Day 6

Lesson Objectives  List the characteristics of a wound needed to determine wound classification.  Define terminology associated with wound care.  Practice documentation associated with wound examination.  List the different types of ulcers.  Identify risk factors associated with pressure ulcers.  Identify the stage of a pressure ulcer based on wound characteristics.  Discuss characteristics of vascular ulcers.  Demonstrate understanding of diabetic foot ulcers.  Discuss characteristics of malignant wounds.

Wound Classification  Wound Age  Wound Depth  Wound Color

Wound Classification Wound Age AcuteChronic  New or relatively new wound  Occurs suddenly  Healing progresses in a timely, predictable manner  Typically heals by primary intention  Examples: surgical and traumatic wounds  May develop over time  Healing has slowed or stopped  Typically heals by secondary intention  Examples: pressure, vascular and diabetic ulcers

Wound Classification Wound Depth  Partial thickness wound Involves only epidermis or epidermis and part of the dermis Does not extend through the dermis  Full thickness wound Extends through the dermis into tissues beneath May expose adipose tissue, muscle or bone

Wound Classification Wound Color  Red-Yellow-Black Classification System Red wounds: indicate normal healing ○ Red because of granulation tissue Yellow wounds: fibrin left from healing process appears as yellow slough or dead tissue on wound base ○ Slough, or soft necrotic tissue, serves as a medium for bacteria growth Black wounds: indicates necrosis ○ Eschar ○ Cannot accurately assess a wound covered in eschar

Wound Color Management Technique Red Cover wound, maintain moist environment, and protect from trauma Yellow Clean wound and remove yellow layer Cover with moisture-retentive dressing Black Debridement as ordered Don’t debride wounds with inadequate blood supply Classifying multicolor wounds: classify according to the least healthy color

Wound Terminology  Abrasion: occurs from a scraping away of the surface layers of skin, often result of trauma  Contusion: skin is not broken; characterized by pain, swelling and discoloration (bruise)  Hematoma: swelling or mass of blood, usually caused by a break in a blood vessel  Laceration: wound or irregular tear of tissues often assoc. with trauma (cut)

Wound Terminology  Penetrating wound: wound that enters into the interior of an organ or cavity  Puncture: a wound made by a sharp pointed instrument or objet by penetrating through the skin into underlying tissues

Wound Terminology  Granulation: beefy red, bumpy, shiny tissue in the base of an ulcer  Epithelial tissue: pale or dark pink skin, first appears at wound borders  Slough: soft, yellow necrotic tissue  Eschar: thick, hard, leathery black tissue; indicates dry, necrotic tissue  Macerated tissue: indicates too much water, white at edges

Wound Terminology Drainage (Exudate) Descriptions  Serous: clear, light color with thin, watery consistency  Sanguineous: red with thin, watery consistency; indicates new vessel growth or disruption of blood vessels  Serosanguineous: light red or pink with thin, watery consistency; can be seen in healthy wound  Purulent: creamy yellow, green, white or tan; thick and opaque

Types of ulcers  Pressure ulcers  Vascular ulcers Arterial ulcers Venous ulcers Lymphatic ulcers  Neuropathic ulcers Diabetic ulcers  Malignant wounds

Pressure ulcers Causes  Occur when pressure compresses soft tissue over bony prominences  Friction and shear contribute to development of pressure ulcers

Pressure Ulcer Risk Factors  Advanced Age  Immobile  Incontinence  Infection  Low blood pressure  Malnutrition

Pressure Ulcers Prevention  Pressure relief Positioning, air mattress  Reduce friction and shear  Maximize nutritional status  Control chronic illness (such as diabetes)  Manage moisture associated with incontinence

Pressure Ulcers Assessment  Length X width Measure the greatest length (head to toe) and the greatest width (side to side). Always use a cm ruler  Exudate amount Estimate the draining present after removing dressing and before applying any ointment Classify as none, light, moderate or heavy Assessment cont.  Tissue type Type of tissue in wound bed Describe as necrotic, slough, granulation, epithelial, or closed

Pressure Ulcers Assessment cont. Staging: National Pressure Ulcer Advisory Panel (NPAUP)  Stage I: intact skin, but color differs from surrounding area; changes in skin temperature, tissue consistency and sensation  Stage II: partial thickness loss of epidermis and/or dermis; shallow, open; may also present as a blister or abrasion

Pressure Ulcers Staging cont.  Stage III: Full thickness tissue loss; subcutaneous fat may be visible; deep crater, with or without undermining or tunneling into adjacent tissue  Stage IV: full thickness tissue loss with exposed bone, tendon, or muscle; undermining and tunneling are common

Pressure Ulcers Treatment  Patient education  Pressure relief  Manage moisture  Nutritional assessment and support  Proper wound care

Vascular Ulcers Type of Ulcer Typical LocationClinical Findings VenousAnywhere ankle to midcalf Most common on medial aspect of ankle above malleolus irregular shape shallow; lots of exudate mild to moderate pain normal pedal pulses edema Normal skin temperature Arterial lower 1/3 of leg distal toes dorsal foot over bony prominences smooth edges, well defined deep severe pain diminished or absent pulses dependent rubor skin is thin and shiny; hair loss; yellow nails Lymphatic arms and legs most common at ankle shallow ulcer bed oozing, moist or blistered skin around wound is firm, fibrotic Edema; cellulitis

