Exam 2 ulcers Flashcards
Describe a stage 1 pressure ulcer
Intact skin with non-blanching redness
Describe a stage 2 pressure ulcer
shallow, open ulcer with red-pink wound bed
Describe a stage 3 pressure ulcer
full-thickness tissue with visible cutaneous fat
Describe a stage 4 pressure ulcer
full-thickness tissue loss with exposed muscle and bone
What is the key nutritional component of ulcer healing
Protien, 1-1.5 g/kg/day
Should you debride a stage 1 pressure ulcer?
NO
What is the main concern of a stage 1 pressure ulcer
Removing the cause of the ulcer
How do you clean a stage 2 pressure ulcer?
saline flush
Should you debride a stage 2 pressure ulcer?
NO
Central concern with a stage 2 ulcer
provide moist wound bed, keep surrounding tissue dry
Should you debride a stage 3 pressure ulcer?
Yes, if eschar or slough is present
What are ways to debride a stage 3 pressure ulcer?
autolytic debridement, wet-to-dry bandages, enzymatic solutions, surgery
How to clean a stage 3 ulcer?
saline flush
What is the central issue with a stage 3 pressure ulcer?
debride necrotic tissue, protect granulation tissue
Should you debride a stage 4 pressure ulcer
yes, all necrotic tissue
What is the central concern of a stage 4 ulcer?
patience, pain control, possible end of life talk
What is the most common cause of lower extremity ulcers?
venous (90+%)
Where is the most typical place for a venous pressure ulcer?
medial malleolus
What is the classic sign of a venous ulcer?
Chronic adema will not diurese, tender upon palpation
What is the pathophysiology of a venous ulcer?
Valves between low and high pressure system breaks, increasing venous pressure in superficial veins, causing them to break
Risk factors for venous ulcers
Overload: CHF, obesity, Obstruction: clot, tumor, “pump” malfunction, neuro dysfunction, injury, inactivity
what is the treatment for a venous ulcer?
same cleansing as a pressure ulcer, same debridement, control edema, external pressure
What is often an underlying disease that accompanies arterial ulcers?
Diabetes
What does an arterial ulcer look like?
circumscribed, “punched-out” ulcers, often multiple, absent pulses, claudication ( muscle pain in area with activity)
Where do arterial ulcers usually occur?
least perfused areas: lateral malleolus, tibia, feet/toes
What is the measurement for arterial ulcer risk?
Ankle-brachial index (ABI): Normal: 1, 0.8=claudication, 0.4= pain at rest
What is Buerger’s disease
thrombangiitis obliterans- a hypersensitivity to smoking. Occurs on young smokers’ hands and feet, thrombophlebitis
What test tests occlusion of ulnar artery?
Allen test
Describe allen test
Make fist, mechanically block ulnar and radial arteries, release ulnar artery to see if hand turns pink. Positive test will indicate a block in ulnar artery
Treatment of arterial arteries
NO external compression, quit smoking, revascularization, skin graft or amputation
Should you provide external pressure to an arterial artery?
NO
Where are the most common areas for a neurotropic ulcer
Plantar aspect of foot or toes
What does a neurotrophic ulcer look like?
often callused with just a small pin prick in the middle- upon opening it’s an ulcer
What does the treatment of neurotrophic ulcers look like?
Protection: change footwear, total contact cast, recombinant platelet-derived growth factor, diabetes menagement
What are some special cases that cause ulcers
pyoderma gangrenosum, cancer (basal cell carcinoma, squamous cell carcinoma)
What does a pyoderma gangrenosum ulcer look like?
margins are serpiginous and elevated, edges are blue or purple hue, pustule or blister precedes
What is pyoderma grangrenosum associated with?
inflammatory bowel, RA, leukema, other autoimmune diseases
How do you treat pyoderma gangrenosum?
Steroids (oral or injection)
What is the most common skin cancer?
Basal cell carcinoma
What does a BCC ulcer look like
“heaped up” or rolled edges
Where do BCC ulcers usually occur
sun-exposed areas
What can cause a squamous cell carcinoma?
a previously benign ulcer
What should you do with an SCC ulcer?
punch biopsy
