Ulcers Flashcards
What is an ulcer?
A lesion through the skin or muscous membranes resulting from loss of tissue, usually with inflammation.
Breakdown in the epithelial skin tissue
What are the three main types of ulcers?
Venous
Arterial
Neuropathic
*pressure may be considered a fourth
What are the aspects of the casual pie theory?
Neuropathy High pressure Limited joint mobility Deformity Trauma
What are factors impairing healing?
Sensory loss Malignancy Infection Tissue trauma Haemtological disease Vascular disease Autoimmune disease Drug therapies (steroids)
What should be included in the initial assessment of a patient with an ulcer?
Patient history and physical examination Thorough wound history Record wound observations Look for signs of infection Identify the status of the ulcer Grade the ulcer
What is included in the history of a wound? *DACPINS
Duration of the wound
Change to the size or appearance
Change to the number of lesions/wounds
Previous incidence of similar lesions
Pain or altered sensations associated with lesion
Any signs and symptoms of ulcer
Does patient know the cause of the wound?
What are 6 points to observe when examining a wound?
- The precise anatomical site
- Size of the wound
- General appearance of wound and surrounding tissue
- Sides of the wound
- Base of the wound
- Discharge (colour, consistency and odour)
What are signs and symptoms of tissue infection?
Heat & redness Oedema Pain Exudate/pus Malaise Haemtological effects
What are the four status of ulcers?
Extending, chronic, healing, infected
What are the 0-3, A-D of ulcers using the Texas Classification?
0 - pre or post ulcerative lesions completely epithelialised
1 - superficial wound not involving tendon, capsule or bone
2 - wound penetrating to tendon or capsule
3 - wound penetrating to bone or joint
A - pre or post ulcerative lesions completely epithelialised
B - with infection
C - with ischemia
D - with infection and ischemia
What do the following colours of a wound base mean:
black, yellow (slough & fibrous tissue), red, pink
Black: dehydrated necrotic tissue, retards healing (remove if possible)
Yellow slough: loose cellular debris (remove)
Yellow fibrous tissue: firm texture appears before granulation tissue develops
Bright red: healthy granulation tissue
Pink: final stage of healing, pink/white or translucent areas may overly healthy granulation tissue
What is maceration?
White, waxy, soft and wet-looking tissue due to uncontrolled exudate
What is induration?
Firm swelling, with/without redness. May indicate infection or inflammation
Finish the rule: if underminining to depth of bone…
Osteomyelitis until proven otherwise
What can high exudate volume indicate?
High exudate volume can indicate local infection or osteomyelitis HOWEVER purulent exudate does not necessarily indicate infection
