Common Wounds Flashcards
Arterial Wounds USUALLY due to _________
Peripheral Artery Disease
PAD
*VERY PAINFUL!!!
Type of wound:
Arterial (usually due to PAD)
- can be ANY arteries
- initial buildup of sclerotic (scarred) tissue
-
*REMEMBER*
- Blood NOT getting to peripheral system
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Arterial Wounds
Describe the Pain
and what is it WORSE w/?
- SEVERE
-
Worse w/ Amb.
- bc blood wont make it to periph. aa’s
- Worse w/ Leg Elevation
Arterial Wounds
Describe the Location
-
LE
-
FURTHEST from the heart
- bc blood has to travel far & cannot make it
-
FURTHEST from the heart
-
Toes, LATERAL malleolus, or ANT. leg
- LESS likely Medial (venous wounds)
Arterial Wounds
Presentation— in general…
Small, shallow
Round, regular
Arterial Wounds
Presentation
Granulation tissue vs. Necrotic tissue
- Granulation tissue
- usually Pale
- Necrotic tissue
- black eschar
Arterial wounds can dev. ___________ w/ advanced disease
Gangrene
Exudate w/ Arterial wounds?
Minimal—>NO exudate
*bc not enough blood there!
What will those w/ PAD and Arterial wounds most likely describe the pain as?
“Ants in pants” feeling
Throbbing ALL the time
Arterial wounds
Describe the Periwound (around)
- DECd perfusion
- Epidermis thin, shiny, dry
- Loss of hair
- thick/brittle nails
- MM atrophy***
- Pale, dusky, cyanotic
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Arterial Wounds
Pulses?
Absent, thready, weak Dorsalis Pedis AND Post. Tib
*the DISTAL pulses!!!
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Arterial wounds
Temperature
*this is CLASSIC SIGN*
COOLER ****
*NOTE: use back of hand
GOLD STANDARD MEASUREMENT FOR PAD
ABI
(Ankle systolic pressure)/(brachial systolic pressure)
*blood/beat making it to ankle
Arterial Wounds
Other examinations?
- ABI==GOLD STANDARD
- Cap. refill
- Rubor of Dependency
-
Look @ leg:
- hairless, dry, atrophy, cool, pale, thin
- Chart review*
- CAD, PAD, renal artherosclerosis
Arterial Wounds
Some Ex’s and WHY
see below
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PT Tx for Arterial wounds:
Debridement
BUT complex decision tree to go thru
Venous wounds usually due to:
Chronic Venous Stasis/Disease/Insuff.
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CVD
RISK FACTORS for Venous Wounds
see below
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Venous Wounds
Describe the Pain
Dull, aching
ANNOYING
VENOUS WOUNDS
Pain gets WORSE w/
WORSE in dependent pos.
Venous wounds
Pain BETTER/IMPROVES w/?
IMPROVES w/ elevation (bc better venous return)
IMPROVES w/ compression (GOLD STANDARD)
VENOUS WOUNDS
Position? Usually?
Medial aspect LOWER leg
BUT can be anywhere on LOWER leg
Venous wounds
Presentation
starts as?
shape?
- STARTS as superficial and MAY progress to full thick.
- Irregular shape
Venous wounds
Drainage?
Mod–> Copious drainage
“Weeping Wounds”
Weeping Wounds think….
Venous Wounds!!!!
Venous wounds
Granulation tissue vs. Necrotic tissue
-
Granulation tissue
- Beefy Red
-
Necrotic tissue
- loose wet slough
Progression of Venous Wounds
tissue wise
- can PROGRESS to subcutaneous tissue BUT DOES NOT extend to tendon or bone******
Venous Wounds
Describe the Periwound
- Ill-defined wound borders
- Indurated (hard/firm) periwound
- Edema**
- Wet**
-
Hemosiderin staining
- HgB+RBCs stain skin
- Fibrotic thick skin**
Venous Wounds
If you are considering using Compression Therapy
What MUST you do?
