Skin Ulcers Flashcards
Venous ulcer - etiology
associated with chronic venous insufficiency, valvular incompetence, hx of DVT, venous hypertension, calf mm pump failure
Recurrence is high
Arterial insufficiency may coexist
Venous ulcer - clinical features
Anywhere in lower leg - common over medial malleolus
Normal pulses
Ache pain in dep. position
Normal temp and color
Edema is often marked
Pigmentation, stasis dermatitis may be present
Ulceration may develop
Venous ulcer - Staging for venous, arterial, or diabetic ulcer
Uses partial and full thickness classifications
Arterial ulcer - etiology
associated with chronic arterial insufficiency; arterioscelrosis obliterans; atheroembolism; hx of minor nonhealing trauma
Arterial ulcer - clinical features
Can occur anywhere in lower leg - common on small toes, feet, bony areas of trauma like shin
Pulses are poor or absent - intermittent claudication
Often severe pain, intermittent, exacerbated with limb elevation
Cool temp with skin trophic changes, loss of hair, and thickened nails
Can develop gangrene
Diabetic ulcer - etiology
Diabetes is associated with arterial disease and peripheral neuropathy
cause by repetitive trauma on insensitive skin
Diabetic ulcer - clinical features
Occurs where arterial ulcers usually appear or where peripheral neuropathy occurs (plantar of foot)
Typically not painful because sensory loss
Pulses might be diminished
Sepsis is common, and can develop gangrene
Pressure ulcer (decubitis ulcer) - etiology
lesions caused by unrelieved pressure resulting in ischemic hypoxia and damage to underlying tissue
Pressure ulcer (decubitis ulcer) - risk factors
Prolonged pressure, shear forces, friction
Nutritional deficiency
Maceration (softening with excessive moisture)
Pressure ulcer (decubitis ulcer) - common in
elderly, debilitated, or immobilized people
People with diabetes or atherosclerosis
Neurologically impaired skin
Cognitive impairment
Pressure ulcer (decubitis ulcer) - staging - Stage 1
Nonblanchable erythema of intact skin
Pressure ulcer (decubitis ulcer) - staging - Stage 2
Partial thickness skin loss
Involves epidermis, dermis, or both
Presents as abrasion, blister or shallow crater
Pressure ulcer (decubitis ulcer) - Staging - Stage 3
Full thickness skin loss
Involves damage or necrosis to subcutaneous tissue
Can extend down, but not through underlying fascia
Presents as deep crater
Pressure ulcer (decubitis ulcer) - staging - stage 4
full thickness skin loss
involves extensice destruction, tissue necrosis, or damage to muscle, bone, or supporting structures
Pressure ulcer (decubitis ulcer) - staging - unstageable
tissue depth is obscured due to slough or eschar and extent of damage can’t be determined
Pressure ulcer (decubitis ulcer) - staging - deep tissue injury
Discolored area of tissue (bruise) that is not reversible and will likely progress to full thickness injury
Examination of wounds - physical exam
Determine location Assess size (l, w, depth, wound area) Examine for tunneling (rimming or undermining) - underlying tissue destruction beneath intact skin Determine exudate (drainage) Color Temp Girth Viability of tissue Sensory integrity Signs of infection Pain
Examination of wounds - physical exam - drainage type
Serous
Prurulent
Sanguineous
watery serum
containing pus
containing blood
Wound Care - Infection Control - Negative Pressure Wound Therapy
Vacuum assisted closure
An open cell foam dressing placed into the wound
Control subatmospheric pressure is applied
Helps to maintain moist wound environment, control edema, inc localized blood flow, reduce infectious material
Wound care - surgical intervention may be required for what stages
3 and 4
Wound care - hyperbaric oxygen therapy (HBO)
Pt breathes 100% oxygen in a sealed, full body chamber with elevated atmospheric pressure
Hyperoxygenation reverses tissue hypoxia and facilitates wound healing due to enhanced solubility of oxygen in blood
Wound care - hyperbaric oxygen therapy (HBO) - contraindicated when
in untreated pneumothorax and with use of some antineoplastic meds
Wound cleansing - ____ recommended for most ulcers
normal saline (0.9% NaCl)
Wound cleansing - mechanical delivery systems
minimal mechanical force - using gauze, cloth, or sponge
Irrigation - recommended pressure ranges from 4 to 15 psi