Vascular Ulcers Venous Ulcers – Causes and S&S  Wounds result from venous insufficiency Incompentent valves Inadequate calf muscle function  Pitting edema is common  Pt c/o itching, fatigue, aching, and heaviness in involved limbs

Vascular Ulcers Venous Ulcers – Continued  Eczema is commons in patients with recurrent ulcers  Skin changes including hemosiderosis (inc localized iron stores) and lipodermatosclerosis (extemely smooth skin that turns brown and becomes tight and painful from inflammation of fatty tissue)

Vascular Ulcers Venous Ulcers – Assessment  Must determine if patient also has arterial insufficiency  Measure and monitor edema  Classify as partial thickness or full thickness wound

Vascular Ulcers Arterial Ulcers – Causes  Result from tissue ischemia caused by insufficient blood flow to an area  Causes Arterial stenosis Obstruction (from thrombosis, emboli, atherosclerosis, vasculitis or Raynaud’s phenomenon

Vascular Ulcers Arterial Ulcers – S&S  Dependent rubor  Pain in legs and feet  Pale, shiny skin  Faint or absent pulses  Ulcers on dorsum of foot, distal toes, lateral malleolus

Vascular Ulcers Arterial Ulcers – Assessment  Ankle Brachial Index (ABI) A test to examine the vascular system. A normal resting ankle-brachial index is 1.0 to 1.4. This means that your blood pressure at your ankle is the same or greater than the pressure at your arm, and suggests that you do not have significant narrowing or blockage of blood flow. Abnormal is.9 or less

Vascular Ulcers Arterial Ulcers – Assessment Medical diagnostic tests are often necessary to determine if there is adequate blood flow to the LE to support healing

Vascular Ulcers Lymphatic Ulcers – Causes and S&S  Result from injury to a body part afflicted with lymphedema Pressure on capillaries Skin folds from massive swelling Traumatic injury or pressure  Ulcers are typically shallow with large amounts of moisture  No pitting edema  Lots of swelling  Thickened skin

Vascular Ulcers Lymphatic Ulcers – Assessment  Patient history of damage or injury to lymphatic system  Inspection  Palpation  Girth measurements  No special tests are usually needed

Vascular Ulcers Treatment Type of Ulcer Treatment GoalsTherapies & procedures Wound care Venous edema control manage underlying venous disease provide appropriate wound care elevate limb compression bandages compression stockings unna’s boot occlusive dressings apply growth factors as ordered Arterial reestablish blood flow provide appropriate wound care arterial bypass angioplasty keep wound dry and protected from pressure never soak arterial ulcers Lymphatic reduce edema prevent infection provide appropriate wound care limb elevation compression therapy comprehensive decongestive therapy follow guidelines for venous ulcer care choose dressings that can manage large amounts of exudate while protecting surrounding skin

Neuropathic Ulcers Causes  diabetes is most common cause S & S  Located on weightbearing surfaces of the foot  Could have sensory, motor and/or autonomic neuropathy  Calluses  Induration is common  Erythema  Skin fissures  Dry, scaly skin  Pedal pulses diminished or absent  Usually good granulation with little to no drainage

Neuropathic Ulcers Prevention  Control diabetes Patient education in regards to maintaining careful glycemic control  Foot hygiene Inspect feet daily for injury or pressure areas Wash feed with mild soap, dry between toes Don’t go barefoot Take extreme caution with cutting toenails, best to see a podiatrist

Neuropathic Ulcers Prevention cont.  Choosing socks Wear natural fiber socks Choose socks that take perspiration away from skin Use diabetic socks for shear and friction control  Choosing shoes Wear shoes that fit well Break in new shoes Inspect shoes prior to putting on

Neuropathic Ulcers Assessment  Semmes-Weinstein test Uses monofilaments to check protective sensation in feet  Wagner Ulcer Grade classification Used to evaluate diabetic ulcers Low scores represent less complex ulcers

Wagner Ulcer Grade Classification GradeCharacteristics 0 pre-ulcerous lesion healed ulcer presence of bony deformity 1 superficial ulcer without subcutaneous tissue involvement 2 deep ulcer with penetration through subcutaneous tissue; may involve bone, tendon, or muscle 3 deep ulcer, abscess or osteomyelitis 4 gangrene of a digit 5 gangrene of foot requiring amputation

Neuropathic Ulcers Treatment  Relieve pressure on area of wound  Surgical referral for bony deformities  Callus debridement  Appropriate wound care  Use of growth factors as ordered

Malignant Wounds Causes  Develop from primary or metastatic tumor that infiltrates the epidermis  Commonly occur in patients with breast cancer  Also in patients with untreated skin cancer

Malignant Wounds Characteristics  Grow rapidly  Often invade surrounding tissues/organs  Sinus tracts and fistulas are common  Cauliflower like appearance  Fragile blood vessels  Large amounts of necrotic tissue

Malignant Wounds Complications  Odor  Bleeding  Exudate  Pruritus (itching)  Pain

Malignant Wounds Treatment  Control exudate and bleeding  Use dressings to minimize odor  Pain management

Summary Review Objectives List the characteristics of a wound needed to determine wound classification. Define terminology associated with wound care. Practice documentation associated with wound examination. List the different types of ulcers. Identify risk factors associated with pressure ulcers. Identify the stage of a pressure ulcer based on wound characteristics. Discuss characteristics of vascular ulcers. Demonstrate understanding of diabetic foot ulcers. Discuss characteristics of malignant wounds.

Documentation Activity