Wound Types Study Guide/ Chart Flashcards
Stages of Healing:
- Inflammation
- Epithelialization
- Proliferation
- Remodeling/Maturation
Inflammation =
(acute): Hemostasis (retraction//sealing off blood vessels), macrophages phagocytise debris, bacteria and damaged tissue
a. Signs: redness, swelling, heat, pain, loss of function
b. Highlights: vascular responses (bleeding), cellular responses
Epithelialization =
starts within a few hrs of injury and occurs simultaneously with other stages
a. Barrier between wound surface and environment (keratinocytes), requires O2 and moist environment
Proliferation =
(approx 3 weeks): neovascularization (angiogenesis), collagen production (fibroplasia), wound contraction (myofibroblast)
a. Key cells: angioblast, fibroblast, myofibroblast (pull entire wound together thereby shrinking defect), keratinocyte
Remodeling/Maturation =
(day 9- 1 yr): remodeling scar/collagen reorganization to fit tissue and function
Arterial Insufficiency leads to what type of ulcer:
Arterial
Arterial Insufficiency causes:
Decrease in arterial blood supply
● Trauma
● Acute embolism
Arterial Insufficiency signs:
● “Dependent rubor” ● slow nail growth
● pulses faint/absent ● atrophic skin
● loss of hair
Arterial Insufficiency risks:
● Age
● Smoking
●DM
● HTN
● Hyperlipoproteinemia
● Elevated WBC count
Atherosclerosis (primary cause) leads to what type of ulcer:
Arterial
Atherosclerosis causes:
Buildup of plaque in inner lining of artery
Atherosclerosis signs:
● Intermittent claudication
● “Rest” pain
Atherosclerosis risks:
● Age
● Smoking
●DM
● HTN
● Hyperlipoproteinemia
● Elevated WBC count
Venous Insufficiency leads to what type of ulcer:
Venous
Venous Insufficiency causes:
● Mechanical insufficiency (failure of valves)
● Physiological insufficiency (imbalance of proteins)
Venous Insufficiency signs:
● Pitting edema
● Hyperpigmentation
● lipodermatosclerosis/ fibrotic
tissue
● Eczema white plaques
Venous Insufficiency risks:
● Age
● Hx of varicose veins
● Obesity
● DVT
● LE trauma
● Legs in dependent position
● Pregnancy
● Impaired lymphatic drainage
● Previous vein surgery
Infected wounds Signs and Sx:
induration
fever
erythema
edema
increased drainage
odor after irrigation
increased pain
Infected wounds types:
cellulitis, lymphangitis, sepsis, osteomyelitis
3 types of ulcers:
Arterial
Venous
Lymphatic
Arterial ulcers causes:
● Arterial insufficiency
● Atherosclero sis (primary cause)
●PAD
Arterial ulcers signs:
● Edges well demarcated
● Wound
● VERY PAINFUL
● Base of ulcer pale and dry
● Minimal drainage
● No granulation tissue present
● Periwound tissue may be black, gangrenous
Arterial ulcers location:
●Toes
● dorsum of foot
● lateral malleolus
● lower 1⁄3 of anterolateral leg
Arterial ulcers tests and measures:
● Pulses
● Doppler US
● ABI (tests perfusion)
● Rubor of Dependency
● Venous Filling Time
Arterial ulcers treatment:
● Protect from pressure
○ Bed rest, Off-loading, Positioning
● Increase blood flow/O2
○ Hyperbaric O2
○ Arterial bypass
○ Angioplasty and stents
● Wound Care
○ Ischemic ulcers kept dry
● Debridement if adequate blood flow present
Arterial ulcers dressings and casting:
● Non-adhere nt foam
● Total contact casting
Venous ulcers causes:
Venous insufficiency
Venous ulcers signs:
● Achiness, decreased pain @ night
● Irregular shape, shallow
● Granulation tissue present (pink→ red)
● Flat borders
● Wet, excessive drainage
● PAINLESS or mild pain
● Slough present
Venous ulcers location:
● Distal, medial third of LE
● Proximal to medial malleolus
Venous ulcers tests and measures:
● Homans’ Sign
● ABI
● Tredelenberg test ● Doppler US
● Venous filling time
Venous ulcers treatment:
● Compression therapy (short stretch wraps, tubular bandages, graduated compression garments)
