Integumentary System Flashcards
1
Q
The integumentary system
A
- is the body’s largest organ consisting of stratified dermal and epidermal layers, hair follicles, nails, sebaceous glands, and sweat glands
2
Q
Superficial burn
A
- involves only the outer epidermis
- the involved area may be red with slight edema
- healing occurs without peeling or evidence of scarring in two to five days
3
Q
superficial partial-thickness burn
A
- involves the epidermis and the upper portion of the dermis
- the involved area may be extremely painful and exhibit blisters
- healing occurs with minimal to no scarring in 5-21 days
4
Q
deep partial thickness burn
A
- involves complete destruction of the epidermis and the majority of the dermis
- the involved area may appear to be discolored with broken blisters and edema
- damage to nerve endings may result in only moderate levels of pain
- hypertrophic or keloid scarring may occur
- in the absence of infection, healing will occur in 21-35 days
5
Q
full thickness burn
A
- involved complete destruction of the epidermis and dermis along with partial damage to the subcutaneous fat layer.
- the involved area typically presents with eschar formation and minimal pain
- Pt with full-thickness burns require grafts and are susceptible to infection
- healing time varies significantly with smaller areas healing in a matter of weeks, with or without grafting, and larger areas requiring grafting and potentially months to heal
6
Q
subdermal burn
A
- involves the complete destruction of teh epidermis, dermis, and subcutaneous tissue.
- may involve muscle and bone and as a result, often require multiple surgical interventions and extensive healing time
7
Q
Anticipated Deformities Based on burn location
- anterior neck
A
- anticipated deformity: flexion with possible lateral flexion
- splinting: soft collar,molded collar, philadephia collar
8
Q
Anticipated Deformities Based on burn location
- anterior chest and axilla
A
- anticipated deformity: shoulder ADD, Ext, and IR
- splinting: axillary or airplane splint, shoulder abduction brace
9
Q
Anticipated Deformities Based on burn location
- elbow
A
- anticipated deformity: Flexion and pronation
- splinting: gutter splint, conforming splint, 3-point splint, air splint
10
Q
Anticipated Deformities Based on burn location
- hand and wrist
A
- Anticipated deformity: ext or hyperextension of the MCP joints; flexion of the IP joints; ADD and flexion of the thumb; flexion of the wrist
splinting: wrist splint, thumb spica splint, palmar or dorsal extension splint
11
Q
Anticipated Deformities Based on burn location
- Hip
A
Anticipated deformities: flexion and ADD
-splint: anterior hip spica, ABD splint
12
Q
Anticipated Deformities Based on burn location
-knee
A
- anticipated deformity: flexion
splint: conforming splint, 3 point splint, air splint
13
Q
Anticipated Deformities Based on burn location
-ankle
A
- anticipated deformity: PF
splint: posterior foot drop splint, posterior ankle conforming splint, anterior ankle conforming splint
14
Q
selective debridement
A
- involves the removal of only noviable tissues from a wound
- selective debridement is most often performed by sharp debridement, enzymatic debridement or autolytic debridement
15
Q
sharp debridement
A
- requires the use of a scalpel, scissors and/or forceps to selectively remove devitalized tissue, foreign material or debris from a wound
- sharp debridement is most often used for wounds with large amts of thick, adherent, necrotic tissue; however, it may also be used in the presence of cellulitis or sepsis
- sharp debridement is the most expedient form of removing necrotic tissue
- PT are permitted to perform sharp, selective debridement as a procedural intervention
16
Q
enzymatic debridement
A
- refers to the topical application of an enzymatic preparation to necrotic tissue
- enzymatic debridement can be used on infected and non-infected wounds with necrotic tissue
- this type of debridement may be used for wounds that have not responded to autolytic debridement or in conjunction with other debridement techniques
- enzymatic debridement can be slow to establish a clean wound bed and should be discontinued once devitalized tissue is removed to avoid damage to adjacent healthy tissue
17
Q
autolytic debridement
A
- refers to the use of the body’s own mechanisms to remove nonviable tissue
- common methods of autolytic debridement include the 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
- non-invasive and pain free
- can be used with any amt of necrotic tissue however, requires a longer healing period and should not be performed on infected wounds
18
Q
non-selective debridement
A
- involves the removal of both viable and nonviable tissues from a awound
- often termed mechanical debridement
- most commonly performed via wet-to -dry dressings, wound irrigation and hydrotherapy
19
Q
wet -to -dry dressings
A
- refers to the application of moistened gauze dressing over an area of necrotic tissue
