Atypical Wounds Flashcards
Other Wound Types
Traumatic wounds
Surgical Wounds
Abscesses
Atypical wounds
What are abrasions?
Wound caused by friction to the skin’s surface
May be superficial or partial thickness
Presentation of abrasions?
May or may not be contaminated
Mild, stinging sensation
Light to moderate bleeding
Rarely progress to be chronic wounds
Interventions for abrasions?
Irrigate thoroughly with water or saline
Whirlpool therapy may assist with removal of debris
Debridement for abrasions?
Selective or nonselective debridement
Dressing for clean abrasions?
Clean wounds: moisture-retentive dressing
Dressing for contaminated wounds:
broad-spectrum antimicrobial and gauze dressing
Skin tears
Traumatic wounds resulting from shear or friction forces that separate the epidermis from dermis
Partial-thickness wound
Age-related skin changes
Who is at risk for skin tears and why?
Age-related skin changes make elderly at increased risk for skin tears
Presentation for skin tears:
Linear tear or flap
Wound edges can readily be approximated or may have tissue defect
Drainage for skin tears:
Slight serous drainage
Bleeding- minimal to significant
Pain with skin tears:
Minimal pain
Skin Tear Category I
IA: Linear
IB: Flap
Skin Tear Category I Presentation
No tissue loss
Epidermis and dermis pulled apart
Epidermal flap covers dermis
Skin Tear Category II
IIA: Scant tissue loss
IIB: Moderate to large tissue loss
Skin Tear Category II Presentation
Partial tissue loss
= 25% epidermal loss
>25% epidermal flap loss
Skin Tear Category III
Skin tear with complete tissue loss
Skin Tear Category III Presentation
No epidermal flap
Surgical Wounds
Treated with Primary Closure
Sutures, staples, or tissue adhesives
Surgical Wounds
Treated with Primary Closure drainage
Expect minimal bleeding/drainage for first
day or so
Surgical Wounds
Treated with Primary Closure Healing
Epithelialized in 7–10 days
Keep clean and dry for 24–48 hours
Factors related to dehiscence
Malnutrition Diabetes Steroids Smoking Excessive tension on wound edges Underlying infection and abscess
Treatment of Dehisced Surgical Wounds
Reduce tension at wound borders
Infection
Reduce tension at wound borders
Use of binder, Montgomery straps, compression
Infection
Antibiotics per MD, wound irrigation, debridement
Monitor for fistulas: sinus tract that connects two epithelial surfaces
Interventions for surgically debrided wounds:
Interventions directed at granulation tissue formation, wound contraction, and epithelialization
Fill Dead space
If there is no infection for surgically debrided wounds, dressing to use:
use moisture-retentive dressing
Amputation management
Manage wound
Diabetics made need advanced interventions to promote healing
Protect stump
Provide compression to shape stump
Stump wrapping:
Reduce stump edema
Promote healing
Shape stump
Advantages of stump wrapping:
Custom fit
Can adjust tightness to patient tolerance
Easily applied over wound dressing
Disadvantages of stump wrapping:
Difficult to apply correctly and with even compression
Slip, become loose
Stump shrinker:
Reduce stump edema
Promote healing
Shape stump
Advantages of stump shrinker:
Convenient
Easy for patient to apply
Variety of sizes and lengths
Disadvantages of stump shrinker:
Difficult to apply over dressing
May not compress distal stump effectively
May roll/slide on conical shaped legs
Rigid Removable Dressing
Reduce edema Protect residual limb Promote wound healing Shape residual limb Decrease pain
Advantages of Rigid Removable Dressing
Good for fall risk patients
Can apply socks to promote shrinking
Easy to apply
Disadvantages of Rigid Removable Dressing
Added expense
Requires fitting/proper size
Presentation of Traumatic Wounds:
Highly variable
Wounds due to gunshots, motor vehicle accidents, falls, industrial accidents
Concomitant injuries such as fractures, spinal cord injuries, and head injuries may be present
Interventions for traumatic Wounds:
Contaminated or infected wounds should be irrigated and debrided
Attain warm, moist wound environment
Protect wound from further trauma
Bites most likely to become infected:
Human wounds are most likely to become infected, followed by cat bites due to microflora