● Wound care
● Medical intervention
(growth factors, surgery-
ligation, venous bypass)
● Keep leg elevated
Venous ulcers dressings and castings:
Unna boot (semirigid dressing)
ulcer subtypes:
Neuropathic/ Diabetic
Pressure
Neuropathic/ Diabetic causes:
Diabetes, HIV/AIDS, Cancer, Vitamin B deficiency, MS, Charcot-Marie Tooth Disease
Neuropathic/ Diabetic signs:
● Round, deep
● Often pink
● Normal pulses
● Normal or slightly higher temperature
● Periwound (callus, dry, hardened)
● induration/hardened edges
● Very little exudate
● Not painful (due to
damaged nerves)
Neuropathic/ Diabetic location:
Plantar surface of foot (3rd met head, 1st met head/great toe, 5th met head)
Neuropathic/ Diabetic tests and measures:
● Diabetic Foot Screening
● Pulse Examination
● Doppler US & ABI
● Capillary Refill
● Sensory integrity
(monofilament test → 5.07= loss of protective sensation)
● Wagner Scale
Neuropathic/ Diabetic treatment:
● Wound care
○ Moist dressings
○ Prevent infection
● Off loading
● Rocker bottom
● Shoe modification (padded ankle foot orthosis)
● PT=ambulation
● Patient education
○ Diet and exercise
○ Disease process
○ Bone evaluation
○ Shoe wear and foot care
guidelines
Neuropathic/ Diabetic dressings and casting:
Total contact casting
Pressure ulcer causes:
Time+pressure= damage
Typically result from repeated episodes without adequate time for recovery in between
External: shear, moisture, friction
Internal: Age, arterial insufficiency/ arteriolar pressure, malnutrition
Impaired sensation
Pressure ulcer risks:
The 5 I’s
● Immobility
● Inactivity
● Incontinence
● Improper Nutrition
● Impaired mental status or sensation
Stage 1 pressure ulcer description:
Observable pressure related change in area of intact skin when compared to adjacent/comparable area of skin. Signs: skin color, skin temp, tissue consistency, sensation
Stage 1 pressure ulcer prevention measures tests and measures:
● Positioning
○ Full body change of position every 2 hrs
○ Every hr in sitting
○ shift/pressure relief every 15 min
● Frequent position changes
● Pressure reduction devices
● Skin care
● Nutrition
● Good clothing choices
● Move with care
● Educate
Stage 1 pressure ulcer treatment:
● Prevention is key
● Eliminate/ reduce sources of pressure
● Improve nutritional status
● Wound management
Stage 2 pressure ulcer description:
Partial-thickness wound presented as abrasion, blister, or shallow crater (epidermis & dermis)
Stage 2 pressure ulcer prevention measures tests and measures:
● Positioning
○ Full body change of position every 2 hrs
○ Every hr in sitting
○ shift/pressure relief every 15 min
● Frequent position changes
● Pressure reduction devices
● Skin care
● Nutrition
● Good clothing choices
● Move with care
● Educate
Stage 2 pressure ulcer treatment:
● Prevention is key
● Eliminate/ reduce sources of pressure
● Improve nutritional status
● Wound management
Stage 3 pressure ulcer description:
Full-thickness wound with damage or necrosis that may extend down to, but not through, fascia that presents as deep crater
Stage 3 pressure ulcer prevention measures tests and measures:
● Positioning
○ Full body change of position every 2 hrs
○ Every hr in sitting
○ shift/pressure relief every 15 min
● Frequent position changes
● Pressure reduction devices
● Skin care
● Nutrition
● Good clothing choices
● Move with care
● Educate
Stage 3 pressure ulcer treatment:
● Prevention is key
● Eliminate/ reduce sources of pressure
● Improve nutritional status
● Wound management
Stage 4 pressure ulcer description:
Full-thickness skin loss with extensive destruction, necrosis, damage to underlying structures (muscle, bone, tendon, joint capsule, etc.)