- the dressing is allowed to dry completely and is later removed, along with any necrotic tissue that has adhered to the gauze
- wet-to dry dressings are most often used to debride wounds with moderate amounts of exudate and necrotic tissue
- this type of debridement should be used sparingly on wounds containing both necrotic and viable tissue since granulation tissue will be traumatized in the process
- removal of dry dressings from granulation may cause bleeding and be extremely painful
20
Q
Wound irrigation
A
- removes necrotic tissue from the wound bed using pressurized fluid
- pulsatile lavage is an example
- most desirable for wounds that are infected r have loose debris
- many devices permit variable pressure settings and provide suction for the removal of exudate and debris
21
Q
hydrotherapy
A
- most commonly employed using a whirlpool tank with agitation directed toward a wound requiring debridement
- this process softens and loosens adherent necrotic tissue
- PT must be aware of potential hydrotherapy side effects such as maceration of viable tissue, edema from dependent LE positioning and systemic effects such as hypotension
22
Q
Alginates
A
- derived from seaweed extraction, specifically, the calcium salt component of alginic acid
- highly absorptive but are also highly permeable and non-occlusive
- as a result, they require a secondary dressing
- alginate dressings act as a hemostat and create a hydrophilic gel through the interaction of calcium ions in the dressing and sodium ions in the wound exudate
23
Q
indications to use Alginates
A
- typically used on partial or full-thickness draining wounds such as pressure or venous insufficiency ulcers
- alginates are often used on infected wounds due to the likelihood of excessive drainage
24
Q
Foam dressings
A
- comprised of a hydrophilic polyurethane base that contacts the wound surface and a hydrophobic outer layer
- the dressings allow exudate to be absorbed into the foam through the hydrophilic layer
- the dressings are most commonly available in sheets or pads with varying degree of thickness
- semipermeable foam dressings are produced in adhesive and non-adhesive forms
- nonadhesive forms require secondary dressing
25
Q
indication to use foam dressings
A
- used to provide protection and absorption over partial and full thickness wounds with varying levels of exudate
- they can also be used as secondary dressings over amorphous hydrogels
26
Q
advantages of foam dressings
A
- provides moist environment for wound healing
- available in adhesive and nonadhesive forms
- provides prophylactic protection and cushioning
- encourages autolytic debridement
- provides moderate absorption
27
Q
foam dressing disadvantage
A
- may tend to roll in areas of excessive friction
- adhesive form may traumatize periwound are upon removal
- lack of transparency makes inspection of wound difficult
28
Q
Gauze indications
A
- most readily available dressing used in inpatient environment
- are commonly used on infected or non-infected wounds of any size
- teh dressings can be used for wet-to-wet, wet-to moist or wet-to-dry debridement
29
Q
gauze advantages
A
- readily available and cost effective short-term dressings
- can be used alone or in combiniation with other dressings and topical agents
- can modify number of layers to accomodate for changing wound status
- can be used on infected or non-infected wounds
30
Q
gauze disadvantages
A
- has a tendency to adhere to the wound bed traumatizing viable tissue on removal
- highly permeable
- Requires frequent dressing changes
- Prolonged use decreases cost effectiveness
- increased infection rate compared to occlusive dressings
31
Q
hydrocolloids indications
A
- dressings consist of gel-forming polymers backed by a strong film or foam adhesive
- the dressing does not attach to the wound itself but instead anchors to the intact surrounding skin
- the dressings absorb exudate by swelling into a gel-like mass and vary in permeability, thickness and transperency
- useful for parttial and full-thickness wounds
- the dressings can be used effectively with granular or necrotic wounds
32
Q
hydrocolloids advantages
A
- provides moist environment
- enables autolytic debridement
- offers protection from microbial contamination
- provides moderate absorption
- does not require a secondary dressing
- provides a waterproof surface
33
Q
disadvantages of hydrocolloids
A
- may traumatize surrounding intact skin upon removal
- may tend to roll in areas of excessive friction
- cannot be used on infected wounds
34
Q
hydrogels indications
A
- consists of varying amounts of water and gel-forming materials such as glycerin. the dressings are typically available in both sheet and amorphous forms
- moisture retentive and commonly used in superficial and partial-thickness wounds that have minimal drainage
35
Q
Hydrogels advantages
A
- Provides a moist environment for wound healing
- enables autolytic debridement
- may reduce pressure and diminish pain
- can be used as a coupling agent for ultrasound
- Minimally adheres to wound
