Wound Types And Characteristics Flashcards
Name the Four types of Ulcers.
- Arterial Insufficiency Ulcers
- Venous Insufficiency Ulcers
- Neuropathic Ulcers
- Pressure Ulcers (Decubitus Ulcer)
Where are arterial wounds most frequently located?
- Lateral malleoli
- Toes
- Dorsum Feet
What is typically the etiology of arterial ulcers?
- Atherosclerosis obliterans: intermittent claudication, rest pain, and tropic changes
- Atheroembolism
Describe the appearance of arterial ulcers?
- Irregular, smooth edges
- Minimum to no granulation
- Usually deep
What are some tell tale signs a patient may have arterial disease?
- abnormal nail growth
- Decreased leg & foot hair
- Dry skin
- Skin is cool upon palpation
Venous are arterial ulcers are painful.
Arterial ulcers are painful, especially with legs elevated
Gangrene may or may not be present with arterial ulcers.
May be present
True or False: Arterial ulcers will have drainage
False. No drainage will be present
What are some associate signs with arterial ulcers?
- Trophic changes
- Pallor on foot elevation
- Dusky rubor on dependency
A type of insufficiency that is refers to a lack of adequate blood flow to a region or regions of the body
Arterial insufficiency
A type of insufficiency that refers to inadequate drainage of venous blood from a body part usually resulting in edema and.or skin abnormalities and ulcerations
Venous insufficiency
What is the most common cause of leg ulcers?
CVI (chronic venous insufficiency)
80% of ulcers are typically caused by venous insufficiency
Etiology of venous ulcers
- Valvular incompetence
2. Venous hypertension
Describe the appearance of venous ulcers
- Irregular; dark pigmentation, sometimes fibrotic
- Good granulation
- Usually shallow
Where are venous ulcers usually located?
- Distal lower leg
2. Medial malleoli (proximal)
The pedal pulses will be absent with venous ulcers or arterial ulcers?
Arterial ulcers (absent)
Venous ulcers (present)
True or false: Venous ulcers great little pain, and with the pain that occurs typically elevation helps relieve this pain.
True
For venous ulcers, expect to see _______ amounts of ________.
Moderate amounts of exudate
What are associated signs with venous ulcers?
- Edema
- Statsis dermatitis
- Possible cyanosis on dependency
What is the most common preventative and treatment therapeutic measure used for venous leg ulcers?
Compression
When is compression contraindicated for venous ulcers?
When ABI is <0.70 or patient has active DVT
A red wound indicates what?
Healthy granulating wounds; absence of necrotic tissue
A yellow wound indicates what?
Included slough (necrotic or dead tissue), fibrous tissue
A black wound indicates?
Covered with eschar (dried necrotic tissue)
What is an indolent ulcer
An ulcer that is slow to heal; is not painful
What is eschar?
hard/leathery, black/brown, dehydrated tissue that firmly adheres to wound bed
What is slough?
moist, stringy/mutinous, white/yellow tissue that tends to be loosely attached in clumps to wound bed
what is recommend for most ulcers to cleanse the wound?
Normal Saline (0.9% NaCl))
True or False: Whirlpool is not supported for wound care. PLWV is a more effective treatment alternative.
True
List the selective debridement options.
- Autolytic debridement
- Enzymatic debridement
- Sharp debridement
Describe autolytic debridement
Use of body’s own mechanisms to remove viable tissue
Moist wound environment which hydrates necrotic tissue/eschar, facilitating enzymatic digestion of nonviable tissue
What are common methods of autolytic debridement?
Use of transparent film, hydrocolloids, and alginates
What are the indications for autolytic debridement?
- Individuals on anticoagulant therapy
- Patients who cannot tolerate other forms of debridement
- All necrotic wounds that are medically stable
List the contraindications for autolytic debridement
- Infected wounds
- Dry gangrene or dry ischemic wounds
- Individuals immunosuppressed
How many days is the autolytic dressing kept in place?
3-7 days
What is enzymatic debridement.
Application of topical agent that breaks down/liquifies necrotic tissue
The following are indications for which type of selective debridement: All moist necrotic wounds, eschar after cross-hatching, homebound individuals, and people who cannot tolerate surgical debridement
Enzymatic debridment
What are the contraindicaitons of enzymatic debridement?
- Ischemic wounds unless adequate vascular s Tatum has been determined
- Dry gangrene
- Clean, granulated wounds
Describe sharp debridement.
Use of scale, scissors, and/or forceps to selectively rove devitalized tissue, foreign material or debris from wound
No anesthesia used
True or false: Sharp debridement can be used in the presence of cellulitis or sepsis
True
List the indications for sharp debridement
- Scoring and/or excision of leathery eschar
2. Remove of moist necrotic tissue
List the Non-selective debridement techniques.
- Wet - to - dry dressings
- Wound irrigation (PLSW)
- Hydrothermal
What medication is currently effective against all staphylococcus infections?
Bactroban ointment and gentamicicin
What modalities are commonly used for wounds to activate cells at the cellular level?
Electrical stimulation (ES) and ultrasound (US)
When using Estimate which form of estim should be used?
High-voltage pulsed current + Pulsed biphasic current
Continous waveform application with direct current
What is the purpose of estim in regards of wound managment?
Improve circulation, facilitate debridement, and enhance tissue repair
What protein is important to look at when trying to determine if delayed wound healing is a result of malnutrition?
Albumin
What are the normal values of albumin?
3.5-55 mg/dl
What values of albumin suggest malnutrition?
