Other Systems_Integ_Ulcers

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  1. Indolent ulcer - define - 2
    • Ulcer that is slow to heal
    • Is not painful
  2. Ulcers - location - arterial, venous, diabetic
    • Arterial - lateral malleolus & toes
    • Venous - Medial malleolus
    • Diabetic - WB areas
  3. Ulcers - appearance - arterial, venous, diabetic
    • Arterial - Smooth, well defined edges; DEEP
    • Venous - Irregular; SHALLOW
    • Diabetic - Well defined oval/circle; callused rim
  4. Ulcers - exudate - arterial, venous, diabetic
    • Arterial - min
    • Venous - large amount
    • Diabetic - low/mod
  5. Ulcers - pain - arterial, venous, diabetic
    • Arterial - severe, intermittent; INC w/limb elevation
    • Venous - none to ache in dependent position; DEC w/limb elevation
    • Diabetic - none
  6. Ulcers - pulses - arterial, venous, diabetic
    • Arterial - Diminished or Absent
    • Venous - normal
    • Diabetic - Diminished or Absent
  7. Ulcers - edema - arterial, venous, diabetic
    • Arterial - absent
    • Venous - present
    • Diabetic - absent
  8. Ulcers - skin T - arterial, venous, diabetic
    • Arterial - cool
    • Venous - normal
    • Diabetic - cool
  9. Ulcers - tissue changes - arterial, venous, diabetic
    • Arterial - thin & shiny; Loss of hair; Yellow thickened nails
    • Venous - Skin pigmentation (hemosiderinosis); flaking dry fibrosed skin
    • Diabetic - Cracked, dry skin; DEC perspiration
  10. Ulcers - granulation - arterial, venous, diabetic
    • Arterial - lack of granulation tissue
    • Venous - ?
    • Diabetic - good granulation
  11. Ulcers - gangrene - arterial, venous, diabetic
    • Arterial - may be present
    • Venous - Absent
    • Diabetic - Sepsis common; present in later stages
  12. Arterial ulcer - Characteristics - 5
    • Deep @ lateral malleolus & toes; shin
    • Pain - Very painful, intermittent claudication, INC w/elevation
    • Pulses poor or absent
    • Thin, shiny skin w/yellow nails
    • Min exudate
  13. Arterial Ulcer - Color w/changes in position - 2
    • Pale on elevation
    • Dusky rubor on dependency
  14. Arterial insufficiency - w/what is compression contraindicated? - 2
    • ABI & 0.7
    • Active DVT
  15. Arterial insufficiency - At what ABI will wound not heal w/o medical intervention (e.g., surgery or medications)
    0.5 or below
  16. Arterial insufficiency ulcer - Tx - 5
    • Head of bed elevated moderately
    • Compression
    • Wound VAC may be useful
    • ROM
    • Stoppage of smoking
  17. Venous Ulcer - Characteristics - 6
    • Superficial @ medial malleolus
    • Pain mild to mod
    • Good peripheral pulses
    • Edema
    • Skin pigmentation (hemosiderinosis)
    • Heavy exudate
  18. Venous Ulcer - color in dependent position
    Normal or cyanotic
  19. Venous insufficiency ulcers - Tx - 5
    • Elevation & compression to control edema
    • Unna boot
    • Custom-fitted elastic stockings
    • Intermittent compression therapy
    • Active exercise
  20. Diabetic ulcer - Characteristics - 5
    • Look - well defined circle/oval w/callused rim; dry cracked skin; DEC perspiration
    • Ankle jerks absent w/neuropathy
    • Exudate - low/Mod
    • Painless
    • DEC sensation & circulation
  21. Diabetic/Neuropathic Ulcer - What is present in later stages? - 2
    • Charcot foot
    • Gangrene can develop
  22. Diabetic/Neuropathic Ulcer - Tx - 2
    • Total contact cast
    • Shoe modification - Rocker bottom sole
  23. Total contact cast - for what ulcer? When is it contraindicated?
    • Diabetic ulcer
    • Infection
    • Ulcer D > W
  24. Diabetic/neuropathic Ulcers - Classification scale - 1; stages 0, 5 - describe wound
    • Wagner Scale
    • 0 - Wound not open
    • 5 - gangrene
  25. Prevention of P ulcers - relief of P sensitive areas - recumbent vs sitting position
    • Recumbent - 3-4x/hr
    • Sitting - 15-20 min
  26. Risk assessment scales for P ulcers - 2
    • Braden
    • Norton
  27. Deep Tissue Injury is what? - 2
    • Last stage in P ulcer scale
    • Discolored area of tissue (e.g., bruise) that is NOT reversible & will likely progress to a full-thickness
  28. P ulcers - Stages - name & damage into what structure?
    • I - Non-blanchable erythema - Reversible, skin INTACT
    • II - Partial thickness - superficial, extends into epidermis & dermis
    • III - Full-thickness - Into fat but NOT into fascia
    • IV - Full-thickness - Into mm, bone, tendon
    • V - Unstageable d/t necrotic tissue
  29. P ulcer - Stage I - name; damage into what structure?
    • Non-blanchable erythema
    • INTACT skin
    • Reversible w/intervention
  30. P ulcer - Stage II - name; damage into what structure? (2); presents clinically how?
    • Partial thickness skin loss - superficial ulcer
    • Damage into Epidermis & Dermis
    • Abrasion, blister, or shallow crater

    • P ulcer - Stage III - name; damage into what structure? (1); presents clinically how?
    • Full-thickness skin loss
    • Damage into fat but NOT into fascia
    • Deep crater
  31. Stage III P Ulcers - Tx - 3
    • Debridement
    • Dressings
    • P alleviating
  32. P ulcer - Stage IV - name; damage into what structure? (3)
    • Full-thickness skin loss
    • Damage into - mm; bone; supporting structures (e.g., tendon, capsule)
  33. Stage IV P Ulcers - Tx - 4
    • Debridement
    • Dressings
    • Grafting
    • Surgery
  34. Unstageable P ulcer - means what? Tx (2)
    • Wound is obscured by necrotic tissue
    • Tx - Antibacterial agents + Modality
  35. Color of P Ulcer - 2
    Red, brown/black, or yellow
  36. Pain w/P Ulcer - 1
    Can be painful if sensation intact
  37. P Ulcer - what happens w/presence of necrotic tissue?
    Inflammatory response: hyperemia, fever, INC WBC count
  38. P ulcer - Dressing
    Occlusive dressing - transparent film

Card Set Information

Author:
Tanuisha
ID:
326896
Filename:
Other Systems_Integ_Ulcers
Updated:
2016-12-14 22:32:21
Tags:
Other Systems Integ Ulcers
Folders:
Other Systems
Description:
Other Systems_Integ_Ulcers
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