Integumentary System Flashcards
1
Q
The integumentary system
A
- is the body’s largest organ consisting of stratified dermal and epidermal layers, hair follicles, nails, sebaceous glands, and sweat glands
2
Q
Superficial burn
A
- involves only the outer epidermis
- the involved area may be red with slight edema
- healing occurs without peeling or evidence of scarring in two to five days
3
Q
superficial partial-thickness burn
A
- involves the epidermis and the upper portion of the dermis
- the involved area may be extremely painful and exhibit blisters
- healing occurs with minimal to no scarring in 5-21 days
4
Q
deep partial thickness burn
A
- involves complete destruction of the epidermis and the majority of the dermis
- the involved area may appear to be discolored with broken blisters and edema
- damage to nerve endings may result in only moderate levels of pain
- hypertrophic or keloid scarring may occur
- in the absence of infection, healing will occur in 21-35 days
5
Q
full thickness burn
A
- involved complete destruction of the epidermis and dermis along with partial damage to the subcutaneous fat layer.
- the involved area typically presents with eschar formation and minimal pain
- Pt with full-thickness burns require grafts and are susceptible to infection
- healing time varies significantly with smaller areas healing in a matter of weeks, with or without grafting, and larger areas requiring grafting and potentially months to heal
6
Q
subdermal burn
A
- involves the complete destruction of teh epidermis, dermis, and subcutaneous tissue.
- may involve muscle and bone and as a result, often require multiple surgical interventions and extensive healing time
7
Q
Anticipated Deformities Based on burn location
- anterior neck
A
- anticipated deformity: flexion with possible lateral flexion
- splinting: soft collar,molded collar, philadephia collar
8
Q
Anticipated Deformities Based on burn location
- anterior chest and axilla
A
- anticipated deformity: shoulder ADD, Ext, and IR
- splinting: axillary or airplane splint, shoulder abduction brace
9
Q
Anticipated Deformities Based on burn location
- elbow
A
- anticipated deformity: Flexion and pronation
- splinting: gutter splint, conforming splint, 3-point splint, air splint
10
Q
Anticipated Deformities Based on burn location
- hand and wrist
A
- Anticipated deformity: ext or hyperextension of the MCP joints; flexion of the IP joints; ADD and flexion of the thumb; flexion of the wrist
splinting: wrist splint, thumb spica splint, palmar or dorsal extension splint
11
Q
Anticipated Deformities Based on burn location
- Hip
A
Anticipated deformities: flexion and ADD
-splint: anterior hip spica, ABD splint
12
Q
Anticipated Deformities Based on burn location
-knee
A
- anticipated deformity: flexion
splint: conforming splint, 3 point splint, air splint
13
Q
Anticipated Deformities Based on burn location
-ankle
A
- anticipated deformity: PF
splint: posterior foot drop splint, posterior ankle conforming splint, anterior ankle conforming splint
14
Q
selective debridement
A
- involves the removal of only noviable tissues from a wound
- selective debridement is most often performed by sharp debridement, enzymatic debridement or autolytic debridement
15
Q
sharp debridement
A
- requires the use of a scalpel, scissors and/or forceps to selectively remove devitalized tissue, foreign material or debris from a wound
- sharp debridement is most often used for wounds with large amts of thick, adherent, necrotic tissue; however, it may also be used in the presence of cellulitis or sepsis
- sharp debridement is the most expedient form of removing necrotic tissue
- PT are permitted to perform sharp, selective debridement as a procedural intervention
16
Q
enzymatic debridement
A
- refers to the topical application of an enzymatic preparation to necrotic tissue
- enzymatic debridement can be used on infected and non-infected wounds with necrotic tissue
- this type of debridement may be used for wounds that have not responded to autolytic debridement or in conjunction with other debridement techniques
- enzymatic debridement can be slow to establish a clean wound bed and should be discontinued once devitalized tissue is removed to avoid damage to adjacent healthy tissue
17
Q
autolytic debridement
A
- refers to the use of the body’s own mechanisms to remove nonviable tissue
- common methods of autolytic debridement include the use of transparent films, hydrocolloids, hydrogels and alginates
- establishes a moist wound environment that rehydrates necrotic tissue and eschar, facilitating enzymatic digestion of the nonviable tissue
- non-invasive and pain free
- can be used with any amt of necrotic tissue however, requires a longer healing period and should not be performed on infected wounds
