Common Wounds Flashcards
1
Q
Arterial Wounds USUALLY due to _________
A
Peripheral Artery Disease
PAD
*VERY PAINFUL!!!
2
Q
Type of wound:
Arterial (usually due to PAD)
A
- can be ANY arteries
- initial buildup of sclerotic (scarred) tissue
-
*REMEMBER*
- Blood NOT getting to peripheral system
3
Q
Arterial Wounds
Describe the Pain
and what is it WORSE w/?
A
- SEVERE
-
Worse w/ Amb.
- bc blood wont make it to periph. aa’s
- Worse w/ Leg Elevation
4
Q
Arterial Wounds
Describe the Location
A
-
LE
-
FURTHEST from the heart
- bc blood has to travel far & cannot make it
-
FURTHEST from the heart
-
Toes, LATERAL malleolus, or ANT. leg
- LESS likely Medial (venous wounds)
5
Q
Arterial Wounds
Presentation— in general…
A
Small, shallow
Round, regular
6
Q
Arterial Wounds
Presentation
Granulation tissue vs. Necrotic tissue
A
- Granulation tissue
- usually Pale
- Necrotic tissue
- black eschar
7
Q
Arterial wounds can dev. ___________ w/ advanced disease
A
Gangrene
8
Q
Exudate w/ Arterial wounds?
A
Minimal—>NO exudate
*bc not enough blood there!
9
Q
What will those w/ PAD and Arterial wounds most likely describe the pain as?
A
“Ants in pants” feeling
Throbbing ALL the time
10
Q
Arterial wounds
Describe the Periwound (around)
A
- DECd perfusion
- Epidermis thin, shiny, dry
- Loss of hair
- thick/brittle nails
- MM atrophy***
- Pale, dusky, cyanotic
11
Q
Arterial Wounds
Pulses?
A
Absent, thready, weak Dorsalis Pedis AND Post. Tib
*the DISTAL pulses!!!
12
Q
Arterial wounds
Temperature
*this is CLASSIC SIGN*
A
COOLER ****
*NOTE: use back of hand
13
Q
GOLD STANDARD MEASUREMENT FOR PAD
A
ABI
(Ankle systolic pressure)/(brachial systolic pressure)
*blood/beat making it to ankle
14
Q
Arterial Wounds
Other examinations?
A
- ABI==GOLD STANDARD
- Cap. refill
- Rubor of Dependency
-
Look @ leg:
- hairless, dry, atrophy, cool, pale, thin
- Chart review*
- CAD, PAD, renal artherosclerosis
15
Q
Arterial Wounds
Some Ex’s and WHY
A
see below
16
Q
PT Tx for Arterial wounds:
A
Debridement
BUT complex decision tree to go thru
17
Q
Venous wounds usually due to:
A
Chronic Venous Stasis/Disease/Insuff.
CVD
18
Q
RISK FACTORS for Venous Wounds
A
see below
19
Q
Venous Wounds
Describe the Pain
A
Dull, aching
ANNOYING
20
Q
VENOUS WOUNDS
Pain gets WORSE w/
A
WORSE in dependent pos.
21
Q
Venous wounds
Pain BETTER/IMPROVES w/?
A
IMPROVES w/ elevation (bc better venous return)
IMPROVES w/ compression (GOLD STANDARD)
22
Q
VENOUS WOUNDS
Position? Usually?
A
Medial aspect LOWER leg
BUT can be anywhere on LOWER leg
23
Q
Venous wounds
Presentation
starts as?
shape?
A
- STARTS as superficial and MAY progress to full thick.
- Irregular shape
24
Q
Venous wounds
Drainage?
A
Mod–> Copious drainage
“Weeping Wounds”
25
Weeping Wounds think....
Venous Wounds!!!!
