Wounds Flashcards
General recommendations with Arterial insufficiency Ulcers
avoid unnecessary leg elevation
avoid using heating pads or soaking feet in water
General recommendations with venous insufficiency ulcers
compression to control edema
elevate legs above heart when resting or sleeping
attempt active exercise including frequent ROM
Monofilament testing looks for changes in
protective sensation
Failure to perceive a 10g monofilament indicates
loss of protective sensation
Protective sensation example
ability to feel a pebble in shoe or developing a blister
Failure to perceive a 75 gm monofilament indicates
area is insensate
Neuropathic ulcers are often associated with
diabetes
Pressure ulcers aka
decubitus ucers
Pressure ulcers general recommendations
repositioning every 2 hours in bed
management of excess moisture
off-loading with pressure relieving devices
Where are arterial insufficiency ulcers usually found?
lower 1/3 of leg, web spaces of toes, dorsum of foot, lateral malleolus
What do arterial insufficiency ulcers usually look like?
smooth edges
well defined
lack of granulation tissue
tend to be deep
Is there exudate with arterial insufficiency ulcers?
minimal
Is there pain with arterial insufficiency ulcers?
severe
Are pedal pulses absent or present in arterial insufficiency ulcers?
diminished or absent
Is edema present with arterial insufficiency ulcers?
no
What is the skin temp like in arterial insufficiency ulcers?
decreased
What tissue changes occur in arterial insufficiency ulcers?
thin and shiny
hair loss
yellow nails
Leg elevation will be ___ in those with arterial insuffciency ulcers.
painful
Where are venous insufficiency ulcers usually located?
proximal to medial mallelous
What appearance do venous insufficiency ulcers have?
irregular shape
shallow
Do venous insufficiency ulcers have exudate?
moderate/heavy
Are venous insufficiency ulcers painful?
mildly
Are pedal pulses normal in venous insufficiency ulcers?
yes
Is there edema associated with venous insufficiency ulcers?
yes
What is the skin temperature like in venous insufficiency ulcers?
normal
What tissue changes occur with venous insufficiency ulcers?
flaking
dry skin
brownish discoloration
Leg elevation ___ pain in venous insufficiency ulcers.
lessens
Neuropathic ulcers locations
areas of foot susceptible to pressure or shear forces during WB
Appearance of neuropathic ulcers
well-defined oval or circle
callused rim
cracked periwound tissue
little to no wound bed necrosis with good granulation
Exudate in neuropathic ulcers
low/moderate
Pain with neuropathic ulcers?
none
dysesthesia could be reported
Pedal pulses with neuropathic ulcers?
diminished or absent
unreliable ABIs with those with diabetes
Edema in neuropathic ulcers?
normal
Tissue changes in neuropathic ulcers?
dry
inelastic
shiny skin
decreased or absent sweat and oil production
Loss of ___ sensation in neuropathic ulcers?
sensation
Wounds that are not characterized as pressure or neuropathic ulcers are classified based on
depth of tissue loss
Superficial wound
non-blistering sunburn
typically will heal as part of the inflammatory process
Partial-thickness wound
extends through the epidermis and possibly into, but not through the dermis
abrasions, blisters and skin tears
Typically will heal by re-epithelialization or epidermal resurfacing depending on depth of injury.
Full-thickness wound
extends through the dermis into deeper structures like fat
wounds deeper than 4 mm are considered full-thickness and heal by secondary intention
Subcutaneous wound
extend through integumentary tissues and involve deeper structures like fat, muscle, tendon or bone.
Typically require healing by secondary intention
Wagner Ulcer Grade Classification System
based on wound depth and presence of infection
commonly associated with diabetic foot assessment.
Neuropathic, ischemic or arterial etiology
Wagner Ulcer Grade Classification System:
0
1
2
3
4
5
no open lesion, may have pre-ulcerative lesions, healed ulcers or presence of bony deformity
superficial ulcer not involving subcutaneous tissue
deep ulcer with penetration through subcutaneous tissue, potentially exposing bone, tendon, ligament or joint capsule
Deep ulcer with osteitis, abscess, or osteomyelitis
gangrene of digit
gangrene of foot requiring disarticulation
Stage 1 pressure injury
non-blanchable erythema of intact skin
changes in sensation, erythema temperature or firmness can precede visual changes.
Color changes are not purple or maroon
Stage 2 pressure injury
partial-thickness skin loss with exposed dermis
wound bed is viable pink, moist, may also present as intact or ruptured serum-filled blister.
Adipose is not visible and deeper tissues are not visible.
Granulation tissue, slough and eschar are not present.