<3.5 mg/dl
What value of BMI with weight loss increases risk of pressure ulcers?
BMI = 21
How many liters of fluids (H20) should a person with wounds drink per day?
3 Liters
What kind of diet should patients with wounds be on?
High calorie/High protein diets
25-35 kcal/kg/body weight)/1.5-2.5 gm/kg bod weight
What is a common antiseptic used topically on wounds?
Providone-iodine
How often should a patient be turned in acute and rehabilitation hospitals to prevent pressure ulcers?
Every 2 hours
How often should a patient perform weight shifting if in a wheelchair to prevent pressure ulcers?
Every 15 minutes
List the types of dressing that can be used in wound care management?
Alginates
- Foam dressing
- Gauze
- Hydrocolloids
- Hydrogels
- Transparent films
Describe characteristics of Alginates.
- Derived from calcium salt comment of aligning acid
- Highly absorptive, but Highly permeable (allows bacteria in)
- non occlusive
- Interacts with wound bed to create gel-like layer keeping wound moist
- absorb up to 20x its weight
How often should alginates be changed?
Varies from every 8 hrs to 2-3 days
When is alginates indicated?
When wounds has moderate to large amounts of exudate (and maybe necrosis)
When wounds require packing and absorption
*GOOD FOR AUTOLYTIC debridement
True or false: Alginates are non-adhering to the wound have often require a second dressing (transparent film or gauze pad) to keep them in place.
true
When should alginates not be used?
When tendons, joints/capsule, or bones are exposed
List characteristics of foam Dressings.
- Made of hydrophilic ((wound surface)) and/or hydrophobic (outer layer
- Semipermeable
- Adhesive and non-adhesive
- Absorbs exudate
How often should foam be changed?
Every 1-5 days; depends on the amount of exudate
What type of wounds are alginates usually used on?
Partial-thickness and full-thickness draining wounds + commonly used on infected wounds
I.e. pressure or venous insufficiency ulcers
Describe characteristics of gauze.
- most readily available (made from yarn or thread)
- Can be impregnated
- Good filler for larger wounds
- commonly used on infections
- Good mechanical debridement if done correctly
- Highly permeable
True or false: if gauze is too wet, it will macerate the surrounding skin
True
Which kind of gauze should be used for debridement?
Mesh gauze
Which kind of gauze should be used for protection?
Fine gauze
True or false: Gauze has an increased infection rate compared to occlusive dressings
True
Describe Hydrocolloids.
- consist of gel-forming polymers backed by strong film/adhesive
- Occlusive or semi-occlusive
- Does not attach wound bed but surrounding skin
- Absorbs exudate by swelling into gel-like mass
- Impermeable/water proof
What are the indications for hydrocolloids?
- Protection of partial/full thickness wounds
- Autolytic debridement of necrosis/slough
- Wounds with MILD exudate
What type of wounds should hydrocolloids not be used on?
- Wounds with heavy exudate
- Sinus tracts/infections
- Bone/tendon/fragile skin
- Infected wounds
Name one disadvantage of hydrocolloids?
- Non transparent
How large of a margin of healthy tissue should be left when applying hydrocolloid?
1 to 1.5 inches
How often should hydrocolloids be changed?
3-7 days
What is a common characteristic seen when using hyrdocolliods after removing dressing?
Odor with yellow exudate that is similar to pus (melted material); normal when dressing is removed
Which dressing is the most occlusive dressing of the moisture-retentive dressings?
Hydrocolloids
Which dressing is the dressing of choice during maggot debridement?
Hydrocolloids dressings
List characteristics of hydrogels (classified as amorphous)
- consist of water (@ least 90%) + gel-forming materials (glycerin)
Purpose of hydrogels?
- Increase moisture in dry wound beds
- Soften necrotic tissue
- Support autolytic debridement
Which dressing can be used as a coupling agent for US?
Hydrogel
What kind of wounds are hydrogels used for?
- Partial/full thickness wounds
- Wounds with necrosis and slough
- Burns and tissue damaged by radiation
How much absorption do hydrogels provided?
Mild to moderate absorption
List some disadvantages when using hydrogel dressings?
- Requires second dressing
- not used for heavily exudating wound
- May dry out and adhere to wound
- May macerate surrounding skin
How often should hydrogels be changed?
1-5 days
Describe transparent films.
Thin membranes made with water-resistant adhesives + highly elastic and contour well to body parts
Permeable to vapor and O2 + Impermeable to bacteria and H2O
Adhesive
What stage of ulcers would you want to use transparent films with?
Stage I and II pressure ulcers
What dressing can be used for skin donor sites?
Transparent films
True or False: Transparent films should be used for wounds with mod to large exudate.
False; Transparent films are nonabsorbtive, therefore should be used for wounds with minimal exudate (scalds, abrasions, lacerations)
Avoid wounds with infections and copious drainage, or tracts.
What is an advantage of a transparent film that other dressings don’t allow?
Visual evolution of the wound without removal
How much of a margin should be left around the wound bed when applying transparents films?
1-2” margin
Which dressing is typically very soothing for the patient?
Hydrogel
List the dressings from most occlusive (transmit moisture vapor/gases b/t wound bed atmosphere) to Non-occlusive
- Hydrocolloids
- Hydrogels
- Semipermeable foams
- Semipermeable film
- Impregnated gauze
- Alginates
- Traditional gauze
List dressings from most to least moisture retentive
- Alginates
- Semipermeable foams
- Hydrocolliods
- Hydrogels
- Semipermeable films