What type of spider bites require interventions:
Black widow
Brown recluse
Black widow spider bites:
Patients are acutely ill within 1–3 hours of bite
Small bite surrounded by erythema with urticarial rash, stinging sensation
Symptoms of black widow spider bites:
Bite causes weakness, headache, nausea/vomiting, hyperreflexia, dyspnea, diaphoresis, HTN, tachycardia
The wound itself rarely requires wound care
Interventions for black widow spider bites:
antivenom, NSAID, muscle relaxer
Brown recluse spider bites:
Lives in enclosed spaces, active in spring
Endemic to parts of the Southeast, Southwest, and Midwest
Bites defensively – majority heal without complication in 3–5 days
Presentation of brown recluse spider bite:
edema, vasodilation, blood vessel degeneration, reddish blisters or bullae may develop
Within 24 hours, red inflammation, blue thrombosis, and white ischemia and possible necrotic center
Fever, nausea, malaise, joint pain
Healing time for brown recluse spider bite:
Healing time for complicated brown recluse spider bites ranges from 5 to 17 weeks
Brown recluse spider wound treatment:
Debride necrotic tissue
Moist wound healing with appropriate dressings
Avoid heat
Brown recluse spider wound medical care:
Monitor for potential systemic complications
3% may require skin graft
Antibiotics if signs and symptoms of infection
Antihistamines
Steroids
Abscesses
A localized collection ofpurulent material
Usually bacterial in origin
Signs and symptoms of abscesses:
redness, pain, warmth, and swelling.
How are abscesses usually addressed?
incision and drainage
Treatment of abscesses:
Irrigation and debridement Fill dead space Systemic Antibiotics Manage exudate Protect surrounding skin
Radiation:
Directly destroys tissue
Indirect tissue damage from free radical production
Inhibits inflammatory response and proliferative phase of healing
What does damage from radiation depend on?
dose, type of radiation, location, surface area
Patient related variables for radiation:
age, comorbidities, medications, nutrition, hydration, immune function
Presentation of Radiation Fibrosis and Radiation Burns
Mild inflammation, slight erythema, and local edema
Dry, scaling, itchy, hyperpigmented skin
If radiation continues, what forms?
bullae formation and fibrinous exudate with increased pain
Radiation fibrosis:
late tissue injury
Skin is dry, discolored, hairless, atrophied, fibrotic, and inelastic
Skin appears translucent
Grade 1 skin reaction to radiation:
faint erythema
epilation
dry desquamation
decreased sweating response
Grade 2 skin reaction to radiation:
bright erythema
tenderness to palpation
moderate edema
moist desquamation
Grade 3 skin reaction to radiation:
moist desquamation with pitting edema
Grade 4 skin reaction to radiation:
ulceration or necrosis
Radiation Fibrosis and Radiation Burns interventions:
Protection from mechanical forces (shear, friction, and pressure) Avoid adhesives Decrease bathing frequency and pat skin dry Avoid superficial heat and ice Avoid heavy detergents or perfumes Amorphous hydrogel to soothe skin Moisturizing ointment Oatmeal baths or topical steroids
Atypical wounds
Pyoderma Gangrenosum Cancerous lesions Psoriasis Discoid lesions Fungal infections Hydradenitis Supurativa Yeast infections Peau d’orange
Pyoderma Gangrenosum
Noninfectious, progressive necrotizing skin condition, uncommon, destructive inflammatory disease of unknown etiology.
Onset of Pyoderma Gangrenosum
50% have a systemic inflammatory condition
25% insidious
25% after trauma or surgery
Differential diagnoses for Pyoderma Gangrenosum:
Cancer, vasculitis, adverse drug reaction, spider bite, chronic venous insufficiency
Presentation of Pyoderma Gangrenosum
Begins as small, painful papule, vesicle, or pustule on lower extremities and trunk
Progresses to full-thickness ulcerations
Irregular borders , Inflammed with gray or purple hue
Undermining
Wound bed and drainage of Pyoderma Gangrenosum
Indurated, boggy, necrotic base
Purulent and hemorrhagic exudates
Erythematous due to inflammation
Wound bed covered with eschar or slough
How does Pyoderma Gangrenosum heal?
Heals with irregular cribriform scars
Treatment of Pyoderma Gangrenosum?
