chandlerrice's version from 2016-12-17 17:22

Pressure Ulcer (decubitus) Stages

Question Answer
Stage INonblanchable erythema of intact skin. May include changes in skin temperature (warm or cool), tissue consistency (firm or boggy), and/or sensation (pain/itching)
Stage IIPartial thickness tissue loss. Involves epidermis, dermis, or both. Presents clinically as an abrasion, blister, or shallow crater
Stage IIIFull thickness skin loss. Involves damage to or necrosis of subcutaneous tissue. May extend down to, but not through underlying fascia. Presents clinically as a deep crater
Stage IVFull thickness skin loss. Involves extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Undermining and sinus tracts may be present

Arterial Ulcer

Question Answer
LocationLower 1/3 of leg, toes, dorsum of foot, lateral malleolus
AppearanceSmooth edges, well defined; lack of granulation tissue; tend to be deep
Pedal PulsesDiminished or absent
Skin TemperatureCool
Tissue ChangesThin and shiny, hair loss, yellow nails
Leg elevationIncreases pain

Venous Ulcer

Question Answer
LocationMedial malleolus
AppearanceIrregular shape, shallow, shaggy edges
ExudateModerate to heavy
PainMild to moderate
Pedal PulsesNormal
Skin TemperatureNormal
Tissue ChangesFlaking, dry skin, brownish discoloration
Leg ElevationDecreases pain

Neuropathic (diabetic) Ulcer

Question Answer
LocationAreas of the foot susceptible to pressure or shear forces during weight bearing
AppearanceWell-defined oval or circle; callused rim; cracked periwound tissue; little to no wound bed necrosis with good granulation
Pedal PulsesDiminished or absent; unreliable ankle-brachial index with diabetes
Skin TemperatureDecreased
Tissue ChangesDry, inelastic, shiny skin, decreased or absent sweat and oil production
SensationLoss of protective sensation


Question Answer
RedWound has pink granulation tissue. Wound must be protected with moist environment maintained
YellowWound has moist yellow slough. Remove exudate and debris; absorb drainage
BlackWound has black, thick eschar (dead skin) firmly adhered. Debride (surgically remove) nectrotic (dead) tissue


Question Answer
SerousClear, light color, with a thin, watery consistency. Considered normal
SanguineousRed color, with a thin watery consistency. The red is due to blood. May be indicative of new blood vessel growth or disruption of blood vessels.
SerosanguineousLight red or pink color. Normal in a healthy, healing wound.
SeropurulentCloudy or opaque, with a yellow or tan color, and a thin, watery consistency. May be an early warning sign of impending infection and is always considered abnormal
PurulentYellow or green color and a thick, viscous consistency. Generally an indicator of wound infection and is considered abnormal.

Rule of 9's

Question Answer
Head and neck9%
Anterior trunk18%
Posterior trunk18%
Bilateral anterior arm, forearm, and hand9%
Bilateral posterior arm, forearm, and hand9%
Genital region1%
Bilateral anterior leg and foot18%
Bilateral posterior leg and foot18%

Wound Dressings

Question Answer
Transparent FilmsClear adhesive semipermeable membrane dressing. Stage I and II pressure ulcers, autolytic debridement, visual evaluation of wound.
HydrocolloidsAdhesive wafers containing hydroactive/absorptive particles that interact with wound fluid to form a gelatinous mass over the wound bed. Partial thickness wounds, wounds with mild exudate. Maintains moist environment, nonadhesive to healing tissue, min-mod absorption
HydrogelsWater or glycerine based gels. Insoluble in water. Partial-full thickness wounds. Wounds with necrosis and slough. Soothing/cooling. Rehydrate dry wounds
FoamsSemipermeable membranes that are either hydrophilic or hydrophobic. Partial-full thickness wounds with min-mod exudate. Secondary dressing for wounds with packing to provide additional absorption. Insulate wounds, provide padding, most are nonadherent
AlginatesSoft, absorbent, non woven dressings derived from seaweed that have a fluffy cotton like appearance. Wounds with moderate to large exudate, wounds with combination of exudate and necrosis, absorb up to 20x their weight in drainage, fill dead space
Gauze DressingsMade of cotton or synthetic fabric that is absorptive and permeable to water and oxygen. May be used wet, moist, or dry. Exudative wounds, wounds with combination of exudate and necrosis. Readily available, can be used with other solutions on it, used on infected wounds, cost effective

Section 9

Section 10

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