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NPTE Integumentary System > Wound Types and Assessment > Flashcards

Wound Types and Assessment Flashcards

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1
Q

List 4 types of ulcers.

A

Arterial insufficiency ulcers
Venous insufficiency ulcers
Neuropathic ulcers
Pressure ulcers

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2
Q

What is the cause of arterial insufficiency ulcers?

A

Inadequate circulation of oxygenated blood (ischemia)

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3
Q

What condition can cause arterial insufficiency ulcers?

A

Atherosclerosis

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4
Q

What are 4 general recommendations a patient with any type of ulcer should follow?

A
  1. Rest
  2. Risk reduction education
  3. Limb protection
  4. Daily inspection of skin (typically legs and feet)
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5
Q

What are 3 general recommendations for arterial insufficiency ulcers?

A
  1. Avoid unnecessary leg elevation
  2. Avoid soaking feet in hot water or using heating pads
  3. Wear appropriately sized shoes with seamless socks
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6
Q

What is the cause of venous insufficiency ulcers?

A

Impaired functioning of the venous system which leads to inadequate circulation and tissue damage

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7
Q

What symptoms may a patient with an arterial insufficiency ulcer present with? (4)

A
  1. Pain in the legs/feet (similar to intermittent claudication)
  2. Skin is cool to palpation
  3. Decreased pulse
  4. Pallor on leg elevation and rubor when dependent
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8
Q

What condition do most patients with arterial insufficiency also have?

A

Diabetes

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9
Q

What type of ulcers are the most common?

A

Venous insufficiency ulcers

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10
Q

What symptoms may a patient with a venous insufficiency ulcer present with? (4)

A
  1. Swelling of LEs
  2. Complaints of itching, fatigue, aching or heaviness in LE
  3. Tissue is wet from large amount of draining exudate
  4. Possible hemosiderin staining and lipodermatosclerosis
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11
Q

What are 4 general recommendations for venous insufficiency ulcers?

A
  1. Compression to control edema
  2. Elevation of legs above the heart when resting or sleeping
  3. Attempt active exercise including frequent ROM
  4. Wear appropriately fitting shoes with seamless socks
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12
Q

What type of ulcers are associated with hemosiderin straining and lipodermatosclerosis?

A

Venous insufficiency ulcers

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13
Q

What condition may occur as a result of chronic venous insufficiency?

A

Lymphedema

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14
Q

What is the most common form of primary lymphedema?

A

Milroy’s disease

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15
Q

What is the most common disease process seen with neuropathy?

A

Diabetes

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16
Q

What are neuropathic ulcers?

A

Ulcers caused by a combination of neuropathy (altered sensation) and ischemia

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17
Q

What symptoms may a patient with a neuropathic ulcer present with? (5)

A
  1. Ulcers on the weight bearing surface of the foot
  2. Diminished sensation
  3. Decreased or absent sweat/oil production
  4. Dry, inelastic skin
  5. Impaired healing time
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18
Q

What are 2 general recommendations for neuropathic ulcers?

A
  1. Inspect footwear for debris prior to donning

2. Wear appropriately sized OFF LOADING footwear with clean, cushioned, seamless socks

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19
Q

What is the most common causative factor of neuropathic ulcers?

A

Mechanical, repetitive stress

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20
Q

What is imperative to assess in patients with neuropathy? What tool can be used to test this?

A

Sensation (especially protective)

Monofilament testing

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21
Q

What finding on a monofilament test indicates loss of protective sensation?

A

Failure to perceive the application of a 10 gm monofilament

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22
Q

What finding on a monofilament test indicates that an area is insensate?

A

Failure to perceive the application of a 75 gm monofilament

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23
Q

What is another name for pressure ulcers?

A

Decubitus ulcers

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24
Q

What is the cause of pressure ulcers?