- SOme products have absorptive properties
36
Q
hydrogels disadvantages
A
- Potential for dressings to dehydrate
- cannot be used on wounds with significant drainage
- typically requires a secondary dressing
37
Q
Transparent film indications
A
- thin membranes made from transparent polyurethane with water-resistant adhesives
- permeable to vapor and oxygen, but are largely impermeable to bacteria and water
- highly elastic, and allow easy visual inspection of the wound since they are transparent
- useful for superficial or partial-thickness wounds with minimal drainage
38
Q
advantages for transparent film
A
- provides a moist environment for wound healing
- enables autolytic debridement
- allows visualization of the wound
- resistant to shearing and frictional forces
- cost effective over time
39
Q
disadvantages for transparent film
A
- excessive exudate accumulationcan result in periwound maceration
- adhesive may traumatize periwound area upon removal
- cannot be used on infected wounds
40
Q
Exudate Classification
- serous
A
- Presents with a clear, light color and a thin, watery consistency
- serous exudate is considered to be normal in a healthy healing wound and is observed during the inflammatory and proliferative phases of healing
41
Q
Exudate Classification
- Sanguineous
A
- Presents with a red color and a thin,watery consistency
- the red appearance of sanguineous exudate is due to the presence of blood which may become brown if allowed to dehydrate
- sanguineous exudate may be indicative of new blood vessel growth or the disruption of blood vessels
42
Q
Exudate Classification
- serosanguineous
A
- presents with a light red or pink color and a thin, watery consistency
- serosanguineous exudate is considered to be normal in a healthy healing wound and is typically observed during the inflammatory and proliferative phases of healing
43
Q
Exudate Classification
- seropurulent
A
- Presents as a cloudy or opaque, with a yellow or tan color and a thin, watery consistency
- seropurulent exudate may be an early warning sign of an impending infection and is always considered an abnormal finding
44
Q
Exudate Classification
- Purulent
A
- Presents with a yellow or green color and a thick, viscous consistency
- purulent exudate is generally and indicator of wound infection and is always considered an abnormal finding
45
Q
Healing by Primary Intention
A
- most commonly occurs in acute wounds with a minimal tissue loss
-smooth clean edges are reapproximated and closed with sutures,staples or adhesives to facilitate re- epithelialization.
-superficial partial thickness wounds such as abrasions or blisters.
minimal scarring, and heal quickly in an uncomplicated and orderly progression
46
Q
healing by secondary intention
A
- permits wounds to close on their own w/o superficial closure
- wounds with significant necrosis, irregular or nonviable wound margins that cannot be reapproximated infection or debris contamination typically heal by secondary intention
- associated with DM, or inflammatory disease
- a layer of granulation tissue will gradually fill the wound bed to the level of teh surrounding skin, with closure occuring by wound contraction and scar formation
- healing by this intention requires ongoing wound care and have larger scars. ex: neuropathic, arterial, venous or pressure ulcers, most full-thickness wounds and chronically inflamed wounds
47
Q
healing by tertiary intention
A
- referred to as delayed primary intention healing
- wounds at risk for developing complications, such as sepsis or dehiscence, may be temporarily left open.
- once risk factors have been alleviated the wound is closed by the usual primary intention methods
48
Q
Integumentary Terminology
- Contusion
A
aninjury, usually caused by a blow, that does not disrupt skin integrity
-the injury is characterized by pain, edema, and discoloration which appears as a result of blood seepage under the surface of the skin
49
Q
Integumentary Terminology
- DEhiscence
A
- the separation, rupture or splitting of a wound closed by primary intention.
- this disruption of previously approximated surfaces may be superficial or involve all layers of tissue
50
Q
Integumentary Terminology
- Dermis
A
- the vascular layer of skin located below the epidermis containing hair follicles sebaceous glands , sweat glands, lymphatic and blood vessels, and nerve endings
51
Q
Integumentary Terminology
- desiccated
A
- the drying out or dehydration of a wound
- desiccation often results from poor dressing selection that does not control the evaporation of wound bed moisture
52
Q
Integumentary Terminology
- desquamation
A
- the peeling or shedding of the outer layers of the epidermis
- normally occurs in small scales, although certain conditions, injuries and medications may cause peeling in larger scales or sheets and extend to deeper layers of the skin
53
Q
Integumentary Terminology
- Ecchymosis
A
- the discoloration occurring below intact skin resulting from trauma to underlying blood vessels and blood seeping into tissues.