26
Venous wounds
## Footnote
**Granulation tissue vs. Necrotic tissue**
* **Granulation tissue**
* ****Beefy Red
* **Necrotic tissue**
* ****loose wet slough
27
Progression of Venous Wounds
## Footnote
**tissue wise**
* can PROGRESS to **subcutaneous tissue BUT DOES NOT extend to tendon or bone\*\*\*\*\*\***
28
Venous Wounds
## Footnote
**Describe the Periwound**
* Ill-defined **wound borders**
* **Indurated (hard/firm) periwound**
* Edema\*\*
* Wet\*\*
* **Hemosiderin staining**
* **HgB+RBCs stain skin**
* Fibrotic thick skin\*\*
29
Venous Wounds
## Footnote
**If you are considering using _Compression Therapy_**
**What MUST you do?**
* NEED:
* **ABI results** to ensure **adequate perfusion\*\***
* ****MILD PAD==precaution
* SEVERE PAD==contraindication
* **Pregnancy status**
* ****Pregnancy== precaution
* **bc blood vol INCs==venous pooling**
* **CHF**
* ****_Controlled Stage I_== precaution
* _Uncontrolled Stage II, III, IV_==contraindication
30
Venous Wounds
## Footnote
**Some Ex's and WHY**
see below
31
Diabetic Wounds
## Footnote
**Usually from...**
Type I or Type II DM
32
Diabetic Wounds
## Footnote
**RISK FACTORS**
SEE BELOW
33
Diabetic Wounds
## Footnote
**Describe the Pain**
* Painful OR
* **NOT painful due to _loss or diminished pain sensation_**
34
Diabetic Wounds
## Footnote
**Certain deformities develop from _Motor Polyneuropathy from Diabetes:_**
* Pes Planus
* Claw toes
* Hammer toes
* PF foot
* Hallux Valgus
* **Charcot Foot**
* Intrinis mm wasting of feet
35
Diabetic Wounds
## Footnote
**Position of the wounds?**
SAME AREAS WHERE **ARTERIAL ULCERS ARE:**
* Toes
* LATERAL malleolus
* ANT leg
36
Diabetic Wounds
## Footnote
**Areas of Altered Pressure Points**
**Where???**
* On **Plantar aspect of _foot, toes, heels_**
* **__Motor Neuropathy**
37
Diabetic Wounds
## Footnote
**Explain the Presentation:**
* Round
* **Frequently Deep**
* **bc progress FAST!!!**
* MIN. drainage
* **HIGH infection rate**
* **THIS IS UNIQUE TO DIABETIC WOUNDS**
* **bc sugar irritation**
38
Diabetic Wounds
## Footnote
**Peri-wound**
* DRY (sometimes Very dry)
* **Elevated rim of wound\*\***
39
Diabetic wounds
## Footnote
**Pulses?**
DIMINISHED
40
Diabetic Wounds
## Footnote
**Temp.**
* Neuropathic foot is **warm and dry**
* **bc Autogenic Neuropathy**
* **==\>** autoreg. of temp affected
41
Diabetic Wounds
## Footnote
**Other Examinations???**
SENSATION TESTING!!!
* Lt. touch
* Protective sensation
* **microfilament testing**
* Sharp touch
* Proprio testing
* 2-pt discrim.
* Temp
* Vibration
**Assess for foot deformities== Motor Testing**
42
Diabetic Wounds
**Some Ex's and other cond**'**s that follow (foot deformities)**
see below
43
PT Tx: Compression Therapy for **Venous Wounds**
What to DO:
44
Pressure Ulcers
## Footnote
**Usually due to:**
* Diminished **sensation** OR **inability to vocalize pain (delirium)**
* INCd **moisture OR incontinence**
* **Immobility\*\*BIG ONE!**
* Inad. **nutrition OR inability to _absorb_ nutrition**
* **Friction/shear forces\*\***
45
Stage 1 Pressure Ulcer
**Describe Stage 1**
* **Intact skin** w/ **localized area erythema**
* Area=**non-blanchable**
* DECd **sensation**
* INCd **firmness**
* **Temp changes: warm or cool**
46
Stage 1 Pressure Ulcers are **NOT:**
NOT **Open**
**NOT scar tissue**
**NOT erythema purple or maroon discoloration**
47
What is the **MOST IMPORTANT THING we want to remember w/ Stage 2 Pressure Ulcers?**
\*THIS IS WHEN WE WANT TO CATCH THEM!!
