Integ: Wound Types

Question 1

With Acute wounds, what are Abrasions?

Answer 1

This is causes by a combination of friction and shear forces, typically over a rough surface, resulting in the scraping away of the skin’s superficial layer

Question 2

With Acute wounds, what are Avulsion?

Answer 2

A soft tissue avulsion, sometimes referred to as degloving, is a serious wound resulting from tension that causes skin to become detached from underlying surface

Question 3

With Acute wounds, what is an Incisional Wound?

Answer 3

This is most often associated with surgery and is created intentionally by means of a sharp object such as a scalpel or scissors

Question 4

With Acute wounds, what are Lacerations?

Answer 4

This is a wound or irregular tear of tissues often associated with trauma
- Lacerations result from shear, tension or high force compression with the resultant wound characteristics dependent on the MOI

Question 5

With Acute wounds, what are Penetrating wounds?

Answer 5

This can result from various MOI’s and is described as a wound that enters the interior of an organ or cavity

Question 6

With Acute wounds, what are Puncture wounds?

Answer 6

This is made by a sharp pointed object as it penetrates the skin and underlying tissues .
- Typically, there is relatively little tissue damage beyond the wound tract, however, the risk of contamination and infection can be significant

Question 7

With Acute wounds, what are Skins Tears?

Answer 7

This often results from trauma to fragile skin such as bumping into an object, adhesive removal, shear or friction forces
- The severity of a skin tear can range from a flap-like tear, that may or may not remain viable, to full-thickness tissue loss

Question 8

What are Arterial Insufficiency Ulcers?

Answer 8

Wounds resulting from arterial insufficiency occur secondary to inadequate circulation of oxygenated blood (e.g., ischemia) often due to complicating factors such as atherosclerosis

Question 9

What are the General Recommendations for Arterial Insufficiency Ulcers?

Answer 9

• 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
• Wear appropriately sized shoes with clean, seamless socks

Question 10

What are Venous Insufficiency Ulcers?

Answer 10

This occurs secondary to impaired functioning to the venous system resulting in inadequate circulation and eventual tissue damage and ulceration

Question 11

What are the General Recommendations for Venous Insufficiency Ulcers?

Answer 11

• Limb protection
• Risk reduction education
• Inspect legs and feet daily
• Elevate legs above heart when resting or sleeping
• Attempt active exercise including frequent ROM
• Wear appropriately sized shoes with clean, seamless socks

Question 12

What are Neuropathic Ulcers?

Answer 12

These are secondary complications usually associated with a combination of ischemia and neuropathy
- Neuropathic ulcers are often associated with diabetes, however, any form of peripheral neuropathy poses an increased risk of wound development

Question 13

What are the General Recommendations for Neuropathic Ulcers?

Answer 13

• 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

Question 14

What are Pressure Ulcers?

Answer 14

Also referred to as decubitus ulcers

• This results from sustained or prolonged pressure on tissue at levels greater than that of capillary pressure. Skin covering bony prominenes is particularly susceptible to localized ischemia and tissue necorsis due to pressure
• Pressure injuries to deeper tissue may initially present as bruising or purple blisters under intact skin before opening to reveal full-thickness damage.
• Factors contributing to pressure ulcers include shearing forces, moisture, heat, friction, meds, muscle atrophy, malnutrition, and debilitating medical conditions
• Valid and reliable pressure injury risk assessment tools are readily available (e.g., Braden Scale, Norton Scale) and typically include intervention recommendations based on the level of risk assessed

Question 15

What are the General Recommendations for Pressure Ulcers?

Answer 15

• Reposition every 2 hrs in bed
• Management of excess moisture
• Off-loading with pressure relieving devices
• Inspect skin daily for signs of pressure damage
• Limit shear, traction, and friction forces over fragile skin

Question 16

What is the typical Location of Arterial Insufficiency Ulcers?

Answer 16

• Lower 1/3 of leg
• Web spaces (distal toes, dorsal foot, lateal malleolus)

Question 17

What is the typical Appearance of Arterial Insufficiency Ulcers?