18
Q
non-selective debridement
A
- involves the removal of both viable and nonviable tissues from a awound
- often termed mechanical debridement
- most commonly performed via wet-to -dry dressings, wound irrigation and hydrotherapy
19
Q
wet -to -dry dressings
A
- refers to the application of moistened gauze dressing over an area of necrotic tissue
- the dressing is allowed to dry completely and is later removed, along with any necrotic tissue that has adhered to the gauze
- wet-to dry dressings are most often used to debride wounds with moderate amounts of exudate and necrotic tissue
- this type of debridement should be used sparingly on wounds containing both necrotic and viable tissue since granulation tissue will be traumatized in the process
- removal of dry dressings from granulation may cause bleeding and be extremely painful
20
Q
Wound irrigation
A
- removes necrotic tissue from the wound bed using pressurized fluid
- pulsatile lavage is an example
- most desirable for wounds that are infected r have loose debris
- many devices permit variable pressure settings and provide suction for the removal of exudate and debris
21
Q
hydrotherapy
A
- most commonly employed using a whirlpool tank with agitation directed toward a wound requiring debridement
- this process softens and loosens adherent necrotic tissue
- PT must be aware of potential hydrotherapy side effects such as maceration of viable tissue, edema from dependent LE positioning and systemic effects such as hypotension
22
Q
Alginates
A
- derived from seaweed extraction, specifically, the calcium salt component of alginic acid
- highly absorptive but are also highly permeable and non-occlusive
- as a result, they require a secondary dressing
- alginate dressings act as a hemostat and create a hydrophilic gel through the interaction of calcium ions in the dressing and sodium ions in the wound exudate
23
Q
indications to use Alginates
A
- typically used on partial or full-thickness draining wounds such as pressure or venous insufficiency ulcers
- alginates are often used on infected wounds due to the likelihood of excessive drainage
24
Q
Foam dressings
A
- comprised of a hydrophilic polyurethane base that contacts the wound surface and a hydrophobic outer layer
- the dressings allow exudate to be absorbed into the foam through the hydrophilic layer
- the dressings are most commonly available in sheets or pads with varying degree of thickness
- semipermeable foam dressings are produced in adhesive and non-adhesive forms
- nonadhesive forms require secondary dressing
25
indication to use foam dressings
- used to provide protection and absorption over partial and full thickness wounds with varying levels of exudate
- they can also be used as secondary dressings over amorphous hydrogels
26
advantages of foam dressings
- provides moist environment for wound healing
- available in adhesive and nonadhesive forms
- provides prophylactic protection and cushioning
- encourages autolytic debridement
- provides moderate absorption
27
foam dressing disadvantage
- may tend to roll in areas of excessive friction
- adhesive form may traumatize periwound are upon removal
- lack of transparency makes inspection of wound difficult
28
Gauze indications
- most readily available dressing used in inpatient environment
- are commonly used on infected or non-infected wounds of any size
- teh dressings can be used for wet-to-wet, wet-to moist or wet-to-dry debridement
29
gauze advantages
- readily available and cost effective short-term dressings
- can be used alone or in combiniation with other dressings and topical agents
- can modify number of layers to accomodate for changing wound status
- can be used on infected or non-infected wounds
30
gauze disadvantages
- has a tendency to adhere to the wound bed traumatizing viable tissue on removal
- highly permeable
- Requires frequent dressing changes
- Prolonged use decreases cost effectiveness
- increased infection rate compared to occlusive dressings
31
hydrocolloids indications
- dressings consist of gel-forming polymers backed by a strong film or foam adhesive
- the dressing does not attach to the wound itself but instead anchors to the intact surrounding skin
- the dressings absorb exudate by swelling into a gel-like mass and vary in permeability, thickness and transperency
- useful for parttial and full-thickness wounds
- the dressings can be used effectively with granular or necrotic wounds
32
hydrocolloids advantages
- provides moist environment
- enables autolytic debridement
- offers protection from microbial contamination
- provides moderate absorption
- does not require a secondary dressing
