration

- incontinence

- impaired mobility

- impaired sensation

- age

- malnutrition

- previous ulceration

With a pressure injury, what will the level of drainage likely be?

moderate/heavily

Where are pressure injuries likely to form?

on bony areas, they are likely "crater-like"

Pressure injuries are susceptible to what type of observable presentation?

tunneling and undermining

Most pressure injuries are not "clinically" infected, but rather are...

colonized

Describe a Stage I pressure ulcer

non-blanchable erythema and intact skin ("pre-ulceration")

Describe a Stage II pressure ulcer

-partial-thickness skin loss of epidermis and/or dermis

- presents as an abrasion, blister, or shallow crater

Describe a Stage III pressure ulcer

- full-thickness skin loss of subcutaneous tissue (possibly down to underlying fascia)

- deep create W/O undermining

Describe a Stage IV pressure ulcer

- full-thickness skin loss with EXTENSIVE destruction

- necrotic tissue present

- damage to mm, bone, tendon

- RISK OF OSTEOMYELITIS**

- possible communication with body cavities

What is a deep tissue injury?

purple/maroon area of intact skin with a blood-fileld blister d/t pressure and/or shear (feels BOGGY and maybe cold or warm)

What is an unstageable pressure injury?

full thickness tissue loss BUT the ulcer is covered in slough and/or eschar in the wound bed

How long does a pressure injury typically take to form?

5-7 days

What is important to know about staging and the wound when it begins to heal?

you do not reverse stage, you instead refer to it as "a healing stage III" pressure injury d/t the high risk of reoccurance

With an individual with dark skin tone, how do stage I ulcers present?

- NOT ALWAYS A VISUAL CHANGE (can be sensation, temp, pain, early signs are often missed)

- can be lighter, darker, violet, blue, or gray

- blanch test NOT reliable

With an individual with dark skin tone, how may deep tissue injuries present?

- often are purple

- intact skin, sometimes non-intact

What are the 4Ts assessment framework for early detection of pressure injuries across all skin tones?

1. TONE (compare to contralat. skin)

2. TEMPERATURE (can be warm d/t inflammation or cool d/r ischemia)

3. TEXTURE (boggy/hard/dimpling)

4. TWINGE (pain/tendernesS)

What is the PSST/BWAT and what is a good score?

pressure sore status tool

- score 13-65 (high is BAD)

- reliable and valid

What is the PUSH tool for wound assessment?

pressure ulcer scale for healing

- score 0-17 (high is BAD)

- is reliable and valid like PSST

just so its here PRESSURE MAPPING can also be used to assess pressure injuries

What is the typical prognosis for healing wounds?

it depends, but substantial decrease in size in the first 2 weeks is a good indicator that the wound may eventually heal

REALLY depends on pt characteristics like adhereance to advice, DM, nutrition...

What are the key components regarding pressure injuries and comprehensive care? (5)

- nutrition

- treat infection w/ antibiotics

- minimize sedation

- manage incontinence

- surgical consult if needed

What are 2 different ways to relieve pressure for a patient in sitting?

- sitting on foam

- sitting on roho cushion thats air/fluid filled (gold standard)

What are 4 differentways to relieve pressure for a patient in laying?

- cyclic inflation/deflation pressure mattress

- low-air-loss mattress

- fluidized bed (filled with silicon beads)

- scheduled transitions with nursing staff

What are the procedural intervention for wound care?

1. address biofilm and infection

2. debride (NOT HEEL w/ ESCHAR)

3. provide moist environment

4. wound dressing cover to protect

5. therapeutic exercise to alleviate pressure and improve mobility

What is the purpose of functional training regarding pressure injuries?

to improve mobility to allow for frequent pressure relief

With a "weight shifting" schedule, how often should pts be moved when laying down?

every 2 hours MINIMUM when lying down

With a "weight shifting" schedule, how often should pts be moved when sitting?

every 15 minutes, perform pressure relief for 30-90 seconds

some individuals need even more frequently!

When attempting to provide pressure relief in sitting, what aspects of the chair need to be considered?

- seat depth

- width + length

- footrest height

- back support

- seat to back angle

- head rest/support

When attempting to provide pressure relief sidelying, what aspects of patient positioning need to be considered?

- avoid direct contact with great trochanters

- USE THE 30º LAT. POSITION OR 150º SL POSITION FOR SAFETY

- use wedges, pillows, towels for support

When attempting to provide pressure relief in supine, what aspects of patient positioning need to be considered?

- too flexed = increased sacral pressure (decrease the head of bed elevation)

- PROPER POSITION IS HIP + KNEE 25-30º FLEXION

- protect the heels (keep elevated)

- "Fowler's" position (supine with head of bed elevated, cna be dangerous for sacrum)

Using the Braden scale, what score indicates a pt is at risk for pressure injuries?

score <18 (highest score is 23)

most common and most validate scale used for admission to hospital