- NEED:
-
ABI results to ensure adequate perfusion**
- MILD PAD==precaution
- SEVERE PAD==contraindication
-
Pregnancy status
-
Pregnancy== precaution
- bc blood vol INCs==venous pooling
-
Pregnancy== precaution
-
CHF
- Controlled Stage I== precaution
- Uncontrolled Stage II, III, IV==contraindication
-
ABI results to ensure adequate perfusion**
Venous Wounds
Some Ex’s and WHY
see below
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Diabetic Wounds
Usually from…
Type I or Type II DM
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Diabetic Wounds
RISK FACTORS
SEE BELOW
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Diabetic Wounds
Describe the Pain
- Painful OR
- NOT painful due to loss or diminished pain sensation
Diabetic Wounds
Certain deformities develop from Motor Polyneuropathy from Diabetes:
- Pes Planus
- Claw toes
- Hammer toes
- PF foot
- Hallux Valgus
- Charcot Foot
- Intrinis mm wasting of feet
Diabetic Wounds
Position of the wounds?
SAME AREAS WHERE ARTERIAL ULCERS ARE:
- Toes
- LATERAL malleolus
- ANT leg
Diabetic Wounds
Areas of Altered Pressure Points
Where???
- On Plantar aspect of foot, toes, heels
- __Motor Neuropathy
Diabetic Wounds
Explain the Presentation:
- Round
-
Frequently Deep
- bc progress FAST!!!
- MIN. drainage
-
HIGH infection rate
-
THIS IS UNIQUE TO DIABETIC WOUNDS
- bc sugar irritation
-
THIS IS UNIQUE TO DIABETIC WOUNDS
Diabetic Wounds
Peri-wound
- DRY (sometimes Very dry)
- Elevated rim of wound**
Diabetic wounds
Pulses?
DIMINISHED
Diabetic Wounds
Temp.
- Neuropathic foot is warm and dry
-
bc Autogenic Neuropathy
- ==> autoreg. of temp affected
-
bc Autogenic Neuropathy
Diabetic Wounds
Other Examinations???
SENSATION TESTING!!!
- Lt. touch
- Protective sensation
- microfilament testing
- Sharp touch
- Proprio testing
- 2-pt discrim.
- Temp
- Vibration
Assess for foot deformities== Motor Testing
Diabetic Wounds
Some Ex’s and other cond‘s that follow (foot deformities)
see below
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PT Tx: Compression Therapy for Venous Wounds
What to DO:
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Pressure Ulcers
Usually due to:
- Diminished sensation OR inability to vocalize pain (delirium)
- INCd moisture OR incontinence
- Immobility**BIG ONE!
- Inad. nutrition OR inability to absorb nutrition
- Friction/shear forces**
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Stage 1 Pressure Ulcer
Describe Stage 1
- Intact skin w/ localized area erythema
- Area=non-blanchable
- DECd sensation
- INCd firmness
- Temp changes: warm or cool
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Stage 1 Pressure Ulcers are NOT:
NOT Open
NOT scar tissue
NOT erythema purple or maroon discoloration
What is the MOST IMPORTANT THING we want to remember w/ Stage 2 Pressure Ulcers?
*THIS IS WHEN WE WANT TO CATCH THEM!!
*Tissue is physiologically reversible over time IF caught @ this stage!!!*
Stage 2 Pressure Ulcers
Describe this stage:
- wound bed is viable
- Pink OR red tissue
- Moist
- Blister
- NO granulation tissue
- NO necrotic tissue
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Stage 3 Pressure Injury
What is going on in this stage?
-
Full thickness loss of skin in which adipose (fat) is visible
- Granulation tissue
- Necrotic tissue MAY be present
- undermining, sinus track, tunneling MAY occur
- ***NO fascia, mm, tendon, lig, cartilage and/or bone exposed***
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Stage 3 Pressure Ulcer
Epibole often present
what is this ?
Epibole (rolled wound edges) often present
Stage 3 pressure ulcer
Healing capacity?
Wound will go thru stages of healing (if tx’d) and form scar tissue
Stage 3 Pressure injury
What makes it an “Unstageable Pressure Injury”
- If slough or eschar obscures (makes it so you cannot tell) the extent of tissue loss == Unstageable
Stage 4 Pressure Injury
What is going on in this Stage?
-
Full thick. loss of skin now WITH exposed fascia, mm, tendon, lig, cart., bone
- SO undermining, sinus track, tunneling MAY occur
- Necrotic tissue (slough and/or eschar) MAY be present
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Stage 4 Pressure Injury
Epibole?
Epibole (rolled wound edges) often present
Stage 4 Pressure Injury
Healing?
Wound will go thru stages of healing (if tx’d) and form scar tissue
Stage 4 pressure injury
What makes this an “Unstageable Pressure Injury?”
