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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
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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
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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
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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
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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
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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
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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
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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

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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

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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
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11
Q

Anticipated Deformities Based on burn location

  • Hip
A

Anticipated deformities: flexion and ADD

-splint: anterior hip spica, ABD splint

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12
Q

Anticipated Deformities Based on burn location

-knee

A
  • anticipated deformity: flexion

splint: conforming splint, 3 point splint, air splint

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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

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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

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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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36
Q

hydrogels disadvantages

A
  • Potential for dressings to dehydrate
  • cannot be used on wounds with significant drainage
  • typically requires a secondary dressing
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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
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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
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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
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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
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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

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