Integumentary: General Overview Flashcards
Arterial Insufficiency Ulners:
Location, Appearance, Exudate, Pain, Pedal Pulses, Edema, Skin Temperature, Tissue Changes
Lower 1/3 of leg, toes, web-spaces, dorsal foot, lateral malleolus Smooth edges, well defined; lack granulation; deep Minimal Exudate Severe Pain Diminished or absent Pulse No edema Decreased skin temp Thin and shiny; hair loss; yellow nails
Venous Insufficiency Ulcers:
Location, Appearance, Exudate, Pain, Pedal Pulses, Edema, Skin Temperature, Tissue Changes
Proximal to medial malleolus Irregular shape; shallow Moderate/heavy exudate Mild/moderate Pain Normal Pedal Pulse Increased Edema Flaking, dry skin; brownish discoloration
Neuropathic Ulcers:
Location, Appearance, Exudate, Pain, Pedal Pulses, Edema, Skin Temperature, Tissue Changes
Areas of foot susceptible to pressure or shear forces during weight bearing
Well-defined oval or circle; callused rim; cracked periwound tissue; little to no wound bed necrosis with good granulation
Low/moderate exudate
No pain (dyesthesia reported)
Diminished/absent pulse; unreliable ankle-brachial index with diabetes
No edema
Decreased skin temp
Dry, inelastic, shiny skin; decreased or absent sweat and oil production
Wagner Classification Scale:
no open lesion, but may possess pre-ulcerative lesions; healed ulcers; presence of bony deformity
0
Wagner Classification Scale:
Superficial ulcer not involving subcutaneous tissue
1
Wagner Classification Scale:
Deep ulcer with penetration through the subcutaneous tissue; potentially exposing bone, tendon, ligament or joint capsule
2
Wagner Classification Scale:
Deep ulcer with osteitis, abscess or osteomyelitis
3
Wagner Classification Scale:
Gangrene of digit
4
Wagner Classification Scale:
Gangrene of foot requiring disarticulation
5
Pressure Ulcer Staging:
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. May be painful, firm, soft, warmer/cooler as compared to adjacent tissue.
Stage I
Pressure Ulcer Staging:
Partial-thickness tissue loss of the dermis presenting as a shallow open ulcer with a red or pink wound bed. May present as an intact or ruptured serum-filled blister or presents as a shiny or dry shallow ulcer without slough or bruising.
Stage II
Pressure Ulcer Staging:
Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present, but does not obscure the depth of tissue loss. May include undermining and tunneling.
Stage III
Pressure Ulcer Staging:
Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Undermining and tunneling may be present.
Stage IV
Pressure Ulcer Staging:
Purple or maroon localized areas of intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear forces. Tissue preceding area may be abnormal compared to adjacent tissue.
Suspected Deep Tissue Injury
Pressure Ulcer Staging:
Full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.
Unstageable
Exudate Classification:
Clear, light color and a thin watery consistency
Serous
Exudate Classification:
Red color and a thin, watery consistency (indicative of new blood vessel growth or the disruption of blood vessels)
Sanguineous
Exudate Classification:
Light red or pink color and a thin, watery consistency.
Serosanguineous
Exudate Classification:
Presents as cloudy or opaque, with a yellow or tan color and a thin, watery consistency.
Seropurulent
Exudate Classification:
Presents with yellow or green color and a thick viscous consistency
Purulent
Necrotic Tissue Types:
Hard or leathery, black/brown, dehydrated tissue that tends to be firmly adhered to the wound bed
Eschar
Necrotic Tissue Types:
Death and decay of tissue resulting from an interruption in blood flow to an area of the body.
Gangrene
Necrotic Tissue Types:
Referred to as callus, is typically white/gray in color and can vary in texture from firm to soggy depending on the moisture level in surrounding tissue
Hyperkeratosis
Necrotic Tissue Types:
Moist, stringy or mucinous, white/yellow tissue that tends to be loosely attached in clumps to the wound bed
Slough
Use of a scalpel, scissors, and/or forceps to selectively remove devitalized tissue, foreign material or debris from a wound. Most expedient form of removing necrotic tissue
Sharp Debridement
Topical application of enzymatic preparation to necrotic tissue. Slow to establish a clean wound bed and should be discontinued once devitalized tissue is removed to avoid damage to adjacent healthy tissue
Enzymatic Debridement
Use of transparent films, hydrocolloids, hydrogels, and alginates. Establishes a moist wound environment that rehydrates necrotic tissue and eschar, facilitating enzymatic digestion of the nonviable tissue.
Autolytic Debridement
Application of a moistened gauze dressing over an area of necrotic tissue. Allowed to dry and is later moved.
Wet-to-dry Dressings
Removes necrotic tissue form wound bed using pressurized fluid. i.e. pulsatile lavage
Wound Irrigation
