Skin Ulcers

Question 1

Venous ulcer - etiology

Answer 1

associated with chronic venous insufficiency, valvular incompetence, hx of DVT, venous hypertension, calf mm pump failure
Recurrence is high
Arterial insufficiency may coexist

Question 2

Venous ulcer - clinical features

Answer 2

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

Question 3

Venous ulcer - Staging for venous, arterial, or diabetic ulcer

Answer 3

Uses partial and full thickness classifications

Question 4

Arterial ulcer - etiology

Answer 4

associated with chronic arterial insufficiency; arterioscelrosis obliterans; atheroembolism; hx of minor nonhealing trauma

Question 5

Arterial ulcer - clinical features

Answer 5

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

Question 6

Diabetic ulcer - etiology

Answer 6

Diabetes is associated with arterial disease and peripheral neuropathy
cause by repetitive trauma on insensitive skin

Question 7

Diabetic ulcer - clinical features

Answer 7

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

Question 8

Pressure ulcer (decubitis ulcer) - etiology

Answer 8

lesions caused by unrelieved pressure resulting in ischemic hypoxia and damage to underlying tissue

Question 9

Pressure ulcer (decubitis ulcer) - risk factors

Answer 9

Prolonged pressure, shear forces, friction
Nutritional deficiency
Maceration (softening with excessive moisture)

Question 10

Pressure ulcer (decubitis ulcer) - common in

Answer 10

elderly, debilitated, or immobilized people
People with diabetes or atherosclerosis
Neurologically impaired skin
Cognitive impairment

Question 11

Pressure ulcer (decubitis ulcer) - staging - Stage 1

Answer 11

Nonblanchable erythema of intact skin

Question 12

Pressure ulcer (decubitis ulcer) - staging - Stage 2

Answer 12

Partial thickness skin loss
Involves epidermis, dermis, or both
Presents as abrasion, blister or shallow crater

Question 13

Pressure ulcer (decubitis ulcer) - Staging - Stage 3

Answer 13

Full thickness skin loss
Involves damage or necrosis to subcutaneous tissue
Can extend down, but not through underlying fascia
Presents as deep crater

Question 14

Pressure ulcer (decubitis ulcer) - staging - stage 4

Answer 14

full thickness skin loss

involves extensice destruction, tissue necrosis, or damage to muscle, bone, or supporting structures

Question 15

Pressure ulcer (decubitis ulcer) - staging - unstageable

Answer 15

tissue depth is obscured due to slough or eschar and extent of damage can’t be determined

Question 16

Pressure ulcer (decubitis ulcer) - staging - deep tissue injury

Answer 16

Discolored area of tissue (bruise) that is not reversible and will likely progress to full thickness injury

Question 17

Examination of wounds - physical exam

Answer 17

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

Question 18

Examination of wounds - physical exam - drainage type
Serous
Prurulent
Sanguineous

Answer 18

watery serum
containing pus
containing blood

Question 19

Wound Care - Infection Control - Negative Pressure Wound Therapy

Answer 19

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

Question 20

Wound care - surgical intervention may be required for what stages

Answer 20

3 and 4

Question 21

Wound care - hyperbaric oxygen therapy (HBO)

Answer 21

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

Question 22

Wound care - hyperbaric oxygen therapy (HBO) - contraindicated when

Answer 22

in untreated pneumothorax and with use of some antineoplastic meds

Question 23

Wound cleansing - ____ recommended for most ulcers

Answer 23

normal saline (0.9% NaCl)

Question 24

Wound cleansing - mechanical delivery systems

Answer 24

minimal mechanical force - using gauze, cloth, or sponge

Irrigation - recommended pressure ranges from 4 to 15 psi

Question 25

Wound cleanings - whirlpool therapy

Answer 25

NOT supported for wound care

Can contaminate and cause infection

Question 26

Wound dressings - ideal wound dressings do what

Answer 26

maintain a moist environment and control excessive exudate, facilitate gas exhange, insulate, prevent contamination

Question 27

Wound dressing - moist wound environment facilitates what

Answer 27

autolytic debridement and promotes faster wound healing with less pain

Question 28

Injury prevention or reduction - pressure relieving devices - static devices used if patient

Answer 28

can assume a variety of positions

Question 29

Injury prevention or reduction - pressure relieving devices - dynamic devices used if patient

Answer 29

cannot assume a variety of positions