Usually result from adverse microclimate and shear over the pelvis and heel
Stage 3 pressure injury
full-thickness skin loss
adipose is visible and granulation is epibole (rolled edges).
Slough or eschar is visible
Undermining and tunneling may occur.
Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed.
If slough or eschar obscures the extent of tissue loss, this is Unstageable
Stage 4 Pressure ulcer
full-thickness skin and tissue loss
exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer.
Slough and/or eschar may be visible.
Epibole, undermining and tunneling often occur.
If slough or eschar obscures extent of tissue loss then unstageable.
Unstageable pressure ulcer
obscured full-thickness skin and tissue loss
slough or eschar is removed, a stage 3 or 4 can be revealed.
Stable eschar on heel or ischemic limb should not be softened or removed.
What is stable eschar?
dry
adherent
intact without erythema
Deep tissue pressure injury
persistent non-blanchable deep red, maroon or purple discoloration
intact or non-intact skin
Epidermal separation revealing dark wound bed or blood filled blister.
Pain and temp changes before skin color changes.
Results from intense and/or prolonged pressure and shear forces at the bone-muscle interface.
Wound may evolve rapidly or can resolve without tissue loss.
Do not use deep tissue pressure injury to describe vascular, traumatic, neuropathic, or dermatologic conditions.
Pressure injury sites while lying supine
occiput
spine of scapula
inferior angle of scapula
vertebral spinous process
medial epicondyle of humerus
posterior iliac crest
sacrum
coccyx
heel
Pressure injury sites while prone
forehead
anterior portion of acromion process
anterior head of humerus
sternum
anterior superior iliac spine
patella
dorsum of foot
Pressure injury sites sidelying
ears
lateral portion of acromion process
lateral head of humerus
lateral epicondyle of humerus
Greater trochanter
head of fibula
lateral and medial malleolus
Pressure injury sites sitting
spine of scapula
vertebral spinous process
ischial tubes
Serous
clear, light color and thin and watery
normal in health wounds
part of inflammatory and proliferative stages
Sanguineous
red color and thin and watery
indicative of new blood vessel growth or disruption of blood vessels
Serosanguineous
light red or pink, thin watery
normal in healthy wound
part of inflammatory and proliferative stages
Seropurulent
cloudy or opaque with a yellow or tan color
thin and watery
early warning sign of infection
always an abnormal finding
Purulent
yellow or green color and thick, viscous consistency
infection and always an abnormal finding
Eschar
hard or leathery
black/brown
firmly adhered to wound bed
Gangrene
death and decay of tissue
some types are from bacterial infection
most commonly affects extremities but can also affect muscles and internal organs
Hyperkeratosis
callus
white/gray in color and can vary in texture from firm to soggy depending on moisture level around
Slough
moist, stringy or mucinous
white/yellow tissue that tends to be loosely attached in clumps to wound bed
Selective debridement
performed by sharp debridement
enzymatic debridement or
autolytic debridement
Sharp debridement
scalpel
scissors
forceps
wounds with large amounts of thick, adherent, necrotic tissue
May be used in presence of cellulitis or sepsis
Most expedient form of removing necrotic tissue
PTs are allowed to perform this
Enzymatic debridement
topical application of an enzymatic preparation for necrotic tissue.
can be used on infected and non-infected wounds with necrotic tissue.
Used for wounds that have not responded to autolytic debridement or in conjunction with other debridement techniques.
Can be slow to establish clean wound bed and should be discontinued once tissue is removed.
Autolytic debridement
use of body’s own mechanisms to remove nonviable tissue.
transparent films, hydrocolloids, hydrogels, and alginates.
establishes moist wound bed and rehydrates necrotic tissue and eschar
facilitates enzymatic digestion of nonviable tissue.
Non-invasive and pain free
can be used with any amount of necrotic tissue but requires longer healing period and is not used in infected wounds.
Non-selective debridement
removal of both viable and nonviable tissues
aka mechanical debridement
through wet-to-dry dressings, wound irrigation and hydrotherapy (whirlpool)
Wet-to-dry dressings
moistened gauze dressing over an area of necrotic tissue
used to debride wounds with moderate amounts of exudate and necrotic tissue
Wound irrigation
pressurized fluid
pulsatile lavage is an example
most desirable for wound that is infected or has loose debris
Hydrotherapy
whirlpool
side effects: maceration of viable tissue, edema from dependent LE positioning and systemic effects such as hypotension
Woundvac is contraindicated for
malignancy
insufficient vascularity
large amounts of necrotic tissue
untreated osteomyelitis
fistulas in organs
exposed arteries or veins and uncontrolled pain
Hyperbaric oxygen indicated for
osteomyelitis
diabetic wounds
crush injuries
compartment syndrome
necrotizing soft tissue infection
thermal burns
radiation necrosis
compromised flaps and grafts
Growth factors
from naturally occurring protein factors
stimulate neutrophils, endothelial cells, fibroblasts
Indications to use growth factors
neuropathic ulcers extending into or through subcutaneous tissue with adequate circulation to sustain wound healing
Ultrasound at a low intensity and pulsed duty cycle can be used for wound healing during what phases?
