Wounds and pressure ulcers Flashcards
abrasions
trauma to the skin resulting in a breakage (often caused by a fall, sliding impact)
punctures
small holes in the skin, allowing air passage into the wound
bites
insect, animal, human
surgical wounds
incisions, resections, grafts, ampulations
pressure injuries
prolonger exposure to pressures
traumatic wounds
burns, thermal, gunshot, devolving, compression, crash
venous stasis ulcers
poor lower extremity circulation, varicose veins
arterial ulcers
from damage to arteries due to lack of blood flow to tissue
diabetic ulcer
high prevalence
from diabetes
commonly on bottom of foot
factors that predispose formation of decubitus ulcers
bed sores!
- immobility, weight loss or gain, edema, incontinence, dec sensation, dec circulation, dehydration, age related skin changes
etiology and risks
pressure, dec circulation leading to necrosis
on bony prominences
intensity and duration determine severity
stage 1 pressure ulcer
- skin intact, non blanch able redness
- may be a different temp or itchy
stage 2 pressure ulcer
- involves the dermis with partial thickness loss
- a shallow open ulcer than can be shiny to dry
- wound bed is pink/red without slough or bruising
- can also be a blister that ruptures
stage 3 pressure ulcer
- full thickness tissue loss
- depth is not insured if slough (necrosis) is present
- bone/tendon/muscle are not exposed
stage 4 pressure ulcer
- full thickness tissue loss with bone, tendon, or muscle visible or directly palpable
- osteomyelitis is possible
