wound types

Question 1

abrasion

Answer 1

caused by combination of friction and shear forces, typically over rough surfaces resulting in the scraping away of skins superficial layers

Question 2

avulsion

Answer 2

soft tissue avulsion (degloving) is a serious wound resulting rom tension that. causes skin to become detached from underlying surfaces

Question 3

arterial insufficiency ulcers

Answer 3

secondary to inadequate circulation of oxygenated blood (ischemia) often due to complicating factors such as atherosclerosis

Question 4

AI ulcer characteristics

- location, appearance, exudate, pain, pedal pulses, edema, skin temp, tissue changes, misc.

Answer 4

• lower 1/3rd of leg, toes, web spaces
• (distal toes, dorsal foot, lateral malleolus)
• smooth edges, well defined, lack granulation tissue, tend to be deep
• minimal exudate
• severe pain
• diminished/ absent pulses
• normal edema
• decreased temp
• skin thin and shiny, hair loss, yellow nails
• leg elevation increases pain

Question 5

venous insufficiency

Answer 5

secondary to impaired functioning of venous system resulting in inadequate circulation and eventual tissue damage/ ulceration

Question 6

VI ulcer characteristics

- location, appearance, exudate, pain, pedal pulses, edema, skin temp, tissue changes, misc.

Answer 6

• proximal to medial malleolus
• irregular shape, shallow
• mod/ heavy exudate
• mild/mod pain, normal pulses
• normal temo
• skin flaky, dry, browning
• leg elevation decreases pain

Question 7

neuropathic ulcers

Answer 7

secondary to complication usually associated with a combo of ischemia and neuropathy
- often associated with DM

Question 8

neuropathic ulcer characteristic

- location, appearance, exudate, pain, pedal pulses, edema, skin temp, tissue changes, misc.

Answer 8

• areas of the foot susceptible to pressure or shear forces during WB
• well defines, oval or circle, callused rum, cracked peri wound tissue, little to no wound bed necrosis with good granulation
• low/ mod exudate
• no pain
• diminished or absent pulses, unreliable ABI
• normal edema
• decreased temp
• kkin dry, inelastic, shiny, decreased or absent seat and oil production
• loss of protective sensation

Question 9

pressure injury risk assessment tools

Answer 9

braden scale, norton scale

Question 10

superficial wound

Answer 10

causes trauma to the skin with the epidermis remaining intact, such as non-blistering sunburn

Question 11

partial- thickness wound

Answer 11

extends through epidermis and possibly into, but not though the dermis

• abrasions, blisters, skin tears
• typically heals through re-epithelization or epidermal resurfacing depending on depth

Question 12

full- thickness wound

Answer 12

extends through the dermis in to deeper structures such as subcutaneous fat

• wouldn’t deeper than 4 mm typically
• heal by secondary intention

Question 13

subcutaneous wound

Answer 13

extends through integumentary tissues and involve deeper structures such as fat, muscle, tendon or bone
- typically require secondary intention