Wound care Flashcards
Wound associated w/ chronic venous insufficiency
venous ulcer
wound associated w/ chronic arterial insufficiency
arterial ulcer
wound associated w/ arterial disease and peripheral neuropathy
diabetic ulcer
lesions caused by unrelieved pressure resulting in ischemic hypoxia and damage to underlying tissue.
pressure ulcer
venous ulcers are common over area of…
medial malleolus
Pain associated w/ venous ulcer…
none
color of venous wound…
normal or cyanotic
arterial ulcers can occur where?
anywhere in lower leg (small toes, feet, bony areas
Pain associated w/ arterial ulcers…
often severe
skin changes associated w/ arterial ulcer (3)
- pale
- shiny
- loss of hair
pain associated w/ diabetic ulcers
typically none
pulse w/ diabetic ulcers may be…
present or diminished
color of pressure ulcers (3)
- red
- brown/black
- yellow
pain associated w/ pressure ulcers
can be painful
Wound that is often full thickness, “punched-out”, pale w/ no granulation, decreased pulse and painful
arterial
Wound that is typically partial thickness, shaggy, yellow w/ granulation and no pain
venous
Nonblanchable erythema of intact skin. May include changes in skin temp, tissue consistency and/or sensation
stage 1 pressure ulcer
partial thickness skin loss: involves epidermis, dermis or both. Ulcer is superficial. Presents clinically as an abrasion, blister or shallow crater
stage 2 pressure ulcer
full-thickness skin loss: damage tot subcutaneous tissue. May extend to but not through underlying fascia. Deep crater
stage 3 pressure ulcer
Full-thickness skin loss: damage to mm, bone, or supporting structures
stage 4 pressure ulcer
healthy granulating wounds. absence of necrotic tissue
clean, red wounds
include slough (necrotic tissue), fibrous tissue
yellow wounds
covered w/ eschar (dried necrotic tissue)
black wounds
ulcer that is slow to heal. Not painful
indolent ulcer