- the discoloration is typically blue-black, changing in time to a greenish brown or yellow color
- an area where ecchymosis is present is commonly referred to as a bruise
54
Q
Integumentary Terminology
- epidermis
A
- the superficial, avascular epithelial layer of the skin that includes flat, scale-like squamous cells, round basal cells and melanocytes which produce melanin and give skin its color
55
Q
Integumentary Terminology
- erythema
A
- a diffuse redness of the skin often resulting from capillary dilation and congestion or inflammation
56
Q
Integumentary Terminology
- friable
A
- tissue that readily tears,fragments or bleeds when gently palpated or manipulated
57
Q
Integumentary Terminology
- Hematoma
A
- a localized swelling or mass of clotted blood confined to a tissue, organ or space usually caused by a break in a blood vessel
58
Q
Integumentary Terminology
- hypergranulation
A
-increased thickness of teh granular layer of the epidermis that exceeds the surface height of teh skin
59
Q
Integumentary Terminology
- hyperpigmentation
A
- an excess of pigment in a tissue that causes it to appear darker than surrounding tissues
60
Q
Integumentary Terminology
- hypertrophic scar
A
- an abnormal scar resulting from excessive collagen formation during healing.
- a hypertrophic scar is typically raised red, and firm with disorganized collagen fibers
61
Q
Integumentary Terminology
-keloid
A
- an abnormal scar formation that is out of proportion to the scarring required for normal tissue repair and is comprised of irregularly distributed collagen bands
- a keloid scar typically exceeds the boundaries of the original wound appearing red, thick, raised and firm
62
Q
Integumentary Terminology
-maceration
A
- the skin softening and degeneration that results from prolonged exposure to water or other fluids
63
Q
Integumentary Terminology
- normotrophic scar
A
- a scar characterized by the organized formation of collagen fibers that align in a parallel fashion
64
Q
Integumentary Terminology
- turgor
A
- the relative speed with which the skin resumes its normal appearance after being lightly pinched
- tugor is an indicator of skin elasticity and hydration and normally occurs more slowly in older adults
65
Q
Integumentary Terminology
- Ulcer
A
- an open sore or lesion of the skin accompanied by sloughing or inflamed necrotic tissue
66
Q
Phases of Wound Healing
- inflammatory phase (1-10 days)
A
- immune system’s initial response to a wound
- temporary repair mechanisms rapidly re-establish hemostasis through platelet activation and the clotting cascade
- debris and necrotic tissue are removed and bacteria are killed by mast cells, neutrophils and leukocytes
- processes occurring in the inflammatory phase establish a clean wound bed which signals tissue restoration and permanent repair processes to begin
- re-epithelialization typically begins within 24 hrs at the wound borders, though visible signs are usuallynot till 3 days after injury
67
Q
Phases of Wound Healing
- Proliferative Phase 3-21 days
A
- the formation of new tissue signals the beginning of the proliferative phase.
- capillary buds and granulation tissue begin to fill the wound bed creating a support structure for the migration of epithelial cells
- Keratinocytes, endothelial cells and fibroblasts are active and the collagen matrix is formed
- skin integrity is restored in the proliferative phase with wound closure occuring through epithelialization and wound contraction
68
Q
Phases of Wound Healing
- Maturation Phase 4 days to 2 years
A
- initiated when gradulation tissue and epithelial differentiation begin to appear in the wound bed
- mechanisms of fiber reorganization and contraction shrink and thin the scar
- an immature scar will appear red, raised and rigid while a mature scar will appear pale,flat, and pliable.