- provides a waterproof surface
33
disadvantages of hydrocolloids
- may traumatize surrounding intact skin upon removal
- may tend to roll in areas of excessive friction
- cannot be used on infected wounds
34
hydrogels indications
- consists of varying amounts of water and gel-forming materials such as glycerin. the dressings are typically available in both sheet and amorphous forms
- moisture retentive and commonly used in superficial and partial-thickness wounds that have minimal drainage
35
Hydrogels advantages
- Provides a moist environment for wound healing
- enables autolytic debridement
- may reduce pressure and diminish pain
- can be used as a coupling agent for ultrasound
- Minimally adheres to wound
- SOme products have absorptive properties
36
hydrogels disadvantages
- Potential for dressings to dehydrate
- cannot be used on wounds with significant drainage
- typically requires a secondary dressing
37
Transparent film indications
- thin membranes made from transparent polyurethane with water-resistant adhesives
- permeable to vapor and oxygen, but are largely impermeable to bacteria and water
- highly elastic, and allow easy visual inspection of the wound since they are transparent
- useful for superficial or partial-thickness wounds with minimal drainage
38
advantages for transparent film
- provides a moist environment for wound healing
- enables autolytic debridement
- allows visualization of the wound
- resistant to shearing and frictional forces
- cost effective over time
39
disadvantages for transparent film
- excessive exudate accumulationcan result in periwound maceration
- adhesive may traumatize periwound area upon removal
- cannot be used on infected wounds
40
Exudate Classification
| - serous
- Presents with a clear, light color and a thin, watery consistency
- serous exudate is considered to be normal in a healthy healing wound and is observed during the inflammatory and proliferative phases of healing
41
Exudate Classification
| - Sanguineous
- Presents with a red color and a thin,watery consistency
- the red appearance of sanguineous exudate is due to the presence of blood which may become brown if allowed to dehydrate
- sanguineous exudate may be indicative of new blood vessel growth or the disruption of blood vessels
42
Exudate Classification
| - serosanguineous
- presents with a light red or pink color and a thin, watery consistency
- serosanguineous exudate is considered to be normal in a healthy healing wound and is typically observed during the inflammatory and proliferative phases of healing
43
Exudate Classification
| - seropurulent
- Presents as a cloudy or opaque, with a yellow or tan color and a thin, watery consistency
- seropurulent exudate may be an early warning sign of an impending infection and is always considered an abnormal finding
44
Exudate Classification
| - Purulent
- Presents with a yellow or green color and a thick, viscous consistency
- purulent exudate is generally and indicator of wound infection and is always considered an abnormal finding
45
Healing by Primary Intention
- most commonly occurs in acute wounds with a minimal tissue loss
-smooth clean edges are reapproximated and closed with sutures,staples or adhesives to facilitate re- epithelialization.
-superficial partial thickness wounds such as abrasions or blisters.
minimal scarring, and heal quickly in an uncomplicated and orderly progression
46
healing by secondary intention
- permits wounds to close on their own w/o superficial closure
- wounds with significant necrosis, irregular or nonviable wound margins that cannot be reapproximated infection or debris contamination typically heal by secondary intention
- associated with DM, or inflammatory disease
- a layer of granulation tissue will gradually fill the wound bed to the level of teh surrounding skin, with closure occuring by wound contraction and scar formation
- healing by this intention requires ongoing wound care and have larger scars. ex: neuropathic, arterial, venous or pressure ulcers, most full-thickness wounds and chronically inflamed wounds
47
healing by tertiary intention
- referred to as delayed primary intention healing
- wounds at risk for developing complications, such as sepsis or dehiscence, may be temporarily left open.
- once risk factors have been alleviated the wound is closed by the usual primary intention methods
48
Integumentary Terminology
| - Contusion
aninjury, usually caused by a blow, that does not disrupt skin integrity
-the injury is characterized by pain, edema, and discoloration which appears as a result of blood seepage under the surface of the skin
49
Integumentary Terminology
| - DEhiscence
- the separation, rupture or splitting of a wound closed by primary intention.