Stage 4 pressure ulcer prevention measures tests and measures:
● Positioning
○ Full body change of position every 2 hrs
○ Every hr in sitting
○ shift/pressure relief every 15 min
● Frequent position changes
● Pressure reduction devices
● Skin care
● Nutrition
● Good clothing choices
● Move with care
● Educate
Stage 4 pressure ulcer treatment:
● Prevention is key
● Eliminate/ reduce sources of pressure
● Improve nutritional status
● Wound management
Unstageable pressure ulcer:
Full thickness tissue loss in which the base of the ulcer is completely covered by slough and/or eschar
Eschar or slough needs to be removed to expose base to determine true stage of wound
Deep Tissue Injury pressure ulcer:
Damage of underlying soft tissue from pressure and/or shear Appears maroon colored
Burns =
Superficial (1st degree)
Superficial Partial Thickness (2nd degree)
Deep Partial Thickness (2nd degree)
Full Thickness (3rd degree)
Electrical (4th degree)
Burn Rehab =
● Chest PT
● Positioning & Splinting
● ROM
● Resting hand position (wrist ext)
● Ambulate with ace bandages with pt who has skin grafts
● Exposed tendons no PROM only AROM/AAROM
Burn Tests and Treatment =
Test:
● Rule of Nines
Treatment:
● Fluid resuscitation
● Critical Care tx/evaluation
● CPT/percussion & PROM
● Positioning (team effort)
● GENTLE ROM → PROM/AAROM
● May see skin blanch
● Outpatient PT
○ Paraffin as tx adjunct
○ Monitor skin 20-30s
○ Prolonged stretch: 1-3min
Burns Dressings and castings:
● Silvadine -wax like substance, topical, antimicrobial , can be covered with gauze
● Sulfamylon -exposed cartilage
● Xeroform -impregnated gauze
● Silver Nitrate -minimize hypergranul ation tissue to prevent hypertrophic scar
Superficial (1st degree) burn =
● No bleeding due to avascular tissue
● No blister formation
● location = Epidermis Only
Superficial Partial Thickness (2nd degree) burn =
● Extremely painful due to irritation of nerve endings and pain sensors
● blister formation
● location = Epidermis and into upper layer of dermis
Deep Partial Thickness (2nd degree) burn =
● Dermal appendages destroyed
● Burn will appear red, tan or white and
dull looking
● Eschar may develop
● Infection can occur to cause it to
develop into a full thickness burn
● location = Severe damage to dermal layer
Full Thickness (3rd degree) burn =
● Burn will not blanch
● location = Epidermal, dermal, and subdermal layer completely destroyed
Electrical (4th degree) burn =
● Entrance and exit wounds
● Fractures may occur
● Internal injuries may occur
● MI involvement
● location = Destruction into bone
Burn Wound 3 zones:
Zone of of Coagulation
Zone of of Stasis
Zone of of Hyperemia
Zone of of Coagulation =
Area that receives the most direct and intense heat
Cells are irreversibly damaged and skin death occurs
Tissue necrosis and eschar are present
Zone of of Stasis =
Contains injured cells that will die within 24-48 hours without specialized treatment
Blood supply is compromised by cellular and vascular changes
It is here that infections and or dying of tissues could result in conversion of tissues into necrotic tissue
Zone of of Hyperemia =
outermost area of burn
vasodilatation and increased blood flow
site of minimal cell damage
should recover within seven days with no lasting effects