- scar tissue is remodeled and strengthened through the processes of collagen lysis and synthesis
- newly repaired tissues have approximately 15% or pre-injury tensile integrity and should be protected to prevent re-injury
- overtime, tensile integrity may incr to as much as 80% of the pre-injury strength
- hypertrophic scarring: especially in relation to burn injuries, can significantly impact maturation phase progression
- a burn w/o hypertrophic scarring will typically mature within 4 to 8 weeks; burn with hypertrophic scarring, however, may require up to two years to reach maturity
69
Q
Pressure Injury Stage 1:
A
- non-blanchable erythema of intact skin
- intact skin with a localized area of non-blanchable erythema
- presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes
- color changes do not include purple or marroon discoloration; these may indicate deep tissue pressure injury
70
Q
Pressure Injury Stage 2
A
- Partial-thickness loss of skin with exposed dermis
- the wound bed is viable, pink or red, moist and may also present as an intact or ruptured serum-filled blister
- adipose is not visible and deeper tissues are not visible
- granulation tissue, slough and eschar are not present
- these injuries commonly result from adverse microclimate and shear over the pelvis and shear in the heel
- this stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis, medical adhesive related skin injury, or traumatic wounds
71
Q
Pressure Injury Stage 3
A
- full thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole (rolled edges) are often present.
- slough and/or eschar may be visible
- the depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds
- undermining and tunneling may occur
- if slough or eschar obscures the extent of tissue loss, this is an unstageable Pressure injury
72
Q
Pressure Injury Stage 4
A
- full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer.
- slough and/or eschar may be visible
- Epibole (rolled edges), undermining and/or tunneling often occur
- depth varies by anatomical location
- if slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury
73
Q
Unstageable Pressure Injury
A
- full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar
- if slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed
- stable eschar on the heel or ischemic limb should not be softened or removed
74
Q
Deep tissue Pressure Injury:
A
- intant or non-intact skin with localized area of persistent non-blanchable deep red, maroon or purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister
- pain and temperature change often percede skin color changes
- discoloration may appear differently in darkly pigmented skin
- this injury results from intense and/or prolonged pressure and shear forces at the bone- muscle interface
- the wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve w/o tissue loss.
- if necrotic tissue, subcutaneous tissue, granulation tissue, fascia muscle or other undelrying structures are visible this indicates a full-thickness pressure injury
- do not use deep tissue pressure injury to describe vascular, traumatic, neuropathic, or dematologic conditions
75
Q
Red-yellow black system
–RED
A
- wound description: pink granulation tissue
- goals: protect wound; mainatin moist environment
76
Q
Red-yellow black system
- YELLOW
A
- wound description: moist, yellow slough
- goals: remove exudate and debris; absorb drainage
77
Q
Red-yellow black system
-BLACK
A
- wound description: black, thick eschar, firmly adhered
- goals: debride necrotic tissue
78
Q
Rule of Nines
A
- allows for a gross approximation of the percentage of the body affected by a burn
- the rule of nines does not account for severity
- head and neck- 9%
- anterior trunk 18%
- Posterior trunk 18%
- B Anterior UE- 9%
- B posterior UR- 9%
- genital region 1%
- B ant LE - 18%
- B post LE - 18%
79
Q
child values —-Rules of Nines
A
- a child under one year has 9% taken from the LE and added to the head and neck region
- each year of life 1% is distributed back to the LE until the age of nine when the head is considered to be the same proportion as an adult.
80
Q
Topical Agents Used in Burn Care
- Silver Sulfadiazine
A
Adv: can be used with or without dressings; painless; can be applied to wound directly; broad-spectrum; effective against yeast
Disadvantages: does not penetrate into eschar
81
Q
Topical Agents Used in Burn Care
- Silver Nitrate
A
A: broad-spectrum ; non-allergenic; dressing application is painless
D: poor penetration;discolors, making assessment difficult; can cause severe electrolyte imbalances; removal of dressings is painful
82
Q
Topical Agents Used in Burn Care
- Povidone- iodine
A
A: broad-spectrum; antifungal; easily removed with water
D: not effective against pseudomonas; may impair thyroid function; painful applictaion
83
Q
Topical Agents Used in Burn Care
- Mafenide Acetate