IF slough or eschar obscures extent of tissue loss== Unstageable
A wound can NEVER heal if what is present?
W/ Eschar present
Unstageable Full Thick. Pressure Injury
2 components that make it Unstageable
- Obscured full thick. skin and tissue loss
- Extent of tissue damage w/in ulcer cannot be confirmed
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Unstageable Full Thick Pressure Injury
Black eschar obscures the full thick of skin and tissue loss
What is the role of eschar?
- Eschar is body’s natural cover of phys. and immune protection
- a wound can NEVER heal w/ eschar present
- Removing stable eschar in the poorly perfused area results in an open wound prone to infection
Deep Tissue Pressure Injury (DTI) OR
Prolooonged deep bruise
Deep Tissue Pressure Injury
DTI
what is this?
- Persistent non-blanchable deep red, maroon or purple discoloration OR epidermal separation revealing a dark wound bed OR blood filled blister
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Deep Tissue Pressure Injury (DTI)
Pain and temp?
Pain and temp change often preced skin color changes
Deep Tissue Pressure Injury (DTI)
What does this result from?
- Results from intense and/or prolonged pressure and shear forces @ bone-muscle interface
PT’s role in Pressure Ulcers
PT’s prevent pressure ulcers!!!!
Physical Tx for Pressure Ulcers
We want to Off-Load 3 things:
- Offload– change pts pos’ing q2h
- Offload– improve surf. selection
- bed, shoes, bandage
- Offload– improve wt. distribution during Function
- shoes (CAM shoes)
Physical Tx for Pressure Ulcers
We want to DECREASE what?
DECREASE Moisture
- speak w/ nurse about catheter/fecal tube
- obtain commode
- PT INTERVENTION: commode transfers
Physical Tx for Pressure Ulcers:
Encourage pt to_________
Encourage pt to assist in mobility to prevent shear forces
Physical Tx for Pressure Ulcers
Interdisciplinary Care?
- Optimize nutrition w/ nutritionist
- INC arousal via reviewing meds w/ pharmacist
- Encourage nursing assist. or family to assist w/ meal prep AND motivation to eat PRO-based foods**
- NEED PRO FOR WOUND TO HEAL!!!
- Optimize IND @ meals w/ OT**
Burns
usually result from…
Trauma!!!
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SUPERFICIAL burn
Involves:
ONLY Epidermis
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SUPERFICIAL Partial Thick. Burn
Involves….
Epidermis AND some of the Papillary dermis
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DEEP PARTIAL Thick Burn
Involves….
damages tissue that extends INTO Reticular layers AND MAY INCLUDE Fat domes of Subcutaneous layer
**NOTE how it says MAY include subcutaneous**
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FULL Thick. Burn
Involves…..
ENTIRE thickness of skin down to AND including Subcutaneous tissue
*NOTE how it says and includes Subcutaneous tissue**
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________type of wound can get infected, BUT ______________ MOST susceptible to infections
ANY type of wound can get infected, BUT Diabetic wounds are MOST susceptible to infections!!!
bc sugar irritation**
wounds+infection
ANY wound can become infected!!!
Diabetic wounds most susceptible to infections!!!
Local evidence of infection:
- ODOR*** (ALWAYS)
- Streaking
- Redness
- Erythema
- Induration (firm)
- Cellulitis== skin infection
- INCd pain
- INCd drainage/purulence
- REALLY opaque
- white, yellow, gree, THICC drainage
LOCAL infection pot. difficult to tell in pts w/ _________
Darker skin pigmentation
BUT odor always there**
How can we confirm a local infection?
Wound culture/biopsy for organisms
EX. Bronchoscopy –> suction out stuff from base of lungs & observe
If the infection moves….HOW is it usually moving?
Wounds are a direct route to the bloodstream
IF infection moves to Bone ====
Osteomyelitis
IF infection moves to Blood ===
Bacteremia
IF infection moves to Heart ===
Endocarditis
*infection of Inner valves
Systemic infection ===
SEPSIS
*infection ALL OVER BODY**
Systemic evidence of infection
*confirms SEPSIS —–>
- ELEVATED WBC
- ELEVATED HR
- == Tachycardia
- ELEVATED body temp
- == Fibrile
- >22 breaths per min.
- == Tachypnea
- SBP <100
- Altered Mental Status (AMS)