inflammatory and proliferative
High voltage pulsed current electrical stimulation has been shown to enhance healing of wounds like
chronic ulcers, burns, donor and graft sites
Two main types of dressings
primary or secondary
Primary dressing
one that comes into direct contact with wound
Secondary dressing
placed directly over primary dressing to provide additional protection, absorption, occlusion and/or to secure primary dressing in place.
Alginates
seaweed extraction
calcium salt component of alginic acid
highly absorptive
requires secondary dressing
Indicated: partial or full-thickness draining wounds such as pressure or venous insufficiency ulcers. Often used on infected wounds.
Cannot be used on those with exposed tendons, joint capsule or bone
Foam dressings
allow exudate to be absorbed into foam through hydrophilic layer
non-adhesive foams require secondary dressing
for partial and full thickness wounds
can be used as secondary dressings over amorphous hydrogels
Gauze is used for what type of wounds and can be used for..
infected or non-infected wounds of any size
wet-to-wet
wet-to-moist
wet-to-dry
Hydrocolloids are
gel-forming polymers
backed by strong film or foam adhesive
does not attach to the wound itself
absorbs exudate by swelling into a gel-like mass and varies in permeability, thickness and transparency
Hydrocolloids are used for
partial and full-thickness wounds
can be used effectively with granular or necrotic wounds
cannot be used with infected fwounds
Hydrogels are
moisture retentive and commonly used on superficial and partial-thickness wounds
abrasions, blisters, pressure ulcers
that have minimal drainage.
Cannot be used on wounds with significant drainage.
Typically requires a second dressing
Transparent film
thin membranes
permeable to vapor and oxygen but are largely impermeable to bacteria and water
Transparent film is indicated for
superficial or partial-thickness wounds with minimal drainage
scalds, abrasions, lacerations
Disadvantages to using transparent film?
excessive exudate accumulation can result in periwound maceration
cannot be used on infected wounds
A dry wound bed slows…
normal metabolic functions, impeding wound healing
Occlusion refers to ability of a dressing to
transmit moisture, vapor or gases between a wound bed and the atmosphere.
Prolonged excessive moisture will cause
maceration damage and erosion of intact peripheral tissue
A fully occlusive substance would be
completely impermeable
like latex gloves
A non-occlusive substance would be
completely permeable
like gauze pads
Most occlusive to non-occlusive dressings:
hydrocolloids
hydrogels
semipermeable foam
semipermeable film
impregnated gauze
alginates
traditional gauze
Dressings from most to least moisture retentive
alginates
semipermeable foams
hydrocolloids
hydrogels
semipermeable films
A patient who is incontinent is at a significantly ….. risk of tissue injury or in the presence of existing tissue injury may experience additional complications including delayed healing.
increased
Therapeutic moisturizers are intended to maintain
skin’s natural moisture and prevent tissue cracking due to dryness but does not typically protect skin from excessive moisture
Moisture barriers are frequently used to protect
surrounding skin from heavily draining wound or perineal tissues from exposure to incontinence
Dehiscence
separation, rupture or splitting of wound closed by primary intention.
Disruption may be superficial or involve all layers of tissue.
Desiccated
drying out or dehydration of a wound. Results from poor dressing selection that does not control the evaporation of wound bed moisture.
Desquamation
peeling or shedding of the outer layers of the epidermis. Normally occurs in small scales
Ecchymosis
discoloration occurring below intact skin from trauma to underlying blood vessels
typically blue-black changing to yellow or brown
bruising
Erythema
diffuse redness of skin from capillary dilation and congestion or inflammation
Friable
tissue that readily tears, fragments or bleeds when gently palpated or manipulated
Hemosiderosis
brown or dark red discoloration that results in rupture of blood vessels and deposition of blood around wound.
Induration
abnormal hardening of the tissue that occurs at the edges of the wound and results from accumulation of edema.
Keloid
abnormal scar formation that is out of proportion to scarring required for normal tissue repair.
red, thick, raised and firm
Maceration
skin softening and degeneration that results from prolonged exposure to water and other fluids
Turgor
speed with which skin resumes normal appearance after being lightly pinched. Indicator of skin elasticity and hydration.