Requires immunosuppressive therapy
Severe pain (burning/searing)
May have fever, malaise, or myalgia
Suspect Pyoderma Gangrenosum if:
Positive wound cultures without response to antibiotics
Wound not responding to standard care for presumed wound etiology
Interventions for Pyoderma Gangrenosum
Immunosuppressive agents – cyclosporin Corticosteroids – systemic, topical locally injected Gentle, limited debridement Topical antimicrobials Gauze or moisture-retentive dressings Elevation and compression Negative pressure therapy, HBO may help
Keratoacanthoma
Non-malignant
Fast growing
Resembles Squamous cell carcinoma
Psoriasis
a chronic, autoimmune disease that appears on the skin
Five types of psoriasis:
plaque, guttate, inverse, pustular and erythrodermic
Most common form of psoriasis and presentation:
plaque psoriasis
appears as raised, red patches or lesions covered with a silvery white buildup of dead skin cells, called scale
Lupus Erythematosus
photosensitive, plaques on hands, may have occasional leg ulcers, scalp lesions in discoid, vasculitis, bullous lesion
Candida Albicans
yeast infection
red pinpoint papules, part of normal flora, occur in areas of moisture, diabetes, with use of antibiotics
Treatment of Candida Albicans
miconazole or other “zoles”, use powder for moisture control
Hydradenitis Supurativa
Clusters of abscesses typical located in the axilla or groin
Heriditary component
Autoimmune characterisits
Weeping, purulent drainage
Tinea Cruris
jock itch
a common skin infection that is caused by a type of fungus called tinea
Common places for fungus in tinea cruris:
warm, moist areas of the body and as a result, infection can affect the genitals, inner thighs, and buttocks. Infections occur more frequently in the summer or in warm, wet climates
Impetigo
Superficial skin infection, strep or staph aureus lesion may form roofed bullae. Treat with Mupirocin 2% ointment or cream & oral antibiotics
Cellulitis
Infection of the dermis and sub cutaneous tissue causes erythema, edema, and pain, usually caused by skin disruption
Treatment of cellulitis:
elevation, antibiotics to fight skin flora.
Erysipelas
Acute inflammatory form of cellulitis involving lymphatic streaking, more superficial, clearly demarcated with skin break as portal of entry
Symptoms with Erysipelas
Fever, chills, anorexia, vomitting, typically strep- treat with oral antibiotics
Actinc Keratosis
Pre-cursor to squamous cell CA, sun-exposure, cresting/pigmentation
Basal Cell Carcinoma
most common cutaneous CA, slow growing, locally destructive, common after 40 & with fair skin
Squamous cell Carcinoma
arising from keratinocytes, second most common (20% of all primary malignancies) metastatic, related to burns, radiation, osteomyelitis, and chronic infections
A
Asymmetry
B
Border
C
Color
D
Diameter
E
Evolving
Hepes Zoster
Involves single dermatome, varicella virus gaining entry to nerve with chicken pox, tender with hyperesthesias in dermatome, pain/itching, fever, may cause lasting neuralgia, skin eruptions
Vasculitis
inflammation and destruction of blood vessels, purpura causing burning, usually below knee
What is hypersensitivity vasculitis associated with?
infection or chemical/drug exposure, blood vessels walls are attacked by immune system, become inflamed and seep blood
Scleroderma
Excessive fibroblasts/collagen, Raynaud’s, treat with ultraviolet A
CREST
Calcinosis Raynauds Esophageal dysfunction Sclerodactyly Telanglectasias
Calcinosis
calcium deposits in the skin
Sclerodactyly
thickening and tightening of the skin on the finger and hands
Telanglectasias
dilation of the capillaries causing red marks on surface of the skin
Necrobiosis Lipoidica
Inflammatory condition, collagen degeneration associated with diabetes, lesions slow, along anterior tibial ridge
Cholesterol Emboli
recent surgery or anticoagulation, “blue toe syndrome
When does Cholesterol Emboli occur?
cholesterolfrom plaques are dislodged and travel through the blood stream, becoming lodged in small vessels
Karposi’s Sarcoma
Malignant tumor of lymph and epithelial cells linked to Herpes & HIV, radiation/chemo
STAR classification 1a
a skin tear where the edges can be realigned to the normal anatomical positions and the skin flap color is not pale, dusky or darkened.
STAR classification 1b
a skin tear where the edges can be realigned to the normal anatomical position and the skin flap color is pale, dusky or darkened
STAR classification 2a
a skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap color is not pale, dusky or darkened
STAR classification 2b
a skin tear where the edges cannot be realigned to the normal anatomical position and the skin flap color is pale, dusky or darkened
STAR classification 3
a skin tear where the skin flap is completely absent
