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Integumentary

Ulcers (PTA)

QuestionAnswer
Stage I Pressure Ulcer skin intact; changes in color, temperature, stiffness, or sensation
Stage II Pressure Ulcer partial-thickness skin loss (epidermis and/or dermis); superficial abrasion, blister, or shallow crater
Stage III Pressure Ulcer full-thickness skin loss; necrosis of subcutaneous tissue & underlying fascia; deep crater w/ or w/o undermining of adjacent tissue
Stage IV Pressure Ulcer full-thickness skin loss; tissue necrosis, damage to muscle, bone, or support structures
(Bony Prominences Associated with pressure injuries) in Supine Occiput---Scapula: spine, inf. angle---(Bony Prominences Associated with pressure injuries) Vertebral spinous processes---Humerus: medial epicondyle---Posterior iliac crest---Sacrum---Coccyx
(Bony Prominences Associated with pressure injuries) in Prone Forehead---Acromion process (ant. portion)---Ant. head of humerus---Sternum---ASIS---Patella---Dorsum of foot
(Bony Prominences Associated with pressure injuries) in Sidelying Ears---Acromion process (lateral portion)---Lateral head of humerus---Gr. Trochanter---Fibular head---Lateral & Medial malleoli
(Bony Prominences Associated with pressure injuries) in Sitting (Chair) Spine of Scapula---Vertebral spinous processes---Ischial tuberosity
Pressure ulcers form because... pressure to soft tissue that exceeds normal capillary pressure of the local circulation
8 Factors contributing to pressure ulcers: shear, friction, heat, moisture, medication, muscle atrophy, malnutrition, debilitating medical conditions
Neuropathic ulcers 2° complication associated with combination of ischemia & neuropathy. Seen with Diabetes.
Where are neuropathic ulcers usually located? plantar surface of foot, beneath met. heads
Describe a neuropathic ulcer wound. prominent callus rim with good granulation tissue & little or no drainage.
Other key facts about neuropathic ulcers usually painless (altered sensation); pedal pulse diminished or absent; distal limb shiny & cool to the touch; periwound skin is dry or cracked
Arterial insufficiency ulcers occur 2° to ischemia from inadequate circulation of oxygenated blood; often due to complicating factors such as atherosclerosis
Location of Arterial Ulcers lower 1/3 of leg: toes, web spaces, lateral malleolus
Appearance of Arterial Ulcers Smooth edges, well defined, deep, NO granulation tissue
Pain Associated with Arterial Ulcers Severe
Pedal Pulse with Arterial Ulcers Diminished or absent
Edema with Arterial Ulcers Normal (localized)
Skin temperature with Arterial Ulcers Decreased
Tissue Changes with Arterial Ulcers Thin & shiny; hair loss; yellow nails
Leg elevation with Arterial Ulcers INCREASES pain!!
Venous insufficiency ulcers occur 2° to inadequate functioning of the venous system resulting in inadequate circulation & eventual tissue damage & ulceration
Location of Venous Ulcers proximal to medial malleolus
Appearance of Venous Ulcers Irregular shape; shallow
Pain associated with Venous Ulcers mild to moderate
Pedal Pulse with Venous Ulcers Normal
Edema with Venous Ulcer INCREASED
Skin Temperature with Venous Ulcer Normal
Tissue Changes with Venous Ulcer Flaking, dry skin, brownish discoloration
Leg Elevation with Venous Ulcer decreases pain
Intervention for Arterial Insufficiency Ulcers Cleansing, Rest, Reducing risk factors, & Limb Protection
General Recommendations for Arterial Insufficiency Ulcers 1)Wash/dry feet thoroughly 2)Avoid unnecessary leg elevation 3)Inspect legs/ feet daily 4). Wear appropriately sized shoes w/seamless socks 5). Use bandages as necessary & avoid any unnecessary pressure 6). Avoid using heating pads or soaking feet in hot
Intervention for Venous Insufficiency Ulcers Cleansing, Compression to control edema
General Recommendations for Venous Insufficiency Ulcers 1). Elevate legs above heart when resting or sleeping 2). Attempt active exercise including frequent ROM 3). Inspect legs & feet daily 4). Wear appropriately sized shoes with clean, seamless socks 5). Use bandages as necessary & avoid scratching or other
How often should bed-bound patients be turned to prevent pressure ulcers? every 2 hours
Created by: s1234 on 2009-02-07



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