Answer 17

• Smooth edges, well defined
• Lack granulation tissue
• Tend to be deep

Question 18

What is the typical amount of Exudate of Arterial Insufficiency Ulcers?

Answer 18

Minimal exudate

Question 19

Typically how much pain do pts have with Arterial Insufficiency Ulcers?

Answer 19

Severe pain

Question 20

What is the typical description of pedial pulse strength of Arterial Insufficiency Ulcers?

Answer 20

Diminished or absent pulse

Question 21

Typically how much Edema is seen with Arterial Insufficiency Ulcers?

Answer 21

normal amount (not usually abnormal)

Question 22

What is the typical Skin Temperature of Arterial Insufficiency Ulcers?

Answer 22

Decreased temp

Question 23

What are typical Tissue changes seen with Arterial Insufficiency Ulcers?

Answer 23

• Thin and shiny
• Hair loss
• Yellow nails

Question 24

With Arterial Insufficiency Ulcers, would there be an increase or decrease of pain with leg elevation?

Answer 24

Increase of pain

Question 25

What is the typical Location of Venous Insufficiency Ulcers?

Answer 25

Proximal to the medial malleolus

Question 26

What is the typical Appearance of Venous Insufficiency Ulcers?

Answer 26

- Irregular shape - Shallow

Question 27

What is the typical amount of Exudate of Venous Insufficiency Ulcers?

Answer 27

Moderate/Heavy Exudate

Question 28

Typically how much pain do pts have with Venous Insufficiency Ulcers?

Answer 28

Mild to moderate pain

Question 29

What is the typical description of pedial pulse strength of Venous Insufficiency Ulcers?

Answer 29

Normal pulse

Question 30

Typically how much Edema is seen with Venous Insufficiency Ulcers?

Answer 30

Increased amount of edema

Question 31

What is the typical Skin Temperature of Venous Insufficiency Ulcers?

Answer 31

Normal skin temp

Question 32

What are typical Tissue changes seen with Venous Insufficiency Ulcers?

Answer 32

- Flaking, dry skin - Brownish discolortion

Question 33

With Venous Insufficiency Ulcers, would there be an increase or decrease of pain with leg elevation?

Answer 33

Pain decreases with elevation

Question 34

What is the typical Location of Neuropathic Ulcers?

Answer 34

Areas of the foot susceptible to pressure or shear forces during weight bearing

Question 35

What is the typical Appearance of Neuropathic Ulcers?

Answer 35

- Well defined oval or circle - Callused rim - Cracked periwound tissue - Little to no wound bed necrosis with good granulation

Question 36

What is the typical amount of Exudate of Neuropathic Ulcers?

Answer 36

Low/Moderate exudate

Question 37

Typically how much pain do pts have with Neuropathic Ulcers?

Answer 37

None, however dysethesia may be reported

Question 38

What is the typical description of pedial pulse strength of Neuropathic Ulcers?

Answer 38

Diminished or absent - Unreliable ABI with diabetes

Question 39

Typically how much Edema is seen with Neuropathic Ulcers?

Answer 39

Normal edema

Question 40

What is the typical Skin Temperature of Neuropathic Ulcers?

Answer 40

Decreased skin temp

Question 41

What are typical Tissue changes seen with Neuropathic Ulcers?

Answer 41

- Dry, inelastic, Shiny skin - Decreased or absent sweat and oil protection

Question 42

With Neuropathic Ulcers, is there an elevated or loss of protective sensation?

Answer 42

Loss of protective sensation

Question 43

How can Protective Sensation be assessed?

Answer 43

Monofilament testing is a reliable method - This contains a variety of filament thickness which are applied perpendicular to the skin and held in place for one second with enough force to bend the filament to a "C" shape - **Failure to perceive the application of a 10 gm monofilament indicates a loss of protective sensation** (e.g., inability to feel a small pebble in shoe or a developing blister) and places a pt at increased risk for developing a neuropathic ulcer - **Failure to perceive a 75 gm monofilament indicates that an area is insenate**