\***Tissue is physiologically reversible over time IF caught @ this stage!!!\***
48
Stage 2 Pressure Ulcers
**Describe this stage:**
* wound bed is **viable**
* Pink OR red tissue
* **Moist**
* **Blister**
* NO **granulation tissue**
* NO **necrotic tissue**
49
Stage 3 Pressure Injury
## Footnote
**What is going on in this stage?**
* **Full thickness loss of skin** **in which _adipose (fat) is visible_**
* **__****Granulation tissue**
* **Necrotic tissue MAY be present**
* **undermining, sinus track, tunneling MAY occur**
* **\*\*\*NO fascia, mm, tendon, lig, cartilage and/or bone exposed\*\*\***
50
Stage 3 Pressure Ulcer
## Footnote
**Epibole often present**
**what is this ?**
Epibole (rolled wound edges) **often present**
51
Stage 3 pressure ulcer
**Healing capacity?**
Wound will go thru **stages of healing (if tx'd)** and form **scar tissue**
52
Stage 3 Pressure injury
## Footnote
**What makes it an "Unstageable Pressure Injury"**
* If **slough or eschar obscures (makes it so you cannot tell) the extent of tissue loss == Unstageable**
53
Stage 4 Pressure Injury
## Footnote
**What is going on in this Stage?**
* **Full thick. loss of skin now WITH exposed fascia, mm, tendon, lig, cart., bone**
* ****SO undermining, sinus track, tunneling MAY occur
* **Necrotic tissue (slough and/or eschar) MAY be present**
54
Stage 4 Pressure Injury
## Footnote
**Epibole?**
Epibole (rolled wound edges) **often present**
55
Stage 4 Pressure Injury
## Footnote
**Healing?**
Wound will go thru **stages of healing (if tx'd) and form _scar tissue_**
56
Stage 4 pressure injury
## Footnote
**What makes this an "Unstageable Pressure Injury?"**
IF **slough or eschar obscures extent of tissue loss== Unstageable**
57
**A wound can NEVER heal if what is present?**
W/ **Eschar present**
58
Unstageable Full Thick. Pressure Injury
## Footnote
**2 components that make it Unstageable**
1. **Obscured full thick. skin and tissue loss**
2. Extent of tissue damage w/in ulcer **_cannot be confirmed_**
59
Unstageable Full Thick Pressure Injury
## Footnote
**Black eschar obscures the full thick of skin and tissue loss**
**What is the role of eschar?**
* Eschar is **body's natural cover of phys. and immune protection**
* **a wound can NEVER heal w/ eschar present**
* Removing **stable eschar** in the poorly perfused area results in an **open wound prone to infection**
60
Deep Tissue Pressure Injury (DTI) OR
Prolooonged deep bruise
61
Deep Tissue Pressure Injury
## Footnote
**DTI**
**what is this?**
* **Persistent** non-blanchable **deep red, maroon or purple** discoloration OR epidermal separation revealing a **dark wound bed** OR **blood filled blister**
62
Deep Tissue Pressure Injury (DTI)
## Footnote
**Pain and temp?**
Pain and temp change **often preced skin color changes**
63
Deep Tissue Pressure Injury (DTI)
**What does this result from?**
* Results from **intense and/or prolonged pressure and shear forces @ bone-muscle interface**
64
PT's role in Pressure Ulcers
PT's **prevent** pressure ulcers!!!!