A

Unrelieved pressure on the dermis results in ischemia = damage

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25
What areas of the body are the most susceptible to pressure ulcers?
Bony prominences
26
What are 5 general recommendations for pressure ulcers?
1. Repositioning every 2 hours in bed 2. Management of excess moisture 3. Off-loading with pressure relieving devices 4. Inspect skin daily for signs of pressure damage 5. Limit shear, traction and friction forces over fragile skin
27
Name 2 pressure injury risk assessment tools,
Braden Scale | Norton Scale
28
What are the 4 classifications of wound based on depth of injury?
1. Superficial 2. Partial thickness 3. Full thickness 4. Subcutaneous
29
What is a superficial wound?
Cause trauma to the skin with the epidermis INTACT
30
What is an example of a superficial wound?
Non-blistering sunburn
31
What process will a superficial wound typically heal by?
Inflammatory process
32
What is a partial thickness wound?
A wound that extends through the epidermis, and possibly into, but not through the dermis.
33
What are 3 examples of partial thickness wounds?
Abrasions Blisters Skin tears
34
What is a full thickness wound?
A wound that extends through the epidermis and dermis and subcutaneous fat. Wounds deeper than 4mm.
35
What process will a full thickness wound typically heal by?
Healing by secondary intention
36
What is a subcutaneous wound?
Wounds that extend through the tissue and involve fat, muscle, tendon or bone
37
What process will a subcutaneous wound typically heal by?
Healing by secondary intention
38
What type of wound extends through the epidermis and possibly into, but not through, the dermis?
Partial thickness wound
39
What type of wound extends through the dermis and subcutaneous fat?
Full thickness wound
40
What type of wound does not extend through the epidermis?
Superficial wound
41
What type of wounds typically heal by secondary intention?
Full thickness wounds | Subcutaneous wounds
42
What tool is used to classify ulcers based on wound depth and the presence of infection?
Wagner Ulcer Grade Classification Scale
43
Describe the Wagner Ulcer Grade classification scale.
Grade 0 = No open lesion but may have pre-ulcerative lesions; healed ulcers; presence of bony deformity Grade 1 = Superficial ulcer not involving subcutaneous tissue Grade 2 = Deep ulcer penetrating the subcutaneous tissue; may involve bone, muscle, tendon, ligaments or joint capsule Grade 3 = Deep ulcer with osteomyelitis, osteitis or abscess Grade 4 = Gangrene on the digit Grade 5 = Gangrene on foot requiring disarticulation
44
Describe a stage I pressure ulcer.
Intact skin with non-blanchable redness of a localized area usually over a bony prominence
45
Describe a stage II pressure ulcer.
Partial thickness tissue loss of the dermis presenting as a shallow open ulcer with a red or pink wound bed.
46
Describe a stage III pressure ulcer.
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are NOT exposed.
47
Describe a stage IV pressure ulcer.
Full thickness tissue loss with exposed bone, tendon or muscle that is visible or directly palpable.
48
Describe a suspected deep tissue injury.
Purple or maroon localized areas of intact skin or blood filled blister due to damage of underlying soft tissue from pressure or shear forces.
49
Describe an unstageable pressure ulcer.
Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.
50
What are the 5 classifications of exudate?
``` Serous Sanguineous Serosanguineous Seropurlulent Purulent ```
51
Describe serous exudate.
Clear, light color and thin, watery consistency
52
Describe sanguineous exudate.
Red color and thin, watery consistency
53
Describe serosanguineous exudate.
Light red or pink color and a thin, watery consistency.
54
Describe seropurulent exudate.
Cloudy or opaque with a yellow or tan color and thin and watery consistency.
55
Describe purulent exudate.
Yellow or green color and a thick, viscous consistency.
56
What types of exudate are considered normal in a healthy healing wound?
Serous exudate | Serosanguineous exudate
57
What type of exudates are a sign of wound infection and are always an abnormal sign?
Seropurulent exudate | Purulent exudate
58
What type of exudates are typically observed during the inflammatory and proliferative phases of healing?
Serous | Serosanguineous
59
What is necrotic tissue?
Dead tissue
60
What are 4 types of necrotic tissue?
Eschar Gangrene Hyperkeratosis Slough
61
What is eschar?
Hard or leathery, black/brown dehydrated tissue that is firmly adhered to the wound bed
62
What is gangrene?
Death and decay of tissue caused by interruption of blood flow to an area
63
What is hyperkeratosis?
A callus | White/gray in color and can vary in texture depending on moisture level around the tissue
64
What is slough?
Moist, stringy, white/yellow tissue that tends to be loosely attached in clumps around the wound bed.
65
Describe the 3 colors of the Red-Yellow-Black System.
Red: Pink granulation tissue Yellow: Moist, yellow slough Black: Black, thick eschar firmly adhered
66
What are the main goals to prioritize for a red wound?
Protect wound | Maintain moist environment
67
What are the main goals to prioritize for a yellow wound?
Remove exudate and debris | Absorb drainage
68
What are the main goals to prioritize for a black wound?
Debride necrotic tissue

NPTE Integumentary System (5 decks)

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