ulcers Flashcards
this leads to distortion/damage to blood vessels, usually at a deep tissue level
Shear force
this is a risk factor for pressure injury
low diastolic BP - takes less pressure in order to impede circulation
patient should turn how often when lying down?
2 hours
patient should shift how often when sitting up
15 minutes
this stage of pressure injury is not yet an open wound, and has nonblanchable erythema & may be “boggy”
stage 1
This stage of pressure ulcer are superficial - partial thickness. include epidermis, sometimes part of dermis and includes blisters
stage II
these are deep ulcers, with extensive necrosis. they are full thickness with dermis and subcutaneous tissue involved - extend to BUT not through subctuaneous fascia
stage III
full thickness ulcer. deep ulceration, may have undermining
involves epidermis, dermis, subcutaneous tissue through fascia to muscle, tendon, joint capsule, and sometimes bone
stage IV
this pressure ulcer has high risk of osteomyelitis
stage IV
Can a stage IV ulcer reverse to a stage II ulcer?
NO no reversal omg
this scale is rated 0 to 7 based on observation of ulcer
sessing scale
this allows clinician to chart progress by subtracting score at reassessment from score initial evaluation
sessing scale
this scale ranges from score 8 to 34
PUSH - pressure ulcer scale for healing
this type of debridement method removes nectrotic tissue only, leaves uninvolved skin intact
selective
this debridement method goes from wet to dry
non-selective
this method of debridement uses semipermeable films, and absorbent dressings
autolytic debridement
this type of debridement can use sharp of hydrotherapy
mechanical debridement
what to diabetic ulcers stem from
peripheral neuropathy (damage to sensory nerves, autonomic nerves, motor nerves)
this is the primary risk factor for development of diabetic foot ulcers
DPN
these count for 50-70% of all non-traumatic amputations in the US
Diabetic foot ulcers
this can lead to increased levels of intracellular glucose in nerves & disruptions in cellular metabolism with the neurons
hyperglycemia
this is decreased perspiration and sebaceous secreations in the distal lower extremities and feet
autonomic neuropathy
with this the skin is prone to dryness, cracks, callus formation and breakdown
autonomic neuropathy
this affects intrinsic muscles of foot
motor neuropathy
atrophy will reduce what?
padding to pressure points
these are common foot deformities in DPN
plantarflexion contracture
claw-toe deromity
hallux varus
forefoot varus or valgus
this is referred to as rocker bottom foot
charcot foot
this is a bone deterioration and pathologic fractures which leads to deformity
charcot foot
this will be involved in your circulatory assessment
peripheral pulses, capillary refill, skin color and temperature, ABI
what is an important thing to do during skin assessment?
indentify areas of callus as potential sites of breakdown, look for cracks and fissures
risk factors for ulcers
numbness, paresthesias. previous h/o ulcer, amputation, high scores on screen
these can be preventative tools for neuropathic ulcers
orthotics, proper footwear, daily inspection of shoes and feet, exercise
these are commonly located at plantar aspect of foot (midfoot, heel, metatarsal heads)
diabetic ulcers
these wound margins often show callus formation
diabetic ulcers
with total contact casting how often should cast be changes to avoid ulcer
at least ones a week - every 2 weeks at maximum
this can be injected under high pressure areas
liquid salicone
this may help replace fat padding that is displaces by bony deformatities
liquid silicone
