Ulcers Flashcards
What is an Arterial Insufficiency Ulcer?
a wound resulting from inadequate circulation of oxygenated blood (ischemia) often due to complicating factors such as atherosclerosis
What are the general recommendations for patients who have an arterial insufficiency ulcer?
rest, protect affected limb, inspect legs and feet daily, avoid unnecessary leg elevation, avoid soaking feet in hot water and heating pads, and wear appropriately sized shoes with clean seamless socks
What monofilament is used to test for protective sensation in the foot?
10 gm
What is a venous insufficiency ulcer?
wound resulting from impaired functioning of the venous system resulting in inadequate circulation and eventual tissue damage and ulceration
What are nueropathic ulcers and what are the general care recommendation for patients who have them?
ulcers which are usually the result of a combination of ischemia and neuropathy and commonly associated with diabetic patients but any patient with neuropathy can develop them
General care includes limb protection, inspection daily and taking time to inspect that there is no debris in patient’s shoes or socks that can cause injury
What monofilament is used to test for protective sensation in the foot?
10gm
What are pressure ulcers and what are the general care recommendations for patient who have them?
Ulcers that are the result of prolonged pressure on the tissues which is greater than the capillary pressure of the tissues which causes ischemia and tissue necrosis
general care includes frequent repositioning every 2 hours, management of excess moisture, off-loading with pressure relieving devices, daily skin inspection, and limiting shear, traction, and friction forces over fragile skin
What are the characteristic of Arterial Insufficiency Ulcers on the lower extremity?
Location Appearance Exudate Pain Pedal Pulse edema skin temp tissue changes response to elevation
Location-lower 1/3 of leg, toes, dorsum of foot and lateral malleolus
Appearance-well defined and smooth edges, usually deep
Exudate-minimal
Pain-severe
Pedal Pulse-diminished or absent
edema-normal
skin temp-decreased
tissue changes-thin and shiny with yellow nails and hair loss
response to elevation-increases pain
What are the characteristic of Venous Insufficiency Ulcers on the lower extremity?
Location Appearance Exudate Pain Pedal Pulse edema skin temp tissue changes response to elevation
Location-proximal to medial malleolus Appearance-irregular shape and shallow Exudate-moderate/heavy Pain-mild to moderate Pedal Pulse-normal edema-increased skin temp-normal tissue changes-flaky dry skin with brownish discoloration response to elevation-lessens pain
What are the characteristic of Neuropathic Ulcers on the lower extremity?
Location Appearance Exudate Pain Pedal Pulse edema skin temp tissue changes
Location-areas of the foot that experience a lot of shear
Appearance-well defined oval or circle with callused rim and cracked periwound
Exudate-low/moderate
Pain-none but dysesthesia may be reported
Pedal Pulse-diminished or absent
edema-normal
skin temp-decreased
tissue changes-dry, inelastic and shiny skin with decreased sweat production
typically loses protective sensation
What would a grade 0 be on the Wagner Ulcer Grade Classification Scale?
no open lesion, but may possess pre-ulcerative lesions; healed ulcers; presence of bony deformity
What would a grade 1 be on the Wagner Ulcer Grade Classification Scale?
superficial ulcer not involving subcutaneous tissue
What would a grade 2 be on the Wagner Ulcer Grade Classification Scale?
deep ulcer with penetration through the subcutaneous tissue; potentially exposing bone, ligament, tendon or joint capsule
What would a grade 3 be on the Wagner Ulcer Grade Classification Scale?
deep ulcer with osteitis, abscess or osteomyelitis
What would a grade 4 be on the Wagner Ulcer Grade Classification Scale?
gangrene of digit