- this disruption of previously approximated surfaces may be superficial or involve all layers of tissue
50
Integumentary Terminology
| - Dermis
- the vascular layer of skin located below the epidermis containing hair follicles sebaceous glands , sweat glands, lymphatic and blood vessels, and nerve endings
51
Integumentary Terminology
| - desiccated
- the drying out or dehydration of a wound
| - desiccation often results from poor dressing selection that does not control the evaporation of wound bed moisture
52
Integumentary Terminology
| - desquamation
- the peeling or shedding of the outer layers of the epidermis
- normally occurs in small scales, although certain conditions, injuries and medications may cause peeling in larger scales or sheets and extend to deeper layers of the skin
53
Integumentary Terminology
| - Ecchymosis
- the discoloration occurring below intact skin resulting from trauma to underlying blood vessels and blood seeping into tissues.
- the discoloration is typically blue-black, changing in time to a greenish brown or yellow color
- an area where ecchymosis is present is commonly referred to as a bruise
54
Integumentary Terminology
| - epidermis
- the superficial, avascular epithelial layer of the skin that includes flat, scale-like squamous cells, round basal cells and melanocytes which produce melanin and give skin its color
55
Integumentary Terminology
| - erythema
- a diffuse redness of the skin often resulting from capillary dilation and congestion or inflammation
56
Integumentary Terminology
| - friable
- tissue that readily tears,fragments or bleeds when gently palpated or manipulated
57
Integumentary Terminology
| - Hematoma
- a localized swelling or mass of clotted blood confined to a tissue, organ or space usually caused by a break in a blood vessel
58
Integumentary Terminology
| - hypergranulation
-increased thickness of teh granular layer of the epidermis that exceeds the surface height of teh skin
59
Integumentary Terminology
| - hyperpigmentation
- an excess of pigment in a tissue that causes it to appear darker than surrounding tissues
60
Integumentary Terminology
| - hypertrophic scar
- an abnormal scar resulting from excessive collagen formation during healing.
- a hypertrophic scar is typically raised red, and firm with disorganized collagen fibers
61
Integumentary Terminology
| -keloid
- an abnormal scar formation that is out of proportion to the scarring required for normal tissue repair and is comprised of irregularly distributed collagen bands
- a keloid scar typically exceeds the boundaries of the original wound appearing red, thick, raised and firm
62
Integumentary Terminology
| -maceration
- the skin softening and degeneration that results from prolonged exposure to water or other fluids
63
Integumentary Terminology
| - normotrophic scar
- a scar characterized by the organized formation of collagen fibers that align in a parallel fashion
64
Integumentary Terminology
| - turgor
- the relative speed with which the skin resumes its normal appearance after being lightly pinched
- tugor is an indicator of skin elasticity and hydration and normally occurs more slowly in older adults
65
Integumentary Terminology
| - Ulcer
- an open sore or lesion of the skin accompanied by sloughing or inflamed necrotic tissue
66
Phases of Wound Healing
| - inflammatory phase (1-10 days)
- immune system's initial response to a wound
- temporary repair mechanisms rapidly re-establish hemostasis through platelet activation and the clotting cascade
- debris and necrotic tissue are removed and bacteria are killed by mast cells, neutrophils and leukocytes
- processes occurring in the inflammatory phase establish a clean wound bed which signals tissue restoration and permanent repair processes to begin
- re-epithelialization typically begins within 24 hrs at the wound borders, though visible signs are usuallynot till 3 days after injury
67
Phases of Wound Healing
| - Proliferative Phase 3-21 days
- the formation of new tissue signals the beginning of the proliferative phase.
- capillary buds and granulation tissue begin to fill the wound bed creating a support structure for the migration of epithelial cells
- Keratinocytes, endothelial cells and fibroblasts are active and the collagen matrix is formed
- skin integrity is restored in the proliferative phase with wound closure occuring through epithelialization and wound contraction
68
Phases of Wound Healing
| - Maturation Phase 4 days to 2 years
- initiated when gradulation tissue and epithelial differentiation begin to appear in the wound bed
- mechanisms of fiber reorganization and contraction shrink and thin the scar
- an immature scar will appear red, raised and rigid while a mature scar will appear pale,flat, and pliable.