A
- A: broad-spectrum; penetrates burn eschar; may be used with or without occlusive dressings
D: may cause metabolic acidosis; may compromise respiratory function; may inhibit epitheliallization; painful application
84
Q
Topical Agents Used in Burn Care
- Gentamicin
A
- A: broad-spectrum; may be cobered or left open to air
D: has caused resistant strains; ototoxic; nephrotoxic
85
Q
Topical Agents Used in Burn Care
- nitrofurazone
A
- A: bacteriocidal;broad-spectrum
D: may lead to overgrowth of fungus and psudomonas, painful application
86
Q
Arterial Insufficiency Ulcers
A
- wounds resulting from arterial insufficiency occur secondary to inadequate circulation of oxygenated blood often due to complicating factors such as atherosclerosis
87
Q
General recommendations for arterial insufficiency Ulcers
A
- Rest
- limb protection
- Risk reduction education
- Inspect legs and feet daily
- avoid unnecessary leg elevation
- avoid using heating pads or soaking feet in hot water
- water appropriately sized shoes with clean,seamless socks
88
Q
Venous Insufficiency Ulcers
A
- Wounds resulting from venous insufficiency occur secondary to impaired functioning of the venous system resulting in inadequate circulation and eventual tissue damage and ulceration
89
Q
General recommendations for Venous Insufficiency Ulcers
A
- Limb protection
- risk reduction education
- inspect legs and feet daily
- compression to control edema
- elevate legs above the heart when resting or sleeping
- attempt active exercise including frequent ROM
- Wear appropriately sized shoes with clean, seamless socks
90
Q
Neuropathic Ulcers
A
- Neuropathic Ulcers are a secondary complication usually associated with a combination of ischemia and neuropathy
- Neuropathic ulcers are often associated with DM, however any form of peripheral neuropathy poses an increased risk of wound development
91
Q
General recommendation of neuropathic Ulcers
A
- limb protection
- Risk reduction education
- Inspect legs and feet daily
- inspect footwear for debris prior to donning
- wear appropriately sized off-loading footwear with clean, cushioned, seamless socks
92
Q
General recommendation for pressure ulcers
A
- re-positioning every two hours in bed
- management of excess moisture
- off-loading with pressure relieving devices
- inspect skin daily for signs of pressure damage
- limit sheer, traction, and friction forces over fragile skin
93
Q
Wagner Ulcer classification System
A
- categorizes dysvascular ulcers based on wound depth and the presence of infection
- most commonly associated with the assessment of diabetic foot ulcers, the scale can be appropriately used to categorize most ulcers arising from neuropathic, ischemic or arterial etiology
94
Q
Wagner Ulcer Classification Scale
- 0
A
- no open lesion, but may possess pre-ulcerative lesions;healed ulcers;presence of bony deformity
95
Q
Wagner Ulcer Classification Scale
- 1
A
- superficial ulcer not involving subcutaneous tissue
96
Q
Wagner Ulcer Classification Scale
- 2
A
- deep ulcer with penetration through the subcutaneous tissue; potentially exposing bone, tendon, ligament or joint capsule
97
Q
Wagner Ulcer Classification Scale
- 3
A
- deep ulcer with osteitis, abscess or osteomyelitis
98
Q
Wagner Ulcer Classification Scale
- 4
A
- gangrene of digit
99
Q
Wagner Ulcer Classification Scale
- 5
A
- gangrene of foot requiring dis articulation
100
Q
Arterial Insufficiency Ulcers
- Location
- Appearance and description
- Pain
A
- Location: lower 1/3 of leg, toes, web spaces (distal toes, distal foot, lateral malleolus)
- Appearance: smooth edges, well defined; lack granulation tissue; tend to be deep
- Exudate: minimal
- Pain: severe
- pedal pulses: DIminished or absent
- Edema: normal
- Skin Temp: DEcreased
- Tissue Changes: thin and shiny; hair loss; yellow nails
- Miscellaneous: leg elevation increases pain
101
Q
Venous Insufficiency Ulcers
- Location
- Appearance and description
- Pain
A
- Location: proximal to the medial malleolus
- Appearance: irregular shape; shallow
- Exudate: moderate/heavy
- Pain: mild to moderate
- pedal pulses normal
- Edema increased
- Skin Temp: normal
- Tissue Changes: flaking, dry skin; brownish discoloration
- Miscellaneous: leg elevation lessens pain
102
Q
Neuropathic Ulcers
- Location
- Appearance and description
- Pain
A
- Location: Areas of the foot susceptible to pressure or shear forces during weight bearing
- Appearance: well-defined oval or circle; callused rim; cracked periwound tissue; little to no wound bed necrosis with good granulation
- Exudate: Low/moderate
- Pain: none, however dysesthesia may be reported
- pedal pulses: diminished or absent; unreliable ABI with diabetes
- Edema: Normal
- Skin Temp: decreased
- Tissue Changes: Dry, inelastic, shiny skin; decreased or absent sweat and oil production
- Miscellaneous:loss of protective sensation
