Wound Types and Assessment Flashcards
List 4 types of ulcers.
Arterial insufficiency ulcers
Venous insufficiency ulcers
Neuropathic ulcers
Pressure ulcers
What is the cause of arterial insufficiency ulcers?
Inadequate circulation of oxygenated blood (ischemia)
What condition can cause arterial insufficiency ulcers?
Atherosclerosis
What are 4 general recommendations a patient with any type of ulcer should follow?
- Rest
- Risk reduction education
- Limb protection
- Daily inspection of skin (typically legs and feet)
What are 3 general recommendations for arterial insufficiency ulcers?
- Avoid unnecessary leg elevation
- Avoid soaking feet in hot water or using heating pads
- Wear appropriately sized shoes with seamless socks
What is the cause of venous insufficiency ulcers?
Impaired functioning of the venous system which leads to inadequate circulation and tissue damage
What symptoms may a patient with an arterial insufficiency ulcer present with? (4)
- Pain in the legs/feet (similar to intermittent claudication)
- Skin is cool to palpation
- Decreased pulse
- Pallor on leg elevation and rubor when dependent
What condition do most patients with arterial insufficiency also have?
Diabetes
What type of ulcers are the most common?
Venous insufficiency ulcers
What symptoms may a patient with a venous insufficiency ulcer present with? (4)
- Swelling of LEs
- Complaints of itching, fatigue, aching or heaviness in LE
- Tissue is wet from large amount of draining exudate
- Possible hemosiderin staining and lipodermatosclerosis
What are 4 general recommendations for venous insufficiency ulcers?
- Compression to control edema
- Elevation of legs above the heart when resting or sleeping
- Attempt active exercise including frequent ROM
- Wear appropriately fitting shoes with seamless socks
What type of ulcers are associated with hemosiderin straining and lipodermatosclerosis?
Venous insufficiency ulcers
What condition may occur as a result of chronic venous insufficiency?
Lymphedema
What is the most common form of primary lymphedema?
Milroy’s disease
What is the most common disease process seen with neuropathy?
Diabetes
What are neuropathic ulcers?
Ulcers caused by a combination of neuropathy (altered sensation) and ischemia
What symptoms may a patient with a neuropathic ulcer present with? (5)
- Ulcers on the weight bearing surface of the foot
- Diminished sensation
- Decreased or absent sweat/oil production
- Dry, inelastic skin
- Impaired healing time
What are 2 general recommendations for neuropathic ulcers?
- Inspect footwear for debris prior to donning
2. Wear appropriately sized OFF LOADING footwear with clean, cushioned, seamless socks
What is the most common causative factor of neuropathic ulcers?
Mechanical, repetitive stress
What is imperative to assess in patients with neuropathy? What tool can be used to test this?
Sensation (especially protective)
Monofilament testing
What finding on a monofilament test indicates loss of protective sensation?
Failure to perceive the application of a 10 gm monofilament
What finding on a monofilament test indicates that an area is insensate?
Failure to perceive the application of a 75 gm monofilament
What is another name for pressure ulcers?
Decubitus ulcers
What is the cause of pressure ulcers?
Unrelieved pressure on the dermis results in ischemia = damage
What areas of the body are the most susceptible to pressure ulcers?
Bony prominences
What are 5 general recommendations for pressure ulcers?
- Repositioning every 2 hours in bed
- Management of excess moisture
- Off-loading with pressure relieving devices
- Inspect skin daily for signs of pressure damage
- Limit shear, traction and friction forces over fragile skin
Name 2 pressure injury risk assessment tools,
Braden Scale
Norton Scale
What are the 4 classifications of wound based on depth of injury?
- Superficial
- Partial thickness
- Full thickness
- Subcutaneous
What is a superficial wound?
Cause trauma to the skin with the epidermis INTACT
What is an example of a superficial wound?
Non-blistering sunburn
What process will a superficial wound typically heal by?
Inflammatory process
What is a partial thickness wound?
A wound that extends through the epidermis, and possibly into, but not through the dermis.
What are 3 examples of partial thickness wounds?
Abrasions
Blisters
Skin tears
What is a full thickness wound?
A wound that extends through the epidermis and dermis and subcutaneous fat. Wounds deeper than 4mm.
What process will a full thickness wound typically heal by?
Healing by secondary intention
What is a subcutaneous wound?
Wounds that extend through the tissue and involve fat, muscle, tendon or bone
What process will a subcutaneous wound typically heal by?
Healing by secondary intention
What type of wound extends through the epidermis and possibly into, but not through, the dermis?
Partial thickness wound
What type of wound extends through the dermis and subcutaneous fat?
Full thickness wound
What type of wound does not extend through the epidermis?
Superficial wound
What type of wounds typically heal by secondary intention?
Full thickness wounds
Subcutaneous wounds
What tool is used to classify ulcers based on wound depth and the presence of infection?
Wagner Ulcer Grade Classification Scale
Describe the Wagner Ulcer Grade classification scale.
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
Describe a stage I pressure ulcer.
Intact skin with non-blanchable redness of a localized area usually over a bony prominence
Describe a stage II pressure ulcer.
Partial thickness tissue loss of the dermis presenting as a shallow open ulcer with a red or pink wound bed.
Describe a stage III pressure ulcer.
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are NOT exposed.
Describe a stage IV pressure ulcer.
Full thickness tissue loss with exposed bone, tendon or muscle that is visible or directly palpable.
Describe a suspected deep tissue injury.
Purple or maroon localized areas of intact skin or blood filled blister due to damage of underlying soft tissue from pressure or shear forces.
Describe an unstageable pressure ulcer.
Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.
What are the 5 classifications of exudate?
Serous Sanguineous Serosanguineous Seropurlulent Purulent
Describe serous exudate.
Clear, light color and thin, watery consistency
Describe sanguineous exudate.
Red color and thin, watery consistency
Describe serosanguineous exudate.
Light red or pink color and a thin, watery consistency.
Describe seropurulent exudate.
Cloudy or opaque with a yellow or tan color and thin and watery consistency.
Describe purulent exudate.
Yellow or green color and a thick, viscous consistency.
What types of exudate are considered normal in a healthy healing wound?
Serous exudate
Serosanguineous exudate
What type of exudates are a sign of wound infection and are always an abnormal sign?
Seropurulent exudate
Purulent exudate
What type of exudates are typically observed during the inflammatory and proliferative phases of healing?
Serous
Serosanguineous
What is necrotic tissue?
Dead tissue
What are 4 types of necrotic tissue?
Eschar
Gangrene
Hyperkeratosis
Slough
What is eschar?
Hard or leathery, black/brown dehydrated tissue that is firmly adhered to the wound bed
What is gangrene?
Death and decay of tissue caused by interruption of blood flow to an area
What is hyperkeratosis?
A callus
White/gray in color and can vary in texture depending on moisture level around the tissue
What is slough?
Moist, stringy, white/yellow tissue that tends to be loosely attached in clumps around the wound bed.
Describe the 3 colors of the Red-Yellow-Black System.
Red: Pink granulation tissue
Yellow: Moist, yellow slough
Black: Black, thick eschar firmly adhered
What are the main goals to prioritize for a red wound?
Protect wound
Maintain moist environment
What are the main goals to prioritize for a yellow wound?
Remove exudate and debris
Absorb drainage
What are the main goals to prioritize for a black wound?
Debride necrotic tissue