- scar tissue is remodeled and strengthened through the processes of collagen lysis and synthesis
- newly repaired tissues have approximately 15% or pre-injury tensile integrity and should be protected to prevent re-injury
- overtime, tensile integrity may incr to as much as 80% of the pre-injury strength
- hypertrophic scarring: especially in relation to burn injuries, can significantly impact maturation phase progression
- a burn w/o hypertrophic scarring will typically mature within 4 to 8 weeks; burn with hypertrophic scarring, however, may require up to two years to reach maturity
69
Pressure Injury Stage 1:
- non-blanchable erythema of intact skin
- intact skin with a localized area of non-blanchable erythema
- presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes
- color changes do not include purple or marroon discoloration; these may indicate deep tissue pressure injury
70
Pressure Injury Stage 2
- Partial-thickness loss of skin with exposed dermis
- the wound bed is viable, pink or red, moist and may also present as an intact or ruptured serum-filled blister
- adipose is not visible and deeper tissues are not visible
- granulation tissue, slough and eschar are not present
- these injuries commonly result from adverse microclimate and shear over the pelvis and shear in the heel
- this stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis, medical adhesive related skin injury, or traumatic wounds
71
Pressure Injury Stage 3
- full thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole (rolled edges) are often present.
- slough and/or eschar may be visible
- the depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds
- undermining and tunneling may occur
- if slough or eschar obscures the extent of tissue loss, this is an unstageable Pressure injury
72
Pressure Injury Stage 4
- full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer.
- slough and/or eschar may be visible
- Epibole (rolled edges), undermining and/or tunneling often occur
- depth varies by anatomical location
- if slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury
73
Unstageable Pressure Injury
- full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar
- if slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed
- stable eschar on the heel or ischemic limb should not be softened or removed
74
Deep tissue Pressure Injury:
- intant or non-intact skin with localized area of persistent non-blanchable deep red, maroon or purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister
- pain and temperature change often percede skin color changes
- discoloration may appear differently in darkly pigmented skin
- this injury results from intense and/or prolonged pressure and shear forces at the bone- muscle interface
- the wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve w/o tissue loss.
- if necrotic tissue, subcutaneous tissue, granulation tissue, fascia muscle or other undelrying structures are visible this indicates a full-thickness pressure injury
- do not use deep tissue pressure injury to describe vascular, traumatic, neuropathic, or dematologic conditions
75
Red-yellow black system
--RED
- wound description: pink granulation tissue
| - goals: protect wound; mainatin moist environment
76
Red-yellow black system
- YELLOW
- wound description: moist, yellow slough
| - goals: remove exudate and debris; absorb drainage
77
Red-yellow black system
-BLACK
- wound description: black, thick eschar, firmly adhered
| - goals: debride necrotic tissue
78
Rule of Nines
- allows for a gross approximation of the percentage of the body affected by a burn
- the rule of nines does not account for severity
- head and neck- 9%
- anterior trunk 18%
- Posterior trunk 18%
- B Anterior UE- 9%
- B posterior UR- 9%
- genital region 1%
- B ant LE - 18%
- B post LE - 18%
79
child values ----Rules of Nines
- a child under one year has 9% taken from the LE and added to the head and neck region
- each year of life 1% is distributed back to the LE until the age of nine when the head is considered to be the same proportion as an adult.
80
Topical Agents Used in Burn Care
| - Silver Sulfadiazine
Adv: can be used with or without dressings; painless; can be applied to wound directly; broad-spectrum; effective against yeast
Disadvantages: does not penetrate into eschar
81
Topical Agents Used in Burn Care
| - Silver Nitrate
A: broad-spectrum ; non-allergenic; dressing application is painless
D: poor penetration;discolors, making assessment difficult; can cause severe electrolyte imbalances; removal of dressings is painful
82
Topical Agents Used in Burn Care
| - Povidone- iodine
A: broad-spectrum; antifungal; easily removed with water
D: not effective against pseudomonas; may impair thyroid function; painful applictaion
83
Topical Agents Used in Burn Care