65
Physical Tx for **Pressure Ulcers**
## Footnote
**We want to _Off-Load_ 3 things:**
1. Offload-- **change pts pos'ing q2h**
2. Offload-- **improve surf. selection**
1. **bed, shoes, bandage**
3. Offload-- **improve wt. distribution during Function**
1. **shoes (CAM shoes)**
66
Physical Tx for Pressure Ulcers
## Footnote
**We want to DECREASE what?**
DECREASE **Moisture**
* **speak w/ nurse about catheter/fecal tube**
* **obtain commode**
* **PT INTERVENTION: commode transfers**
67
Physical Tx for Pressure Ulcers:
## Footnote
**Encourage pt to\_\_\_\_\_\_\_\_\_**
Encourage pt to **assist in mobility** to **prevent shear forces**
68
Physical Tx for Pressure Ulcers
## Footnote
**Interdisciplinary Care?**
* Optimize **nutrition** w/ **nutritionist**
* INC **arousal** via reviewing meds w/ **pharmacist**
* Encourage nursing assist. or family to assist w/ **meal prep** AND motivation to eat **PRO-based foods\*\***
* **NEED PRO FOR WOUND TO HEAL!!!**
* Optimize IND @ meals w/ OT\*\*
69
Burns
## Footnote
**usually result from...**
Trauma!!!
70
SUPERFICIAL burn
## Footnote
**Involves:**
**ONLY Epidermis**
71
SUPERFICIAL **Partial Thick. Burn**
**Involves....**
**Epidermis AND _some_ of the Papillary dermis**
72
DEEP PARTIAL Thick Burn
## Footnote
**Involves....**
damages **tissue that extends INTO _Reticular layers_** AND MAY INCLUDE **Fat domes of _Subcutaneous layer_**
\*\***NOTE how it says MAY include subcutaneous\*\***
73
FULL Thick. Burn
## Footnote
**Involves.....**
**ENTIRE thickness of skin _down to AND including_** **Subcutaneous tissue**
**\*NOTE how it says _and includes_** **Subcutaneous tissue\*\***
74
\_\_\_\_\_\_\_\_type of wound can get **infected**, BUT ______________ **MOST susceptible to infections**
**ANY** type of wound can get **infected, BUT Diabetic wounds** are **MOST susceptible to infections!!!**
## Footnote
**bc sugar irritation\*\***
75
wounds+infection
ANY wound can become infected!!!
Diabetic wounds **_most susceptible_** to infections!!!
76
**_Local_** evidence of **infection:**
* **ODOR\*\*\* (ALWAYS)**
* Streaking
* Redness
* Erythema
* **Induration (firm)**
* Cellulitis== skin infection
* INCd **pain**
* INCd **drainage/purulence**
* ****REALLY **opaque**
* **white, yellow, gree, THICC drainage**
77
LOCAL infection **pot. difficult to tell in pts w/ \_\_\_\_\_\_\_\_\_**
Darker skin pigmentation
BUT **odor always there\*\***
78
How can we **confirm** a **local infection?**
Wound culture/biopsy for **organisms**
EX. **Bronchoscopy --\>** suction out stuff from **base of lungs & observe**
79
If the **infection moves....HOW is it usually moving?**
Wounds are a **direct route** to the **bloodstream**
80
IF infection moves to **Bone ====**
Osteomyelitis
81
IF infection moves to **Blood ===**
Bacteremia
82
IF infection moves to **Heart ===**
Endocarditis
\***infection of Inner valves**
83
**Systemic** infection ===
**SEPSIS**
**\*infection ALL OVER BODY\*\***
84
**Systemic evidence of infection**
**\*confirms SEPSIS -----\>**
* ELEVATED **WBC**
* ELEVATED **HR**
* **== Tachycardia**
* ELEVATED **body temp**
* **== Fibrile**
* \>22 breaths per min.
* == **Tachypnea**
* **SBP \<100**
* Altered **Mental Status (AMS)**
85
