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NPTE Integumentary System > Wound Types and Assessment > Flashcards

Wound Types and Assessment Flashcards

1
Q

List 4 types of ulcers.

A

Arterial insufficiency ulcers
Venous insufficiency ulcers
Neuropathic ulcers
Pressure ulcers

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2
Q

What is the cause of arterial insufficiency ulcers?

A

Inadequate circulation of oxygenated blood (ischemia)

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3
Q

What condition can cause arterial insufficiency ulcers?

A

Atherosclerosis

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4
Q

What are 4 general recommendations a patient with any type of ulcer should follow?

A
  1. Rest
  2. Risk reduction education
  3. Limb protection
  4. Daily inspection of skin (typically legs and feet)
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5
Q

What are 3 general recommendations for arterial insufficiency ulcers?

A
  1. Avoid unnecessary leg elevation
  2. Avoid soaking feet in hot water or using heating pads
  3. Wear appropriately sized shoes with seamless socks
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6
Q

What is the cause of venous insufficiency ulcers?

A

Impaired functioning of the venous system which leads to inadequate circulation and tissue damage

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7
Q

What symptoms may a patient with an arterial insufficiency ulcer present with? (4)

A
  1. Pain in the legs/feet (similar to intermittent claudication)
  2. Skin is cool to palpation
  3. Decreased pulse
  4. Pallor on leg elevation and rubor when dependent
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8
Q

What condition do most patients with arterial insufficiency also have?

A

Diabetes

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9
Q

What type of ulcers are the most common?

A

Venous insufficiency ulcers

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10
Q

What symptoms may a patient with a venous insufficiency ulcer present with? (4)

A
  1. Swelling of LEs
  2. Complaints of itching, fatigue, aching or heaviness in LE
  3. Tissue is wet from large amount of draining exudate
  4. Possible hemosiderin staining and lipodermatosclerosis
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11
Q

What are 4 general recommendations for venous insufficiency ulcers?

A
  1. Compression to control edema
  2. Elevation of legs above the heart when resting or sleeping
  3. Attempt active exercise including frequent ROM
  4. Wear appropriately fitting shoes with seamless socks
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12
Q

What type of ulcers are associated with hemosiderin straining and lipodermatosclerosis?

A

Venous insufficiency ulcers

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13
Q

What condition may occur as a result of chronic venous insufficiency?

A

Lymphedema

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14
Q

What is the most common form of primary lymphedema?

A

Milroy’s disease

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15
Q

What is the most common disease process seen with neuropathy?

A

Diabetes

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16
Q

What are neuropathic ulcers?

A

Ulcers caused by a combination of neuropathy (altered sensation) and ischemia

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17
Q

What symptoms may a patient with a neuropathic ulcer present with? (5)

A
  1. Ulcers on the weight bearing surface of the foot
  2. Diminished sensation
  3. Decreased or absent sweat/oil production
  4. Dry, inelastic skin
  5. Impaired healing time
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18
Q

What are 2 general recommendations for neuropathic ulcers?

A
  1. Inspect footwear for debris prior to donning

2. Wear appropriately sized OFF LOADING footwear with clean, cushioned, seamless socks

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19
Q

What is the most common causative factor of neuropathic ulcers?

A

Mechanical, repetitive stress

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20
Q

What is imperative to assess in patients with neuropathy? What tool can be used to test this?

A

Sensation (especially protective)

Monofilament testing

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21
Q

What finding on a monofilament test indicates loss of protective sensation?

A

Failure to perceive the application of a 10 gm monofilament

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22
Q

What finding on a monofilament test indicates that an area is insensate?

A

Failure to perceive the application of a 75 gm monofilament

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23
Q

What is another name for pressure ulcers?

A

Decubitus ulcers

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24
Q

What is the cause of pressure ulcers?

A

Unrelieved pressure on the dermis results in ischemia = damage

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25
Q

What areas of the body are the most susceptible to pressure ulcers?

A

Bony prominences

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26
Q

What are 5 general recommendations for pressure ulcers?

A
  1. Repositioning every 2 hours in bed
  2. Management of excess moisture
  3. Off-loading with pressure relieving devices
  4. Inspect skin daily for signs of pressure damage
  5. Limit shear, traction and friction forces over fragile skin
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27
Q

Name 2 pressure injury risk assessment tools,

A

Braden Scale

Norton Scale

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28
Q

What are the 4 classifications of wound based on depth of injury?

A
  1. Superficial
  2. Partial thickness
  3. Full thickness
  4. Subcutaneous
29
Q

What is a superficial wound?

A

Cause trauma to the skin with the epidermis INTACT

30
Q

What is an example of a superficial wound?

A

Non-blistering sunburn

31
Q

What process will a superficial wound typically heal by?