| - Mafenide Acetate
- A: broad-spectrum; penetrates burn eschar; may be used with or without occlusive dressings
D: may cause metabolic acidosis; may compromise respiratory function; may inhibit epitheliallization; painful application
84
Topical Agents Used in Burn Care
| - Gentamicin
- A: broad-spectrum; may be cobered or left open to air
| D: has caused resistant strains; ototoxic; nephrotoxic
85
Topical Agents Used in Burn Care
| - nitrofurazone
- A: bacteriocidal;broad-spectrum
| D: may lead to overgrowth of fungus and psudomonas, painful application
86
Arterial Insufficiency Ulcers
- wounds resulting from arterial insufficiency occur secondary to inadequate circulation of oxygenated blood often due to complicating factors such as atherosclerosis
87
General recommendations for arterial insufficiency Ulcers
- Rest
- limb protection
- Risk reduction education
- Inspect legs and feet daily
- avoid unnecessary leg elevation
- avoid using heating pads or soaking feet in hot water
- water appropriately sized shoes with clean,seamless socks
88
Venous Insufficiency Ulcers
- Wounds resulting from venous insufficiency occur secondary to impaired functioning of the venous system resulting in inadequate circulation and eventual tissue damage and ulceration
89
General recommendations for Venous Insufficiency Ulcers
- Limb protection
- risk reduction education
- inspect legs and feet daily
- compression to control edema
- elevate legs above the heart when resting or sleeping
- attempt active exercise including frequent ROM
- Wear appropriately sized shoes with clean, seamless socks
90
Neuropathic Ulcers
- Neuropathic Ulcers are a secondary complication usually associated with a combination of ischemia and neuropathy
- Neuropathic ulcers are often associated with DM, however any form of peripheral neuropathy poses an increased risk of wound development
91
General recommendation of neuropathic Ulcers
- limb protection
- Risk reduction education
- Inspect legs and feet daily
- inspect footwear for debris prior to donning
- wear appropriately sized off-loading footwear with clean, cushioned, seamless socks
92
General recommendation for pressure ulcers
- re-positioning every two hours in bed
- management of excess moisture
- off-loading with pressure relieving devices
- inspect skin daily for signs of pressure damage
- limit sheer, traction, and friction forces over fragile skin
93
Wagner Ulcer classification System
- categorizes dysvascular ulcers based on wound depth and the presence of infection
- most commonly associated with the assessment of diabetic foot ulcers, the scale can be appropriately used to categorize most ulcers arising from neuropathic, ischemic or arterial etiology
94
Wagner Ulcer Classification Scale
- 0
- no open lesion, but may possess pre-ulcerative lesions;healed ulcers;presence of bony deformity
95
Wagner Ulcer Classification Scale
| - 1
- superficial ulcer not involving subcutaneous tissue
96
Wagner Ulcer Classification Scale
| - 2
- deep ulcer with penetration through the subcutaneous tissue; potentially exposing bone, tendon, ligament or joint capsule
97
Wagner Ulcer Classification Scale
| - 3
- deep ulcer with osteitis, abscess or osteomyelitis
98
Wagner Ulcer Classification Scale
| - 4
- gangrene of digit
99
Wagner Ulcer Classification Scale
| - 5
- gangrene of foot requiring dis articulation
100
Arterial Insufficiency Ulcers
- Location
- Appearance and description
- Pain
- Location: lower 1/3 of leg, toes, web spaces (distal toes, distal foot, lateral malleolus)
- Appearance: smooth edges, well defined; lack granulation tissue; tend to be deep
- Exudate: minimal
- Pain: severe
- pedal pulses: DIminished or absent
- Edema: normal
- Skin Temp: DEcreased
- Tissue Changes: thin and shiny; hair loss; yellow nails
- Miscellaneous: leg elevation increases pain
101
Venous Insufficiency Ulcers
- Location
- Appearance and description
- Pain
- Location: proximal to the medial malleolus
- Appearance: irregular shape; shallow
- Exudate: moderate/heavy
- Pain: mild to moderate
- pedal pulses normal
- Edema increased
- Skin Temp: normal
- Tissue Changes: flaking, dry skin; brownish discoloration
- Miscellaneous: leg elevation lessens pain
102
Neuropathic Ulcers
- Location
- Appearance and description
- Pain
- Location: Areas of the foot susceptible to pressure or shear forces during weight bearing
- Appearance: well-defined oval or circle; callused rim; cracked periwound tissue; little to no wound bed necrosis with good granulation
- Exudate: Low/moderate
- Pain: none, however dysesthesia may be reported
- pedal pulses: diminished or absent; unreliable ABI with diabetes
- Edema: Normal
- Skin Temp: decreased
- Tissue Changes: Dry, inelastic, shiny skin; decreased or absent sweat and oil production
- Miscellaneous:loss of protective sensation
