Integumentary Flashcards
Wagner ulcer classification scale
0-5
1- superficial ulcer
5- gangrene of foot requiring disarticulation
Pressure Ulcer Staging
I - intact skin
II - partial thickness
III - full thickness
IV - full thickness beyond fascia
Arterial Insufficiency Wound
Lateral malleolus
Well-defined, deep, minimal exudate
Severe pain, elevation increases pain
Venous Insufficiency Wound
Medial malleolus
Irregular edges, shallow, moderate exudate, edematous, mild pain, leg elevation decreases pain
Neuropathic wound
High pressure/WBing areas
Well-defined, circular, painless
Rule of 9s
Head/neck- 9
Ant trunk- 18
Post trunk- 18
UE- 9
LE- 18
Genitals- 1
Wagner scale vs staging
Wagner: 0-5, gangrene of foot being 5
Staging: I-IV
Burn staging
1st degree: read, tender, no blistering. Damage to epidermis
2nd: blisters, painful, damage to epidermis and dermis
3rd: Full thickness burn, nonpainful, fluid loss, damage to epidermis and dermis, dry, leathery, scarring
4th: subdermal burn, electrical burns. Extensive tissue damage. surgery needed
Braden scale
Risk for developing pressure ulcers
Range: 6–23
15–18: at risk for developing pressure ulcers
13–14: moderate risk
10–12: high risk
Less than 9: very high risk
Hydrocolloids
Anchors to intact surrounding skin
Max absorbent, Max occlusive
Cannot be used on infected wounds
Hydrogels
Protects wounds, moisture – retentive
Minimal absorbent, minimal occlusive
Cannot be used on wounds with heavy drainage
Transparent film
Permeable to vapor and oxygen, but keeps water and bacteria out
Minimal absorbent, maximum occlusive
Cannot be used on infected wounds
Foam
Hydrophilic interlayer, hydrophobic outer layer
Difficult to inspect wound
Max absorbent, Max occlusive
Can be used secondary overtop hydrogels
Alginates
Highly absorptive, permeable, nonocclusive
Cannot be used with exposed tendon or bone
Requires secondary dressing
Gauze
Versatile, cost-effective
Con: adherence, increased infection rate
Minimal absorbent, minimal occlusive