A

Inflammatory process

32
Q

What is a partial thickness wound?

A

A wound that extends through the epidermis, and possibly into, but not through the dermis.

33
Q

What are 3 examples of partial thickness wounds?

A

Abrasions
Blisters
Skin tears

34
Q

What is a full thickness wound?

A

A wound that extends through the epidermis and dermis and subcutaneous fat. Wounds deeper than 4mm.

35
Q

What process will a full thickness wound typically heal by?

A

Healing by secondary intention

36
Q

What is a subcutaneous wound?

A

Wounds that extend through the tissue and involve fat, muscle, tendon or bone

37
Q

What process will a subcutaneous wound typically heal by?

A

Healing by secondary intention

38
Q

What type of wound extends through the epidermis and possibly into, but not through, the dermis?

A

Partial thickness wound

39
Q

What type of wound extends through the dermis and subcutaneous fat?

A

Full thickness wound

40
Q

What type of wound does not extend through the epidermis?

A

Superficial wound

41
Q

What type of wounds typically heal by secondary intention?

A

Full thickness wounds

Subcutaneous wounds

42
Q

What tool is used to classify ulcers based on wound depth and the presence of infection?

A

Wagner Ulcer Grade Classification Scale

43
Q

Describe the Wagner Ulcer Grade classification scale.

A

Grade 0 = No open lesion but may have pre-ulcerative lesions; healed ulcers; presence of bony deformity
Grade 1 = Superficial ulcer not involving subcutaneous tissue
Grade 2 = Deep ulcer penetrating the subcutaneous tissue; may involve bone, muscle, tendon, ligaments or joint capsule
Grade 3 = Deep ulcer with osteomyelitis, osteitis or abscess
Grade 4 = Gangrene on the digit
Grade 5 = Gangrene on foot requiring disarticulation

44
Q

Describe a stage I pressure ulcer.

A

Intact skin with non-blanchable redness of a localized area usually over a bony prominence

45
Q

Describe a stage II pressure ulcer.

A

Partial thickness tissue loss of the dermis presenting as a shallow open ulcer with a red or pink wound bed.

46
Q

Describe a stage III pressure ulcer.

A

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are NOT exposed.

47
Q

Describe a stage IV pressure ulcer.

A

Full thickness tissue loss with exposed bone, tendon or muscle that is visible or directly palpable.

48
Q

Describe a suspected deep tissue injury.

A

Purple or maroon localized areas of intact skin or blood filled blister due to damage of underlying soft tissue from pressure or shear forces.

49
Q

Describe an unstageable pressure ulcer.

A

Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.

50
Q

What are the 5 classifications of exudate?

A 
Serous 
Sanguineous 
Serosanguineous 
Seropurlulent 
Purulent
51
Q

Describe serous exudate.

A

Clear, light color and thin, watery consistency

52
Q

Describe sanguineous exudate.

A

Red color and thin, watery consistency

53
Q

Describe serosanguineous exudate.

A

Light red or pink color and a thin, watery consistency.

54
Q

Describe seropurulent exudate.

A

Cloudy or opaque with a yellow or tan color and thin and watery consistency.

55
Q

Describe purulent exudate.

A

Yellow or green color and a thick, viscous consistency.

56
Q

What types of exudate are considered normal in a healthy healing wound?

A

Serous exudate

Serosanguineous exudate

57
Q

What type of exudates are a sign of wound infection and are always an abnormal sign?

A

Seropurulent exudate

Purulent exudate

58
Q

What type of exudates are typically observed during the inflammatory and proliferative phases of healing?

A

Serous

Serosanguineous

59
Q

What is necrotic tissue?

A

Dead tissue

60
Q

What are 4 types of necrotic tissue?

A

Eschar
Gangrene
Hyperkeratosis
Slough

61
Q

What is eschar?

A

Hard or leathery, black/brown dehydrated tissue that is firmly adhered to the wound bed

62
Q

What is gangrene?

A

Death and decay of tissue caused by interruption of blood flow to an area

63
Q

What is hyperkeratosis?

A

A callus

White/gray in color and can vary in texture depending on moisture level around the tissue

64
Q

What is slough?

A

Moist, stringy, white/yellow tissue that tends to be loosely attached in clumps around the wound bed.

65
Q

Describe the 3 colors of the Red-Yellow-Black System.

A

Red: Pink granulation tissue
Yellow: Moist, yellow slough
Black: Black, thick eschar firmly adhered

66
Q

What are the main goals to prioritize for a red wound?

A

Protect wound

Maintain moist environment

67
Q

What are the main goals to prioritize for a yellow wound?

A

Remove exudate and debris

Absorb drainage

68
Q

What are the main goals to prioritize for a black wound?

A

Debride necrotic tissue

NPTE Integumentary System (5 decks)

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