Wound Care - Ch 11 And 12

Front 1

Describe the pressure ulcer staging system

Back 1

Stage I: nonblanchable erythema
Stag II: Superficial ulcer wih shallow crater/blister = partial thickness including epidermis and dermis
Stage III: Deep ulcer, possible undermining. Full thickness into SubQ
Stage IV: Deep ulcer with necrosis. Full thickness into fascia, mm, tendon, capsule, bone, etc

Front 2

What is an unstageable pressure ulcer?

Back 2

Whe the base is obscured by eschar or slough. LIkely to be full thickness (III or IV)

Front 3

Limitations of pressure ulcer staging system?

Back 3

1. Does not take into account shear, moisture, other factors
2. System implies that ulcer begins at skin's surface and progress to involve deeper tissue (underlying tissue damage BEFORE surface signs)
Ulcers covered with eschar can't be stages b/c depth can't be assessed

Front 4

Can you reverse stage a pressure ulcer

Back 4

No, call it a "healing grade IV"

Front 5

Name some pressure ulcer risk assessment tools?

Back 5

Braden Scale, Norton scale, Gosneell scale
Includesmobility, activity, nutrition status, skin moisture, mental cognition, continence

Front 6

Pain and position characteristics for pressure ulcers

Back 6

Tender/painful if senesory intact
Bony prominence: sacrum, GT, isch tub, heel, lat mal

Front 7

Pressure ulcer wound presentation

Back 7

Deeper ulcers covered w/ black eschar
Possible exposed tendon, mm, capsule, bone
Tunneling/undermining common
May drain profusely

Front 8

Periwound characteristics of pressure ulcer?

Back 8

Nonblanchable erythema, ring of erythema
Localized warmth and dermatitis
Fibrosis and induration

Front 9

Pulses and temperature characteristics of pressure ulcers?

Back 9

Normal pulses
Hyperemia = warm
Necrosis = cold

Front 10

5 scales used for the Assessment of Healing Prognosis for Pressure Wounds

Back 10

Sessing
Pressure Sore Status Tool
Pressure Ulcer Scale for Healing
Wound Healing Scale
Sussman Wound Healing Tool

Front 11

What tests/measures should be performed on all pt's with neuropathic ulcerations?

Back 11

Circulation and Sensory

Front 12

What circulation tests should be performed on neuropathic ulcer pts?

Back 12

Pulses
Doppler and ABI if pulses abnormal
Capi refill if digita ulcer or abnormal ABI
Refer for vessel calcifcation or abnormal Doppler/ABI

Front 13

Standard locations to test sensation of neuropathic pt?

Back 13

First, third, fifth digits, med and lat midfoot and calcaneus and one over the dorsal foot

Front 14

Monofilament size and interpretation of sensory?

Back 14

4.17 = dec sensation
5.07 = loss of protective sensation
6.10 = absent sensation

Front 15

What is the Wagner classification system? Grades and descriptions?

Back 15

Specific to neuropathic foot ulcerations
0 = no lesion or cellulitis
1 = superficial lesion (C)
2 = deep to tendon, capsule, bone
3 = deep with abcess, osteomyelitis, joint sepsis
4 = gangrene localized
5 = gangrene entire foot

Front 16

Pain and position characteristics of Neuropathic wounds?

Back 16

Absent or significantly dec
Plantar aspect of foot, areas of inc plantar pressure or shear

Front 17

Wound presentation characteristics of neuropathic wounds

Back 17

Round, punched out lesoin
Callus rim with little or no drainage (unless infected)
Necrotic base UNCOMMON

Front 18

Periwound characteristics of neuropathic wounds

Back 18

Dry, cracked, callus
Deformities = claw toes, rocker bottom foot

Front 19

Pulses and temp for neuropathic wounds

Back 19

Normal.. possibly inc temp or normal

Front 20

Good prognostic indicators for neuropathic wounds

Back 20

Smaller or more superficial
Shorter duration (<2 mo)
Not infected
Initial dec in first 4 weeks = 53% reduction