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Flashcards in Wound Types and Assessment Deck (68)
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1

List 4 types of ulcers.

Arterial insufficiency ulcers
Venous insufficiency ulcers
Neuropathic ulcers
Pressure ulcers

2

What is the cause of arterial insufficiency ulcers?

Inadequate circulation of oxygenated blood (ischemia)

3

What condition can cause arterial insufficiency ulcers?

Atherosclerosis

4

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

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

5

What are 3 general recommendations for arterial insufficiency ulcers?

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

6

What is the cause of venous insufficiency ulcers?

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

7

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

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

8

What condition do most patients with arterial insufficiency also have?

Diabetes

9

What type of ulcers are the most common?

Venous insufficiency ulcers

10

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

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

11

What are 4 general recommendations for venous insufficiency ulcers?

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

12

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

Venous insufficiency ulcers

13

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

Lymphedema

14

What is the most common form of primary lymphedema?

Milroy's disease

15

What is the most common disease process seen with neuropathy?

Diabetes

16

What are neuropathic ulcers?

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

17

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

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

18

What are 2 general recommendations for neuropathic ulcers?

1. Inspect footwear for debris prior to donning
2. Wear appropriately sized OFF LOADING footwear with clean, cushioned, seamless socks

19

What is the most common causative factor of neuropathic ulcers?

Mechanical, repetitive stress

20

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

Sensation (especially protective)
Monofilament testing

21

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

Failure to perceive the application of a 10 gm monofilament

22

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

Failure to perceive the application of a 75 gm monofilament

23

What is another name for pressure ulcers?

Decubitus ulcers

24

What is the cause of pressure ulcers?

Unrelieved pressure on the dermis results in ischemia = damage

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